Does methadone maintenance treatment based on the new national guidelines work in a primary care setting?

BACKGROUND: General practitioners (GPs) are being encouraged to treat more drug users but there are few studies to demonstrate the effectiveness of primary care treatment. AIM: To determine whether patients retained on methadone maintenance treatment for one year in a modern British primary care setting, with prescribing protocols based on the new national guidelines, can achieve similar harm reduction outcomes to those demonstrated in other settings, using objective outcome measures where available. DESIGN OF STUDY: Longitudinal cohort study. SETTING: The Primary Care Clinic for Drug Dependence, Sheffield. METHOD: The intervention consisted of a methadone maintenance treatment provided by GPs with prescribing protocols based on the 1999 national guidelines. The first 96 eligible consenting patients entering treatment were recruited; 65 completed the study. Outcome measures were current drug use, HIV risk-taking behaviour, social functioning, criminal activity, and mental and physical health, supplemented by urinalysis and criminal record data. RESULTS: Frequency of heroin use was reduced from a mean of 3.02 episodes per day (standard deviation [SD] = 1.73) to a mean of 0.22 episodes per day (SD = 0.54), (chi 2 = 79.48, degrees of freedom [df] = 2, P < 0.001), confirmed by urinalysis. Mean numbers of convictions and cautions were reduced by 62% (z = 3.378, P < 0.001) for all crime. HIV risk-taking behaviour, social functioning, and physical and psychological wellbeing all showed significant improvements. CONCLUSION: Patients retained on methadone maintenance treatment for one year in a primary care setting can achieve improvements on a range of harm reduction outcomes similar to those shown by studies in other, often more highly structured programmes.     

Social support in treatment-seeking heroin-dependent and alcohol dependent patients

Social support is being recognized as a positive influence on health. It may influence motivation, treatment compliance and outcome in drug dependent patients. On the basis of clinical impression, it was hypothesized that social support in heroin (illicit drug) dependent patients is poorer than in alcohol dependent patients. The current study was undertaken to assess and compare the social support amongst treatment seeking alcohol dependent patients and heroin dependent patients. Despite lesser proportion of patients with any legal source of income in the heroin dependent subject group, the mean social support score across the two study groups was comparable. Overall, the mean social support scores were low in both the groups. The study provides some undestanding about the perceived social support amongst treatment seeking drug dependent individuals from India and also indicates the need to address the issue of social support in substance users.     

Drug users attending general practice in Eastern Regional Health Authority (ERHA) area

Dublin has an estimated 13,460 opiate drug users. The role of general practice in providing care for this group has increased over the last four years. A Central Methadone Treatment List (CMTL) registers all clients currently on treatment. To obtain a social, demographic and drug using profile of opiate users attending general practitioners (GPs) for methadone maintenance. A cross sectional survey of opiate users attending general practice for methadone maintenance in the Dublin area in early 1999. Data was collected on 571 clients (62% of total number attending general practice), of whom 97% had used heroin in the past and 12% had never injected. Although clients had been receiving methadone maintenance in general practice for a mean of 14 months, 16% were still using heroin, of whom 31% were still injecting. The mean age of first drug use was 15.5 years and of first injecting was 19.4 years. Younger clients are starting both to use drugs and inject drugs at an earlier age. Record keeping was good, with most items of information present in over 70% of the charts surveyed. A total of 17% of clients recorded on the CMTL could not be traced to the GP recorded as providing care. Despite treatment with methadone maintenance, there is a high level of continued risk activity in this group. Furthermore, a trend towards earlier initiation to drug use is apparent. The CMTL registration process requires further exploration.     

Factors affecting the outcome of methadone maintenance treatment in opiate dependence

This study aimed to measure the rates of ongoing heroin abuse among patients on methadone maintenance treatment (MMT) and sought to identify patient and treatment characteristics associated with poorer outcome. The study was carried out at an outpatient drug treatment clinic and included all patients who were on the MMT during a three month period in 2004. Treatment response was measured from analysis of opiate positive urine samples. Of the 440 patients, 63% were male and their mean age was 32 years (range 17 to 52 years). 163 patients (37%) had a comorbid psychiatric illness. The average methadone dose was 74 mg. On average, 71% of urine samples were opiate negative. Shorter time in treatment (less than 24 months), lower dose of methadone, cocaine abuse and intermittent benzodiazepine abuse were each found to be significantly associated with lower rates of opiate abstinence. Outcomes were not associated with gender, age and accessing counselling. Dual diagnosed patients tended to have higher rates of abstinence (p = 0.08). MMT clients who abuse cocaine and benzodiazepines are at increased risk of continuing opiate abuse. Higher doses of methadone might be necessary to prevent illicit opiate abuse.     

海洛因成瘾者停用海洛因后的脑功能情况-静息状态下fMRI研究

目的：探讨海洛因成瘾者停止用药后静息状态下脑功能的变化情况。方法：对海洛因成瘾者在停止使用海洛因3天（10人），1个月（10人）以及2个月（14人）时分别在静息状态下进行功能磁共振检测。并与正常对照进行比较。结果：成瘾者停用海洛因3天时出现额叶内侧，扣带回。颞上回等异常，停用1个月，额叶脑功能异常加重，海马功能出现异常，停用2个月，脑功能逐步恢复。结论：脑区的变化可能反映出海洛因成瘾者停药后渴求和复发可能性先增加。再下降的变化过程。额叶和海马发生变化时有时间上的关联性。本研究结果一方面为成瘾的动机假说提供了新的支持，另一方面提出海洛因依赖者在停药1个月左右复发的风险最大。     

Attachment and substance use disorders: a review of the literature and a study in drug dependent adolescents

Earlier studies on attachment and substance use disorders using the Hazan and Shaver (1987) self-report mainly indicate a link with "avoidant" attachment styles. Studies working with the Adult Attachment Interview (Main & Goldwyn, 1998) have produced inconsistent results. The present study used the Bartholomew (1990) interview coding system to assess attachment in a sample of 71 German opiate using, drug dependent adolescents (DDAs, age 14 - 25) and 39 non-clinical controls. Fearful attachment was predominant in DDAs, while controls were predominantly secure. Severity of drug use, as assessed with the European Addiction Severity Index (Gsellhofer, Fahrner, & Platt, 1994) and urinalyses, was positively correlated with fearful attachment, but negatively correlated with dismissing attachment. The presence of comorbid psychiatric disorders was associated with fearful attachment but not with addiction severity.     

Influence of injection drug use behavior on reported antiretroviral therapy use among women in the HIV Epidemiology Research study: on-site versus referral care

BACKGROUND: HIV-infected injection drug users consistently report poor antiretroviral therapy use and little contact with health care providers. It has been suggested that the clinical setting where patients are seen affects the use of highly active antiretroviral therapy. OBJECTIVES: The purpose of this study was to determine whether ease of access to medical care affects self-report of taking antiretroviral therapy, particularly among female injection drug users. DESIGN: The study is a cross-sectional analysis from a prospective cohort study of HIV-infected women. SETTING: Women were enrolled at four sites in the United States: Detroit, Michigan, and Providence, Rhode Island, where on-site HIV care and treatment were offered, and Baltimore, Maryland, and the Bronx, New York, where all participants were referred elsewhere for HIV care and treatment. PATIENTS: Patients were HIV-infected women with no AIDS diagnosis or women who were at risk for HIV infection either through self-reported injection drug use since 1985 or through sexual contact. MEASUREMENTS: The study measured self-reported use of antiretroviral therapy (ART) alone or combined with Pneumocystis carinii (PCP) prophylaxis in the previous 6 months. RESULTS: In multivariate analysis including type of study site (on-site compared with referral care) and injection drug use, any self-reported ART use associated with low CD4 cell count category, older age, and race. However, at on-site care centers, women were equally likely to report ART use regardless of current, former, or no injection drug use, whereas at referral sites only women identified as sexual contacts were more likely to report any ART use, independent of all other variables. CONCLUSIONS: Easy access to medical care has an important impact on HIV-infected women receiving ART, particularly those who are active injection drug users.     

The role of withdrawal in heroin addiction: enhances reward or promotes avoidance?

The compulsive nature of heroin abuse has been attributed to the fact that drug self-administration enables an addict to escape from and avoid the severe withdrawal symptoms resulting from opiate dependence. However, studies of incentive learning under natural motivational states suggest an alternative hypothesis, that withdrawal from heroin functions as a motivational state that enhances the incentive value of the drug, thereby enabling it to function as a much more effective reward for self-administration. In support of this hypothesis, we show here that previous experience with heroin in withdrawal is necessary for subsequent heroin-seeking behavior to be enhanced when dependent rats once again experience withdrawal.     

Evidence for controlled heroin use? Low levels of negative health and social outcomes among non‐treatment heroin users in Glasgow (Scotland)

Objectives. This longitudinal study focused on 126 long‐term heroin users who had never been in specialist treatment for use of any drug. The primary aim of the study was to assess whether this ‘hidden’ population resembled heroin users identified with drug treatment agencies, or alternatively, to test whether heroin could indeed be used in a controlled, non‐intrusive fashion for an extended period of time. Design and methods. Recruitment was achieved through chain‐referred purposive sampling methods, and data were collected through two semi‐structured interviews. 67% of participants were re‐recruited for follow‐up. Results. Participants had levels of occupational status and educational achievement comparable to that in the general UK population, and considerably higher than typically found in heroin research. At the conclusion of the study, six participants had entered treatment. While there was evidence of intensive risky patterns of drug use among the sample, there was equal evidence for planned, controlled patterns of use. Some drug‐related negative health and social outcomes had occurred on a lifetime basis, but ongoing problems were rare, and heroin was not a significant predictor in either context. In contrast to typical samples of heroin users, high levels of negative health and social outcomes did not appear to be inevitable within this sample. Frequency of heroin use was predicted by attributional items, indicating the importance of psychological factors in drug use and addiction. Conclusions. Drug research should more fully incorporate previously hidden populations to more fully inform theory and practice. The pharmacological properties of specific substances should not be assumed to inevitably lead to addictive and destructive patterns of drug use.     

Methadone treatment practices and outcome for opiate addicts treated in drug clinics and in general practice: results from the National Treatment Outcome Research Study.

BACKGROUND: General practitioners (GPs) are increasingly urged to become more involved in the care and treatment of drug misusers. Little information is available about the effectiveness of treatments delivered in primary health care or specialist settings. The impact of treatment setting is investigated as part of the National Treatment Outcome Research Study (NTORS). This is the largest study of treatment outcome for drug misusers ever conducted in the United Kingdom (UK). AIM: This paper presents six-month treatment outcomes for patients who received community-based methadone treatment in either a specialist drug clinic or a general practice setting. METHOD: A prospective, multisite follow-up study of treatment outcome was conducted with 452 opiate addicts who had been given methadone treatment in primary health care and specialist clinic settings. Outcome data are presented for substance use behaviours, health, and crime. RESULTS: Improvements at follow-up were found among both the GP and the clinic-treated groups in drug-related problems, health, and social functioning. Problems at intake were broadly comparable among the clinic-based and the GP patients. Similar levels and types of improvement were found for both groups at six-month follow-up. CONCLUSIONS: Results demonstrate the feasibility of treating opiate addicts using methadone in primary health care settings, and show that treatment outcomes for such patients can be as satisfactory as for patients in specialist drug clinics. The GPs in our study are unrepresentative in their willingness to be actively involved with problem drug users; moreover, several services treated relatively large numbers of drug users. Issues surrounding the growth of 'GP specialists' are discussed.     

Clinical Update of Opioid Agonist and Partial Agonist Medications for the Maintenance Treatment of Opioid Addiction

After years of failures in managing heroin addiction by both supportive and punitive abstinence-based treatment modalities or incarceration, with or without initial short-term detoxification using an opioid agonist, research into the potential use of primarily mu opioid receptor directed agonist (or use of a partial agonist) in the chronic maintenance treatment of long-term opiate (primarily heroin) addiction was performed and such treatments have been developed. Of these treatments, chronic “maintenance” with the long-acting, orally effective, synthetic opioid methadone has been shown to be both highly effective and very safe. The extent of its effectiveness is directly related to its appropriate use in maintenance treatment, combining the use ofproperdoses of methadone (60 to 120 mg/day in most patients) with adjunctive treatment, including counseling and access to medical, behavioral, and psychiatric care. More recently, a second long-acting opioid,l-α-acetylmethadol (LAAM) has been approved for chronic maintenance of opiate addiction. This agent has also been shown to be safe and effective when used in appropriate doses and with adjunctive treatment as needed by each individual. A third agent, a partial agonist (or mixed agonist–antagonist) buprenorphine, is currently under rigorous study in the United States and is already being used in other parts of the world in the chronic maintenance treatment of opiate addiction. Other novel approaches such as using a kappa opioid receptor agonist, like the natural opioid receptor peptide dynorphin A, or a synthetic peptide or heterocyclic congener thereof, are now under study. This paper presents a historical review of the development, the pharmacokinetic and pharmacodynamic properties of each agent, their neurobiological effects and safety, and efficacy in treatment. A formulation of the rationale for use of these and other opioid agonist-like compounds which might be developed in the future for the treatment of opioid addiction will be discussed.     

The validity of self-reported cocaine use in two groups of cocaine abusers

To evaluate the validity of 2 self-report methods for estimating cocaine use, Timeline Follow-Back (TLFB) and weekly calendar reports from 65 patients with a cocaine use disorder were compared with urine drug test results. The TLFB showed fair to moderate validity, and the weekly calendar showed moderate to high validity in measuring the frequency of cocaine use. Similar results were obtained when the self-report measures were used to time specific cocaine use episodes. In addition to evidence for superiority of the weekly calendar, the validity of self-reports was inversely related to the percentage of positive urine test results. Furthermore, there was some evidence that validity increased as the time window over which the comparisons were drawn increased. Given the central role of self-reports in the clinical and research evaluation of drug use, factors affecting their validity warrant further investigation.     

Partner concordance in reports of joint risk behaviors

OBJECTIVE: To evaluate the accuracy of self reports on sexual and drug use behaviors. METHODS: Data from a network study of HIV transmission among a sample of drug users and nonusers are used to compare reports of sexual and drug use behaviors by partners who engaged in those behaviors. Partner concordance (self-report agreement between two people) was used as an estimate of validity. RESULTS: Results showed that persons are able to recall and report about 85% of their recent partners (15%-20% less for recent drug use partners). For relationships that were reported by both partners, a high degree of concordance existed about recent behaviors (83%-96%) and variable agreement about frequency (0.48 相似文献   

Opiate tolerance to daily heroin administration: an apparent phenomenon associated with enhanced pain sensitivity

From a classical viewpoint, tolerance to analgesic effects of opiates refers to the decreased effectiveness of a given opiate following its repeated use. Despite much research, it has not been conclusively demonstrated in vivo that functional changes observed at the opioid receptor level in the responsiveness to opiates account for development of tolerance. An alternative hypothesis is that opioid receptors remain operative following repeated opiate administration but that opioid receptor activation rapidly induces a prolonged increase in pain sensitivity which opposes the predominant opiate analgesic effect following repeated opiate administration. We recently showed that a single heroin administration induces an enhanced pain sensitivity for several days, a phenomenon which is prevented by the non-competitive N-methyl-D aspartate receptor antagonist MK-801. Herein we report that repeated once-daily heroin injections induced a gradual lowering of the nociceptive threshold which progressively masked a sustained heroin analgesic functional effect. MK-801 prevented such opiate-induced allodynia and thereby prevented development of an apparent decrease in the effectiveness of heroin. These results indicate that intermittent heroin administration induced a persistent increase in the basal pain sensitivity which, if not taken into account gives the impression of less analgesia, i.e. apparent tolerance.     

Augmented production of proinflammatory cytokines and accelerated allotransplantation reactions in heroin-treated mice

Heroin treatment or abusive drug addiction influences many physiological functions, including the reactions of the immune system. Although suppression of various manifestations of the immune system after heroin (or morphine) administration has been reported, we show here that production of proinflammatory cytokines and nitric oxide (NO) was enhanced and allotransplantation reactions were accelerated significantly in heroin-treated recipients. Mice were treated by a subcutaneous administration of heroin (diacetylmorphine) given in one or repeated daily doses. The ability of spleen cells from treated mice to respond in vitro to alloantigens and to produce IL-2, IL-4, IL-10 and IFN-gamma, and the production of IL-1beta, IL-12 and NO by peritoneal macrophages, were tested. Within 2 h after heroin administration, proliferative responses to alloantigens and the production of IL-1beta, IFN-gamma, IL-12 and NO were enhanced significantly. In contrast, the production of anti-inflammatory cytokines IL-4 and IL-10 was at the same time rather decreased. As a consequence, skin allografts in heroin-treated mice were rejected more promptly than in untreated or vehicle-treated recipients. Similarly, the growth of allogeneic tumours induced by high doses of tumour cells was suppressed significantly in heroin-treated mice. The enhancing effects of heroin on the production of proinflammatory cytokines were antagonized by naltrexone, a specific inhibitor of classic opioid receptors. These results show that heroin treatment augments production of proinflammatory cytokines and accelerates allotransplantation reactions. The observations thus illustrate the complexity of the effects of heroin on the immune system and should be taken into account during medical treatment of opiate addicts and in the use of morphine to decrease pain in various clinical situations.     

Motivational control of heroin seeking by conditioned stimuli associated with withdrawal and heroin taking by rats

The authors investigated the impact of conditioned withdrawal on drug seeking by training rats to work for a heroin infusion on a seeking-taking schedule, which required responding on a seeking lever in order to gain the opportunity to self-administer the drug by a single response on a taking lever. Following the establishment of opiate dependence, a conditioned stimulus (CS) that had been previously paired with naloxone-precipitated withdrawal suppressed heroin seeking in extinction. However, when the rats had prior experience of heroin taking in the presence of the withdrawal CS, drug seeking was elevated in the presence of this stimulus. The authors conclude that the conditioned motivation of drug seeking in withdrawal depends on previous association of the CS with drug taking.     

Clinical and laboratory assessment of the subjective experience of drug craving

Measures of subjective drug craving — often defined as the experience of an intense or compelling urge or desire — may be used to predict relapse, evaluate psychological and pharmacological treatments, and test theories of addiction and craving. This review summarizes both direct self-report questionnaires and indirect behavioral, physiological and reaction time measures designed to assess craving for alcohol, amphetamines, cocaine, heroin, marijuana, and tobacco. Multi-item questionnaires have typically been based on one of four underlying conceptualizations of addiction or craving (obsessive–compulsive, approach-avoidance, multi-dimensional, intensity–frequency–duration). Most multi-item self-report questionnaires have high internal consistency, correlate significantly with single-item craving ratings, and demonstrate several aspects of construct validity. Proposed indirect or proxy measures of craving include drug dreams, speed of drug consumption, willingness to work for drug access, selection of monetary rewards over drug access, psychophysiological reactivity, and attentional bias to drug cues. These proxy measures of craving are presumed to obviate self-report biases, to be less subject to conscious self-control, and to reflect craving which the person may not be able to articulate; however, there have been too few demonstrations of their validity and they have too many practical limitations to supplant self-report measures of craving at this time.     

Measurement of children's asthma medication adherence by self report, mother report, canister weight, and Doser CT.

BACKGROUND: Accurate assessment of medication adherence has been difficult to achieve but is essential to drug evaluation in clinical trials and improved outcomes in clinical care. OBJECTIVE: This study was conducted to compare four adherence assessment methods: child report, mother report, canister weight, and electronic measurements of metered dose inhaler (MDI) actuation. METHODS: Participants included 27 children with mild-to-moderate asthma who were followed prospectively for 6 months. All patients used an MDI equipped with an electronic Doser attached to their inhaled steroid. At each 2-month follow-up visit, Doser and canister weight data were recorded, while child and mother were interviewed separately regarding medication use. RESULTS: Children and mothers reported, on average, over 80% adherence with the prescribed inhaled steroid. Canister weight revealed, on average, adherence of 69%, significantly lower than self-report. When adherence recorded by the electronic Doser was truncated to no more than 100% of prescribed daily use, average adherence was 50%. Older children and adolescents, nonwhite children, and those from poorer functioning families were least adherent. CONCLUSIONS: Electronic adherence monitoring was significantly more accurate than self-report or canister weight measures. Such accuracy is an essential prerequisite to increasing understanding of the treatment, setting, and patient factors that influence adherence, and to the consequent design of effective intervention strategies.     

Drug use and validity of substance use self-reports in veterans seeking help for posttraumatic stress disorder

The present study assessed drug use and the validity of self-reports of substance use among help-seeking veterans referred to a specialty clinic for the assessment of posttraumatic stress disorder (PTSD). Patients (n = 341) were asked to provide a urine sample for use in drug screening as part of an evaluation of PTSD. Self-reports of substance use were compared with same-day supervised urine samples for 317 patients who volunteered to participate in a drug screening. Results suggested that self-reports were generally quite valid. Only 8% of the cases involved patients not reporting substance use detected by urine screens. A total of 42% of the participants were identified as using drugs of abuse (excluding alcohol) through self-report and urine drug screens. Among participants using drugs, PTSD diagnosis was significantly associated with greater marijuana and depressant use as compared with stimulant (cocaine and amphetamines) use.