The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Substance Use and Related Disorders. Part 2: Opioid dependence

Abstract

Objectives. To develop evidence-based practice guidelines for the pharmacological treatment of opioid abuse and dependence. Methods. An international task force of the World Federation of Societies of Biological Psychiatry (WFSBP) developed these practice guidelines after a systematic review of the available evidence pertaining to the treatment of opioid dependence. On the basis of the evidence, the Task Force reached a consensus on practice recommendations, which are intended to be clinically and scientifically meaningful for physicians who treat adults with opioid dependence. The data used to develop these guidelines were extracted primarily from national treatment guidelines for opioid use disorders, as well as from meta-analyses, reviews, and publications of randomized clinical trials on the efficacy of pharmacological and other biological treatments for these disorders. Publications were identified by searching the MEDLINE database and the Cochrane Library. The literature was evaluated with respect to the strength of evidence for efficacy, which was categorized into one of six levels (A–F). Results. There is an excellent evidence base supporting the efficacy of methadone and buprenorphine or the combination of buprenorphine and naloxone for the treatment of opioid withdrawal, with clonidine and lofexidine as secondary or adjunctive medications. Opioid maintenance with methadone and buprenorphine is the best-studied and most effective treatment for opioid dependence, with heroin and naltrexone as second-line medications. Conclusions. There is enough high quality data to formulate evidence-based guidelines for the treatment of opioid abuse and dependence. This task force report provides evidence for the efficacy of a number of medications to treat opioid abuse and dependence, particularly the opioid agonists methadone or buprenorphine. These medications have great relevance for clinical practice.     

Locations of facilities with special programs for older substance abuse clients in the US

BACKGROUND: Given the growth of our aging population, developing strategies for managing late-life alcoholism is increasingly important. OBJECTIVE: We compared substance abuse treatment facilities with and without services designed for older adults and explored the location of these services relative to the regional distribution of older adults across the United States. METHODS: A public use dataset from a national survey of facilities offering substance abuse treatment was used to address this issue. This survey included all identified substance abuse/dependence treatment facilities in the US and surveyed the facilities' treatment services, services for special groups, number of clients admitted, type of ownership (e.g. public, private for profit), and whether or not the facility was associated with a hospital, as well as questions about licensure and income sources. RESULTS: Of the 13 749 responding facilities, relatively few programs (17.7%) were specifically designed for older adults (i.e. over age 65). Facilities with such programs tended to be associated with hospitals, particularly those with a psychiatric inpatient service. Importantly, the number of facilities with special programs for older adults did not correlate with size of the older population in each state. CONCLUSION: Despite an increasing need for older adult substance abuse services, there are relatively few programs available designed for this age group. The setting where patients with substance abuse are identified (e.g. in a hospital) may partially explain the pattern of locations of age-specific programs.     

Psychiatric consultation to a state board of medical examiners

This article describes the evolution of psychiatric consultation to the Oregon Board of Medical Examiners. The board is charged with the licensing and regulation of physicians in the state of Oregon in order to protect the public and uphold the standards of the medical profession. Psychiatric consultation has focused on the board's investigations of physicians with mental illness and/or substance abuse and physicians who inappropriately prescribe psychoactive drugs or sexually abuse patients. Each of these physician groups is described, and remedial programs for each group are discussed. The authors conclude that psychiatric consultation to medical boards is a feasible and productive activity that can make a positive contribution to the lives of a large number of physicians and patients.     

James Parkinson. On child abuse and other things

James Parkinson, a general physician, was interested in all facets of medical care, and wrote two books for the lay public that contained comments on diverse things. He may have been one of the first physicians to publicly describe child abuse. Some of his advice to the public was of a neurologic nature, and included directions on the diagnosis and treatment of pseudoseizures, epilepsy, drowning, and stroke.     

Can We Really Prevent Suicide?

Every year, suicide is among the top 20 leading causes of death globally for all ages. Unfortunately, suicide is difficult to prevent, in large part because the prevalence of risk factors is high among the general population. In this review, clinical and psychological risk factors are examined and methods for suicide prevention are discussed. Prevention strategies found to be effective in suicide prevention include means restriction, responsible media coverage, and general public education, as well identification methods such as screening, gatekeeper training, and primary care physician education. Although the treatment for preventing suicide is difficult, follow-up that includes pharmacotherapy, psychotherapy, or both may be useful. However, prevention methods cannot be restricted to the individual. Community, social, and policy interventions will also be essential.     

Treatment of opioid-dependent adolescents and young adults with buprenorphine

Rising rates of opioid use among teenagers and young adults are a public health concern. Despite short durations of opioid use compared with those of adults, youth with opioid dependence have a host of co-occurring conditions, including polysubstance abuse, psychiatric disorders, hepatitis C infection, HIV risk, and high-risk sexual and criminal behaviors. Opioid-dependent youth typically are offered outpatient/residential treatment with brief detoxification, but one study showed that heroin users fare worse following residential treatment. Although abundant research supports the use of medication-assisted treatment for opioid-dependent adults, research is only recently emerging for youth. Buprenorphine, a partial opioid agonist, was proven safe and effective in improving abstinence from opioids in two controlled clinical trials. More research is needed to determine several clinically relevant areas: appropriate duration of agonist treatment, ways to enhance medication adherence, the value of integrated treatments for co-occurring conditions, and the role of opioid antagonists in opioid-dependent youth.     

Adolescent chemical use and dependence: current issues in epidemiology, treatment and prevention

This review provides a pragmatic and clinical orientation to current issues in adolescent chemical dependence in addition to exploring legitimate and relevant unanswered questions about chemical dependence. The lack of research on adolescent chemical dependence is addressed in light of the updated epidemiology. Patterns of use, abuse and dependence among adolescents are reviewed. The article examines treatment issues as well as prevention strategies among children and adolescents. Future clinically oriented research directions are suggested to promote further investigation into these areas.     

Past anabolic-androgenic steroid use among men admitted for substance abuse treatment: an underrecognized problem?

BACKGROUND: Recent reports suggest that anabolic-androgenic steroids (AAS) may cause mood disorders or dependence syndromes and may help to introduce some individuals to opioid abuse. At present, however, little is known about prior AAS use among men entering inpatient substance abuse treatment. METHOD: We assessed lifetime AAS use in 223 male substance abusers admitted to a substance abuse treatment unit primarily for treatment of alcohol, cocaine, and opioid dependence. Subjects reporting definite or possible AAS use were then asked to participate in a detailed semistructured interview that covered demographics, drug use history, and symptoms experienced during AAS use and withdrawal, and whether AAS use had helped introduce the subject to other classes of drugs. RESULTS: Twenty-nine men (13%) reported prior AAS use, but this history was documented on physicians' admission evaluations in only 4 cases. Among 88 men listing opioids as their drug of choice, 22 (25%) acknowledged AAS use, versus only 7 (5%) of the other 135 men (p <.001). Twenty-four (83%) of the 29 AAS users were interviewed in detail. Seven (29%) of the men interviewed, all with opioid dependence, reported that they first learned about opioids from friends at the gym and subsequently first obtained opioids from the same person who had sold them AAS. Eighteen (75%) of the men interviewed reported that AAS were the first drugs that they had ever self-administered by injection, 4 (17%) reported severe aggressiveness or violence during AAS use, 1 (4%) attempted suicide during AAS withdrawal, and 5 (21%) described a history of AAS dependence. CONCLUSION: Prior AAS use appears to be common but underrecognized among men entering inpatient substance abuse treatment, especially those with opioid dependence. AAS use may serve as a "gateway" to opioid abuse in some cases and may also cause morbidity in its own right.     

Treatment Issues for Aboriginal Mothers with Substance Use Problems and Their Children

In many cultures, approximately one third of people with drug dependence are women of child-bearing age. Substance use among pregnant and parenting women is a major public health concern. Aboriginal people have some of the highest rates of substance abuse in Canada, increasing concern for detrimental health impacts, including those for women and their children. For many women, substance abuse offers a means of coping with trauma, such as childhood abuse, partner violence, and, for Aboriginal women, the intergenerational effects of colonization. In this paper, we review treatment issues for Aboriginal mothers with substance use problems and their children. We discuss gender-specific issues in substance abuse, the need for women-specific treatment, the impact of substance abuse on children and parenting, the additional risks for Aboriginal women and children, and the need for integrated programs (those that integrate pregnancy-, parenting-, and child-related services with women-specific addiction treatment). We describe New Choices as an example of an integrated program, review research on existing treatment for Aboriginal mothers with substance use issues, and describe Sheway as a promising integrated program for Aboriginal women with substance abuse issues and their young children. There are few treatment programs specifically for Aboriginal mothers with substance use issues and their children and very little research on their effectiveness. Based on our review of existing evidence, we offer recommendations for future research and practice.