Prevalence of stimulant use and the role of opioid agonist treatment among people who inject drugs in France: Results from the COSINUS cohort study.

INTRODUCTION: The co-use of stimulants and opioids, including opioid agonist treatment (OAT), is very prevalent worldwide. A large body of data exists on the association between stimulant use and its health complications, and on OAT effectiveness among people with opioid use disorder. However, few data exist on stimulant-opioid co-use among people receiving OAT. Using data from the COSINUS cohort study, we investigated the association between the type of OAT and problematic stimulant use among persons who inject drugs (PWID). METHODS: COSINUS is a 12-month French cohort study of 665 PWID. Data were collected in face-to-face interviews at enrolment, at 6 and 12 months. We defined problematic stimulant use as daily use of and/or injecting stimulants. We used Bayesian model averaging (BMA) to identify factors associated with problematic stimulant use. RESULTS: At baseline, 76% (n = 505) of the participants reported problematic stimulant use. The optimal model from the BMA estimation showed that, after adjusting on social precarity and daily injection, participants on prescribed morphine sulfate as an OAT (compared with methadone) and those who use daily unprescribed buprenorphine were less likely to report problematic stimulant use. DISCUSSION AND CONCLUSIONS: Our work highlights the high prevalence of problematic stimulant use among PWID in France but also the potential association between the type of OAT taken and stimulant use, by suggesting a protective effect of morphine sulfate on stimulant use. Since it has a higher intrinsic activity than other opioids, PWID on this OAT may be less interested in stimulants. Our findings warrant further investigation in clinical studies.

A Scoping Review of Evidence-Based Interventions and Health-Related Services for Youth Who Use Nonmedical Opioids in Canada and the United States.

PURPOSE: This scoping review synthesizes the characteristics and outcomes of recent evidence-based treatments and services for youth with nonmedical opioid use/opioid use disorder in the context of the ongoing opioid crisis in Canada and the United States. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Extension for Scoping Reviews guidelines, empirical health databases were searched for literature describing treatments or health-related services for nonmedical opioid use/opioid use disorder among youth (ages 12-25). Two independent reviewers conducted study screening, selection, and data extraction. A deductive content analysis further synthesized the interventions' characteristics following the Consolidated Framework for Implementation Research and an inductive content analysis synthesized the interventions' efficacy/effectiveness outcomes. RESULTS: Twenty-five articles met inclusion from 2,761 screened; 88% described opioid agonist treatment (alone or in combination with nonpharmacological treatment). Following the Consolidated Framework for Implementation Research, commonly identified adaptable characteristics included treatment decision-making processes, integrated health and social services, and treatment settings. Efficacy/effectiveness outcomes most frequently included substance use and treatment engagement. DISCUSSION: This study informs future development, implementation, and evaluation of practices and policies that could be tailored to improve the quality of opioid agonist treatment for youth at risk of significant harms from nonmedical opioid use.

Trends in polysubstance use among patients in methadone maintenance treatment in Ireland: Evidence from urine drug testing 2010-2020.

INTRODUCTION: The benefits of methadone maintenance treatment (MMT) may be compromised by the continued use of other substances during treatment. Polysubstance use has been identified as a major contributing factor to treatment discontinuation, a known risk factor for drug overdose. We examined trends in immunoassay drug positivity rates for amphetamines, benzodiazepines, cannabis, cocaine and opioids, and (2) trends in polysubstance positivity rates for drug combinations associated with increased risk of drug overdose among patients attending the national drug treatment centre in Ireland for MMT between 2010 and 2020. METHODS: Repeated cross-sectional study of patients attending the national drug treatment centre (NDTC) for MMT (total N = 1942) between 2010 and 2020, focused on urine drug samples provided for testing to the NDTC clinical testing laboratory (n = 221,564). Samples were analysed using immunoassay during the study period. Mixed-effects logistic regression models evaluate time trends in drug positivity. A random intercept accounts for repeat testing of individual patients. The study reports Adjusted Odds Ratios (AOR) for time (per year) with 95 % Confidence Intervals (95 % CI). RESULTS: Drug positivity rates increased over time for benzodiazepines (AOR 1.02, 95 % CI 1.01-1.03, p < .0001), cannabis (AOR 1.06, 95 % CI 1.05-1.08, p < .0001) and cocaine (AOR 1.28, 95 % CI 1.27-1.29, p < .0001), with decreasing trends for opioids (AOR 0.91, 95 % CI 0.91-0.92, p < .0001). Methadone and benzodiazepines were co-detected in over two-thirds of all samples during the study period. Co-detection of methadone and benzodiazepines with cocaine was also found to be increasing (AOR 1.24, 95 % CI 1.23-1.25, p < .0001), with weighted polysubstance positivity rates reaching 29.2 % in 2020. The co-detection of methadone and benzodiazepines with opioids decreased over the study period (AOR 0.92, 95 % CI 0.91-0.92, p < .0001), ranging from 36.7 % in 2010 to 26.9 % in 2020. CONCLUSION: Interventions are needed to target the persistently high use of benzodiazepines among patients in receipt of methadone due to their synergistic effects with opioids on respiratory depression, enhancing the risk of overdose. The growing use of cocaine among people in MMT also needs to be addressed.

Naloxone cascade of care among people who regularly inject drugs in Australia, 2020-2022.

BACKGROUND: Examining take-home naloxone (THN) uptake using a 'cascade of care' framework could help identify targets for increasing THN training and carriage among people who may witness or experience opioid overdose. We describe the THN cascade and factors associated with engagement among people who inject drugs. METHODS: People aged ≥18 years in Australia who inject drugs were interviewed from 2020 to 2022, reporting lifetime THN awareness and acquisition and past-month carriage. We examined factors associated with engagement using multivariable logistic regression. RESULTS: Of 2,149 participants (64 % men, mean age 44.5), 85 % had heard of naloxone, of whom 76 % were aware of THN programs. Of these, 72 % had ever participated in THN training/brief education, 92 % of whom had acquired THN. Of those who had ever acquired THN and reported past-month opioid use, 63 % always/often carried THN when using opioids. Past six-month opioid agonist treatment (OAT) (adjusted odds ratio [AOR] 2.55; 95 %CI 1.91-3.42) and ≥daily injecting (1.32; 1.01-1.73) were associated with awareness. OAT (1.79; 1.38-2.33), past-year opioid overdose (1.68; 1.18-2.42) and older age (1.02; 1.00-1.03) were associated with acquisition. Primarily injecting methamphetamine (versus heroin) in the past month was associated with lower awareness (0.43; 0.31-0.58) and acquisition (0.59; 0.44-0.78). Reporting no accommodation (squatting/sleeping rough) was associated with reduced odds of carriage (0.46; 0.24-0.88). CONCLUSION: Participants reported high THN awareness and acquisition, with lower carriage. Future efforts should focus on improving THN access and reducing barriers to carriage, particularly for people experiencing homelessness or who primarily inject non-opioids.

Neurocognitive performance of patients undergoing intravenous versus oral opioid agonist treatment: a prospective multicenter study on three-month treatment effects.

Introduction: The first-line treatment for opioid dependence is opioid agonist treatment (OAT) with oral opioids. However, in some cases, treatment with intravenous diacetylmorphine (IV-DAM) is indicated. Research on neurocognitive impairments and treatment effects of OAT - particularly with IV-DAM - on neurocognitive functioning, is scarce. The current study is the first to investigate the neurocognitive performance of individuals on OAT with IV-DAM. Using a prospective study design with two timepoints of measurement, the first aim was to assess the nature and extent of neurocognitive functioning in individuals with opioid dependence by comparing participants' neurocognitive performance with normative data of the general population on admission to treatment (baseline) and after an initial three-month period of OAT (study end). The second aim was to examine whether and to what extent neurocognitive performance would improve after three months on OAT. The third aim was to investigate whether, and if so, to what extent the treatment method (IV-DAM vs. oral opioids) would lead to higher neurocognitive improvements at study end. Methods: Forty-seven opioid-dependent individuals (baseline; 33 individuals at study end) participated in this study (mean age: 34.3 years; 27.7% female). Participants underwent neuropsychological testing with a battery of 12 tests covering different neurocognitive domains, including attention, memory, and executive functions. Results: Compared to normative data, opioid-dependent individuals showed impairments in almost every test both at baseline and at study end. At baseline, neurocognitive performance did not differ between individuals receiving IV-DAM or oral opioids for OAT. Compared to baseline, the neurocognitive performance did neither improve nor deteriorate after three months of treatment with neither IV-DAM nor oral opioids. However, a trend towards improvement was found for the memory domain. Discussion: Given that neurocognitive impairments should be considered in treatment planning and therapeutic interventions. Since a reduced cognitive performance may affect both the treatment outcome and the therapeutic relationship unfavorably, specific neurocognitive training at the beginning of treatment should be considered.

Evidence-based treatment for opioid use disorder is widely unavailable and often discouraged by providers of residential substance use services in North Carolina.

INTRODUCTION: Opioid agonist treatment (OAT) is the only treatment for opioid use disorder (OUD) proven to reduce overdose mortality, yet access to this evidence-based treatment remains poor. The purpose of this cross-sectional audit study was to assess OAT availability at residential substance use services in North Carolina. METHODS: We conducted a state-wide inventory of residential substance use service providers in North Carolina and subsequently called all providers identified, posing as uninsured persons who use heroin, seeking treatment services. Program characteristics, as reported in phone calls, were systematically recorded. We used Fisher's exact tests to assess what program characteristics were associated with OAT availability and with staff making discouraging comments about OAT. We used unsupervised agglomerative clustering to identify facilities with similar characteristics. RESULTS: Of the 94 treatment providers identified, we successfully contacted and collected data from 66. Of those, only 7 (10.6 %) provide OAT on site; an additional 9 (13.6 %) allow OAT through an outside or community-based prescriber. Only 8 (12.1 %) providers were licensed to provide residential substance use treatment. Staff from 33 (50.0 %) providers made negative, discouraging, or stigmatizing remarks about OAT-for example, that OAT substitutes one addiction for another or does not constitute "true recovery." OAT availability was positively associated with a provider holding a state license for any substance use-related service (41.9 % vs 8.6 %, p = 0.002) and offering 12-step programming (36.1 % vs. 10/0 %, p = 0.020). OAT availability was negatively associated with faith-based programming (6.1 % vs 42.4 %, p = 0.001), dress codes (5.3 % vs 50.0 %, p < 0.001), and mandates that residents work in a provider-owned and -operated commercial enterprise (5.0 % vs 32.6 %, p = 0.026). Cluster analysis revealed that the most common (n = 21) type of service provider in North Carolina is an unlicensed, faith-based organization that prohibits OAT, imposes a dress code, and mandates that residents work, often in provider-owned and -operated commercial enterprises. CONCLUSION: Evidence-based treatments for OUD are largely unavailable at providers of residential substance use services in North Carolina. The prohibition of OAT occurs most often among providers who are unlicensed and impose labor and/or 12-step mandates on residents. Changes to state licensure requirements and exemptions may help improve OAT availability.

Assessing predictors of adequate individual buprenorphine maintenance dosage for the treatment of opioid use disorder: Listening to the patient.

OBJECTIVE: Dose optimization plays a key role in determining clinical outcomes in patients on opioid agonist treatment (OAT). The objective of this study was to identify the variables independently associated with buprenorphine/naloxone (B/N) dose adequacy in patients with opiate use disorder (OUD). METHOD: Cross-sectional study of a convenience sample of patients with OUD treated with B/N (n = 315) in four regions in Spain. The Opiate Dosage Adequacy Scale (ODAS) was used to determine B/N dose adequacy. The ODAS evaluate the six components of the "dose adequacy" construct, as follows: continued use of heroin; narcotic blockade or crossed tolerance; objective opioid withdrawal symptoms (OWS); subjective OWS; craving for heroin; and overmedication. A binomial logistic regression analysis was performed to identify the variables associated with the condition "ODAS Adequate B/N dose". Participants completed a battery of instruments to assess sociodemographic, substance use, clinical, and treatment variables. RESULTS: The B/N dose was considered adequate in 231 of the 315 participants (73.3 %). Two variables, satisfaction with B/N as a medication (OR=5.764, 95 % CI=2.211-15.030) and patient-perceived participation in B/N dose decisions (OR=1.790, 95 % CI=1221-2623), were independently, significantly, and positively associated with the "ODAS Adequate B/N dose" condition. While the severity of heroin dependence was significantly associated with buprenorphine dose adequacy in the bivariate analyses, significance was lost in the full regression model. CONCLUSION: Satisfaction with B/N as a medication and patient-perceived involvement in the dose decision are associated with clinician-assessed dose adequacy. In the context of good clinical practice, it is important to take into account both of these variables to individualize the prescribed dose through a shared decision-making process.

Accessing opioid agonist treatment in prison in England and Scotland remains problematic - the views of people with lived experience.

PURPOSE: The purpose of this paper is to examine lived experiences of opioid agonist treatment (OAT) during and immediately following release from detention in prisons in England and Scotland. DESIGN/METHODOLOGY/APPROACH: Surveys were completed by serving prisoners in both countries and by those recently released from prison (England only). The survey findings were discussed in focus groups of people with lived experience. The combined findings from the surveys and focus groups were shared with an expert group of prison OAT providers and people with lived experience with the purpose of making recommendations for more accessible and effective OAT in custodial environments and continuity of OAT on release. FINDINGS: The quality and accessibility of OAT varied considerably between establishments. It was reported to be harder to access OAT in Scottish prisons. It was often hard for people in prison to get the dosage of OAT they felt they needed and it was generally harder to access buprenorphine than methadone in English prisons. Only Scottish people in prison were aware of long-lasting forms of buprenorphine. People in English prisons had mixed experiences of the help available in prison, with no improvement recorded since a 2016 study. People in Scottish prisons were more likely to rate the help available as poor. RESEARCH LIMITATIONS/IMPLICATIONS: The number of people accessed while actually in prison (73) was reduced by the impact of the pandemic, making it more difficult to access people in prison and because some were resistant to participating on the basis that they had already been consulted for a wide variety of research projects focused on the impact of COVID. The Scottish cohort (a total of 19 individuals comprising 14 survey respondents and five focus group members) is clearly too small a number on which to base robust claims about differences in OAT provision between the English and Scottish prison systems.. PRACTICAL IMPLICATIONS: The study identifies key barriers to accessing OAT in prisons and suggests key components of more user-friendly approaches. SOCIAL IMPLICATIONS: This study provides an overview of the recent lived experiences of people accessing OAT in prison and on release and offers valuable recommendations on how to make service provision more effective and consistent. ORIGINALITY/VALUE: This study provides an overview of the recent lived experiences of people accessing OAT in prison and on release in England and Scotland and offers valuable recommendations on how to make service provision more effective and consistent.

Opioid Medical Detoxification Compared to Opioid Agonist Treatment during Pregnancy: A Scoping Review.

Opioid use disorder (OUD) is highly prevalent, affecting up to 1% of pregnancies. The current standard of care for the management of OUD during pregnancy has been maintained with opioid agonist treatment (OAT), using either methadone or buprenorphine. OAT use has been associated with a risk of neonatal abstinence syndrome (NAS), which requires a longer neonatal length of stay for monitoring and possible pharmacological treatment. As a result, opioid medical detoxification (OMD) was proposed as an alternative strategy to reduce the stigma associated with OAT and to eliminate the risk of NAS by detoxifying or tapering pregnant persons during their pregnancy before delivery; however, the safety and effectiveness of OMD during pregnancy have not been established. This scoping review aims to summarize recent evidence related to maternal, obstetrical, and neonatal outcomes of OMD in comparison to OAT maintenance. This review also provides recommendations for future research initiatives to fill gaps in managing this patient population.

Client preferences for the design and delivery of injectable opioid agonist treatment services: Results from a best-worst scaling task.

BACKGROUND AND AIMS: Clinical trials support injectable opioid agonist treatment (iOAT) for individuals with opioid use disorder (OUD) for whom other pharmacological management approaches are not well-suited. However, despite substantial research indicating that person-centered care improves engagement, retention and health outcomes for individuals with OUD, structural requirements (e.g. drug policies) often dictate how iOAT must be delivered, regardless of client preferences. This study aimed to quantify clients' iOAT delivery preferences to improve client engagement and retention. DESIGN: Cross-sectional preference elicitation survey. SETTING: Metro Vancouver, British Columbia, Canada. PARTICIPANTS: 124 current and former iOAT clients. MEASUREMENTS: Participants completed a demographic questionnaire package and an interviewer-led preference elicitation survey (case 2 best-worst scaling task). Latent class analysis was used to identify distinct preference groups and explore demographic differences between preference groups. FINDINGS: Most participants (n = 100; 81%) were current iOAT clients. Latent class analysis identified two distinct groups of client preferences: (1) autonomous decision-makers (n = 73; 59%) and (2) shared decision-makers (n = 51; 41%). These groups had different preferences for how medication type and dosage were selected. Both groups prioritized access to take-home medication (i.e. carries), the ability to set their own schedule, receiving iOAT in a space they like and having other services available at iOAT clinics. Compared with shared decision-makers, fewer autonomous decision-makers identified as a cis-male/man and reported flexible preferences. CONCLUSIONS: Injectable opioid agonist treatment (iOAT) clients surveyed in Vancouver, Canada, appear to prefer greater autonomy than they currently have in choosing OAT medication type, dosage and treatment schedule.

'Matters-of-concern' associated with discontinuation of long-acting injectable buprenorphine: Findings from a longitudinal qualitative study.

BACKGROUND: Discontinuation of medications such as methadone and buprenorphine amongst patients receiving opioid agonist treatment (OAT) is an international phenomenon. Recent developments in OAT medication include depot-injections of buprenorphine. Circumstances underlying discontinuation of these new formulations of medication are not fully understood from a qualitative perspective. METHODS: Data derive from a longitudinal qualitative study of patients' experience of long-acting injectable buprenorphine (LAIB), involving semi-structured telephone-interviews held at six-points in time. The relevant dataset for this article consists of 44 interview transcripts, generated from 8 participants who were each affected by discontinuation of LAIB prescriptions (during the first 12-months of treatment). Analyses sought to identify circumstances associated with LAIB discontinuation and data were further situated within a framework of 'evidence making intervention' and associated 'matters-of-concern'. Matters-of-concern relate to the ways in which an intervention is 'made' and constructed through engagement and practice, from the perspective of the recipient. FINDINGS: In this study, participants experienced either 'discontinuation of LAIB prescriptions by treatment services' or patient-led 'opt-out' from treatment. Matters-of-concern underlying the former were associated with late attendance for scheduled appointments, non-prescribed substance use or receiving a custodial sentence. Matters-of-concern relating to patient-initiated discontinuation were associated with personal circumstances that affected treatment motivation, side-effects (of buprenorphine), a preference to resume heroin use, or because individual treatment goals had been achieved. CONCLUSION: The assorted matters-of-concern that influence discontinuation of LAIB demonstrate that such OAT is complex and multi-faceted, is neither fixed nor stable, and does not generate universally shared outcome. Experiences of LAIB discontinuation are shaped by a wide range of social, temporal and treatment-related effects that include disconnected therapeutic alliance between patient and treatment providers. In order to maximise the benefits of LAIB it is necessary to develop meaningful therapeutic alliances (notwithstanding policy boundaries) to enable exploration of matters-of-concern during treatment.

Pain in people seeking and receiving opioid agonist treatment: A systematic review and meta-analysis of prevalence and correlates.

BACKGROUND AND AIMS: People with opioid use disorder (OUD) commonly experience pain including chronic pain. Despite the high prevalence, few studies have systematically examined the prevalence and correlates of pain among people seeking or receiving opioid agonist treatment (OAT) for OUD. This review aimed to determine the prevalence of pain in this population globally, and estimate the association between chronic pain and other demographic and clinical characteristics. METHODS: Electronic searches were conducted in three databases (Medline, Embase and PsycINFO) from the inception until October 2022. Eligible studies reported prevalence rates of current and/or chronic pain. Meta-analyses examining the main prevalence estimates were conducted by Stata SE 18.0, and comorbid clinical conditions were analysed by Review Manager 5.4. RESULTS: Fifty-six studies (n participants = 35 267) from sixty-seven publications were included. Prevalence estimates of current and chronic pain were reported in 27 (48.2%) and 40 studies (71.4%), respectively. Most studies were conducted in North America (71.4%, n = 40) and used cross-sectional designs (64.3%, n = 36). Meta-analyses revealed a pooled prevalence of 60.0% (95% confidence interval [CI]: 52.0-68.0) for current pain and 44.0% [95% CI: 40.0-49.0] for chronic pain. Chronic pain was positively associated with older age (mean deviation of mean age: 2.39 years, 95% CI: 1.40-3.37; I2 = 43%), unemployment (odds ratio [OR] = 0.57, 95% CI: 0.42-0.76; I2 = 78%), more severe mental health symptoms (e.g. more severe depression (standardised mean difference [SMD] of mean scores: 0.45, 95% CI: 0.20-0.70; I2 = 48%) and anxiety symptoms (SMD: 0.52, 95% CI: 0.17-0.88; I2 = 67%), and hepatitis C (OR = 1.41, 95% CI: 1.03-1.94; I2 = 0%). No association was observed between chronic pain and the onset and type of OAT, geographic location, study design, survey year, participant age or use of specific pain assessment tools. CONCLUSIONS: There appears to be a high prevalence of pain among people seeking or receiving opioid agonist treatment for opioid use disorder compared with the general population, with positive associations for older age, unemployment, hepatitis C and the severity of some mental health symptoms.

Assessment of treatment retention rates and predictors of retention on opioid agonist treatment among adolescents.

INTRODUCTION: Opioid agonist treatment (OAT) is an effective treatment for opioid dependence syndrome in adults. However, studies on effectiveness of OAT in adolescents are limited; existing studies show varying retention rates. The present study aimed to assess OAT retention rates in adolescent patients with opioid dependence syndrome registered in a community drug treatment clinic in Delhi, India, and to analyse factors associated with retention at 1 year. METHODS: Retrospective cohort study. All adolescents (n = 130) aged 10-19 years, started on OAT from January 2020 to July 2022 were included. Baseline and follow-up data was extracted from online record system maintained at the clinic. OAT retention rates at different timepoints were assessed. Multivariable logistic regression was used to discern factors associated with one-year retention. RESULTS: The participants' mean age was 16.9 (SD 1.4) years. Mean age of starting opioids was 14.9 (SD 2.2) years; 29.5% (n = 38) injected opioids. The 6-, 12-, 18- and 24-month retention rate on OAT was 64.4%, 45.6%, 38.7% and 29% respectively. The retention rates with buprenorphine and methadone were comparable. Multivariate logistic regression showed retention for less than 12 months to be significantly associated with younger age of starting heroin, involvement in illegal activities, absenteeism from school and substance use in family. DISCUSSION AND CONCLUSIONS: The 12-month retention rates on OAT in adolescents is comparable to retention rates in adults. Various factors associated with early age of onset of opioid use are also associated with lower retention rates on OAT.

Buprenorphine deaths confirmed by toxicology reveal a low proportion of opioid agonist treatment before death in Finland.

We studied opioid agonist treatment (OAT) status before buprenorphine-related death in Finland, where buprenorphine is the principal OAT medicine and also the most misused opioid, through a retrospective population-based study using medico-legal cause-of-death investigation and OAT patient records. The study included all death cases (N = 570) between 2018 and 2020 with a buprenorphine or norbuprenorphine finding in post-mortem toxicology and with known drug misuse history or concomitant findings of illicit drugs. Of the deceased, 10% had received OAT in the year before death. Less than 1% of individuals < 25 years had received OAT, whereas the proportion in individuals ≥ 25 years was 13% (p < 0.001). There were significantly more females and more fatal poisonings (p < 0.001) among those < 25 years than among those ≥ 25 years. OAT medication at the time of death was sublingual buprenorphine-naloxone in 74% and subcutaneous buprenorphine in 23%. Except for significantly fewer benzodiazepine findings among those receiving OAT, minimal differences were found in terms of age, gender, cause and manner of death, or concomitant substance use between the deceased in and outside of OAT. Concomitant misuse of benzodiazepines, psychostimulants, alcohol, and gabapentinoids was frequent both in and outside of OAT and likely contributed to the death. These results suggest that access to OAT especially for young people and treatment of multiple addictions should be improved. Comprehensive information from medico-legal cause-of-death investigation as a starting point, combined with subsequent ante-mortem patient records, proved to be a successful approach to shed light on the Finnish scene of buprenorphine mortality.

Risk of drug-related death associated with co-prescribing of gabapentinoids and Z-drugs among people receiving opioid-agonist treatment: A national retrospective cohort study.

BACKGROUND: Prescribing of gabapentinoids and Z-drug-hypnotics has increased in the population and among people receiving opioid-agonist treatment (OAT) for opioid dependence. Evidence is mixed on whether co-prescribing of sedatives such as gabapentinoids and Z-drugs during OAT increases risk of drug-related death (DRD). METHODS: We conducted a retrospective cohort study of individuals prescribed OAT between 2011 and 2020 in Scotland. Prescribing records were linked to mortality data and other healthcare datasets (sociodemographic, comorbidity). We identified episodes of treatment with gabapentinoids/Z-drugs and used multivariable quasi-Poisson regression to model associations between co-prescription and DRD risk. RESULTS: Among 46,602 individuals with 304,783 person-years of follow-up, we found that co-prescription was common, with 25 % and 34 % ever being co-prescribed gabapentinoids and Z-drugs, respectively. Gabapentinoid exposure was strongly associated (adjusted hazard ratio (aHR)=2·18, 95 % CI=1·92, 2·46) and Z-drug exposure moderately associated (aHR=1·39, 95 % CI=1·15, 1·66) with elevated risk of DRD. Gabapentinoid exposure was associated with DRD risk on and off OAT; Z-drug exposure was less strongly associated with DRD risk when on OAT. CONCLUSIONS: Co-prescription of gabapentinoids and Z-drugs is common among OAT patients. However, co-prescription is associated with increased risk of DRD. Alternatives to prescribing sedative medications to OAT patients and/or greater monitoring - if prescribed - are needed.

Factors associated with SARS-CoV-2 testing, diagnosis and COVID-19 disease among individuals prescribed opioid-agonist treatment: a nationwide retrospective cohort study.

OBJECTIVES: Among people receiving opioid-agonist treatment (OAT), the risk of COVID-19 infection and disease may be higher owing to underlying health problems and vulnerable social circumstances. We aimed to determine whether recent OAT, when compared with past exposure, affected the risk of (i) testing for SARS-CoV-2, (ii) testing positive for SARS-CoV-2, and (iii) being hospitalized or dying with COVID-19 disease. METHODS: We included individuals prescribed OAT in Scotland from 2015 to 2020. We performed record linkage to SARS-CoV-2 PCR testing, vaccination, hospitalization, and mortality data, and followed up from March 2020 to December 2021. We used proportional hazards analysis and multivariate logistic regression to estimate associations between recent OAT prescription (in the previous 2 months), compared with past exposure (off treatment for over a year), and COVID-19 outcomes. Models were adjusted for confounders. RESULTS: Among 36 093 individuals prescribed OAT, 19 071 (52.9%) were tested for SARS-CoV-2; 2896 (8.3%) tested positive; and 552 (1.5%) were hospitalized or died with COVID-19. Recent OAT, compared with past exposure, was associated with lower odds of testing positive among those tested (aOR, 0.63; 95% CI, 0.57-0.69). However, among those testing positive, recent OAT was associated with two-fold higher odds of hospitalization or death (aOR, 2.04; 95% CI, 1.60-2.59). DISCUSSION: We found that recent OAT was associated with lower odds of SARS-CoV-2 infection, but with higher odds of disease once diagnosed. Clinical studies are needed to unravel the role of OAT in these associations. An enhanced effort is warranted to increase vaccine coverage among OAT patients to mitigate the severe consequences of COVID-19.

Exploring dual diagnosis in opioid agonist treatment patients: a registry-linkage study in Czechia and Norway.

BACKGROUND: Knowledge of co-occurring mental disorders (termed 'dual diagnosis') among patients receiving opioid agonist treatment (OAT) is scarce. This study aimed (1) to estimate the prevalence and structure of dual diagnoses in two national cohorts of OAT patients and (2) to compare mental disorders between OAT patients and the general populations stratified on sex and standardized by age. METHODS: A registry-linkage study of OAT patients from Czechia (N = 4,280) and Norway (N = 11,389) during 2010-2019 was conducted. Data on mental disorders (F00-F99; ICD-10) recorded in nationwide health registers were linked to the individuals registered in OAT. Dual diagnoses were defined as any mental disorder excluding substance use disorders (SUDs, F10-F19; ICD-10). Sex-specific age-standardized morbidity ratios (SMR) were calculated for 2019 to compare OAT patients and the general populations. RESULTS: The prevalence of dual diagnosis was 57.3% for Czechia and 78.3% for Norway. In Czechia, anxiety (31.1%) and personality disorders (25.7%) were the most prevalent, whereas anxiety (33.8%) and depression (20.8%) were the most prevalent in Norway. Large country-specific variations were observed, e.g., in ADHD (0.5% in Czechia, 15.8% in Norway), implying differences in screening and diagnostic practices. The SMR estimates for any mental disorders were 3.1 (females) and 5.1 (males) in Czechia and 5.6 (females) and 8.2 (males) in Norway. OAT females had a significantly higher prevalence of co-occurring mental disorders, whereas SMRs were higher in OAT males. In addition to opioid use disorder (OUD), other substance use disorders (SUDs) were frequently recorded in both countries. CONCLUSIONS: Results indicate an excess of mental health problems in OAT patients compared to the general population of the same sex and age in both countries, requiring appropriate clinical attention. Country-specific differences may stem from variations in diagnostics and care, reporting to registers, OAT provision, or substance use patterns.

Practitioner perspectives on working with older patients in opioid agonist treatment (OAT) in Norway: opportunities and challenges.

BACKGROUND: Norway has a growing proportion of ageing opioid agonist treatment (OAT) patients, with 42% of the 8300 Norwegian OAT patients aged over 50 in 2022. This study aims to explore practitioners' views and experiences from treatment of ageing OAT patients. METHODS: Data were collected as a series of semi-structured interviews with treatment staff (roles interviewed: doctor, psychologist, social worker, nurse, and learning disability nurse). Participants were recruited from three OAT outpatient clinics, one with an urban catchment area and two with a mix of urban and rural. The interviews incorporated questions on patients' somatic and mental health, strengths and weaknesses of the service for this group, and patients' quality of life. RESULTS: Older patients were perceived to be more often stable in terms of substance use and housing situation, but also experiencing some key challenges in terms of cognitive impairment, loneliness and isolation, and comorbidities. Both the practitioner-patient relationship and healthcare interactions outside OAT had the potential to impact treatment quality positively or negatively depending on how they were managed. CONCLUSIONS: Treating older patients in a way that respects and enhances their dignity is important. We argue that this requires better services for those whose functioning is impacted by cognitive impairment/dementia, an age-informed treatment model for this patient group, along with urgent work to improve municipal-level services given practitioners describe them as unacceptable in certain areas.

Management of loperamide-related opioid use disorder with buprenorphine within an Australian context: A case report.

Loperamide is an over-the-counter peripheral mu-opioid agonist commonly used to manage diarrhoea. When taken in an excessive dose, loperamide's penetration of the central nervous system increases, leading to euphoria, respiratory depression and other opioid effects. A health warning was released in the United States in 2016 with increased reports of excessive loperamide use leading to cardiac conduction abnormalities such as ventricular tachycardia, prolonged QTc and Torsades des Pointes. The growing number of cases is likely due to the increased restrictions on other opioids. Loperamide use disorder has been managed effectively in the United States and the United Kingdom using buprenorphine. In Australia, there have been recent opioid restrictions limiting easy access to opioids. We describe the case of a 28-year-old male who was admitted to hospital on multiple occasions with symptoms relating to loperamide use disorder. Buprenorphine was used to manage withdrawal symptoms in the hospital and maintain abstinence from loperamide in the community through an opioid agonist treatment program. To our knowledge, this is the first case study to describe the successful management of loperamide use disorder with buprenorphine within Australia. Our findings suggest that buprenorphine can be used to manage patients with loperamide associated withdrawal and help them remain abstinent upon discharge. Extramedical use of over-the-counter opioid medication may be becoming an emerging trend in Australia, and increased monitoring is warranted to prevent detrimental health outcomes.