What to do about “much ado” about drug courts?

A drug court is a mandated judicial supervision and addiction treatment alternative to incarceration for drug offenders. Enthusiasm for drug courts is high in the USA where the number of programs has expanded exponentially over the past decade in an attempt to reduce high incarceration rates for convicted drug offenders. Despite the popularity of drug courts, there is no evidence that drug court programs produce outcomes that are superior or even equal to outcomes achieved by voluntary treatment programs. Canadian drug policy should promote expansion of proven effective voluntary treatment for illicit drug misusers before endorsing unproven mandatory treatment programs, e.g. drug courts, that rely on legal coercion.     

Implementation of a Medication for Addiction Treatment (MAT) and Linkage Program by Leveraging Community Partnerships and Medical Toxicology Expertise

IntroductionImplementing a hospital medication for addiction treatment (MAT) and a linkage program can improve care for patients with substance use disorder (SUD); however, lack of hospital funding and brick and mortar SUD resources are potential barriers to feasibility.MethodsThis study assesses the feasibility of implementation of a SUD linkage program. Components of the program include a county-funded hospital opioid support team (HOST), a hospital-employed addiction recovery specialist (ARS), and a medical toxicology MAT induction service and maintenance program. Data for linkage by HOST, ARS, and MAT program were tracked from July 2018 to December 2019.ResultsFrom July 2018 through December 2019, 1834 patients were linked to treatment: 1536 by HOST and 298 by the ARS. The most common disposition categories for patients linked by HOST were 16.73% to medically monitored detoxification, 9.38% to intensive outpatient, and 8.59% to short-term residential treatment. Among patients linked by the ARS, 65.66% were linked to outpatient treatment and 9.43% were linked directly to inpatient treatment. A total of 223 patients managed by the ARS were started on MAT by medical toxicology and linked to outpatient MAT clinic: 72.68% on buprenorphine/naloxone, 24.59% on naltrexone, 1.09% buprenorphine, and 0.55% acamprosate.ConclusionImplementing a MAT and linkage program in the ED and hospital setting was feasible. Leveraging medical toxicology expertise as well as community and funding partnerships was crucial to successful implementation.     

Perceived Relapse Risk and Desire for Medication Assisted Treatment among Persons Seeking Inpatient Opiate Detoxification

Most patients with opioid addiction do not receive medication at the time of discharge from brief inpatient detoxification programs despite the high risk of relapse and the availability of three FDA-approved medications. We surveyed 164 inpatient opioid detoxification patients to assess desire for pharmacotherapy following detoxification program discharge. Participants were predominantly male (71.3%) and 80% had detoxed in the past. Reporting on their most recent previous inpatient detoxification, 27% had relapsed the day they were discharged, 65% within a month of discharge, and 90% within a year of discharge. 63% reported they wanted medication-assisted treatment (MAT) after discharge from the current admission. The odds of desiring a treatment medication increased by a factor of 1.02 for every 1% increase in perceived relapse risk (p < .01). These data suggest patient preference discussions including relapse risk could increase post-detox abstinence. Source of funding: K24 DA00512     

Intent to Refer: Exploring Bias Toward Specific Medication-Assisted Treatments by Community Corrections Employees

Background: As opioid use increases in the United States, especially in the correctional population, the most effective treatment approaches need to be utilized. Research has shown that medication-assisted treatment (MAT) provides better outcomes than traditional treatment approaches alone, but is underutilized among correctional-supervised populations. Objective: This article looks at how previously identified barriers to implementing MAT can create potential biases regarding the intent to refer individuals to either buprenorphine or methadone among treatment and correctional staff within community corrections. The varying advantages of each medication are discussed to highlight the importance of individualized treatment planning. Methods: Data were collected from 959 treatment specialists and community-corrections officers between 2010 and 2013. The participants were employed by one of 20 community corrections agencies that were selected and randomized within a cluster design. The data were part of a larger study that tested how the experimental condition of organizational linkages impacted the use of MAT in the criminal justice system. In order to analyze the data, multinomial logistic regression was used. Results: Results showed that some community corrections employees were likely to refer clients to use methadone, but not buprenorphine (or vice versa) which was influenced by work setting, level of education, training, and negative perceptions of MAT as a substitute addiction. However, these biases could be minimized by proper training. Conclusion: These findings suggest that proper training should be mandatory for these employees and include information about various MATs while also addressing the negative perception that MAT is a substitute addiction.     

Injectable and implantable sustained release naltrexone in the treatment of opioid addiction

Sustained release technologies for administering the opioid antagonist naltrexone (SRX) have the potential to assist opioid-addicted patients in their efforts to maintain abstinence from heroin and other opioid agonists. Recently, reliable SRX formulations in intramuscular or implantable polymers that release naltrexone for 1–7 months have become available for clinical use and research. This qualitative review of the literature provides an overview of the technologies currently available for SRX and their effectiveness in reducing opioid use and other relevant outcomes. The majority of studies indicate that SRX is effective in reducing heroin use, and the most frequently studied SRX formulations have acceptable adverse events profiles. Registry data indicate a protective effect of SRX on mortality and morbidity. In some studies, SRX also seems to affect other outcomes, such as concomitant substance use, vocational training attendance, needle use, and risk behaviour for blood-borne diseases such as hepatitis or human immunodeficiency virus. There is a general need for more controlled studies, in particular to compare SRX with agonist maintenance treatment, to study combinations of SRX with behavioural interventions, and to study at-risk groups such as prison inmates or opioid-addicted pregnant patients. The literature suggests that sustained release naltrexone is a feasible, safe and effective option for assisting abstinence efforts in opioid addiction.     

“You are not clean until you're not on anything”: Perceptions of medication-assisted treatment in rural Appalachia

BackgroundMedication-assisted treatment (MAT) is an evidence-based strategy to treat opioid use disorder (OUD). However, MAT-related stigma reduces MAT uptake, which is particularly low in rural areas. To date, perceptions and attitudes towards MAT in rural settings have not been described.ObjectiveThis qualitative study aims to characterize perceptions and attitudes towards MAT and the environmental factors contributing to these views in Appalachian Ohio.MethodsFrom February to July 2018, semi-structured interviews were conducted with 34 stakeholders (12 healthcare professionals, 12 substance use treatment providers, 7 law enforcement agents and judicial officials, and 3 members of relevant organizations) in three rural counties in Appalachian Ohio. Interviews were transcribed, coded, and analyzed to characterize the risk environment and participants’ perceptions and attitudes towards MAT.ResultsParticipants expressed or described pervasive MAT-related stigma in the region. Participants consistently described three elements of the environment affecting stigma: (1) a “conservative” culture in which abstinence is necessary to be in recovery successfully, (2) fear of medication diversion and abuse, and (3) drug court policies that keep MAT out of the criminal justice system.ConclusionMAT-related stigma will need to be addressed to tackle the opioid epidemic through evidence-based treatment effectively.     

Clinical experiences with 959 opioid-dependent patients treated with levo-alpha-acetylmethadol (LAAM)

Levo-alpha-acetylmethadol (LAAM) is an orphan drug that will soon be generally available to treatment facilities. We have recently treated 959 opioid addicts with LAAM for periods up to 36 consecutive months. Three times per week dosing of LAAM proved to be a safe and effective treatment agent for the majority of subjects. During LAAM induction there is a delay in opioid activity as LAAM forms its long-acting metabolites, therefore, symptomatic withdrawal medication must usually be administered during the first 96 hours of treatment to adequately suppress opioid withdrawal symptoms and prevent self-administration of drugs by the patient. No long-term hepatic toxicity or tumor formation could be demonstrated by liver function studies and liver-spleen imaging in a subgroup of patients. Some opioid addicts report that they prefer LAAM over methadone, but the reverse was reported by about 40% of our patients which suggests that both drugs are needed for adequate maintenance treatment of the opioid-addicted population.     

Future directions for medication assisted treatment for opioid use disorder with American Indian/Alaska Natives

The U.S. is experiencing an alarming opioid epidemic, and although American Indians and Alaska Natives (AI/ANs) are especially hard hit, there is a paucity of opioid-related treatment research with these communities. AI/ANs are second only to Whites in the U.S. for overdose mortality. Thus, the National Institute on Drug Abuse convened a meeting of key stakeholders to elicit feedback on the acceptability and uptake of medication assisted treatment (MAT) for opioid use disorders (OUDs) among AI/ANs. Five themes from this one-day meeting emerged: 1) the mismatch between Western secular and reductionistic medicine and the AI/AN holistic healing tradition; 2) the need to integrate MAT into AI/AN traditional healing; 3) the conflict between standardized MAT delivery and the traditional AI/AN desire for healing to include being medicine free; 4) systemic barriers; and 5) the need to improve research with AI/ANs using culturally relevant methods. Discussion is organized around key implementation strategies informed by these themes and necessary for the successful adoption of MAT in AI/AN communities: 1) type of medication; 2) educational interventions; 3) coordination of care; and 4) adjunctive psychosocial counseling. Using a community-based participatory research approach is consistent with a “two eyed seeing” approach that integrates Western and Indigenous worldviews. Such an approach is needed to develop impactful research in collaboration with AI/AN communities to address OUD health disparities.     

Mobile opioid agonist treatment and public funding expands treatment for disenfranchised opioid-dependent individuals

The New Jersey Medication Assisted Treatment Initiative (NJ-MATI) sought to reduce barriers to treatment by providing free, opioid agonist treatment (OAT, methadone or buprenorphine) via mobile medication units (MMUs). To evaluate barriers to OAT, logistic regression was used to compare opioid dependent patients enrolled in NJ-MATI to those entering treatment at fixed-site methadone clinics or non-medication assisted treatment (non-MAT). Client demographic and clinical data were taken from an administrative database for licensed treatment providers. The MMUs enrolled a greater proportion of African-American, homeless, and uninsured individuals than the fixed-site methadone clinics. Compared to non-MAT and traditional methadone clients, NJ-MATI patients were more likely to be injection drug users and daily users but less likely to have a recent history of treatment. These observations suggest that the patient-centered policies associated with NJ-MATI increased treatment participation by high severity, socially disenfranchised patients who were not likely to receive OAT.     

Addiction: the clinical interface

This review gives an overview of what we see as the key issues in the human pharmacology of drugs of addiction. We review evidence of efficacy and mechanisms by which treatments act and point out areas where further work is needed. The role of agonist, partial agonist and antagonist treatments for opioid addiction is detailed and current issues relating to the mechanisms of actions at the receptor level and how to improve on compliance are discussed. The role of the brain dopamine and GABA-A systems in drug dependence is considered in relation to the growing pharmacology of these receptor systems, and the current status of novel preclinical targets reviewed. In addition, the different roles of dynamic and kinetic factors in both addiction and its treatment are discussed in relation to the underlying neuropharmacology of the disorders as defined from human and preclinical studies. Finally, some pointers to future research and especially to drug development by pharma are elaborated.     

Drug treatment courts,British style: the drug treatment court movement in Britain

There has been an uneven pattern of development of drug treatment courts throughout Britain. The Republic of Ireland has a drug treatment court and Scotland will have one by the end of 2001, but there are no drug treatment courts in England and Wales, or Northern Ireland, although in the latter there is a growing interest. It is suggested the Drug Treatment and Testing Order (DTTO) in England and Wales has acted as an impediment as this is a very weak version of drug treatment court and was proposed by the Prime Minister when Shadow Home Secretary. Drug treatment courts in Eire and Scotland have adapted their program to fit local conditions, although neither have opted for a fully fledged drug user treatment court on the Miami model.     

DRUG TREATMENT COURTS,BRITISH STYLE: THE DRUG TREATMENT COURT MOVEMENT IN BRITAIN*

There has been an uneven pattern of development of drug treatment courts throughout Britain. The Republic of Ireland has a drug treatment court and Scotland will have one by the end of 2001, but there are no drug treatment courts in England and Wales, or Northern Ireland, although in the latter there is a growing interest. It is suggested the Drug Treatment and Testing Order (DTTO) in England and Wales has acted as an impediment as this is a very weak version of drug treatment court and was proposed by the Prime Minister when Shadow Home Secretary. Drug treatment courts in Eire and Scotland have adapted their program to fit local conditions, although neither have opted for a fully fledged drug user treatment court on the Miami model.     

Provider satisfaction with office-based treatment of opioid dependence: a systematic review.

PURPOSE: New federal regulations allow for office-based treatment of opioid dependent patients with opioid agonist medication (e.g., buprenorphine). We sought to evaluate the literature on office-based physicians' acceptance of this practice. METHODS: We searched the MEDLINE database for original research examining office-based providers' acceptance or satisfaction with office-based treatment. Articles included in the analysis met the following criteria: (1) discussed the treatment of patients with substance abuse disorders, (2) focused on the treatment of opioid dependent patients, (3) discussed treatment with opioid agonist therapy, (4) discussed treatment by office-based physicians, (5) presented original research, and (6) provided data examining physician acceptance or satisfaction. RESULTS: Eight studies met the criteria. Their heterogeneity precluded aggregate analysis. Four of 8 studies revealed that providers had a positive perception concerning the efficacy of opioid agonist treatment, 4/8 indicated that providers believed that opioid dependent patients were more complex than others in their practices, and 3/8 studies indicated the need for additional support services. CONCLUSIONS: There are few studies of provider satisfaction with office-based treatment of opioid dependence. This literature reveals overall provider acceptance of this practice but highlights the need for support services. Further research, designed to identify the barriers to provider satisfaction with office-based opioid agonist therapy, is needed to ensure that these barriers do not limit expansion of this practice.     

Practical considerations for the clinical use of buprenorphine

Buprenorphine is a new and attractive medication option for many opioid-addicted adults and their physicians. Before initiating buprenorphine treatment, providers must be aware of such critical factors as how the medication works, its efficacy and safety profile, how it is used in opioid withdrawal as well as maintenance treatment, and how patients can best be selected, educated about buprenorphine, and monitored throughout treatment. This article reviews these important issues as well as requirements for physician and staff training and needs for additional research on this unique medication.     

Availability of Drugs and Psychological Proneness in Opioid Addiction

The role of drug availability and psychological proneness in opioid addiction was examined using longitudinal data from the Drug Abuse Reporting Program (DARP). The sample included 424 addicts who were followed up and interviewed approximately 12 years after admission to treatment in the DARP, and for whom admission, during-treatment, and 6-year follow-up data were also available. Drug availability and prone-ness were both found to be important for drug use at any given time- from initial stages of addiction as well as in Year 12 of the follow-up- but proneness was rated as relatively more important for opioid use in the later stages of the addiction career. Proneness measures contributed more to the prediction of long-term drug use outcomes.     

抗阿片成瘾药物研究历史与现状

阿片成瘾是一种慢性复发性脑疾病,临床症状包括躯体依赖、稽延症状、精神依赖和复吸, 治疗的关键是防复吸。防复吸药物的研究包括以阿片受体和非阿片受体为靶标的药物。代表性药物分别为阿片受体激动剂美沙酮和受体阻断剂纳屈酮,新型阿片受体配体噻吩诺啡能够完全阻断吗啡等阿片类药物引起的躯体和精神依赖,防止阿片复吸。研究表明,参与调节阿片精神依赖和复吸的非阿片受体作用系统包括多巴胺受体、兴奋性氨基酸受体、γ-氨基丁酸受体、乙酰胆碱受体、5-HT受体、CB1受体和神经营养因子受体等。多巴胺D3受体阻断剂Y-QA14自身无致成瘾性,同时具有抗可卡因和海洛因成瘾及防复吸的作用。咪唑啉Ⅰ型受体激动剂胍丁胺具有抗阿片躯体和精神依赖、缓解稽延症状和防复吸的作用,机制与激活咪唑啉Ⅰ型受体后减轻阿片受体、多巴胺系统和谷氨酸系统的代偿性适应用关。本文将就阿片、阿片成瘾生物学基础、防阿片复吸药物研发展、作用机制、历史、现状和发展趋势加以综述。     

INTRODUCTION: PROGRESS AND ISSUES IN DRUG TREATMENT COURTS

The first drug treatment court began in Miami, Florida in 1989, in direct response to the backlog of court cases for drug possession and trafficking. By mid-2001, there were 700 operational drug treatment courts and 400 more in the planning stages in the United States. In addition to providing an overview of the growth and development of drug treatment courts in the United States, this special issue examines their development in Australia, Canada, and the United Kingdom. The primary focus is the evaluation research conducted to date, which identifies some of the critical unresolved issues facing drug treatment courts.