Exploring the relationship between homelessness and risk factors for heroin-related death--a qualitative study

The aim of this study was to explore the relationship between housing status, associated social networks and risk factors for heroin-related death. We used semi-structured face-to-face qualitative interviews, recorded, transcribed and analysed thematically by framework techniques at three centres providing services to homeless people in a large cosmopolitan city. Different types of accommodation for homeless people have differing social cultures which have an impact upon the amount of heroin used, likelihood of injecting alone or likelihood of achieving abstinence. Hostel accommodation appeared to be linked with a culture of group injecting, which tends to increase the amount of heroin taken. Those with experience of rough sleeping described heroin use to ameliorate the uncomfortable realities of outdoor sleeping, although the overall amount used tended to be less due to having less money to spend on drugs. The prison setting was described as a setting where heroin use was reduced or stopped. Moving away from homelessness towards sustaining an independent tenancy appeared to be associated with a move towards solitary use. We postulate that a progression towards solitary use in a housed environment is one explanation for previous research findings showing the average age of heroin-related death to be increasing despite a decrease in the average age of initiation into heroin use. Hostel accommodation should form a priority setting for future health promotion interventions aimed to reduce heroin-related death. They appear to be linked with an increase in heroin use in the presence of a third party. Drug users sleeping rough in cold climates need to be made aware of the dangers of medicating with heroin to address problems of insomnia due to cold weather.     

Mapping heroin careers: utilising a standardised history-taking method to assess the speed of escalation of heroin using careers in a treatment-seeking cohort

Introduction and aims. Although there has been increasing research attention to the concept of addiction careers and treatment careers, there are few standardised measures for assessing illicit drug using careers. A new instrument for mapping lifetime drug use history (LDUH) was used to assess transitions in the initial stages of heroin use careers among illicit drug users. Design and Methods. 58 lifetime heroin users completed a one-off researcher-administered interview in treatment settings in two English cities, London and Birmingham, about their histories of drug use, drug treatment and other key life events. Results. The sample reported initiating heroin use at a mean age of 21 years and escalated to daily use by 23 years. On average, there was a gap of nearly 8 years before seeking treatment and at the time of interview the cohort averaged one-third of their heroin careers in treatment. However, there was marked variability across the group, with three discernible groups identified based on use patterns. While one group (n = 21) showed consistent escalation in total quantity of heroin used across the first year, the second group had an intermittent pattern of use and the third group reported an unchanging monthly heroin use pattern. These groups differed in the time taken to initiate treatment and in the proportion of their heroin careers in active use. Discussion and Conclusions. The instrument was acceptable to research participants and identified important variability in onset and escalation factors in heroin careers. The implications for therapeutic interventions and for clinical use of the instrument are discussed. [Best D, Day E, Cantillano V, Gaston RL, Nambamali A, Sweeting R, Keaney F. Mapping heroin careers: utilising a standardised history-taking method to assess the speed of escalation of heroin using careers in a treatment-seeking cohort. Drug Alcohol Rev 2008;27:165-170]     

Patterns of sustained heroin abstinence amongst long-term, dependent heroin users: 36 months findings from the Australian Treatment Outcome Study (ATOS)

AIMS: To determine patterns of past month, 12 month and sustained 36 month heroin abstinence. METHODS: As part of a longitudinal cohort study, 429 heroin users re-interviewed at 36 month follow-up for the Australian Treatment Outcome Study (ATOS). RESULTS: The proportion who had sustained heroin abstinence since baseline declined from 14% at 12 months to 8% at 36 months. The proportion who reported abstinence over the preceding 12 months, however, increased significantly from 14% at 12 months to 40% at 36 months. There were no significant gender differences in the proportions reporting sustained 36 month abstinence. Females, however, were significantly more likely to have maintained abstinence over the 12 months preceding 36 month follow-up. Independent predictors of sustained abstinence over 36 months were fewer treatment episodes since baseline, not committing crime at baseline and higher levels of global psychological distress. CONCLUSIONS: Despite a decline in the proportion who had maintained complete heroin abstinence over 36 months, there were substantial increases in 12 month abstinence patterns. The results illustrate the importance of stable treatment retention.     

Long-term methadone maintenance reduces protracted symptoms of heroin abstinence and cue-induced craving in Chinese heroin abusers

BACKGROUND: Cession of heroin use may be followed by a protracted-abstinence (PA) syndrome consisting of craving, negative mood, and physiological changes. PA symptoms have rarely been compared between drug-free and methadone-maintained former heroin users after similar lengths of heroin abstinence. METHODS: Seventy former heroin users were included in one of four groups: in day 15-45 of methadone maintenance therapy (short-term MMT), in month 5-6 of MMT (long-term MMT), opiate-free for 15-45 days after methadone-assisted heroin detoxification (short-term post-methadone), and opiate-free for 5-6 months after methadone-assisted heroin detoxification (long-term post-methadone). PA symptoms (negative mood, dyssomnia, somatization, and craving), and blood pressure and pulse were assessed pre- and post-neutral videotape and pre- and post-heroin videotape. RESULTS: Dyssomnia and the total PA score were worst in short-term post-methadone participants, mood was best in long-term MMT participants, and cue-induced craving was least severe in long-term MMT participants. Blood pressure and pulse did not differ across groups. CONCLUSIONS: Even after acute withdrawal, the first months of heroin abstinence after methadone-assisted detoxification may be more difficult in terms of cue-induced craving and other PA symptoms than the first months of heroin abstinence during MMT. Our findings add to the literature supporting MMT for prevention of cue-induced heroin craving.     

Treatment failures? Scope of the treatment system for long‐term heroin addicts

In a study of 50 long‐term heroin addicts in Hamburg with an average usage period of 17.4 years, it was found that heroin usage patterns differed in the course of addiction. It appeared that two‐thirds of the sample had had longer periods of uncontrolled heroin use that were interrupted by phases of abstinence or by phases of controlled use. Almost all of them use different drugs. Currently, as well as in the course of their addiction, they use numerous other drugs in an uncontrolled way, especially benzodiazepines. Long‐term heroin addicts on the whole have less treatment experience than persons in the reference studies. The percentage of treatment dropouts is as high among them as among the persons surveyed in other studies. Completed treatment correlated with better results with regard to the duration of abstinence following treatment. The level of information regarding the pending treatment was low among long‐term heroin addicts.     

Mapping the recovery stories of drinkers and drug users in Glasgow: quality of life and its associations with measures of recovery capital

Introduction and Aims. The study investigates what ‘recovery’ means for those who describe themselves as in alcohol or drug recovery. Design and Methods. The project used multiple methods—snowballing, recruitment through recovery groups and advertisements in local press—to recruit 205 people (107 in alcohol and 98 in heroin recovery) who reported a lifetime dependence on alcohol and/or heroin; had not used their primary substance in the last year and perceived themselves to be either recovered or in recovery. They were interviewed by researchers using a structured questionnaire reported in the current paper and a semi‐structured interview reported elsewhere. Results. The average time dependent for heroin users was 10.8 years and for drinkers 15.7 years, but onset and desistance were earlier for heroin. Longer time since last use of alcohol or heroin was associated with better quality of life. Greater engagement in meaningful activities was associated with better functioning, and was associated with quality of life, followed by number of peers in recovery in the social network. Heroin users in abstinent recovery generally reported better functioning than those in maintained recovery. Discussion and Conclusions. Recovery experiences vary widely, but better functioning is typically reported after longer periods and is associated with supportive peer groups and more engagement in meaningful activities, and supports models promoting the development of peer networks immersed in local communities.[Best D, Gow J, Knox T, Taylor A, Groshkova T, White W. Mapping the recovery stories of drinkers and drug users in Glasgow: Quality of life and its associations with measures of recovery capital. Drug Alcohol Rev 2012;31:334–341]     

PET imaging of dopamine transporter and drug craving during methadone maintenance treatment and after prolonged abstinence in heroin users

It has been documented that methadone maintenance treatment is effective in reducing drug craving and relevant risk behaviors in heroin users. However, it is not understood whether methadone maintenance treatment impairs the dopamine transporter in the striatum. To establish whether chronic opiate use might impair brain dopamine neurons in humans, we assessed dopamine transporter (DAT) uptake function in the striatum (caudate and putamen), and analyzed the correlation between DAT in the striatum and heroin craving and subjective anxiety in former heroin users with prolonged abstinence and in patients receiving methadone maintenance treatment. Binding of [(11)C]-2beta-carbomethoxy-3beta-aryltropane ([(11)C] CFT) as a brain dopamine transporter ligand was measured with positron emission tomography (PET) in eleven former heroin users with prolonged abstinence, ten patients receiving methadone maintenance treatment and ten healthy control subjects. Heroin craving and subjective anxiety in prolonged abstinence and methadone maintenance treatment groups were assessed and the correlations between DAT of striatum and heroin craving or subjective anxiety were determined. In comparison with healthy control subjects, methadone maintenance treatment subjects had lower DAT uptake function in the bilateral caudate and putamen and prolonged abstinence subjects showed significantly lower DAT uptake function in the bilateral caudate. Moreover, in comparison to the prolonged abstinence subjects, the methadone maintenance treatment subjects showed significant decreases of DAT uptake in the bilateral putamen. DAT uptake function in bilateral striatum was not associated with heroin craving in prolonged abstinence or in methadone maintenance treatment subjects; however, DAT uptake function in the bilateral caudate was significantly correlated with subjective anxiety in methadone maintenance treatment subjects. Our findings suggest that chronic opioid use induces long-lasting striatum dopamine neuron impairment, and prolonged withdrawal from opioids can benefit the recovery of impaired dopamine neurons in the brain.     

The effects of sponsorship in 12-step treatment of injection drug users

What contributes to sustained abstinence from injection drug use by those who participate in community-based Narcotics Anonymous (NA) and Alcoholics Anonymous (AA) is not well understood. We know that sponsorship is a central element in these programs. To investigate the relationship between sponsorship and abstinence, we evaluated NA/AA sponsorship over a 1-year period in a longitudinal study of 500 former and current injection drug users in inner-city Baltimore recruited from the community-at-large, independent of treatment center affiliation. The findings indicated that having a sponsor in NA/AA for this population was not associated with any improvement in 1-year sustained abstinence rates than a non-sponsored group. However, being a sponsor over the same time period was strongly associated with substantial improvements in sustained abstinence rates for the sponsors, controlling for involvement with community organizations, NA/AA meeting attendance, marital status, employment, participation in drug and alcohol treatment centers and HIV status. Involvement in community organizations was also strongly associated with successful abstinence, controlling for the same variables. Of those participants involved with community organizations, more than half reported involvement in church activities. Our investigation suggests that, for NA/AA sponsors in this study population, providing direction and support to other addicts is associated with improved success in sustained abstinence for the sponsors but does little to improve the short-term success of the persons being sponsored.     

Sustained incentive value of heroin-related cues in short- and long-term abstinent heroin users

Models of addiction and addiction memory propose that drug-associated cues elicit incentive effects in drug users, which play an important role in maintenance of drug use and relapse. Incentive effects have been demonstrated for smoking and alcohol-related cues but evidence for heroin-related cues has been inconclusive. Furthermore, it is unknown whether appetitive effects of heroin-related cues persist after prolonged abstinence, although heroin addiction is known to have high relapse rates. Therefore, we investigated implicit and explicit valence of heroin-related cues in dependent users at different stages of abstinence using affective startle modulation. In Study I, 15 current heroin users were measured before and after detoxification. Correspondingly, 15 healthy control participants were tested twice at an interval of 14 days. In Study II, 14 long-term abstinent heroin users were additionally measured in a single session. Implicit processing of drug-related stimuli was assessed using affective startle modulation by pictures of heroin and smoking scenes. Explicit reactions were measured using ratings of valence and craving. In contrast to controls, heroin-dependent participants showed a clear reduction of startle response during heroin-related pictures (p<0.05). Detoxification did not significantly change their startle responses to heroin-cues. No difference between non-detoxified current and long-term abstinent heroin users was found in implicit reactions to heroin-cues, whereas explicit measures differed between both groups (all p<0.05). After detoxification and even after prolonged abstinence, heroin cues still exert implicit appetitive effects in heroin users. This implies that drug-induced adaptations of reward circuits are long-lasting, resulting in a highly stable addiction memory.     

AMERICAN SOCIETY OF ADDICTION MEDICINE

Reported here is a study of the effectiveness of treatment in reducing the duration of heroin careers, with a special focus on gender differences. The longitudinal research is based on a community representative sample of urban black youth, ages 18-23, and utilizes a recently introduce statistical methodology, event-history analysis. Simple hazard probability analysis confirmed that males and females did not differ significantly in their cumulative probabilites of abstinence from heroin. The more elaborated event-history model demonstrated, however, that treatment played a significantly different role among young men and women in attaining abstinence. While a man's likelihood of abstinence was but marginaly greater with treatment than without it, women's likelihood of abstinence was significantly increased by entering treatment.     

Factors associated with 12 months continuous heroin abstinence: findings from the Australian Treatment Outcome Study (ATOS)

AIMS: To determine the role of treatment and client characteristics associated with the achievement of continuous heroin abstinence. DESIGN: Longitudinal cohort study. SETTING: Sydney and Adelaide, Australia. PARTICIPANTS: 570 heroin users re-interviewed at 12 month follow-up for the Australian Treatment Outcome Study (ATOS). FINDINGS: Continuous heroin abstinence was reported by 14% of participants. Continuous abstinence was associated with no previous treatment history, having entered treatment at baseline, and cumulative treatment exposure over the follow-up period. Longer retention times in index maintenance and residential rehabilitation treatments, but not detoxifications, were most associated with abstinence. At baseline, abstinent participants were more likely to have been classified as treatment ready, or to have used heroin less frequently; and less likely to have been daily injectors, using cocaine or criminally involved. CONCLUSIONS: Approximately 14% of ATOS participants achieved continuous heroin abstinence over 12 months. Such an achievement was strongly associated with a longer "dose" of treatment, and with more treatment stability over the follow-up period.     

Changes in brain gray matter in abstinent heroin addicts

Background

Previous neuroimaging studies have documented changes in the brain of heroin addicts. However, few researches have detailed whether such changes can be amended after short-term abstinence.

Methods

We used magnetic resonance imaging (MRI) to investigate gray matter volume in 20 heroin-dependent patients at 3 days and at 1 month after heroin abstinence; 20 normal subjects were also included as controls.

Results

Decreased gray matter density in frontal cortex, cingulate and the occipital regions were found in heroin users after three days of abstinence. In contrast, after 1-month abstinence, no significant difference was found in superior frontal gyrus between heroin addicts and controls, but changes in other brain regions, including right middle frontal gyrus, left cingulate gyrus and left inferior occipital gyrus, still remained.

Conclusion

Our findings illustrate that abnormal gray matter in some brain regions of heroin addicts can return to normal after one-month abstinence.     

Neuropsychological functioning in opiate-dependent subjects receiving and following methadone maintenance treatment

OBJECTIVE: An accumulating body of research suggests that former heroin abusers in methadone maintenance therapy (MMT) exhibit deficits in cognitive function. Whether these deficits are present in former methadone maintained patients following discontinuation of MMT is unknown. This study tests the hypothesis that former heroin users who have detoxified from methadone maintenance therapy and are drug-free have less pronounced cognitive impairment than patients continuing long-term MMT. METHOD: A series of neuropsychological tests were administered to three groups of subjects: 29 former heroin addicts receiving methadone maintenance treatment, 27 former heroin addicts withdrawn from all opiates, and 29 healthy controls without a history of drug dependence. Testing included Wechsler Adult Intelligence Scale-Revised Vocabulary Test, the Stroop Color-Word Test, the Controlled Oral Word Association Test, the Benton Visual Retention Test, and a Substance Use Inventory. FINDINGS: Both methadone-maintained and abstinent subject groups performed worse than controls on tasks that measured verbal function, visual-spatial analysis and memory, and resistance to distractibility. Abstinent subjects performed worse than their methadone maintained counterparts on tests measuring visual memory and construct formation. Cognitive impairment did not correlate with any index of drug use. CONCLUSIONS: We confirmed previous findings of neuropsychological impairment in long-term MMT recipients. Both patients receiving MMT and former heroin users in prolonged abstinence exhibited a similar degree of cognitive impairment. Cognitive dysfunction in patients receiving methadone maintenance may not resolve following methadone detoxification.     

Seven year follow-up of heroin addicts: Life histories summarised

Data from a seven-year follow-up study of heroin addicts were analysed to show group trends. Time spent in various activities was quantified for each person for each year of the follow-up period and used to provide a composite life history. Time spent by the sample using drugs has decreased over the follow-up period. The most marked decrease appeared in the use of heroin, but the analysis suggests that a hard core of heroin users still used heroin several years after coming to the clinic. There seems to be an overall congruence between abstinence and non-clinic attendance. For this sample the use of illegal opiates without attending a clinic was relatively rare, and total time spent in hospitals and in prisons was rather small. Death occurred randomly during the follow-up period.     

Overdose deaths following previous non‐fatal heroin overdose: Record linkage of ambulance attendance and death registry data

Introduction and Aims. Experiencing previous non‐fatal overdoses have been identified as a predictor of subsequent non‐fatal overdoses; however, few studies have investigated the association between previous non‐fatal overdose experiences and overdose mortality. We examined overdose mortality among injecting drug users who had previously been attended by an ambulance for a non‐fatal heroin overdose. Design and Methods. Using a retrospective cohort design, we linked data on non‐fatal heroin overdose cases obtained from ambulance attendance records in Melbourne, Australia over a 5‐year period (2000–2005) with a national death register. Results. 4884 people who were attended by ambulance for a non‐fatal heroin overdose were identified. One hundred and sixty‐four overdose deaths occurred among this cohort, with an average overdose mortality rate of 1.20 per 100 person‐years (95% CI, 1.03–1.40). Mortality rate decreased 10‐fold after 2000 coinciding with widely reported declines in heroin availability. Being male, of older age (>35 years) and having been attended multiple times for previous non‐fatal overdoses were associated with increased mortality risk. Discussion and Conclusions. As the first to show a direct association between non‐fatal overdose and subsequent overdose mortality, this study has important implications for the prevention of overdose mortality. This study also shows the profound effect of macro‐level heroin market dynamics on overdose mortality.[Stoové MA, Dietze PM, Jolley D. Overdose deaths following previous non‐fatal heroin overdose: Record linkage of ambulance attendance and death registry data. Drug Alcohol Rev 2009;28:347–352]     

Primary heroin users + drug-free treatment: an equation for success?

This study of persons referred to publicly funded drug-free substance abuse treatment in Washington State compares 122 primary heroin users (those specifying heroin as a drug of choice) with 532 persons who preferred other substances. Information on treatment entry and completion was obtained through review of client charts at the referral agency. Follow-up interviews with 587 participants provided self-reports of substance use during a 90-day period 3-6 months following removal from the treatment waitlist. Primary heroin users were significantly less likely than others to enter the treatment programs to which they were referred. Among treatment entrants, primary heroin users were somewhat less likely than other users to complete inpatient programs but no less likely to complete outpatient programs. The heroin preference group reported less abstinence and greater frequency of use during the follow-up period than did other users, patterns that almost entirely coincided with the lower treatment compliance in the heroin group. The authors note the importance of investigating methods for increasing treatment entry rates for opiate users who desire drug-free treatment.     

Negative affect heightens opiate withdrawal-induced hyperalgesia in heroin dependent individuals

This study examined the effect of emotion on opiate withdrawal induced hyperalgesia to determine whether emotional states modulate the magnitude of hyperalgesia. One hundred Hispanic men were recruited into one of three groups: heroin withdrawal, long-term heroin abstinence, and control. Participants were presented with pictures to induce neutral, positive, and negative emotional states. Affective valence, arousal, pain threshold, and tolerance to ischemic pain were measured. When pain threshold and tolerance were compared, the withdrawal group displayed significant heightened pain sensitivity when negative affect was induced. The authors also found that former heroin addicts showed heightened pain sensitivity following months of abstinence.     

Changes in patterns of drug injection concurrent with a sustained reduction in the availability of heroin in Australia

Between 1996 and 2000, heroin was the drug most frequently injected in Australia, and viable heroin markets existed in six of Australia's eight jurisdictions. In 2001, there was a dramatic and sustained reduction in the availability of heroin that was accompanied by a substantial increase in its price, and a 14% decline in the average purity of seizures analysed by forensic laboratories. The shortage of heroin constitutes a unique natural experiment within which to examine the impact of supply reduction. This paper reviews one important correlate of the shortage, namely changes in patterns of illicit drug injection. A number of studies have consistently suggested that between 2000 and 2001, there was a sizeable decrease in both prevalence and frequency of heroin injection among injecting drug users. These changes were accompanied by increased prevalence and frequency of stimulant injection. Cocaine was favoured in NSW, the sole jurisdiction in which a cocaine market was established prior to the heroin shortage; whereas methamphetamine predominated in other jurisdictions. Some data suggest that, at least in the short-term, some drug injectors left the market altogether subsequent to the reduced heroin availability. However, the findings that (1) some former heroin users switched their drug preference to a stimulant; and (2) subsequently attributed this change to the reduced availability of heroin, suggests that reducing the supply of one drug may serve to increase the use of others. Given the differential harms associated with the use of stimulants and opiates, this possibility has grave implications for Australia, where the intervention and treatment system is designed primarily to accommodate opiate use and dependence.