Evaluation of heroin-assisted treatment in Norway: protocol for a mixed methods study.

BACKGROUND: Opioid agonist treatment (OAT) for patients with opioid use disorder (OUD) has a convincing evidence base, although variable retention rates suggest that it may not be beneficial for all. One of the options to include more patients is the introduction of heroin-assisted treatment (HAT), which involves the prescribing of pharmaceutical heroin in a clinical supervised setting. Clinical trials suggest that HAT positively affects illicit drug use, criminal behavior, quality of life, and health. The results are less clear for longer-term outcomes such as mortality, level of function and social integration. This protocol describes a longitudinal evaluation of the introduction of HAT into the OAT services in Norway over a 5-year period. The main aim of the project is to study the individual, organizational and societal effects of implementing HAT in the specialized healthcare services for OUD. METHODS: The project adopts a multidisciplinary approach, where the primary cohort for analysis will consist of approximately 250 patients in Norway, observed during the period of 2022-2026. Cohorts for comparative analysis will include all HAT-patients in Denmark from 2010 to 2022 (N = 500) and all Norwegian patients in conventional OAT (N = 8300). Data comes from individual in-depth and semi-structured interviews, self-report questionnaires, clinical records, and national registries, collected at several time points throughout patients' courses of treatment. Qualitative analyses will use a flexible inductive thematic approach. Quantitative analyses will employ a wide array of methods including bi-variate parametric and non-parametric tests, and various forms of multivariate modeling. DISCUSSION: The project's primary strength lies in its comprehensive and longitudinal approach. It has the potential to reveal new insights on whether pharmaceutical heroin should be an integral part of integrated conventional OAT services to individually tailor treatments for patients with OUD. This could affect considerations about drug treatment even beyond HAT-specific topics, where an expanded understanding of why some do not succeed with conventional OAT will strengthen the knowledge base for drug treatment in general. Results will be disseminated to the scientific community, clinicians, and policy makers. TRIAL REGISTRATION: The study was approved by the Norwegian Regional Committee for Medical and Health Research Ethics (REK), ref.nr.:195733.

Psychological factors predicting patients' risk of relapse after enrollment in drug use treatment: A systematic review.

BACKGROUND AND AIMS: Despite high rates of relapse after treatment for drug use, to our knowledge there is no systematic literature identifying psychological factors that predict risk of relapse to drug use (excluding alcohol or tobacco). Our aim was to identify psychological factors that predict risk of relapse to drug use after enrollment in drug use treatment. The identification of such factors can support treatment planning and relapse prevention. METHODS: We searched for peer-reviewed articles published between 2000 and 2023 in PsycINFO, PsycArticles, Web of Science, and PubMed. The inclusion criteria were: peer-reviewed publications, quantitative studies, in English, adult samples, with a prospective design, and analyses of minimum one psychological factor as predictor of relapse to drug use. All authors were involved in abstract and full-text screening, and in assessing risk of bias. The findings are presented in a narrative synthesis and tables are organized by type of drug. RESULTS: Of 2226 publications initially identified, 45 were eligible. Twenty-three focused on predicting relapse to stimulants, 15 to opioids, and 7 to unspecified drugs. Substance use at baseline was an important factor predicting risk of relapse to opioids, and possibly stimulants. There was an indication that craving and attention problems potentially predict relapse to use of some drugs. Mental health factors (e.g., psychiatric diagnosis) did not predict relapse. Several psychological factors (e.g., cognition, emotion, personality, motivation) were scarcely examined. Over half of the studies had moderate to high risk of bias. CONCLUSIONS: Based on the 45 studies, few psychological factors predicted risk of relapse to drug use. Higher comparability between studies and more rigorous methodology are necessary in order to derive more precise recommendations that inform and improve clinical practice. PRE-REGISTRATION: PROSPERO, CRD42020182839.

The prevalence of substance use disorders among people in Norwegian, Danish and Swedish prisons: A multi-national cohort study, 2010-19.

AIMS: We estimated the prevalence of substance use disorders (SUDs) in the Norwegian, Danish and Swedish prison populations and compared the prevalence of SUDs in the national prison populations with country-specific general population prevalence rates. DESIGN: A multi-national cohort study using data from the National Prison Registries linked to the National Patient Registries in Norway, Denmark and Sweden. SETTING AND PARTICIPANTS: We used data from the PriSUD-Nordic study, including national prison populations aged 19 years and older in Norway (2010-19), Denmark (2010-18) and Sweden (2010-13). A total of 119 507 Individuals (108 971 men and 10 536 women) contributing to 191 549 incarcerations were included in the study (Norway: 45432 men; 5429 women, Denmark: 42 162 men; 3370 women, Sweden: 21 377 men; 1737 women). MEASUREMENT: We calculated a study prevalence and prevalence at entry to prison for all types of SUDs before imprisonment each consecutive year of observation in each prison population. We also extracted country-specific 1-year prevalence rates from the Global Burden of Diseases database to calculate comparative national prevalence ratios. FINDINGS: The study prevalence of any SUD was approximately 40% [Norway: 44.0%, 95% confidence interval (CI) = 43.6-44.5%; Denmark: 39.9%, CI = 39.5-40.4%; Sweden: 39.1%, CI = 38.4-39.7%] in all three countries. Women had a significantly higher study prevalence of any SUD compared with men (Norway: 55.8 versus 42.6%, P < 0.001; Denmark 43.1 versus 39.7%, P = 0.004; Sweden: 51.7 versus 38.0%, P < 0.001). Prevalence estimates were higher for SUDs among people in prison than in the general population. We observed an increasing proportion of people with SUDs entering prison in Norway (P = 0.003), while the proportion was more stable in Denmark and Sweden. CONCLUSIONS: Substance use disorders (SUDs) appear to be highly prevalent among the Scandinavian prison populations compared with the general population, especially among women. In Norway, there was a relative increase in SUDs from 2010 to 2019.

The prevalence and comorbidity of mental health and substance use disorders in Scandinavian prisons 2010-2019: a multi-national register study.

BACKGROUND: Mental health disorders are common among people in prison, but their prevalence in the Scandinavian prison population remain unclear. In this multinational register study, we examined the prevalence of mental health disorders and the comorbidity of substance use disorders (SUDs) with other mental health disorders in this population. Further, we investigated how the prevalence of mental disorders at prison entry had changed in Norway, Denmark, and Sweden over the study period. METHODS: The three study cohorts included all individuals, aged 19 or older, whom had been imprisoned in Norway (2010-2019), Denmark (2011-2018), and Sweden (2010-2013). Mental disorders were defined as ICD-10 diagnoses (F-codes) registered in the national patient registers. The study prevalence was estimated based on recorded diagnoses during the entire study follow-up period in each respective country. The one-year prevalence of mental disorders was estimated for each calendar year for individuals entering prison during that year. RESULTS: The Scandinavian prison cohorts included 119 507 individuals released 191 549 times during the study period. Across all three countries a high proportion of both women (61.3%-74.4%) and men (49.6%-57.9%) had at least one mental health disorder during the observation period. The most prevalent disorders were SUDs (39.1%-44.0%), depressive disorder (8.1%-17.5%), and stress related disorder (8.8%-17.1%). Women (31.8%-41.1%) had higher levels of mental health and substance use comorbidities compared to men (20.8%-27.6%). The one-year prevalence of any mental health disorder increased over time with a 33% relative increase in Norway, 8% in Denmark, and 10% in Sweden. The proportion of individuals entering prison with a comorbid SUD and other mental disorder had also increased. CONCLUSIONS: While the incarceration rate has been decreasing during the past decade in the Scandinavian countries, an increasing proportion of people entering prison have a diagnosed mental health disorder. Our results suggest that prisons should provide adequate treatment and scale up services to accommodate the increasing proportion of people with complex health needs among incarcerated people.

Who receives heroin-assisted treatment? A comparison of patients receiving opioid maintenance treatment in Denmark.

BACKGROUND: Since 2010, heroin-assisted treatment (HAT) has been one of the treatment options available to people with opioid use disorder (OUD) in Denmark. This study aimed to characterize HAT patients at treatment start and compare their individual characteristics to those of patients entering traditional opioid maintenance treatment (OMT) with methadone or buprenorphine during the same period. METHODS: Patients who initiated HAT or OMT with methadone or buprenorphine in Denmark from 2010 to 2018 were included (n=6798). Multiple national registers were linked to compare treatment groups in terms of socio-demographic variables, previous OUD treatment episodes, hospital-based care, and criminal conviction history. RESULTS: Nearly all HAT patients had a history of methadone treatment (91%) and half had residential treatment experience (48%). In the year previous to admission, HAT patients recorded the highest percentages of non-fatal overdoses (12%) and chronic hepatitis C diagnoses (16%), and the lowest percentages of psychiatric disorders (11%) compared to traditional OMT patients. Criminal convictions were also common: 39% of the HAT group had committed a property crime and 18% a drug-related crime the year before HAT entry. During the study period, an overall reduction in OMT enrollments for each year was recorded. The HAT proportion to the total remained fairly stable (4%-10%), while the buprenorphine proportion increased. CONCLUSIONS: In Denmark, OMT patients exhibited numerous vulnerabilities at treatment start, and among the patient groups, HAT patients were the most burdened. HAT seems to reach the target group and adhere to formulated eligibility criteria.

Met and unmet prison-based treatment needs for people who are incarcerated with a history of substance use disorder: A nationwide cohort study.

BACKGROUND: Substance use disorders (SUD) are highly prevalent among incarcerated people. However, in some prisons, only a small percentage of those who need treatment receive it. The aims of this study were to examine coverage of treatment for SUD in Danish prisons and assess whether treatment differed by substance class. Further, we examined factors associated with receiving treatment for SUD, and types of services received. DATA AND METHODS: We linked multiple Danish register data using unique personal identification numbers. This study retrospectively analysed data for 49,330 individuals (aged 18-90) incarcerated in Danish prisons between 2008 and 2018. We used a multivariable logistic regression model to predict enrolment in treatment for SUD in prison. RESULTS: Of incarcerated people with a history of SUD, 34.6 % received treatment care during incarceration. We observed only minor variations in terms of substance classes concerning the type of treatment. Those who were women, immigrants, had higher education, or were married were less likely to receive treatment. CONCLUSIONS: Improving access and increasing treatment coverage in the Danish Prison and Probation Services is crucial to reduce the burden of SUD in incarcerated populations.

Large variations in all-cause and overdose mortality among >13,000 patients in and out of opioid maintenance treatment in different settings: a comparative registry linkage study.

Background: Opioid maintenance treatment (OMT) has the potential to reduce mortality rates substantially. We aimed to compare all-cause and overdose mortality among OMT patients while in or out of OMT in two different countries with different approaches to OMT. Methods: Two nation-wide, registry-based cohorts were linked by using similar analytical strategies. These included 3,637 male and 1,580 female patients enrolled in OMT in Czechia (years 2000-2019), and 6,387 male and 2,078 female patients enrolled in OMT in Denmark (years 2007-2018). The direct standardization method using the European (EU-27 plus EFTA 2011-2030) Standard was employed to calculate age-standardized rate to weight for age. All-cause and overdose crude mortality rates (CMR) as number of deaths per 1,000 person years (PY) in and out of OMT were calculated for all patients. CMRs were stratified by sex and OMT medication modality (methadone, buprenorphine, and buprenorphine with naloxone). Results: Age-standardized rate for OMT patients in Czechia and Denmark was 9.7/1,000 PY and 29.8/1,000 PY, respectively. In Czechia, the all-cause CMR was 4.3/1,000 PY in treatment and 10.8/1,000 PY out of treatment. The overdose CMR was 0.5/1,000 PY in treatment and 1.2/1,000 PY out of treatment. In Denmark, the all-cause CMR was 26.6/1,000 PY in treatment and 28.2/1,000 PY out of treatment and the overdose CMR was 7.3/1,000 PY in treatment and 7.0/1,000 PY out of treatment. Conclusion: Country-specific differences in mortality while in and out of OMT in Czechia and Denmark may be partly explained by different patient characteristics and treatment systems in the two countries. The findings contribute to the public health debate about OMT management and may be of interest to practitioners, policy and decision makers when balancing the safety and accessibility of OMT.

Cause-Specific Mortality among Patients in Treatment for Opioid Use Disorder in Multiple Settings: A Prospective Comparative Cohort Study.

INTRODUCTION: Among people receiving current or previous opioid maintenance treatment (OMT), the leading cause of premature death is an opioid overdose. However, other causes of mortality remain high in this group. An understanding of causes of deaths across multiple settings can be useful in informing more comprehensive prevention responses. The aim of this study was to describe all non-overdose causes of death in three national cohorts (Czechia, Denmark, and Norway) among OMT patients and to explore associations of non-overdose mortality with age and gender. METHODS: This prospective comparative cohort study used national mortality registry databases for OMT patients from Czechia (2000-2019), Denmark (2000-2018), and Norway (2010-2019). Crude mortality rates and age-standardized mortality rates (ASMRs) were calculated as deaths per 1,000 person years for cause-specific mortality. RESULTS: In total, 29,486 patients were included, with 5,322 deaths recorded (18%). We found variations in causes of death among the cohorts and within gender and age groups. The leading non-overdose causes of death were accidents in Czechia and Denmark, and neoplasms in Norway. Cardiovascular deaths were highest in Czechia, particularly for women in OMT (ASMR 3.59 vs. 1.24 in Norway and 1.87 in Denmark). CONCLUSION: This study found high rates of preventable death among both genders and all age groups. Different demographic structures, variations in risk exposure, as well as variations in coding practices can explain the differences. The findings support increased efforts towards screening and preventative health initiatives among OMT patients specific to the demographic characteristics in different settings.

The predictive value of brief measures of externalizing behavior and internalizing problems in young people receiving substance use treatment: A secondary analysis.

BACKGROUND: Identifying people at risk of poor outcomes following treatment for substance use disorders is important for developing tailored services. The aim of this study was to test whether a brief measure of internalizing and externalizing behavior could identify young adults at high risk of psychiatric care episodes and criminal offending up to four years after enrolment in treatment for substance use disorder. METHODS: Clients aged 15-25 years from a randomized multicenter study were included (N = 457). At baseline, all completed the YouthMap12 screener, a measure of internalizing symptoms (IP6) and externalizing problems (EP6). We used accelerated failure time regression to assess time to psychiatric care and criminal offending, adjusting for baseline occurrence, gender, age, treatment group, and uptake area. Youden's J was used to assess optimal cut-points for risk of events. RESULTS: The IP6 was associated with shorter time to psychiatric care following treatment enrolment (beta = -0.71, 95% confidence interval [CI] = -0.94 to -0.48; adjusted beta = -0.45, 95% CI = -0.66 to -0.25). The EP6 was associated with shorter time to criminal offending, coefficient = -0.32, 95% CI = -0.44 to -0.19; adjusted coefficient = -0.18, 95% CI = -0.30 to -0.06). Optimal cut-points were two or more for the IP6 and three or more for the EP6. CONCLUSIONS: The IP6 and the EP6, two simple and easily administered instruments, can identify young adults who are at an increased risk of future criminal offending or in need of psychiatric care. The findings lend support to using the 12-item YouthMap, as it identifies relevant risks, is compatible with local service delivery needs, and is theoretically and empirically supported.

Impulsive Lifestyle Counselling versus treatment as usual to reduce offending in people with co-occurring antisocial personality disorder and substance use disorder: a post hoc analysis.

OBJECTIVES: To assess the impact of a short psychoeducation intervention for antisocial personality disorder on offending after randomization to treatment. DESIGN: Multicentre, superiority, non-blinded randomized controlled trial. Random assignment was conducted in blocks of varying sizes at a central randomization centre. Participants were followed using national register data until 365 days after randomization, migration, or death, whichever occurred first. SETTING: Thirteen outpatient uptake areas in Denmark. PARTICIPANTS: Patients with antisocial personality disorder in treatment for substance use disorders were randomized to treatment as usual (TAU, n = 80) or Impulsive Lifestyle Counselling (ILC, n = 96). A total of 165 patients could be linked to criminal records (TAU, n = 74; ILC, n = 91). INTERVENTION: ILC is a brief psychoeducational program targeting antisocial behavior. The trial was conducted between January 2012 and June 2014. OUTCOMES: Number of criminal offences leading to convictions based on national registers. RESULTS: The mean number of offences was 2.76 in the TAU group (95% Poisson confidence interval [CI] = 2.39, 3.16) and 1.87 in the ILC group (95% CI = 0.97, 1.43). Negative binomial regression was used to assess total number of convictions, as well as convictions for violent, property, driving under the influence, and drug-related crimes. In both adjusted and unadjusted analyses, random assignment to ILC was associated with a lower number of total offences (incidence rate risk ratio [IRR] = 0.43, p = .013; adjusted IRR = 0.45, p < .001) and convictions related to violence (IRR = 0.19, p = .001 adjusted IRR = 0.19, p = .007) and property offences (unadjusted IRR = 0.30, p = 0.003, adjusted IRR = 0.42, p = 0.010). Differences between conditions were not significant for driving under the influence (unadjusted IRR = 0.49, p = .370; adjusted IRR = 0.53, p = .417) or drug offences (unadjusted IRR = 1.06, p = .907; adjusted IRR = 0.55, p = .223). CONCLUSIONS: The ILC program shows promise in reducing offending behavior in people with comorbid substance use and antisocial personality disorder. TRIAL REGISTRATION: ISRCTN registry, ISRCTN67266318 , 15/10/2012.

The impact of the COVID-19 lockdown on services for substance use in Denmark: Implications for meeting users' needs and recommendations for the future.

Background: The aim of this study was to document employees' experiences of changes in service provision for substance use disorders (SUDs) during the first COVID-19 lockdown in Denmark (spring 2020), as well as to examine their relation to challenges in meeting the service users' needs. Methods: Employees (N = 373) working in SUD treatment and harm reduction services completed an online survey soon after the first national lockdown. The survey included questions about changes in service provision during the lockdown, perceived concerns of the service users, and challenges in meeting the users' emerging needs. Results: Employees reported some positive changes in service provisions, such as increased flexibility in appointments, administering medication-assisted treatment (MAT), and use of telehealth. Negative changes were related to reduced contact with practitioners and harm reduction facilities. Approximately one third of employees reported significant challenges in meeting the users' emerging needs. This was particularly so when users' concerns were about physical and mental well-being, and substance use. In regression models, negative changes in the access to practitioners and MAT administration (but not other changes) predicted difficulties meeting the users' needs. Conclusion: Employees in SUD treatment and harm reduction services in Denmark experienced both positive and negative changes as a result of the first lockdown. However, not all the provision changes were linked to challenges in meeting the users' needs. We discuss practical and research implications of our findings with a focus on the users' physical and mental health, use of telehealth, MAT, and overall service reorganisation.

Substance Use and Violent Victimization: Evidence from a Cohort of >82,000 Patients Treated for Alcohol and Drug Use Disorder in Denmark.

Although the association between substance use and violence has been well established, knowledge on predictors for violent victimization of individuals treated for alcohol use disorder (AUD) or drug use disorder (DUD) is lacking. Using Goldstein's tripartite conceptual framework, this study examines the relationship between substance use and violent victimization. Data were derived from national registers on persons aged between 15 and 75 years, living in Denmark, and admitted for AUD or DUD treatment during 2006-2016 (n = 82,767). Rates of new incidence of violent victimization were estimated per 10,000 person years for the patient cohort, and for an age- and gender-matched control group of 492,397 people with no history of treatment for drug and alcohol problems. The incidence of victimization for the AUD/DUD sample was 145.6 per 10,000 person years and 5.4 per 10,000 person years for the comparison cohort. Results of multivariate Cox regression on specific types of substance use supported Goldstein's psychopharmacological and economic compulsive models of victimization, but not the systemic model. Gender-stratified results showed that the use of cannabis and methadone was associated with victimization in women treated for AUD and DUD. Patients with a non-Western background were more likely to experience victimization than Danish patients. The study highlights the strong association between substance use disorder and victimization, and the important role that service providers play in addressing the high levels of victimization experienced by patients with AUD or DUD.

Effects of contingency management and use of reminders for drug use treatment on readmission and criminality among young people: A linkage study of a randomized trial.

INTRODUCTION: An increasing number of adolescents and emerging adults are entering treatment for drug use disorders in high-income countries. This fact points not only to a need to evaluate treatment outcomes related to drug use reduction, but also to evaluate other indicators of treatment success. The aim of this study was to examine treatment effects on predicting readmission to drug use treatment and being convicted for a criminal offence among youth. A second aim was to examine whether a psychiatric history had an impact on these outcomes. METHODS: Participants were 460 youth aged 15-25 who took part in the YouthDAT, a randomized pragmatic clinical trial for outpatient drug use treatment. The trial compared four treatment conditions consisting of 12 sessions of a manualized treatment based on cognitive behavioral therapy and motivational interviewing. Condition one was the standard (only the manual); condition two consisted of standard treatment and contingency management (CM) (Vouchers); condition three included standard treatment, text reminders, and low-intensity aftercare (Reminders+LIA); and condition four combined the standard treatment, CM, text reminders, and low-intensity aftercare (Combined+LIA). The study linked participants to register data on psychiatric history, drug use treatment history, and criminal convictions. RESULTS: Treatment conditions Reminders+LIA (aB = 0.42, p = .026) and Combined+LIA (aB = 0.69, p = .000) predicted longer time to readmission compared to standard treatment. The Vouchers condition predicted a lower risk for criminal convictions (aIRR = 0.26, p = .001). Half of the participants had a psychiatric history. The treatments with additional strategies were useful in delaying readmission and reducing convictions for these youth. The results remained significant in the adjusted models accounting for relevant participant characteristics. CONCLUSIONS: Additional treatment strategies in outpatient drug use treatment, such as CM, text reminders, and low-intensity aftercare, predicted delayed readmission to treatment and fewer legal problems. Mental health problems were common among youth. However, the treatments with additional strategies were effective with youth with a psychiatric history. Overall, while the additional strategies may be resource demanding for clinical settings, they support treatment success and may also help to decrease other public costs. TRIAL REGISTRATION: ISRCTN registry ISRCTN27473213.

Cannabinoids for the treatment of cannabis use disorder: New avenues for reaching and helping youth?

Cannabis use peaks during adolescence and emerging adulthood, and cannabis use disorder (CUD) is associated with a wide range of adverse outcomes. This is particularly pertinent in youth, because the developing brain may be more vulnerable to adverse effects of frequent cannabis use. Combining evidence-based psychosocial interventions with safe and effective pharmacotherapy is a potential avenue to improve youth outcomes, but we lack approved CUD pharmacotherapies. Here, we review new potential avenues for helping youth with CUD, with a particular focus on cannabinoid-based treatments. Evidence from placebo-controlled RCTs suggests synthetic delta-9-tetrahydrocannabinol (THC) decreases withdrawal symptoms, but not cannabis use, in adults with daily cannabis use/CUD, while findings regarding formulations containing THC combined with cannabidiol (CBD) are mixed. Preliminary evidence from two placebo-controlled RCTs in adults with CUD suggests that both Fatty Acid Amide Hydrolase inhibitors and CBD can reduce cannabis use. However, larger trials are needed to strengthen the evidence. Findings from adults point to cannabinoid-based treatments as a potential strategy that should be examined in youth with CUD.

Purity of street-level cocaine across Denmark from 2006 to 2019: Analysis of seized cocaine.

Cocaine-related emergency department admissions are increasing, and cocaine seizures are at an all-time high in Europe. Our aim was to investigate the trends in purity and adulterants over time in cocaine available to cocaine users at street level in Denmark. We used a representative sample of cocaine seized at street level and analyzed by the national departments of forensic medicine between 2006 and 2019 (n = 1460). Latent profile analysis was used to classify the samples based on cocaine, levamisole, and phenacetin content. Low purity cocaine comprised most of the cocaine seizures in early years, but its share began to decline in 2013, and from 2016 to 2019, the high purity profile was dominant. While the total number of samples containing adulterants decreased, levamisole remained a common and dangerous adulterant. The findings underline the need to inform the public, medical doctors, and service providers for people with drug use disorders about the higher potency of street cocaine.

Voucher Reinforcement Decreases Psychiatric Symptoms in Young People in Treatment for Drug Use Disorders - A Post Hoc Secondary Analysis of a Randomized Controlled Trial.

OBJECTIVE: This multicenter, parallel randomized, open study examined the effect of using vouchers and session reminders as an added element to outpatient treatment for drug use disorders in youth. It was hypothesized that being randomly assigned to a contingency management condition would lead to a reduction of psychiatric symptoms, and that this reduction would be mediated through abstinence and treatment completion. METHODS: A total of 460 participants aged 15 to 25 years from nine outpatient sites were randomized to one of four treatment conditions (standard treatment alone [STD], i.e., 12 sessions using motivational interviewing and cognitive behavioral therapy, STD plus vouchers for attendance [VOU], STD plus text reminders [REM], or STD plus vouchers and text reminders [REM + VOU]). Participants' symptoms of psychological distress were assessed using the YouthMap 12 instrument at intake, and at 3, 6, and 9 months post-treatment initiation. Interviewers were blinded to interventions. RESULTS: 114 participants were randomized to STD, 112 to REM, 113 to VOU, and 121 to VOU + REM. 69 clients were never interviewed for follow-up, leaving 391 for analysis (n = 90, n = 94, n = 99, n = 108). The mean age was 20.5 years (SD = 2.6), 23% were female, and 34% reported having a psychiatric diagnosis. Random effects regression showed that participants randomized to one of the two voucher-based conditions experienced significantly steeper declines in symptoms compared with STD (p < .01). Structural equation modeling results indicated that the effects of contingency management on symptoms were mediated through abstinence, but not sessions attended. CONCLUSIONS: Adding contingency management to interventions for drug use disorders can reduce symptoms of psychological and emotional distress among populations of treatment-seeking youth, in part due to indirect effects through abstinence at follow-up. The data is collected from a clinical trial registered as ISRCTN27473213, at https://www.isrctn.com/.

Exploring the use of cannabis as a substitute for prescription drugs in a convenience sample.

BACKGROUND: The use of cannabis as medicine (CaM) both prescribed and non-prescribed has increased markedly in the last decade, mirrored in a global shift in cannabis policy towards a more permissive stance. There is some evidence that cannabis functions as a substitute for prescription drugs, particularly opioids; however, more knowledge is needed on the motives of substitution users, their patterns of use, and perceived effects of substitution use. AIMS: To explore who substitutes prescription drugs with cannabis, the type of prescription drugs substituted and the type of cannabis used, and the impact that substitution with cannabis has on prescription drug use as well as the motives for substitution in terms of experienced effects and side effects. METHODS: A self-selected convenience sample was recruited through social media, public media, and patient organizations to take part in an anonymous online survey. Inclusion criteria were 18 years or older and use of cannabis (prescribed or non-prescribed) with a medical purpose. RESULTS: The final sample included 2.841 respondents of which the majority (91%) used non-prescribed cannabis, and more than half (54.6%) had used CaM with the purpose of replacing a prescribed drug. Compared to non-substitution users, substitution users were more likely to be women and to use CaM in the treatment of chronic pain and other somatic conditions. Pain medication (67.2%), antidepressants (24.5%), and arthritis medication (20.7%) were the most common types of drugs replaced with CaM. Among substitution users, 38.1% reported termination of prescription drug use, and 45.9% a substantial decrease in prescription drug use. The most frequent type of cannabis used as a substitute was CBD-oil (65.2%), followed by 'hash, pot or skunk' (36.6%). More than half (65.8%) found CaM much more effective compared to prescription drugs, and 85.5% that the side effects associated with prescription drug use were much worse compared to use of CaM. CONCLUSION: CaM is frequently used as a substitute for prescription drugs, particularly opioids. More research is needed on the long-term consequences of use of CaM, including the impact from low and high THC cannabis products on specific somatic and mental health conditions.

A retrospective cohort study of medication dispensing at pharmacies: Administration matters!

BACKGROUND: Opioid agonist treatment (OAT) for opioid use disorders may be delivered at treatment clinics or dispensed from pharmacies, however the type of delivery may be associated with different risks and benefits. The aim of the study was to investigate whether dispensing of methadone or buprenorphine at pharmacies during treatment for opioid use disorders was associated with adverse outcomes. METHODS: Retrospective cohort study using a national, linked, population-level data set from Denmark. Patients included were between 18 and 75 years, living in Denmark, and admitted for treatment for opioid use disorders during 2000-2016 (n = 9299). Cox proportional hazards regression was estimated for convictions, non-fatal overdoses, and death, after the first dispensing of either methadone or buprenorphine from a pharmacy after starting treatment. FINDINGS: Of all patients, 68 % had methadone and 31 % had buprenorphine dispensed at a pharmacy. Compared with the time prior to pharmacy dispension, the risk of criminal convictions increased after having methadone dispensed from a pharmacy (adjusted hazard ratio (aHR) = 1.22, 95 % confidence interval (CI) = 1.16-1.28), non-fatal overdoses (aHR = 1.55, CI 1.41-1.71), and all-cause mortality (aHR = 1.54, CI = 1.43-1.76). After having buprenorphine dispensed at a pharmacy, risk of criminal convictions increased (aHR = 1.08, CI = 1.01-1.16) and non-fatal overdoses (aHR = 1.31, CI = 1.18-1.45), but not all-cause mortality (aHR = 1.07, CI = 0.94-1.23). CONCLUSIONS: For almost all outcomes investigated across medication type, the risk of adverse events increased following a switch from clinic dispension to pharmacy dispension of medications in OAT. Medically responsible and safe provision of OAT may often require more clinical follow-up than what is typically provided when medication is dispensed at pharmacies.

Opioid maintenance treatment in the Czech Republic, Norway and Denmark: a study protocol of a comparative registry linkage study.

INTRODUCTION: Opioid maintenance treatment (OMT) varies across settings and between countries. We plan to use data from several nationwide health and population registers to further improve the knowledge base established from earlier studies. Our aim is to study OMT adherence trajectories and to identify factors associated with improved outcomes for OMT patients across the Czech Republic, Norway and Denmark, in order to further improve OMT and our understanding of the key elements of treatment success. METHODS AND ANALYSIS: The registry-based cohort approach across the three countries allows us to link data from a range of registers on the individual level, by using personal identifiers in nationwide cohorts of OMT and non-OMT patients and the general non-using populations. A total of ~21 500 OMT patients over the last two decades in all three countries will be included in the study. The following outcome variables (based on the International Classification of Diseases, 10th Revision codes) will be obtained from relevant registers: treatment adherence to OMT, comorbidity (somatic and mental health), and all-cause and cause-specific mortality. Outcomes of the country-specific analyses will be pooled. ETHICS AND DISSEMINATION: The national OMT cohorts have been approved by the ethics committees in the respective countries. Data will be stored according to national and local guidelines and treated confidentially, and all data will be analysed separately for each country and compared across countries. Findings will be disseminated in peer-reviewed scientific journals, national and international conferences, and in briefings to inform clinical decision-making.