Illicit drug use and injection practices among drug users on methadone and buprenorphine maintenance treatment in France

Aims To evaluate the associations between methadone and high‐dose buprenorphine maintenance treatment and illicit drug use and injection among drug users in France. Design A cross‐sectional study. Data were gathered using a questionnaire administered containing closed‐ended questions. Setting Drug dependence clinics (DDC) and general practitioners’ (GPs) offices in three French cities. Participants Drug users undergoing maintenance treatment with methadone (n = 197) and buprenorphine (n = 142). Measurements Interviews covered the use of illicit drugs (heroin, cocaine or crack) and injection practices (illicit drugs and/or substitution drugs) during the last month, current treatment modalities, socio‐demographic and health characteristics. Bivariate analysis and multivariate logistic regressions were conducted. Findings Overall, 35.4% of respondents (34.5% in the methadone group, 36.6% in the buprenorphine group, P= 0.69) had used at least one illicit drug, 25.7% reported having injected drugs and 15.3% had injected the substitution drug. Injection was more common among buprenorphine‐maintained individuals (40.1%) than among users on methadone (15.2%) (P < 0.01). Multivariate analyses indicate that the type of substitution drug (buprenorphine versus methadone) was not associated with illicit drug use (OR = 1.1; 95% CI = 0.7–1.8). In the buprenorphine group, injection was related independently to social situation, as measured by housing (unstable versus stable housing, OR = 4.3; 95% CI = 1.6–11.5), but this was not the case in the methadone group. The risk of injection increased with buprenorphine dosage (high/low dosage OR = 6.2; 95% CI = 2.0–19.7), but this association was not observed in the methadone group. Conclusion Further studies comparing the benefits of these two types of treatment should be carried out, taking outcomes such as physical health, mental health and social functioning into consideration.     

Continued Use of Illicit Substance among Methadone Treatment Patients in Primary Health Care Clinics in East Coast Region of Malaysia

ABSTRACT

Studies investigating the continued use of illicit substances among patients in Methadone Maintenance Treatment (MMT) programs are limited. This study aimed to determine the association of methadone dose with illicit substance misuse among MMT patients in East Coast Region of Malaysia. Validated substance use pattern questionnaire was used to fulfill the study objectives. 55% (n = 130/237) of the respondents received a ≤ 50 mg methadone dose daily. Low methadone dose (≤50 mg/daily) was associated with opiate use in the last 30 days, while high methadone dose (>50 mg/daily) was associated with methamphetamine injection in the last 30 days (OR: 1.97; 1.01–3.82; p< .044). An optimum methadone maintenance dose is deemed appropriate to reduce use of illicit opiates, and necessary psychosocial intervention to reduce methamphetamine injection behavior is suggested.     

Risk factors for methadone outside treatment programs: implications for HIV treatment among injection drug users

BACKGROUND: Diversion of methadone outside treatment programs occurs, yet reasons for use of 'street methadone' are characterized poorly. Self-medication for withdrawal symptoms is one plausible hypothesis. Among HIV-infected drug users, some antiretroviral medications can reduce potency of methadone, yet any association between such effects and the use of supplemental methadone sources remains undetermined. OBJECTIVE: To estimate the frequency and risk factors for use of street methadone. METHODS: Injection drug users (IDUs) recruited through extensive community outreach in 1988-89 and 1994 were followed semi-annually with questionnaires about health history, use of licit and illicit drugs including methadone and HIV-related assays. Analyses were performed using generalized estimating equation logistic regression. RESULTS: Of 2811 IDUs enrolled and eligible for analysis, 493 people reported use of street methadone over 12 316 person-years of follow-up (4.0/100 person-years). In multivariate analyses, street methadone use was more common among women, whites, those 40-59 years old, those who reported withdrawal symptoms, past methadone program attendance (6-12 months before visit), recent heroin injection with or without cocaine (but not cocaine alone), smoking or sniffing heroin and reported trading sex. Street methadone was not associated with HIV infection or treatment. CONCLUSION: The results suggest that older IDUs still using heroin may be using street methadone to treat signs of withdrawal. The absence of a higher rate of street methadone use in HIV seropositive IDUs reveals that antiretroviral/methadone interactions are not a primary determinant of use outside of treatment settings.     

Risk Factors of Hepatitis C Virus Infection in Drug Users From Eleven Methadone Maintenance Treatment Clinics in Xi’an,China

Background:

Hepatitis C virus (HCV) infection rates in drug users vary among different regions of China. Drug users who are unaware of their HCV serostatus tend to engage in more risky behaviors.

Objectives:

This prospective study aimed to assess risk factors of HCV infection in drug users among 11 methadone maintenance treatment (MMT) clinics in Xi’an, China.

Patients and Methods:

Baseline characteristics and drug use information of patients were collected upon enrollment in the study and anti-HCV tests were performed within one month after the enrollment. Data on daily medication, monthly random urine morphine test results, illicit drug use and MMT retention time were recorded during a 5-year follow-up.

Results:

Of 10243 patients, 58.0% had positive results for anti-HCV. Injection drug use, longer duration of drug abuse, older age, female gender, unmarried status and unemployment were independent risk factors of HCV infection. Urine test positivity rate was lower (14.8% vs. 16.7%, χ² = 100.235, P < 0.05), but MMT retention rate was higher (log-rank χ² = 4.397, P < 0.05) in the anti-HCV positive group than anti-HCV negative one. However, multivariate regression revealed no significant association between anti-HCV serostatus and either MMT retention time or illicit drug use.

Conclusions:

The major risk factor of HCV infection was injection drug use. The patient’s awareness of his or her HCV status had a minor effect in reduction of illicit drug use and improvement in MMT retention. Therefore, adequate counseling is necessary for drug users in MMT clinics in Xi’an.     

Transitioning from methadone to buprenorphine maintenance in management of opioid use disorder during pregnancy

Background: Opioid use disorder during pregnancy is a growing health concern. Methadone maintenance is the treatment of choice but emerging data indicate buprenorphine is a viable alternative. Due to costs and limited accessibility of methadone, pregnant women may require transition from methadone to buprenorphine for maintenance treatment. Objectives: To assess safety and effectiveness of transitioning from methadone to buprenorphine when necessary during pregnancy. Methods: A standardized protocol using low buprenorphine doses to minimize emergent withdrawal symptoms under careful obstetric and psychiatric monitoring was implemented in 20 pregnant women. Outpatient maternal and neonatal outcomes were assessed. Results: Women maintained on an average methadone dose of 44 ± 4.77 (20–100) mg/day (mean±standard error mean (SEM); range) were successfully transitioned to 12.60 ± 0.8 (8–16) mg/day (mean±SEM; range) of buprenorphine. Within 4 weeks of transition, 15% had illicit drugs detected in urine drug screens. Ninety percent of women maintained outpatient follow-up until delivery. At delivery, 38.9% of mothers were exclusively adherent to buprenorphine (without use of illicit substances and/or other psychotropic medications); this resulted in significantly lower rates of neonatal abstinence syndrome (NAS) and shorter hospital stays. Discussion: Pregnant women transitioned from methadone to buprenorphine maintenance showed maternal and neonatal outcomes comparable to studies of women on buprenorphine throughout pregnancy. Infants born to buprenorphine-maintained women who abstained from illicit substances and other prescribed psychotropic medications experienced less severe NAS and shorter hospitalizations compared with women with illicit substance use and other psychotropic medications. These findings suggest women can safely be transitioned from methadone to buprenorphine during pregnancy.     

Treatment Entry among Individuals on a Waiting List for Methadone Maintenance

Background: Many methadone programs in the United States have waiting lists for care. Objectives: To examine specific predictors of treatment entry among individuals on a waiting list for methadone maintenance. Methods: Heroin users placed on a waiting list for methadone treatment (n = 120) were administered a urine screen for drug use and assessed with a battery of measures at study entry and at 4 month follow-up as part of a larger clinical trial. Logistic regression was used to examine hypothesized predictors of treatment entry. Outcomes for those failing to enter treatment were also examined. Results: Only 25 individuals (20.8%) entered treatment within four months of being placed on a waiting list. Intravenous drug users were more likely to enter treatment (p <.05) whereas cocaine users were less likely to do so (p <.01). Motivation did not predict treatment entry, and cocaine use did not moderate this relationship. There were some improvements in heroin use among those who did not enter treatment. Conclusions: Additional research is needed on the relationship between motivation and treatment entry. Programs may need to make special efforts to facilitate entry for treatment-seeking heroin users who also use cocaine. Scientific Significance: These findings have implications for improving access to methadone treatment.     

Rate of detoxification service use and its impact among a cohort of supervised injecting facility users

BACKGROUND: Vancouver, Canada recently opened a medically supervised injecting facility (SIF) where injection drug users (IDU) can inject pre-obtained illicit drugs. Critics suggest that the facility does not help IDU to reduce their drug use. METHODS: We conducted retrospective and prospective database linkages with residential detoxification facilities and used generalized estimating equation (GEE) methods to examine the rate of detoxification service use among SIF participants in the year before versus the year after the SIF opened. In secondary analyses, we used Cox regression to examine if having been enrolled in detoxification was associated with enrolling in methadone or other forms of addiction treatment. We also evaluated the impact of detoxification use on the frequency of SIF use. RESULTS: Among 1031 IDU, there was a statistically significant increase in the uptake of detoxification services the year after the SIF opened. [odds ratio: 1.32 (95% CI, 1.11-1.58); P = 0.002]. In turn, detoxification was associated independently with elevated rates of methadone initiation [relative hazard = 1.56 (95% CI, 1.04-2.34); P = 0.031] and elevated initiation of other addiction treatment [relative hazard = 3.73 (95% CI, 2.57-5.39); P < 0.001]. Use of the SIF declined when the rate of SIF use in the month before enrolment into detoxification was compared to the rate of SIF use in the month after discharge (24 visits versus 19 visits; P = 0.002). CONCLUSIONS: The SIF's opening was associated independently with a 30% increase in detoxification service use, and this behaviour was associated with increased rates of long-term addiction treatment initiation and reduced injecting at the SIF.     

Drug use in rural China: a preliminary investigation in Hunan Province

Aims To compare characteristics and illicit drug abuse patterns among drug abusers in rural and urban areas of Hunan Province, China. Measurements and design Data collected by public security bureau on newly registered drug abusers between 2005 and 2008 in five urban and five rural areas (n = 1639) were extracted anonymously and analyzed. Setting and participants All newly registered drug users in urban (n = 812) and rural (n = 827) areas of Hunan Province were included. Findings Drug users from the rural areas were younger [31 (6.6) versus 34 (8.0) years, P < 0.001], with a higher proportion of males (86% versus 82%, P < 0.05) or married (34% versus 27%, P < 0.01). Rural drug users reported an earlier onset of drug use [27 (5.9) versus 30 (7.9) years old, P < 0.001], were more likely to report heroin as their primary drug of abuse (53% versus 47%, P < 0.001) and had a lower prevalence of criminal activities (19% versus 31%, P < 0.001). Rural drug users were less likely to report needle sharing (1.8% versus 4.3%, P < 0.01), less likely to report being human immunodeficiency virus positive (0.8% versus 2.6%, P < 0.01) and less likely to report prior drug treatment participation (2.8% versus 6.8%, P < 0.001). Conclusions Drug abuse is a substantial problem in both urban and rural areas in China. The very low proportion of newly registered drug users reporting any prior drug abuse treatment points to the importance of expanding substance abuse treatments, especially in rural areas where treatment penetration is even lower than in urban areas.     

Does retention matter? Treatment duration and improvement in drug use

Aim This study examines whether there is a minimum threshold, continuous or non‐linear relationship between the duration of addiction treatment and improvements in drug use. Design Longitudinal cohort study of 62 drug treatment units and 4005 clients in the US National Treatment Improvement Evaluation Study, fielded from 1993 to 1995. Subjects Baseline and 1‐year follow‐up interviews with clients in methadone maintenance, out‐patient non‐methadone, short‐term residential and long‐term residential treatment programs. Measures Improvement in drug use is the difference between the client‐reported peak frequency of drug use (in days per month) in the year prior to the baseline interview minus the peak frequency in the year after discharge. Primary drug, and overall use of the major illicit drugs (heroin, cocaine powder, crack cocaine, and marijuana) are considered separately. Results Controlling for multiple factors, treatment duration had a positive linear relationship with primary drug use improvement among methadone clients and an inverted‐U‐shaped relationship with overall and primary drug use improvements among out‐patient and long‐term residential clients. Improvement with longer duration is greatest for long‐term residential clients. Conclusions Contrary to previous arguments for a sharp retention threshold for onset of treatment effects, we find smooth curves relating treatment duration to drug use improvements in methadone maintenance, out‐patient non‐methadone and long‐term residential modalities. These relationships are effectively linear for durations typically observed in single treatment episodes, but unusually long retention in out‐patient non‐methadone and long‐term residential units appear steadily less predictive of improvement.     

Anxiety and Mood Disorders and Cannabis Use

Background: Cannabis use has been linked to anxiety and mood disorders (AMD) in clinical cases, but little research on this relationship has been reported at the epidemiological level. Objectives: We examined the relationship between self-reported frequency of cannabis use and risk for AMD in the general Ontario adult population. Methods: Data were based on the CAMH Monitor survey of Ontario adults from 2001 to 2006 (n = 14,531). AMD was assessed with the 12-item version of the General Health Questionnaire (GHQ12). Frequency of cannabis use within the past year was grouped into five categories: No use (abstainer), less than once a month but at least once a year, less than once a week but at least once a month, less than daily but at least once a week, almost every day to more than once a day. Logistic regression analysis of AMD and cannabis use was implemented while controlling for demographics and alcohol problems. Results: AMD was most common among heavy cannabis users (used almost every day or more) (18.1%) and lowest for abstainers (8.7%). Compared to abstainers, the risk of AMD was significantly greater for infrequent cannabis users (OR = 1.43) and heavy cannabis users (OR = 2.04) but not for those in between. Conclusion: These data provide epidemiological evidence for a link between both light and heavy cannabis use and AMD. Scientific Significance: Recognizing the comorbidity of heavy cannabis use and AMD should facilitate improved treatment efforts. Our results also suggest the possibility that, for some individuals, AMD may occur at relatively low levels of cannabis use.     

Prevalence of illicit drug use in young Australian women, patterns of use and associated risk factors

Objectives To estimate the prevalence of illicit drug use in young Australian women, determine their patterns of drug use and identify associated risk factors. Methods Data were collected in 2000 as part of the second survey of the youngest cohort in the Australian Longitudinal Study on Women's Health (n = 9512). Results Among women aged 22–27 years, 58% reported having used an illicit drug at some time with most (57%) having used cannabis. Amphetamines (16%), ecstasy/designer drugs (15%) and LSD (14%) were the next three most commonly used drugs. Four different patterns of drug use were identified: past users of cannabis only (39%); current users of cannabis only (17%); past multiple drug users (13%) and current multiple drug users (31%). Living in a de‐facto relationship or never being married, living with non‐family members, a history of physical abuse, sexual intercourse, smoking and binge drinking were associated significantly with exclusive use of cannabis and with use of multiple drugs compared to never using illicit drugs. Living with a partner, experience of sexual or emotional abuse, pregnancy, diagnosis of depression and taking sleeping medication were associated significantly with being a multiple drug user, but not for exclusive cannabis use. Multiple drug users had, on average, used cannabis 2–3 years before using any other drug. Conclusions Given the strong association found between smoking, heavy drinking and drug use of varied patterns, public health initiatives targeted at preventing young women from smoking and drinking should additionally target illicit drug use.     

Infrequent illicit methadone use among stimulant-using patients in methadone maintenance treatment programs: a national drug abuse treatment clinical trials network study

We sought to determine the prevalence, patterns, and correlates of past-month illicit methadone use and history of regular illicit use among stimulant-using methadone maintenance treatment patients. We obtained self-reported information on illicit methadone use from 383 participants recruited from six community-based methadone maintenance programs. Overall, 1.6% of participants reported illicit use in the past month, and 4.7% reported a history of regular use. Younger age and history of outpatient psychological treatment were associated with increased odds of past-month illicit use. Illicit methadone use among patients in maintenance programs is infrequent; however, a number of factors may increase risk of illicit use.     

Non-prescribed drug use during methadone treatment by clinic- and community-based patients

We investigated the efficacy of methadone maintenance treatment in clinic-based (n= 10) and community-based (n= 10) patients by studying the relationships between dose, plasma concentrations of methadone and non-prescribed drug-use using logistic regression. We found that clinic-based patients had significantly reduced odds of having a urine sample test positive for illicit drugs when compared to community-based patients (OR = 0.20; 95% confidence interval 0.10–0.38: p < 0.001). There was no relationship between either methadone dose or plasma methadone concentration and testing positive for non-prescribed drugs (including cocaine, cannabis, amphetamine, ecstasy, benzodiazepines). We looked specifically at the misuse of opiate drugs. Location was again important and clinic-based patients had significantly reduced odds of having a urine sample test positive for opiate drugs (OR= 0.36, 95% confidence internal 0.13–0.71: p～0.004). Opiate drug use in our patients was also significantly related to plasma methadone concentration, increasing noticeably when the drug concentration < 0.48 nmol/L (p～0.04). We found no relationship between methadone dose and odds of having a positive urine drug test in either clinic- or community-based patients.     

Reducing bias in telephone survey estimates of the prevalence of drug use: a randomized trial of telephone audio-CASI

AIM: To assess the impact of telephone audio computer-assisted self-interviewing (T-ACASI) on reporting of alcohol use, alcohol problems and illicit drug use in telephone surveys of the general population. Prior research suggests that illicit drug use is underreported in traditional, interviewer-administered, telephone surveys. DESIGN: Randomized experiment embedded in telephone survey of probability samples of populations of USA and Baltimore, MD. Survey respondents were randomly assigned to be interviewed either by human telephone interviewers or by T-ACASI after household screening, recruitment, and informed consent procedures were completed. SETTING: Respondents were interviewed by telephone in their homes. PARTICIPANTS: Probability samples of 1543 English-speaking adults ages 18-45 residing in telephone-accessible households in USA and 744 similarly defined adults residing in Baltimore, MD, USA. MEASUREMENTS: Nine questions on alcohol, marijuana, cocaine, and injection drug use adapted from 1994 NHSDA and four CAGE questions on alcohol problems. Crude odds ratios and odds ratios controlling for demographic factors calculated to test for differences between responses obtained by T-ACASI and human interviewers. FINDINGS: T-ACASI had mixed effects on reporting of alcohol use, but it did increase reporting of one of four CAGE alcohol problems: feeling guilty about drinking (23.0% in T-ACASI vs. 17.6% in T-IAQ, OR = 1.4, P < 0.01). T-ACASI also obtained significantly more frequent reporting of marijuana, cocaine, and injection drug use. The impact of T-ACASI was most pronounced for reporting of recent use of 'harder' drugs. Thus T-ACASI respondents were more likely to report marijuana use in the past month (10.0% vs. 5.7%, crude OR = 1.9, P < 0.001), cocaine use in the past month (2.1% vs. 0.7%, crude 3.2, P < 0.001) and injection drug use in the past five years (1.6% vs. 0.3%, crude OR = 4.8, P < 0.01). CONCLUSIONS: Telephone survey respondents were more likely to report illicit drug use and one alcohol problem when interviewed by T-ACASI rather than by human telephone interviews.     

Differences in Self-Reported Discrimination by Primary Type of Drug Used among New York City Drug Users

Background: Illicit drug users experience various forms of discrimination which may vary by type of drug used, as there are different levels of stigma associated with different types of drugs. Objectives: This study investigated self-report of perceived discrimination by primary type of drug used. Methods: This analysis used data from “Social Ties Associated with Risk of Transition into Injection Drug Use” (START), a cross-sectional study of recently initiated injection drug users (IDUs) and prospective study of heroin/crack/cocaine-using non-IDUs (n = 652). Using log binomial regression, the relationship between primary drug used (i.e., single drug used most often) with discrimination due to drug use was examined. Results: Heroin users were significantly more likely (Prevalence ratio (PR): 1.52 (95% Confidence interval (CI): 1.15?2.07)) to report discrimination due to drug use compared to cocaine users. Conclusion and Scientific Significance: More research is needed to understand the mechanism through which discrimination affects heroin users, and its potential relation with other discrimination-related outcomes, namely depression and drug treatment.