Injection opioid use as a predictor of treatment outcomes among methadone-maintained opioid-dependent patients

BackgroundInjection opioid use is associated with more severe health and psychosocial consequences relative to non-injection use, but few studies have examined whether injection use is associated with methadone maintenance treatment outcomes. The present study examined differential MMT outcomes among opioid injectors and non-injectors.MethodsData were extracted from the clinic charts of opioid-dependent MMT patients (N = 290; n = 115 injectors) enrolled in a university-affiliated, urban MMT clinic. Injection status was examined as a predictor of short- (3-month opioid, cocaine, benzodiazepine and cannabis urine drug screens) and long- (days retained in treatment) term MMT outcomes.ResultsBivariate analyses revealed injection users were less likely to be African American and to have completed high school, were more likely to have started heroin use before age 21, to report having hepatitis C, to report a baseline cocaine use disorder, and had higher methadone doses at 3-months into treatment. Injection status significantly predicted a greater proportion of cocaine-positive urine drug screens in the first 3 months of treatment, but did not significantly predict opioid, benzodiazepine or cannabis drug screens, or length of treatment retention.ConclusionThis is one of a handful of studies to examine injection status as a predictor of MMT outcomes. Injection status is associated with cocaine use early in treatment, which has implications for the focus of treatment.     

Concordance between self-report and urine drug screen data in adolescent opioid dependent clinical trial participants

Objective measures of drug use are very important in treatment outcome studies of persons with substance use disorders, but obtaining and interpreting them can be challenging and not always practical. Thus, it is important to determine if, and when, drug-use self-reports are valid. To this end we explored the relationships between urine drug screen results and self-reported substance use among adolescents and young adults with opioid dependence participating in a clinical trial of buprenorphine–naloxone. In this study, 152 individuals seeking treatment for opioid dependence were randomized to a 2-week detoxification with buprenorphine–naloxone (DETOX) or 12 weeks of buprenorphine–naloxone (BUP), each with weekly individual and group drug counseling. Urine drug screens and self-reported frequency of drug use were obtained weekly, and patients were paid $5 for completing weekly assessments. At weeks 4, 8, and 12, more extensive assessments were done, and participants were reimbursed $75. Self-report data were dichotomized (positive vs. negative), and for each major drug class we computed the kappa statistic and the sensitivity, specificity, positive predictive value, and negative predictive value of self-report using urine drug screens as the “gold standard”. Generalized linear mixed models were used to explore the effect of treatment group assignment, compensation amounts, and participant characteristics on self-report. In general, findings supported the validity of self-reported drug use. However, those in the BUP group were more likely to under-report cocaine and opioid use. Therefore, if used alone, self-report would have magnified the treatment effect of the BUP condition.     

A pilot study of community-friendly manual-guided drug counseling

Therapist training manuals that are more “community friendly” are needed to facilitate effectiveness testing and dissemination of treatments to community based setting. The aim of the current project was to create revised versions of individual drug counseling (IDC) and group drug counseling (GDC) treatment manuals for cocaine dependence and to conduct a preliminary study of their effectiveness. After changing the format and context of existing drug counseling manuals to have greater ease of use in the community, draft manuals were given to 23 community-based counselors for their feedback. Final versions were then used in a pilot randomized clinical trial involving 41 cocaine-dependent patients who received 3 months of either IDC + GDC or GDC-alone treatment. Counselors implemented the new treatment manuals with acceptable levels of adherence and competence. Outcome results indicated that substantial change in drug use was evident, but the amount of abstinence obtained was limited.     

Patterns of Abstinence or Continued Drug Use Among Methadone Maintenance Patients and Their Relation to Treatment Retention

The efficacy and effectiveness of methadone maintenance treatment (MMT) in the medical management of opioid addiction has been well-established, but treatment outcomes are compromised by the continued use of licit and illicit drugs during MMT. The present study examined the relationship between in-treatment illicit drug use and retention and dropout of 604 MMT patients in Washington, D.C. Sixty-eight percent of patients did not test positive for an unprescribed drug during the study period. Of patients who tested positive for an illicit drug during the baseline period, 55% tested positive for cocaine, 44% for opiates, 23% for THC, 20% for benzodiazepines, 7% for PCP, and 4% for amphetamines. Those testing positive were three times more likely to leave treatment than those who did not test positive. Testing positive for one drug doubled the rate of attrition; testing positive for multiple drugs quadrupled the risk of attrition. Non-prescribed opioid or benzodiazepine use was a predictor of MMT dropout, but prescribed opioid or benzodiazepine use was not. Continued illicit drug use poses significant risk for subsequent premature termination of MMT. Assertive clinical management of continued illicit drug use could provide mechanisms to enhance MMT retention and long-term recovery outcomes.     

Effectiveness of drug dependence treatment in HIV prevention

This review considers the effectiveness of drug dependence treatment in preventing HIV transmission among injecting drug users (IDUs). Substitution programmes using agonist pharmacotherapy (e.g. methadone and buprenorphine maintenance treatment) are available only for drug users who are primarily opioid dependent. There are over half a million people in receipt of methadone maintenance treatment (MMT) and it is estimated that this number will double in the coming decade. There is evidence that MMT is associated with a significant decrease in injecting drug use and sharing of injecting equipment. Data on sex-related risk behaviour change are limited, but suggest that MMT is associated with a lower incidence of multiple sex partners or exchanges of sex for drugs or money, but no change, or only small decreases, in unprotected sex. Studies of seroconversion, which is the toughest and most robust standard for assessing the role of MMT in HIV prevention, suggest that the reductions in risk behaviours do translate into actual reductions in cases of HIV infection. While the data on HIV risk behaviour are limited, there is strong evidence that substitution treatment with either methadone or buprenorphine suppresses illicit opioid use. There is also evidence that substitution treatment for HIV-positive IDUs is associated with better compliance with anti-retroviral treatment and improved health outcomes. The only antagonist being used for opioid dependence relapse prevention treatment is naltrexone. There is currently insufficient evidence to draw firm conclusions as to its effectiveness. Behavioural interventions add to the effectiveness of substitution treatment, while the effectiveness of different types of psychological therapy alone has been found to be variable. There have been few comparative studies of abstinence-based treatment, however, available evidence indicates good outcomes for those who remain in treatment for three months or more. All countries with a population of IDUs should aim to develop a comprehensive range of treatments, including substitution treatment, as a critical component of HIV prevention.     

HIV-infected intravenous drug users in methadone maintenance treatment: clinical problems and their management.

Infection with the human immunodeficiency virus (HIV) is a significant and growing problem among intravenous drug users (IVDUs), both from the standpoint of personal morbidity and public health concerns regarding spread of the virus. Most HIV-infected IVDUs are opioid addicts. The most common form of long-term treatment of opioid dependence is methadone maintenance treatment (MMT). MMT can therefore play an important role in both AIDS prevention and reduction of HIV-related morbidity through diminishing drug use, promoting a healthier life-style, and providing direct medical and psychiatric care. Attempts to manage patients with a triple diagnosis of drug abuse, medical, and psychiatric problems can pose significant clinical challenges, requiring the efforts of a multidisciplinary team. The management of HIV-infected patients in MMT is discussed and case examples from the MMT program of the San Francisco General Hospital Substance Abuse Services are presented to illustrate useful strategies in the care of these complicated patients.     

Predictors of methadone maintenance treatment utilization in a multisite cohort of illicit opioid users (OPICAN)

Although methadone maintenance treatment (MMT) has been a primary treatment response to illicit opioid use in Canada for decades, analytical treatment data are scarce. Using data from the multisite OPICAN cohort of illicit opioid and other drug users repeatedly assessed between 2002 (baseline) and 2005 (last follow-up [FU]), we (1) longitudinally examined characteristics associated with MMT uptake between baseline and FU and (2) cross-sectionally compared drug use patterns between cohort participants in MMT (n = 133) and those not in MMT (n = 400) at the last FU through bivariate and multivariate analyses (stepwise logistic regression). Significant baseline predictors of MMT uptake emerging in the logistic regression model included injection drug, heroin, as well as alcohol use, housing status, and Quebec City as a site. Furthermore, lower prevalence levels of opioid (e.g., morphine and OxyContin) and nonopioid (e.g., cocaine and crack) drug use as well as lower frequency of heroin use days were observed among MMT users. This study highlights potential factors relevant for improved MMT uptake and illustrates possible reductions of drug use related to MMT.     

A Stage I pilot study of acceptance and commitment therapy for methadone detoxification

Background

While agonist replacement therapies are effective for managing opioid dependence, community treatment programs are increasingly choosing detoxification. Unfortunately, success rates for opioid detoxification are very low, in part, due to physical and psychological symptoms associated with opioid withdrawal. Few behavior therapies specifically address the distressing experiences specific to opioid withdrawal. A novel behavioral treatment, acceptance and commitment therapy (ACT), works from the premise that the avoidance of unpleasant private experiences (thoughts, feelings, bodily sensations) is ubiquitous yet may be pathogenic, resulting in treatment drop-out and further drug use.

Methods

This Stage I pilot study developed and tested an ACT-based opioid detoxification behavioral therapy. Opioid dependent patients (N = 56) who were attending a licensed methadone clinic were randomized to receive either 24 individual therapy sessions of ACT or drug counseling (DC) in the context of a 6-month methadone dose reduction program.

Results

While no difference was found on opioid use during treatment, 37% of participants in the ACT condition were successfully detoxified at the end of treatment compared to 19% of those who received DC. Fear of detoxification was also reduced across time in the ACT condition relative to DC.

Conclusion

This first study of ACT to assist opioid detoxification indicates promise. Research is needed to refine specific treatment strategies for this population to further strengthen effects.     

Effect of buprenorphine dose on treatment outcome

The goal of this meta-analysis is to provide evidence based information about proper dosing for buprenorphine maintenance treatment to improve treatment outcome. To be selected for the review and inclusion in the meta-analysis, articles had to be randomized, controlled, or double-blind clinical trials, with buprenorphine as the study drug; the length of buprenorphine maintenance treatment had to be 3 weeks or longer; doses of buprenorphine had to be clearly stated; outcome measures had to include retention rates in buprenorphine treatment; outcome measures had to include illicit opioid use based on analytical determination of drugs of abuse in urine samples as outcome variables; and outcome measures had to include illicit cocaine use based on analytical determination of drugs of abuse in urine samples as outcome variables. Twenty-nine articles were excluded because they did not meet the inclusion criteria. The authors present the results of 21 articles that met inclusion criteria. The higher buprenorphine dose (16-32 mg per day) predicted better retention in treatment compared with the lower dose (less than 16 mg per day) (P = .009, R(2) adjusted = 0.40), and the positive urine drug screens for opiates predicted dropping out of treatment (P = .019, R(2) Adjusted = 0.40). Retention in treatment predicted less illicit opioid use (P = .033, R(2) Adjusted = 0.36), and the positive urine drug screens for cocaine predicted more illicit opioid use (P = .021, R(2) Adjusted = 0.36). Strong evidence exists based on 21 randomized clinical trials that the higher buprenorphine dose may improve retention in buprenorphine maintenance treatment.     

Family history influence on drug abuse severity and treatment outcome

Influence of parental alcohol/substance abuse on methadone maintenance therapy (MMT) outcome was examined in 164 DSM-III-R opioid dependent adults with no other current DSM Axis I disorder. Family history positive patients had more DSM-III-R opioid dependence symptoms and were more likely to be classified as severely dependent. However, when placed on identical daily doses of methadone (50 mg), they had lower rates of illicit opioid use but higher rates of cocaine use than family history negative patients. Both effects remained significant after adjusting for gender and race. These results suggest that common genetic factors may underlie both susceptibility to heroin dependence and response to therapeutic methadone treatment.     

Naltrexone for heroin dependence treatment in St. Petersburg, Russia

Naltrexone may be more effective for treating opioid (heroin) dependence in Russia than in the U.S. because patients are mostly young and living with their parents, who can control medication compliance. In this pilot study we randomized 52 consenting patients who completed detoxification in St. Petersburg to a double blind, 6-month course of biweekly drug counseling and naltrexone, or counseling and placebo naltrexone. Significant differences in retention and relapse favoring naltrexone were seen beginning at 1 month and continuing throughout the study. At the end of 6 months, 12 of the 27 naltrexone patients (44.4%) remained in treatment and had not relapsed as compared to 4 of 25 placebo patients (16%; p<0.05). Since heroin dependence is the main way HIV is being spread in Russia, naltrexone is likely to improve treatment outcome and help reduce the spread of HIV if it can be made more widely available.     

Repetitive transcranial magnetic stimulation is effective following repeated courses in the treatment of major depressive disorder--a case report

Repetitive transcranial magnetic stimulation (rTMS) is a relatively new treatment modality for psychiatric patients. rTMS was demonstrated to be effective in the treatment of depression. However, longitudinal outcome studies have not yet been published. Relapse rates are higher in depressed patients and most of them do not respond to the same treatment with similar success. In this report we present a patient, who experienced relapse with the various conventional drug treatments, but responded well to rTMS at three different points in time.     

Pharmacotherapy of Opioid Addiction: “Putting a Real Face on a False Demon”

Methadone maintenance therapy (MMT), a pharmacological treatment for opioid use disorder for the past 50 years, continues to remain controversial. Despite consistent and overwhelming evidence confirming the effectiveness and safety of MMT, misconceptions and myths persist regarding its legitimacy as a treatment for opioid addiction. This often results in the underutilization and limited availability of this treatment modality. Despite successful outcomes, the controversial nature of MMT, and the stigma experienced by the patients on methadone, has been a particularly difficult obstacle to overcome. We present the history of MMT, review the evidence for its efficacy in the treatment of opioid dependence, and explore the origins of the stigma and misconceptions related to MMT.     

美沙酮维持治疗门诊患者HCV感染状况及HCV知识评估

目的:调查参加美沙酮维持治疗患者的HCV感染状况及其对HCV相关知识的了解情况。方法:对114名接受MMT治疗的患者进行HCV感染状况调查,并采用HCV相关知识调查问卷、酒精使用筛查问卷(AUDIT)对该人群的HCV相关知识和酒精使用状况进行评估。结果:MMT门诊患者中HCV感染率为57.0%,HCV知识评估平均得分为11.3±s2.1,酒精使用状况平均得分为3.2±s5.4。68.4%的患者对自身HCV感染状况不了解,其中59.2%患者为HCV阳性,15.3%的HCV阳性患者接受过HCV抗病毒治疗,18.4%的患者曾主动进行HCV相关咨询。结论:美沙酮维持治疗门诊患者HCV感染率高,但HCV相关知识缺乏,对自身感染情况缺乏了解。MMT门诊应将HCV相关知识的普及教育整合到日常工作中,对患者进行HCV相关教育。     

Unintended impacts of regulatory changes to British Columbia Methadone Maintenance Program on addiction and HIV-related outcomes: An interrupted time series analysis

BackgroundIn February 2014, several regulatory reforms were introduced to the methadone maintenance treatment (MMT) program in British Columbia, Canada, including a switch to a ten-times more concentrated methadone formulation and restrictions in pharmacy delivery services. We evaluated possible unintended effects of these changes on illicit drug use patterns and HIV treatment outcomes among HIV-positive opioid users.MethodsData was drawn from ACCESS, a prospective community-recruited cohort of HIV-positive people who use illicit drugs in Vancouver, Canada. Interrupted Time Series Analyses were used to evaluate impacts of the policy change on monthly rates of MMT enrolment, illicit heroin injection, antiretroviral therapy (ART) adherence, and HIV viral suppression among HIV-positive opioid users between November 2012 and May 2015.ResultsA total of 331 HIV-positive opioid users were included. The MMT policy change led to a significant immediate 11.5% increase in heroin injection, and 15.9% drop in optimal ART adherence. A gradual increase in the prevalence of MMT enrolment after the policy change was also documented (0.9% per month). No changes in viral suppression rates were observed.ConclusionWe observed immediate increases in illicit heroin injection and decreases in ART adherence in the wake of regulatory changes to the local MMT program. These findings underscore the need to consider potential unintended effects of altering health programmes for vulnerable populations, the need to develop appropriate mitigation strategies, as well as to involve all relevant stakeholders in the planning and implementations of new policies.     

Medication assisted treatment of drug abuse and dependence: global availability and utilization

Clinical trials and clinical studies, using patented drugs and drugs off patent, provide data that impact the best treatment practices for substance abuse and dependence. In the United States, medications have been approved for use in the treatment of both alcohol and opioid dependence. Medications are used in the detoxification from drug abuse and dependence in the symptomatic relief of withdrawal. For long term treatment or medical maintenance treatment, medications eliminate the physiological effects of drug use by blocking drug-receptor binding in the brain. Therefore, patented drugs showing interactions with neurotransmitters in the brain, are attractive candidates for treatment efficacy trials. An effective long term treatment paradigm for reducing drug dependence is the combinatorial use of medications that block the effects of drug use with behavior change counseling and psychotherapy. Medications used for the long term treatment of opioid dependence are methadone, buprenorphine, and naltrexone. Pharmacotherapies used in the treatment of alcohol dependence include acamprosate, antabuse and naltrexone. A reliable indicator for successful treatment of drug dependence is time in treatment. Patients remain in long term treatment when they perceive that their health care environment is supportive and non-stigmatizing and with a good patient-provider relationship where their needs are identified and met. Additional medications are needed for individual comprehensive substance abuse treatment plans, particularly for individuals who abuse stimulants. Patented drugs remain an important source of candidate pharmacotherapies comprising medication assistant treatment, part of a comprehensive treatment plan for drug dependence that addresses the medical, social, and psychological needs of the patient. Adapting this drug treatment paradigm globally requires identifying and testing new drug candidates while building and changing programs to patient centered treatment programs that promote access to care and treatment and integrate medical, psychological, and social services.     

Characteristics of methadone maintenance treatment patients prescribed opioid analgesics

ABSTRACT

Background: Opioid analgesic use and disorders have dramatically increased among the general American population and those receiving methadone maintenance treatment (MMT). Most research among MMT patients focuses on opioid analgesics misuse or disorders; few studies focus on MMT patients prescribed opioid analgesics. We describe demographic, clinical, and substance use characteristics of MMT patients prescribed opioid analgesics and compare them with MMT patients not prescribed opioid analgesics. Methods: We conducted a cross-sectional secondary data analysis using screening interviews from a parent study. From 2012 to 2015, we recruited adults from 3 MMT Bronx clinics. Questionnaire data included patterns of opioid analgesic use, substance use, comorbid illnesses, and demographic characteristics. Our main dependent variable was patients' report of currently taking prescribed opioid analgesics. To compare characteristics between MMT patients prescribed and not prescribed opioid analgesics, we conducted chi-square tests, t tests, and Mann-Whitney U tests. Results: Of 611 MMT patients, most reported chronic pain (62.0%), hepatitis C virus (HCV) infection (52.1%), and current use of illicit substances (64.2%). Of the 29.8% who reported currently taking prescribed opioid analgesics, most misused their opioid analgesics (57.5%). Patients prescribed (versus not prescribed) opioid analgesics were more likely to report human immunodeficiency virus (HIV) infection (adjusted odds ratio [aOR] = 1.6, 95% confidence interval [CI]: 1.1–2.3) and chronic pain (aOR = 7.6, 95% CI: 4.6–12.6). Conclusion: Among MMT patients primarily in 3 Bronx clinics, nearly one third reported taking prescribed opioid analgesics. Compared with patients not prescribed opioid analgesics, those prescribed opioid analgesics were more likely to report chronic pain and HIV infection. However, between these patients, there was no difference in illicit substance use. These findings highlight the complexity of addressing chronic pain in MMT patients.     

Heroin use and HIV risk-taking behaviour among women injecting drug users

This study compares drug use, injecting and sexual risk-taking behaviour among pregnant injecting drug users (IDUs) enrolled in methadone maintenance treatment (MMT), non-pregnant women IDUs enrolled in MMT and women IDUs not enrolled in treatment. There was no significant difference between pregnant IDUs enrolled in MMT and women IDUs not enrolled in treatment in terms of their injecting risk-taking behaviour. Both groups reported significantly higher levels of injecting risk-taking behaviour compared to (non-pregnant) women enrolled in MMT. Pregnant women enrolled in MMT reported a significantly lower methadone dose compared to non-pregnant women in MMT. There was a trend for pregnant women enrolled in MMT to report a higher level of heroin use compared to non-pregnant women in MMT. The lack of evidence for a difference in level of injecting risk-taking behaviour between pregnant IDUs enrolled in MMT and women IDUs not enrolled in treatment suggests the need for additional strategies among pregnant IDUs to reduce IDU and injecting risk-taking behaviour. Possible strategies include maintenance on higher doses of methadone and the application of relapse prevention strategies.     

A randomized trial of 6-month methadone maintenance with standard or minimal counseling versus 21-day methadone detoxification

BACKGROUND: Important questions remain regarding the necessary duration and intensity for methadone treatment to be effective. METHODS: As part of a clinical trial of tuberculosis chemoprophylaxis [Batki, S.L., Gruber, V.A., Bradley, J.M., Bradley, M., Delucchi, K., 2002. A controlled trial of methadone treatment combined with directly observed isoniazid for tuberculosis prevention in injection drug users. Drug Alcohol Depend. 66 283-293. doi:10.1016/S0376-8716(01)00208-3], patients with opioid dependence were recruited from an outpatient 21-day methadone detoxification program and were randomly assigned to one of three treatment conditions: (1) continuation in 21-day methadone detoxification; (2) transfer to 6-month methadone maintenance with only minimal counseling; or (3) transfer to 6-month methadone maintenance with standard twice monthly counseling and as-needed social work and psychiatric services. Both the 6-month maintenance treatments were followed by 1.5 months of detoxification. Urine drug tests and self-report measures were collected at baseline, months 1-6, and month 8.5. RESULTS: Compared to 21-day methadone detoxification, 6-month methadone maintenance with either minimal or standard counseling resulted in fewer opiate positive urine tests and days of self-reported heroin and alcohol use. There was no change in cocaine use or other outcome measures. The increased counseling available in the standard counseling condition did not appear to reduce heroin use further than the minimal counseling condition, in contrast to the effect found for more structured counseling in long-term methadone maintenance (McLellan et al., 1993). CONCLUSIONS: Six months of methadone maintenance, even with minimal counseling, reduces heroin and alcohol use more than 21-day methadone detoxification.