Psychological predictors of retention in a low-threshold methadone maintenance treatment for opioid addicts: a 1-year follow-up study.

This study investigated the role of psychological variables and judicial problems in treatment retention for a low-threshold methadone program in Montreal, Canada. Logistic regression analyses were computed to examine associations between psychological variables (psychological distress, self-esteem, stages of change), criminal justice involvement, and treatment retention for 106 highly-disorganized opioid users. Higher methadone dosage was associated with increased odds of treatment retention, whereas criminal charges and lower self-esteem decreased these odds. Psychological variables could be identified early in treatment and targeted to increase potential treatment retention. Financial support for this study was provided by the Fonds de Recherche en Santé du Québec.

[Opioid use disorder in patients with chronic non-cancer pain]. / Les troubles liés à l'utilisation des opioïdes prescrits médicalement.

Epidemiology Canada now has the second highest number of opioid prescriptions per capita in the world. The rate of prescriptions has increased over the last decade, most notably in adults over 55 years of age. A recognition of the importance of treating pain has influenced this increase, but higher rates of opioid prescribing have produced undesirable outcomes including the misuse of medication as well as an increased number of deaths and emergency department visits attributable to opioids. Diverse psychiatric disorders, such as major depression, now also occur in 40% of those with an opioid use disorder (OUD). Neuroscience We now understand that addictive behaviors are caused by both environmental and genetic factors. Although OUD has historically been perceived as a weakness of character, it is now clear that it is a chronic disease, which results from a complex interaction between a substance, such as opioid, environmental factors, and an individual's genotype. Unfortunately, this evidence has yet to be successfully translated into clinical practice and most physicians are unable to diagnose and manage OUD patients appropriately.Clinical guidelines Many clinical guidelines for the management of chronic, non-cancer pain are available. All guidelines identify the need to assess the patient appropriately and screen for factors associated with misuse before prescribing opioids. Guidelines generally acknowledge that patients should not be denied appropriate pain management, but that some patients will require close supervision and frequent follow-up to prevent the misuse of prescription opioids.

Diacetylmorphine versus methadone for the treatment of opioid addiction.

BACKGROUND: Studies in Europe have suggested that injectable diacetylmorphine, the active ingredient in heroin, can be an effective adjunctive treatment for chronic, relapsing opioid dependence. METHODS: In an open-label, phase 3, randomized, controlled trial in Canada, we compared injectable diacetylmorphine with oral methadone maintenance therapy in patients with opioid dependence that was refractory to treatment. Long-term users of injectable heroin who had not benefited from at least two previous attempts at treatment for addiction (including at least one methadone treatment) were randomly assigned to receive methadone (111 patients) or diacetylmorphine (115 patients). The primary outcomes, assessed at 12 months, were retention in addiction treatment or drug-free status and a reduction in illicit-drug use or other illegal activity according to the European Addiction Severity Index. RESULTS: The primary outcomes were determined in 95.2% of the participants. On the basis of an intention-to-treat analysis, the rate of retention in addiction treatment in the diacetylmorphine group was 87.8%, as compared with 54.1% in the methadone group (rate ratio for retention, 1.62; 95% confidence interval [CI], 1.35 to 1.95; P<0.001). The reduction in rates of illicit-drug use or other illegal activity was 67.0% in the diacetylmorphine group and 47.7% in the methadone group (rate ratio, 1.40; 95% CI, 1.11 to 1.77; P=0.004). The most common serious adverse events associated with diacetylmorphine injections were overdoses (in 10 patients) and seizures (in 6 patients). CONCLUSIONS: Injectable diacetylmorphine was more effective than oral methadone. Because of a risk of overdoses and seizures, diacetylmorphine maintenance therapy should be delivered in settings where prompt medical intervention is available. (ClinicalTrials.gov number, NCT00175357.)

[Treatment retention and evolution of clientele in a low threshold methadone substitution treatment program in Montreal]. / Rétention en traitement et évolution de la clientèle d'un programme montréalais de substitution à la méthadone à exigences peu élevees.

OBJECTIVES: To evaluate client treatment retention and evolution in terms of living conditions, at-risk behaviours, and the use of psychoactive substances (PAS) over a one-year period, following admission into a low-threshold methadone program in Montreal. METHOD: Individual interviews were administered to 114 clients from Relais-Méthadone (RM) at admission and one year after treatment initiation. Participants reported on PAS consumption and unsafe practices of drug use and sexual behaviours at high risk for transmission of HIV, sexually transmitted infections (STI) and other blood-borne viruses (BBV). Services utilized by clients were documented from Relais-Méthadone files. Bivariate analyses were used to compare data recorded at admission and one-year follow-up. RESULTS: The treatment retention rate after one year at RM was 64%. However, by taking into account those clients who were transferred to a regular program during the study period, as well as those who voluntarily tapered their methadone treatment (16.7%), the status of 80.7% of clients demonstrated improvement one year after admission into treatment. Furthermore, the clients who remained in treatment for a year for whom information was available (n = 60) showed a tendency towards more stable living conditions. They also demonstrated a significant decrease in both the number of PAS injections and in risky behaviours related to drug consumption. A statistically significant decrease in the frequency of heroine and cocaine use was also observed. By contrast, however, two thirds of the individuals in treatment after a year (n = 42) maintained or increased their daily consumption of other PAS. DISCUSSION: The treatment retention rate is comparable to other low or regular threshold substitution programs. The results support previous studies showing that the methadone substitution treatment reduces heroine and cocaine consumption, and decreases the number of unsafe behaviours that could potentially transmit HIV, STI and BBV for the majority of clients who remained in treatment. Future research could focus attention on people who abandon treatment and those who present at-risk behaviours during treatment.

Pain of first-trimester abortion: a study of psychosocial and medical predictors.

Pain during first-trimester abortion by suction-curettage under local anesthesia alone was measured with the McGill Pain Questionnaire (MPQ), and verbal and visual analogue scales in 109 women. The average intensity of abortion pain ranked among moderately intense pain recorded with the MPQ. However, the pain scores had a wide range and appeared influenced by several demographic, psychosocial and medical variables. A correlation/stratified multiple regression design was used to examine the sources of individual variability in pain reports. The results indicated that over a third of the variance in pain reports could be predicted by a set of variables which included the patient's age, self-reports of pre-operative depression, anxiety, fear, low pain tolerance, social and moral concerns, and gynecological characteristics such as uterus retroversion, menstrual pain and gestational age. Pain scores were significantly higher for women who reported moderate to severe levels of pre-abortion depression and for younger patients (13-17 years); other psychosocial and gynecological features made small additional contributions to the prediction of pain scores. The implications of the results are discussed in relation to pain management strategies and underscore the special needs of each woman facing an abortion.

[Accessibility to methadone substitution treatment: the role of a low-threshold program]. / Accessibilité aux traitements de substitution à la méthadone et réduction des méfaits: le rôle d'un programme à exigences peu élevées.

OBJECTIVE: To evaluate the accessibility to a Montreal low-threshold methadone program (Relais-Méthadone). This program is aimed at a marginalized population of heroin addicts who are injection drug users (IDU). METHOD: The data (n = 141 clients) were collected during the first year of the program implementation with questionnaires administered by the programme workers. RESULTS: Analysis of the characteristics of the clients revealed that the program does reach the target population. The program's clientele is characterized by long-time and frequent heroin use, unstable lifestyles, and the presence of numerous behaviours that put them at high risk for HIV transmission. The retention of clients in the program is very high (88%) within the first 30 days. INTERPRETATION: These results demonstrate the importance and value of flexible intervention programs in reaching a marginalized clientele exposed to the HIV virus, who would not have access to regular programs characterized by restrictive selection criteria and limited availability.