Heroin-assisted treatment as a response to the public health problem of opiate dependence

Injection drug use (involving the injection of illicit opiates) poses serious public health problems in many countries. Research has indicated that injection drug users are at higher risk for morbidity in the form of HIV/AIDS and Hepatitis B and C, and drug-related mortality, as well as increased criminal activity. Methadone maintenance treatment is the most prominent form of pharmacotherapy treatment for illicit opiate dependence in several countries, and its application varies internationally with respect to treatment regulations and delivery modes. In order to effectively treat those patients who have previously been resistant to methadone maintenance treatment, several countries have been studying and/or considering heroin-assisted treatment as a complementary form of opiate pharmacotherapy treatment. This paper provides an overview of the prevalence of injection drug use and the opiate dependence problem internationally, the current opiate dependence treatment landscape in several countries, and the status of ongoing or planned heroin-assisted treatment trials in Australia, Canada and certain European countries.     

Contraceptive practice of women with opiate addiction in a rural centre

ABSTRACT: This study aimed to explore the contraceptive practices of women in methadone treatment for opiate use in rural New South Wales and the reasons for those practices. Demographic characteristics, including age, marital status, sexual activity and contraceptive use, of all 23 women on a rural methadone program were documented. A smaller subgroup of seven women was interviewed using a semi-structured qualitative technique and issues around contraception explored in more depth. The study found that women who did not use contraception often had a low perceived risk of pregnancy for a variety of reasons including past infertility, menstrual irregularities and effect of drugs. The women had concerns about, and often felt guilty about, the effect of drug use on their children. They also had concerns about the side-effects of contraception. The study has implications for education and counselling of women when they enter drug treatment programs. Problems associated with opiate use are not just restricted to metropolitan areas but are part of rural health.     

Trends in deaths from drug overdose and poisoning in England and Wales 1993-1998

BACKGROUND: The study examines time trends and sociodemographic aspects of drug poisoning deaths in England and Wales. METHODS: Socio-demographic data from the four drug groups most commonly used in poisoning were extracted, and annual age- and sex-specific mortality rates calculated. Enumeration districts were ranked into five groups on the basis of their Carstairs scores, and the number of deaths in each of the five groups was calculated. RESULTS: There were 15720 deaths from drug poisoning between 1993 and 1998. More deaths occurred in men than in women (10 223 versus 5497). Opiates were the most commonly used drugs in deaths from drug poisoning (32 per cent of deaths); mortality rates increased twofold for these drugs. Males had higher number of deaths from opiate poisoning than females (4523 versus 1221). Highest mortality rates from opiate poisoning (77.4 per million) occurred in men aged 24-35 years. Deaths from drug poisoning were strongly associated with deprivation. CONCLUSION: There are substantial socio-demographic differences in mortality rates from drug poisoning.     

10 years development in the treatment of opiate dependent patients in the Kaufbeuren district hospital

Discussing drug abuse and the concept of "low-threshold" in the treatment of drug addicts, we investigated development of detoxification strategies in the Department of Psychiatry at Kaufbeuren during the last 10 years. In the following we describe 4 different phases of this development: In 1988 we admitted 34 opiate-dependent patients treated in general psychiatric units. In 1998 almost, 1,000 drug addicts were treated in specialised drug detoxification units. In the beginning we realised opiate detoxification treatment without medication. In the second phase we treated the subjects symptomatically. During the last four years we have been offering homologue opiate withdrawal with L-polamidone. Last year we extended the opiate detoxification treatment to the day hospital and outpatient setting. The comparative examination of patient moods during the so called qualified and the homologue splitted opiate withdrawal treatment shows amazing similarities regarding the oscillations, leaving out of account that the remarkable worsening after one week of drug assisted detoxification was seen one week later in the homologue splitted detoxification group.     

The long-term outcomes of drug use by methadone maintenance patients

The aim of the study is to predict long-term outcomes of methadone maintenance (MM), other than continued heroin use, on the basis of drug use occurring early in MM treatment. In previous research, the weak association of initial drug use during MM with measures of rehabilitation status may be due to the use of measures that do not differentiate trends in different types of drug use. In the present study, 222 patients who completed 6 months of MM were assessed at program intake, evaluated for opiates and cocaine in the first 6 months of treatment, and given a follow-up assessment 2 years after treatment entry. The intake status of the patients was assessed using the Addiction Severity Index. Opiate and cocaine use during the first 6 months of MM was assessed by urine toxicology. Outcomes were assessed using a structured interview and official criminal records at follow-up. Cluster analysis of urine toxicologies during treatment identified 3 trajectory classes of MM patients: (A) variably high levels of opiate use, but consistently low cocaine use; (B) low and diminishing opiate and cocaine use; and (C) consistently high cocaine use, with diminishing opiate use. In an 18-month period, after these trends were observed, Cluster C had significantly more criminal charges than Cluster B had (3 times as many), but not significantly more than those of Cluster A. Clusters A and B did not differ significantly in criminal charges. Regardless of cluster membership, subjects with increasing levels of cocaine use in the first 6 months of MM had more hospitalizations for drug and alcohol problems during the follow-up period than subjects without increasing levels of cocaine use had. The results provide evidence of negative sequelae of cocaine use during MM that underscore the importance of clinical efforts to reduce levels of cocaine and other nonopiate drug use by MM patients.     

Temporal correlation between opiate seizures in East/Southeast Asia and B.C. heroin deaths: a transoceanic model of heroin death risk

BACKGROUND: Because heroin supply changes cannot be measured directly, their impact on populations is poorly understood. British Columbia has experienced an injection drug use epidemic since the 1980s that resulted in 2,590 illicit drug deaths from 1990-1999. Since previous work indicates heroin seizures can correlate with supply and B.C. receives heroin only from Southeast Asia, this study examined B.C. heroin deaths against opiate seizures in East/Southeast Asia. METHODS: Opiate seizures in East/Southeast Asia and data from two B.C. mortality datasets containing heroin deaths were examined. The Pearson correlation coefficient for seizures against each mortality dataset was determined. RESULTS: Opiate seizures, all illicit drug deaths and all opiate deaths concurrently increased twice and decreased twice from 1989-1999, and all reached new peak values in 1993. Three B.C. sub-regions exhibited illicit drug deaths rate trends concurrent with the three principal datasets studied. The Pearson correlation coefficient for opiate-induced deaths against opiate seizures from 1980-1999 was R=0.915 (p<0.0001), and for illicit drug deaths against opiate seizures from 1987-1999 was R=0.896 (p<0.0001). CONCLUSIONS: From 1980-1999, opiate seizures in East/Southeast Asia were very strongly correlated with B.C. opiate and illicit drug deaths. The number of B.C. heroin-related deaths may be strongly linked to heroin supply. Enforcement services are not effective in preventing harm caused by heroin in B.C.; therefore, Canada should examine other methods to prevent harm. The case for harm reduction is strengthened by the ineffectiveness of enforcement and the unlikelihood of imminent eradication of heroin production in Southeast Asia.     

On drug treatment and social control: Russian narcology's great leap backwards

The medical discipline of narcology in Russia is a subspecialty of psychiatry from the Soviet era and it is given warrant to define the scope of health activities with regard to alcohol and other drug use, drug users, and related problems. Narcological practice is in turn constrained by the State. The emergence of widespread injection opiate use and associated HIV morbidities and mortalities during the first decade following the collapse of the Soviet Union has brought the contradictions in Russian narcological discourse into high relief. Narcology officials in the Russian Federation have consistently opposed substitution treatment for opiate dependence – the replacement of a short-acting illegal substance with a longer acting prescribed drug with similar pharmacological action but lower degree of risk. Thus, despite the addition of methadone and buprenorphine to WHO's list of essential medicines in 2005 and multiple position papers by international experts calling for substitution treatment as a critical element in the response to HIV (IOM, 2006; UNODC, UNAIDS, and WHO, 2005), methadone or buprenorphine remain prohibited by law in Russia.     

Estimating long-term trends in the incidence and prevalence of opiate use/injecting drug use and the number of former users: back-calculation methods and opiate overdose deaths

The authors explored an age-specific back-calculation approach to estimating long-term trends in the incidence and prevalence of opiate use/injecting drug use (IDU) in England for 1968-2000. The incidence of opiate use/IDU was estimated by combining information on the observed opiate overdose deaths of persons aged 15-44 years with knowledge on the distribution of the time between starting opiate use/IDU and death by overdose (incubation time distribution). The resulting incidence, together with the incubation time distribution, other drug-related mortality, and the general age-specific mortality rate, was then used to estimate the prevalence of current and former users. Provisional estimates suggested two major increases in incidence in the late 1970s and early 1990s, with models including information on age at death suggesting a recent decline since 1997 and that prevalence of opiate use/IDU increased substantially in the 1990s. Results were crucially dependent on assumptions about key parameters of the back-calculation framework. In theory, the approach is a valuable addition to the portfolio of indirect methods for estimating incidence and prevalence of dependent opiate use/IDU. In practice, its full potential will be realized only once better information on the process of stopping opiate use/IDU becomes available and more precise estimates of current and historical overdose mortality are obtained.     

Effect of naloxone on luteinizing hormone secretion in eating disorders: A pilot study

Previous studies have suggested that increased activity in endogenous opiate systems can lead to suppression of LH secretion in certain normal and patho- logical states. Increased food intake has also been linked to increased en- dogenous opiate activity. We hypothesized that in some women with the syndrome of bulimia there is an increase in endogenous opiate system activ- ity which contributes both to a suppression of LH secretion and to an in- creased drive to eat. We tested the endocrine aspect of this hypothesis by determining the effect of naloxone on LH secretion in nine amenorrheic or oligomenorrheic women with bulimia. Naloxone failed to increase LH in five underweight women with bulimia and anorexia nervosa. There was a slight increase in LH secretion during naloxone infusion in two of four women of normal weight with bulimia.     

The Readiness Ruler as a measure of readiness to change poly-drug use in drug abusers

Readiness to change is a crucial issue in the treatment of substance use disorders. Experiences with methadone maintenance treatment (MMT) has shown that continuous drug and alcohol use with all its consequences characterize most MMT programs. In a prospective study of drug abusers seeking opiate agonist maintenance treatment in the City of Copenhagen, subjects were administered the Addiction Severity Index, and the Readiness Ruler for each of 11 different licit and illicit drugs by research technicians. Data was collected upon admission to the program and at a 18 month follow-up. Subjects who indicated they wanted to quit or cut down upon admission, reported less drug use at 18 month follow-up, after controlling for severity of drug problems at intake. Subjects who expressed readiness to change their drug use upon admission decreased their drug use. It is concluded that the Readiness Ruler measures a construct related to actual readiness, supporting its use in the clinical context.     

Gender differences in health related quality of life of young heroin users

Background  

Health Related Quality of Life (HRQL) of opiate users has been studied in treatment settings, where assistance for drug use was sought. In this study we ascertain factors related to HRQL of young opiate users recruited outside treatment facilities, considering both genders separately.     

Estimating the number of HIV-infected injection drug users in Bangkok: a capture--recapture method.

OBJECTIVES. The purpose of the study was to estimate the number of injection drug users infected with the human immunodeficiency virus (HIV) in Bangkok to allow planning for health services for this population. METHODS. A two-sample capture-recapture method was used. The first capture listed all persons on methadone treatment for opiate addiction from April 17 through May 17, 1991, at 18 facilities in Bangkok. The second capture involved urine testing of persons held at 72 Bangkok police stations from June 3 through September 30, 1991. Persons whose urine tests were positive for opiate metabolites or methadone were included on the second list. RESULTS. The first capture comprised 4064 persons and the recapture 1540 persons. There were 171 persons included on both lists, yielding an estimate of 36,600 opiate users in Bangkok. Existing data indicate that 89% of opiate users in Bangkok inject drugs and that about one third are infected with HIV, yielding an estimate of approximately 12,000 HIV-infected injection drug users in Bangkok in 1991. CONCLUSIONS. During the 1990s the number of cases of acquired immunodeficiency syndrome (AIDS) and other HIV-related diseases, including tuberculosis, in the population of HIV-infected injection drug users in Bangkok will increase dramatically, placing new demands on existing health care facilities. The capture-recapture method may be useful in estimating difficult-to-count populations, including injection drug users.     

Comparing opiate users in methadone treatment with untreated opiate users: results of a follow-up study with a Toronto opiate user cohort

Untreated opiate use is correlated with major social harms and costs in Canada. While methadone treatment has existed in Canada since the 1960s, there is little specific Canadian research on its effects. This paper reports on the one-year follow-up results of a Toronto cohort study of opiate users (N = 114) who were not in treatment at baseline. Sixty-nine people were recruited for re-interviewing. A number of these individuals (N = 29) had entered methadone treatment during the year between baseline and follow-up interviews. Comparisons with respect to social functioning, health status and health care utilization, drug use and related risks, and criminal justice system involvement were made between the follow-up subsample who remained untreated, and the subjects who entered methadone treatment. Differences were found with respect to illegal income generation, illicit opiate and other drug use, illicit drug market activities and emergency care and aspects of socio-economic integration, but no major effects on health and criminal justice status could be shown. Research and policy implications are discussed.     

Cannabis-Related treatment demands in Belgium: a socio-demographic and treatment seeking profile

Aims

Most people appear to stop using cannabis when getting older, but a certain subgroup becomes cannabis dependent, has problems in various life areas and needs treatment. Our aim is to compare a number of sociodemographic and treatment seeking variables between treatment seekers with primary cannabis problems and those with primary alcohol, opiate, amphetamine or cocaine problems. Understanding how primary canna-bis users seeking treatment differ from other treatment seekers may assist clinicians in better tailoring treatment processes to clients' needs.

Methods

For this purpose, intake information on 1,626 persons seeking treatment in one of 16 treat-ment agencies in the province of Antwerp (Belgium) was registered via an on-line web application. Primary cannabis users seeking treatment were compared with primary alcohol, opiate, amphetamine and cocaine users by means of bivariate analyses (Chi-square tests and analyses of variance), followed by four logistic regression analyses.

Findings

14.5% of all clients used cannabis as their primary drug. Compared to primary alcohol, opiate, amphetamine or cocaine users seeking treatment, cannabis users seeking treatment appeared to be more often male, younger than 30 years old, Belgian and student. They are often referred to treatment by police or justice and 43.6% of them can be considered single-substance users. Multivariate analyses showed that besides age and sex, using no other substances than the primary drug and being registered in outpatient facilities only were significant determinants for being a primary cannabis user seeking treatment.

Conclusions

Primary cannabis users can clearly be differentiated from other drug users seeking treatment. Although cannabis plays an important part in a polydrug use pattern, persons who have cannabis as their primary drug often use only this one substance. Since they regularly have brief contacts with treatment agencies, more research is needed to measure the effect of this brief intervention.

     

Obstetric medication versus residential area as perinatal risk factors for subsequent adult drug addiction in offspring

Summary. In an attempt to explain pronounced uneven distributions of births of subsequent amphetamine and opiate addicts at seven hospitals in Stockholm, two possible mechanisms for adult drug addiction were weighed against each other: (1) risk factors associated with the obstetric care at the hospitals of birth of the addicts and (2) risk factors associated with the phenomenon of 'contagious' transmission of drug addiction in certain residential areas during adolescence. The subjects comprised 200 amphetamine addicts and 200 opiate addicts born between 1945 and 1966. By loglinear analysis the relative risk for future addiction was determined for eight residential areas as well as for the seven hospitals and four periods of birth. For the opiate addicts only one weak association was found for the residential area, which could not explain fully a clustering of births at any particular hospital. For the amphetamine addicts, hospital of birth was found to be an important risk factor even after controlling for residential area. Hence, the variable residential area has not been able to explain the uneven distribution of births of drug abusers among the studied hospitals.     

Attitudes and practices regarding the use of methadone in US State and federal prisons

In the United States, vigorous enforcement of drug laws and stricter sentencing guidelines over the past 20 years have contributed to an expanded incarcerted population with a high rate of drug use. One in five state prisoners reports a history of injection drug use, and many are opiate dependent. For over 35 years, methadone maintenance therapy has been an effective treatment for opiate dependence; however, its use among opiate-dependent inmates in the United States is limited. In June 2003, we conducted a survey of the medical directors of all 50 US states and the federal prison system to describe their attitudes and practices regarding methadone. Of the 40 respondents, having jurisdiction over 88% (n=1,266,759) of US prisoners, 48% use methadone, predominately for pregnant inmates or for short-term detoxification. Only 8% of respondents refer opiate-dependent inmates to methadone programs upon release. The results highlight the need to destigmatize the use of methadone in the incarcerated setting, expand access to methadone during incarceration, and to improve linkage to methadone treatment for opiate-dependent offenders who return to the community.