Respondent-driven sampling to recruit young adult non-medical users of pharmaceutical opioids: problems and solutions

Respondent-driven sampling (RDS) has been promoted as a superior method in recruiting hard-to-reach and hidden populations. Although its application has expanded enormously, there remains a need for empirical data evaluating the performance of RDS in different settings. This study describes the application of RDS to recruit a community sample (N=396) of young adults (18-23 years old) into a natural history study of non-medical pharmaceutical opioid use. Since recruitment targeted non-dependent pharmaceutical opioid users, and applied other eligibility restrictions, several modifications had to be made to make RDS work with this narrowly defined target population. RDS recruitment was less efficient than expected, and produced greater numbers of African American recruits than anticipated. Although the sampling quota was met, sample analysis revealed a lack of equilibrium in terms of ethnic composition and very strong in-group recruitment tendencies among White and African American respondents. This study contributes potentially helpful insights into the strengths and limitations of using RDS which may benefit future studies.     

Psychometric validation of the Leeds Dependence Questionnaire (LDQ) in a young adult clinical sample

Objective

Measures of substance dependence severity that are both clinically efficient and sensitive to change can facilitate assessment of clinical innovation necessary for improving current evidence-based practices. The Leeds Dependence Questionnaire (LDQ) is a 10-item, continuous, self-report measure of dependence that is not specific to any particular substance and has shown promise in preliminary psychometric research. The present study investigates its psychometric properties in a large clinical sample of young adults.

Method

Young adults (N = 300) were enrolled in a naturalistic treatment process and outcome study of residential substance dependence treatment (mean age 20.4 [1.6], range 18–25; 27% female; 95% White). Dependence severity by demographic and diagnostic groupings, factor structure and internal consistency, and criterion- and construct-related validity were examined.

Results

Dependence severity in this cohort of youth overall was high (M = 18.65 [8.65]). LDQ scores were highest among opiate and stimulant users, and there was a trend for higher scores among women compared to men (t = 1.869, p = .063). Factor analysis using a robust alpha factoring extraction revealed a single factor accounting for 63% of the variance in reported dependence severity. The internal consistency was also very high (alpha = .93). Concurrent and convergent validity with dependence criteria, substance use frequency, and general symptom severity, respectively, were also acceptable.

Conclusions

The LDQ shows considerable promise as a brief, psychometrically sound, measure of substance dependence useful across a variety of substances, that has clinical and research utility. This study supports its use among young adults.     

High enhancer,downer, withdrawal helper: Multifunctional nonmedical benzodiazepine use among young adult opioid users in New York City

BackgroundBenzodiazepines are a widely prescribed psychoactive drug; in the U.S., both medical and nonmedical use of benzodiazepines has increased markedly in the past 15 years. Long-term use can lead to tolerance and dependence, and abrupt withdrawal can cause seizures or other life-threatening symptoms. Benzodiazepines are often used nonmedically in conjunction with other drugs, and with opioids in particular—a combination that can increase the risk for fatal and non-fatal overdose. This mixed-methods study examines nonmedical use of benzodiazepines among young adults in New York City and its relationship with opioid use.MethodsFor qualitative analysis, 46 90-minute semi-structured interviews were conducted with young adult opioid users (ages 18–32). Interviews were transcribed and coded for key themes. For quantitative analysis, 464 young adult opioid users (ages 18–29) were recruited using Respondent-Driven Sampling and completed structured interviews. Benzodiazepine use was assessed via a self-report questionnaire that included measures related to nonmedical benzodiazepine and opioid use.ResultsParticipants reported using benzodiazepines nonmedically for a wide variety of reasons, including: to increase the high of other drugs; to lessen withdrawal symptoms; and to come down from other drugs. Benzodiazepines were described as readily available and cheap. There was a high prevalence (93%) of nonmedical benzodiazepine use among nonmedical opioid users, with 57% reporting regular nonmedical use. In bivariate analyses, drug-related risk behaviours such as polysubstance use, drug binging, heroin injection and overdose were strongly associated with regular nonmedical benzodiazepine use. In multivariate analysis, growing up in a middle-income household (earning between $51,000 and $100,000 annually), lifetime overdose experience, having ever used cocaine regularly, having ever been prescribed benzodiazepines, recent drug binging, and encouraging fellow drug users to use benzodiazepines to cope with opioid withdrawal were consistently strong predictors of regular nonmedical benzodiazepine use.ConclusionNonmedical benzodiazepine use may be common among nonmedical opioid users due to its drug-related multi-functionality. Harm reduction messages should account for the multiple functions benzodiazepines serve in a drug-using context, and encourage drug users to tailor their endorsement of benzodiazepines to peers to include safer alternatives.     

Recommendations for buprenorphine and methadone therapy in opioid use disorder: a European consensus

Introduction: Management of patients with opioid use disorder (OUD) commonly includes opioid agonist therapy (OAT) as a part of an integrated treatment plan. These interventions are associated with proven benefits to the individual and society.

Areas covered: The use of methadone and buprenorphine within an integrated treatment plan in the management of patients with OUD: this work provides consensus recommendation on pharmacotherapy in OUD to assist clinicians with practical decision making in this field.

Expert opinion: Pharmacotherapy is recommended as part of an integrated OUD treatment approach with psychosocial interventions, with the goal of reducing risks of illicit opioid use, overdose mortality, infection with HIV or HCV, improving health, psychological and social outcomes. Access to OAT should be prioritised in the treatment of OUD. Treatment choices in OUD pharmacotherapy should be based on the needs of the individual and characteristics of medications. Recommendations for choices of OAT are based on clinical efficacy, safety, patient preference, side effects, pharmacological interactions, quality of life, dose titration potential and outcomes (control craving, ongoing opioids consumption or other drugs, and potentially psychiatric comorbidities). Special groups, pregnant women, prisoners, patients with mental health problems have specific needs which must be addressed with expert input.     

Abuse liability of buprenorphine-naloxone tablets in untreated IV drug users

Buprenorphine (Subutex) is widely abused in Finland. A combination of buprenorphine plus naloxone (Suboxone) has been available since late 2004, permitting a comparison of the abuse of the two products among untreated intravenous (IV) users. A survey was distributed to attendees at a Helsinki needle exchange program over 2-weeks in April, 2005, At least 30% were returned anonymously. Survey variables included: years of prior IV opioid abuse, years of buprenorphine abuse, frequency, dosage, route of administration and reasons for use, concomitant IV abuse of other substances and amount paid on the street for both buprenorphine and buprenorphine+naloxone. Buprenorphine was the most frequently used IV drug for 73% of the respondents. More than 75% said they used IV buprenorphine to self-treat addiction or withdrawal. Most (68%) had tried the buprenorphine+naloxone combination IV, but 80% said they had a "bad" experience. Its street price was less than half that of buprenorphine alone. The buprenorphine+naloxone combination appears to be a feasible tool, along with easier access to addiction treatment, for decreasing IV abuse of buprenorphine.     

Contextual profiles of young adult ecstasy users: A multisite study

These analyses assess contextual profiles of 612 young adult ecstasy users, 18-30 years of age, from St. Louis (USA), Miami (USA) and Sydney (Australia). Bivariate analyses revealed different contextual factors influencing ecstasy use. Friends were the most common sources of ecstasy at all sites and most used with friends. St. Louis and Miami use mostly occurred in residences, whereas in Sydney use was mostly at clubs, bars or restaurants. Ecstasy consumption at public places and in cars, trains or ferries was significantly higher in Miami (89% and 77%) than in St. Louis (67% and 65%) and Sydney (67% and 61%). At all sites, simultaneous use of LSD/mushroom and nitrous oxide with ecstasy was common; concurrent amphetamines predominated in Sydney and heroin/opiates in St. Louis Contextual factors influencing ecstasy use among young adults vary by geographic region. Their inclusion may help tailor effective prevention programs to reduce or ameliorate ecstasy use.     

Substance use and treatment seeking in young offenders on community orders

Both international and Australian studies reveal very low rates of treatment utilization for substance abuse among young offenders despite very high problematic rates of substance abuse among this group. The current study reports on substance use patterns of a representative sample of 712 young offenders serving community orders with the New South Wales Department of Juvenile Justice (Australia) and their history of and attitudes toward treatment. Most (87%) young offenders had used marijuana, and 47% had used amphetamines in the last 12 months. One third of the sample reported problematic use of alcohol (being drunk at least weekly, on average). Forty-three percent reported that they engaged in crime to maintain their substance use. On the substance abuse scale of the Adolescent Psychopathology Scale—Short Form, 36.4% of the sample fell into the moderate to severe problem range. Despite such problems, treatment motivation was poor: 10% reported willingness to access treatment for their drug problems. Eighteen percent reported accessing some form of treatment in the past; the most common form of help seeking was approaching their family (12%). Self-reported access to other drug treatments was even lower, with the more intensive treatments revealing low rates of treatment completion. Despite almost 40% of the sample revealing significant substance abuse problems, referral for treatment was also low, with only 18% of the sample being offered an appointment with juvenile justice drug and alcohol workers. This study reveals the gap between awareness of problematic drug use and treatment-seeking behavior, and has implications for improving outreach to young offenders with substance abuse problems.     

Individual and contextual predictors of severity of marijuana use events among young frequent users

This study used momentary sampling to characterize marijuana events among young frequent users and determine contextual and individual predictors of use severity. Medical clinic outpatients aged 15–24 who used marijuana at least twice a week completed a baseline assessment, then used a handheld computer to report marijuana use at 4–6 signal-prompted times per day and before/after use for 2 weeks. Reports assessed event characteristics (when, with whom, where, how, why, how much, how high). Timestamps identified time, weekend, and duration for each event. Generalized estimating equations tested associations of individual and event-specific contextual characteristics with hits/event, duration, and high. Forty-one youth completed 3868 momentary reports; 40 (98%) reported at least one marijuana use event (N = 432 events; M = 10.5/participant) and thus provided data for these analyses. Marijuana was most commonly used with other people (74% of events), at home (58%), via blunt (66%), and for social or enhancement reasons (86%). Most events (62%) occurred on weekdays; use was least likely in the morning (8%). Most events involved 6 or more hits (81%). Mean high was 5.2 (out of 8). Of events with start and end times (n = 250), mean duration was 46.8 min. Poor mental health and use with a blunt or a bong, in the morning or evening, and on the weekend were associated with 6 or more hits/event. Female gender was associated with greater event duration. Poor mental health predicted higher high. Among youth who used it frequently, marijuana was used in a variety of contexts, with diversity in method, dose, and duration. Contextual factors appeared to predict marijuana dose for a given event, while individual characteristics were more predictive of high and duration.     

A multi-level analysis of counselor attitudes toward the use of buprenorphine in substance abuse treatment

Despite evidence that buprenorphine is effective and safe and offers greater access as compared with methadone, implementation for treatment of opiate dependence continues to be weak. Research indicates that legal and regulatory factors, state policies, and organizational and provider variables affect adoption of buprenorphine. This study uses hierarchical linear modeling to examine National Treatment Center Study data to identify counselor characteristics (attitudes, training, and beliefs) and organizational factors (accreditation, caseload, access to buprenorphine, and other evidence-based practices) that influence implementation of buprenorphine for treatment of opiate dependence. Analyses showed that provider training about buprenorphine, higher prevalence of opiate-dependent clients, and less treatment program emphasis on a 12-step model predicted greater counselor acceptance and perceived effectiveness of buprenorphine. Results also indicate that program use of buprenorphine for any treatment purpose (detoxification, maintenance, and/or pain management) and time (calendar year in data collection) was associated with increased diffusion of knowledge about buprenorphine among counselors and with more favorable counselor attitudes toward buprenorphine.     

Non-daily smoking predicts hazardous drinking and alcohol use disorders in young adults in a longitudinal U.S. sample

Background

It is known that daily smoking is associated with the development of alcohol use disorders. However, non-daily smoking is prevalent in young adults and is associated with increased rates of problematic alcohol use in cross-sectional data. It is unknown whether non-daily smoking is predictive of hazardous drinking and alcohol use disorders using longitudinal data. The primary aim of the present investigation was to explore the temporal relationship between non-daily smoking and drinking in young adults, and secondarily, whether college status modified this relationship.

Methods

Using Waves 1 (2001-2002) and 2 (2004-2005) of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), we examined the predictive relationship of smoking status at Wave 1 and change in college status between Waves on alcohol drinking, hazardous drinking, and alcohol abuse and dependence disorders at Wave 2. The sample was restricted to individuals aged 18-25 years at Wave 1.

Findings

Daily and non-daily smokers at Wave 1, compared to nonsmokers, were at a greater risk for hazardous drinking and alcohol use disorders at Wave 2, after controlling for Wave 1 drinking. College status did not modify smoking and drinking interactions.

Conclusions

The findings indicate non-daily smoking is predictive of increased, problematic alcohol use among young adults longitudinally and they support increasing evidence that non-daily smokers represent an important population. Future research should be conducted to continue developing targeted interventions. Early treatments for smoking behavior might have a beneficial effect on reducing the development of problematic patterns of alcohol use and alcohol use disorders.     

Methadone and buprenorphine-naloxone are effective in reducing illicit buprenorphine and other opioid use,and reducing HIV risk behavior—Outcomes of a randomized trial

Aims

Determine the extent to which buprenorphine injectors continue treatment with buprenorphine-naloxone or methadone, and the impact of these treatments on substance use and HIV risk in the Republic of Georgia.

Methods

Randomized controlled 12-week trial of daily-observed methadone or buprenorphine-naloxone followed by a dose taper, referral to ongoing treatment, and follow-up at week 20 at the Uranti Clinic in Tbilisi, Republic of Georgia. Eighty consenting treatment-seeking individuals (40/group) aged 25 and above who met ICD-10 criteria for opioid dependence with physiologic features and reported injecting buprenorphine 10 or more times in the past 30 days. Opioid use according to urine tests and self-reports, treatment retention, and HIV risk behavior as determined by the Risk Assessment Battery.

Results

Mean age of participants was 33.7 (SD5.7), 4 were female, mean history of opioid injection use was 5.8 years (SD4.6), none were HIV+ at intake or at the 12-week assessment and 73.4% were HCV+. Sixty-eight participants (85%) completed the 12-week medication phase (33 from methadone and 35 from buprenorphine/naloxone group); 37 (46%) were in treatment at the 20-week follow-up (21 from methadone and 16 from the buprenorphine/naloxone group). In both study arms, treatment resulted in a marked reduction in unprescribed buprenorphine, other opioid use, and HIV injecting risk behavior with no clinically significant differences between the two treatment arms.

Conclusions

Daily observed methadone or buprenorphine-naloxone are effective treatments for non-medical buprenorphine and other opioid use in the Republic of Georgia and likely to be useful for preventing HIV infection.     

Relapse prevention medications in community treatment for young adults with opioid addiction

ABSTRACT

Background: Despite the well-known effectiveness and widespread use of relapse prevention medications such as extended release naltrexone (XR-NTX) and buprenorphine for opioid addiction in adults, less is known about their use in younger populations. Methods: This was a naturalistic study using retrospective chart review of N = 56 serial admissions into a specialty community treatment program that featured the use of relapse prevention medications for young adults (19–26 years old) with opioid use disorders. Treatment outcomes over 24 weeks included retention and weekly opioid-negative urine tests. Results: Patients were of mean age 23.1, 70% male, 86% Caucasian, 82% with history of injection heroin use, and treated with either buprenorphine (77%) or XR-NTX (23%). The mean number of XR-NTX doses received was 4.1. Retention was approximately 65% at 12 weeks and 40% at 24 weeks, and rates of opioid-negative urine were 50% at 12 weeks and 39% at 24 weeks, with missing samples imputed as positive. There were no statistically significant differences in retention (t = 1.87, P = .06) or in rates of weekly opioid-negative urine tests (t = 1.96, P = .06) between medication groups, over the course of 24 weeks. The XR-NTX group had higher rates of weekly negative urine drug tests for other nonopioid substances (t = 2.83, P < .05) compared with the buprenorphine group. Males were retained in treatment longer and had higher rates of opioid-negative weeks compared with females. Conclusions: These results suggest that relapse prevention medications including both buprenorphine and XR-NTX can be effectively incorporated into standard community treatment for opioid addiction in young adults with good results. Specialty programming focused on opioid addiction in young adults may provide a promising model for further treatment development.     

Providing opioid substitution treatment to Indigenous heroin users within a community health service setting in Adelaide

In the late 1990s there was major concern regarding heroin use among the Nunga community in Adelaide. [Nunga is a generic term used for Aboriginal people from South Australia, similar to Koori's from Victoria and Nyungars from south-western Australia.] Heroin use was so common that community members reported that most families were affected by it in some way. There were few Nunga specific services provided, and those mainstream services available were not seen as culturally appropriate or for other reasons were difficult to access. In response to this, the Parks Community Health Centre, together with the Drug and Alcohol Services Council (DASC) [in 2005 the Drug and Alcohol Services Council (DASC) changed its name to Drug and Alcohol Services South Australia (DASSA)], and with the assistance of Nunkuwarrin Yunti Aboriginal Health Service [Adelaide's Aboriginal Community Controlled Health Service, based in the City Centre], commenced a programme offering treatment interventions for Nunga heroin users. The 'Way Out' Program commenced in March 1999. It is multi-faceted and includes an opioid substitution programme which is attracting and maintaining Nunga clients in greater numbers than ever before in South Australia. The programme locates the drug problem within a holistic view of the individual's health. It utilises networks throughout the Nunga community and in recent years has formed a strong working partnership with the Aboriginal Kinship Program [the Aboriginal Kinship Program (Department of Human Services, Metropolitan Health Division) works with Aboriginal families and individuals seeking support for family members in relation to illicit drug issues by providing support, referral, follow-up and advocacy services]. The 'Way Out' Program is succeeding in making essential treatment services available to Aboriginal people using heroin within Adelaide. This article provides an overview of the programme. [Williams N, Nasir R, Smither G, Troon S. Providing opioid substitution treatment to Indigenous heroin users within a community health service setting in Adelaide. Drug Alcohol Rev 2006;25:227 - 232]     

A population-based examination of trends and disparities in medication treatment for opioid use disorders among Medicaid enrollees

Background: Medication treatment (MT) with methadone and buprenorphine are effective treatments for opioid use disorders, but little information is available regarding the extent to which buprenorphine's approval resulted in more individuals receiving MT nor to what extent receipt of such treatment was equitable across communities. Methods: To examine changes in MT utilization and the association between MT utilization and county-level indicators of poverty, race/ethnicity, and urbanicity, we used Medicaid claims of non-dually eligible Medicaid enrollees aged 18–64 from 14 states for 2002–2009. We generated county-level aggregate counts of MT (methadone, buprenorphine, and any MT) by year (N = 7760 county-years). We estimated count data models to identify associations between MT and county characteristics, including levels of poverty and racial/ethnic concentration. Results: The number of Medicaid enrollees receiving MT increased 62% from 2002 to 2009. The number of enrollees receiving methadone increased 20%, with the remaining increase resulting from buprenorphine. Urban county residents were significantly more likely to receive MT in both 2002 and 2009 than rural county residents. However, buprenorphine substantially increased MT in rural counties from 2002 to 2009. Receipt of MT increased at a much higher rate for residents of counties with lower poverty rates and lower concentrations of black and Hispanic individuals than for residents of counties without those characteristics. Conclusions: The increase in Medicaid enrollees receiving MT in the years following buprenorphine's approval is encouraging. However, it is concerning that MT trends varied so dramatically by characteristics of the county population and that increases in utilization were substantially lower in counties with populations that historically have been disadvantaged with respect to health care access and quality. Concerted efforts are needed to ensure that MT benefits are equitably distributed across society and reach disadvantaged individuals who may be at higher risk of experiencing opioid use disorders.     

Motives for cannabis use as a moderator variable of distress among young adults

This study examined the moderating effect of social and coping motives on distress among young cannabis-using adults. A random sample of 2031 young Swiss adults was interviewed by means of a computer-assisted telephone interview. Cannabis users showed more distress, less positive health behaviour and higher hedonism compared to non-users. Taking motive for use as a moderator variable into consideration, it became evident that only cannabis users with coping motives showed lower mental health, more symptoms of psychopathology, more psychosocial distress and more life events than non-users. Young adults with social motives for use on the other hand did not differ from non-users in terms of distress. These differences between cannabis users with social and those with coping motives remained stable over two years. In both subgroups, participants with regular cannabis use at baseline did not increase distress nor did participants with higher distress at baseline increase the frequency of their cannabis use. Our results suggest that secondary prevention for cannabis users should target especially young adults with coping motives for use.