The Cost-Effectiveness of Financial Incentives to Achieve Heroin Abstinence in Individuals With Heroin Use Disorder Starting New Treatment Episodes: A Cluster Randomized Trial-Based Economic Evaluation.

OBJECTIVES: Cost-effectiveness analysis of two 12-week contingency management (CM) schedules targeting heroin abstinence or attendance at weekly keyworker appointments for opioid agonist treatment compared with treatment as usual (TAU). METHODS: A cost-effectiveness analysis was conducted alongside a cluster randomized trial of 552 patients from 34 clusters (drug treatment clinics) randomly allocated 1:1:1 to opioid agonist treatment plus weekly keyworker appointments with (1) CM targeted at heroin abstinence (CM abstinence), (2) CM targeted at on-time attendance at weekly appointments (CM attendance), or (3) no CM (TAU). The primary cost-effectiveness analysis at 24 weeks after randomization took a societal cost perspective with effects measured in heroin-negative urine samples. RESULTS: At 24 weeks, mean differences in weekly heroin-negative urine results compared with TAU were 0.252 (95% confidence interval [CI] -0.397 to 0.901) for CM abstinence and 0.089 (95% CI -0.223 to 0.402) for CM attendance. Mean differences in costs were £2562 (95% CI £32-£5092) for CM abstinence and £317 (95% CI -£882 to £1518) for CM attendance. Incremental cost-effectiveness ratios were £10 167 per additional heroin-free urine for CM abstinence and £3562 for CM attendance with low probabilities of cost-effectiveness of 3.5% and 36%, respectively. Results were sensitive to timing of follow-up for CM attendance, which dominated TAU (better outcomes, lower costs) at 12 weeks, with an 88.4% probability of being cost-effective. Probability of cost-effectiveness remained low for CM abstinence (8.6%). CONCLUSIONS: Financial incentives targeted toward heroin abstinence and treatment attendance were not cost-effective over the 24-week follow-up. Nevertheless, CM attendance was cost-effective over the treatment period (12 weeks), when participants were receiving keyworker appointments and incentives.

Use of contingency management incentives to improve completion of hepatitis B vaccination in people undergoing treatment for heroin dependence: a cluster randomised trial.

BACKGROUND: Poor adherence to treatment diminishes its individual and public health benefit. Financial incentives, provided on the condition of treatment attendance, could address this problem. Injecting drug users are a high-risk group for hepatitis B virus (HBV) infection and transmission, but adherence to vaccination programmes is poor. We aimed to assess whether contingency management delivered in routine clinical practice increased the completion of HBV vaccination in individuals receiving opioid substitution therapy. METHODS: In our cluster randomised controlled trial, we enrolled participants at 12 National Health Service drug treatment services in the UK that provided opioid substitution therapy and nurse-led HBV vaccination with a super-accelerated schedule (vaccination days 0, 7, and 21). Clusters were randomly allocated 1:1:1 to provide vaccination without incentive (treatment as usual), with fixed value contingency management (three £10 vouchers), or escalating value contingency management (£5, £10, and £15 vouchers). Both contingency management schedules rewarded on-time attendance at appointments. The primary outcome was completion of clinically appropriate HBV vaccination within 28 days. We also did sensitivity analyses that examined vaccination completion with full adherence to appointment times and within a 3 month window. The trial is registered with Current Controlled Trials, number ISRCTN72794493. FINDINGS: Between March 16, 2011, and April 26, 2012, we enrolled 210 eligible participants. Compared with six (9%) of 67 participants treated as usual, 35 (45%) of 78 participants in the fixed value contingency management group met the primary outcome measure (odds ratio 12·1, 95% CI 3·7-39·9; p<0·0001), as did 32 (49%) of 65 participants in the escalating value contingency management group (14·0, 4·2-46·2; p<0·0001). These differences remained significant with sensitivity analyses. INTERPRETATION: Modest financial incentives delivered in routine clinical practice significantly improve adherence to, and completion of, HBV vaccination programmes in patients receiving opioid substitution therapy. Achievement of this improvement in routine clinical practice should now prompt actual implementation. Drug treatment providers should employ contingency management to promote adherence to vaccination programmes. The effectiveness of routine use of contingency management to achieve long-term behaviour change remains unknown. FUNDING: National Institute for Health Research (RP-PG-0707-10149).

Sexual health risks and health-seeking behaviours among substance-misusing women.

AIMS: To report on a survey of sexual health service needs among substance-misusing women attending a substance misuse service. BACKGROUND: Substance-misusing women carry a disproportionate burden of sexual ill health, yet the range and frequency of their sexual health risks, morbidities and service engagement are poorly understood. DESIGN: A cross-sectional survey of a convenience sample of substance-misusing women attending a substance misuse service. METHODS: From 4 April 2010-17 September 2010, substance-misusing women in Hastings & Ore, UK, were invited to complete a paper questionnaire addressing: drug use; cervical cytology, sexually transmitted infection and HIV screening history; pregnancy history, perceived pregnancy risk and contraceptive advice and supply; sexual activity and assault. Of 91 respondents, 77 attended local drug treatment services - results comprise analysis of this sub-sample. RESULTS: The study sample was characterized by long-term opioid and crack cocaine use. Of 53% sexually active in the previous 4 weeks, 66% perceived they had experienced sexual intercourse that could lead to pregnancy during that time. Fifty-five per cent had been forced to have sex against their will during their lifetime. High rates of sexually transmitted infections, pregnancy termination, miscarriage and abnormal cervical cytology were reported. CONCLUSIONS: Findings indicate the need to recognize the breadth of elevated sexual health risks and morbidities experienced by substance-misusing women with long-term opioid/crack use, including those not identifying as intravenous drug users. Poor recall of drop-in and appointment times, reluctance to disclose substance misuse and likelihood of previous sexual assault present significant challenges to nurses, who must take a sensitive, opportunistic approach to referral and provision of sexual health interventions to substance-misusing women.

Using a pragmatically adapted, low-cost contingency management intervention to promote heroin abstinence in individuals undergoing treatment for heroin use disorder in UK drug services (PRAISE): a cluster randomised trial.

INTRODUCTION: Most individuals treated for heroin use disorder receive opioid agonist treatment (OAT)(methadone or buprenorphine). However, OAT is associated with high attrition and persistent, occasional heroin use. There is some evidence for the effectiveness of contingency management (CM), a behavioural intervention involving modest financial incentives, in encouraging drug abstinence when applied adjunctively with OAT. UK drug services have a minimal track record of applying CM and limited resources to implement it. We assessed a CM intervention pragmatically adapted for ease of implementation in UK drug services to promote heroin abstinence among individuals receiving OAT. DESIGN: Cluster randomised controlled trial. SETTING AND PARTICIPANTS: 552 adults with heroin use disorder (target 660) enrolled from 34 clusters (drug treatment clinics) in England between November 2012 and October 2015. INTERVENTIONS: Clusters were randomly allocated 1:1:1 to OAT plus 12× weekly appointments with: (1) CM targeted at opiate abstinence at appointments (CM Abstinence); (2) CM targeted at on-time attendance at appointments (CM Attendance); or (3) no CM (treatment as usual; TAU). Modifications included monitoring behaviour weekly and fixed incentives schedule. MEASUREMENTS: Primary outcome: heroin abstinence measured by heroin-free urines (weeks 9-12). SECONDARY OUTCOMES: heroin abstinence 12 weeks after discontinuation of CM (weeks 21-24); attendance; self-reported drug use, physical and mental health. RESULTS: CM Attendance was superior to TAU in encouraging heroin abstinence. Odds of a heroin-negative urine in weeks 9-12 was statistically significantly greater in CM Attendance compared with TAU (OR=2.1; 95% CI 1.1 to 3.9; p=0.030). CM Abstinence was not superior to TAU (OR=1.6; 95% CI 0.9 to 3.0; p=0.146) or CM Attendance (OR=1.3; 95% CI 0.7 to 2.4; p=0.438) (not statistically significant differences). Reductions in heroin use were not sustained at 21-24 weeks. No differences between groups in self-reported heroin use. CONCLUSIONS: A pragmatically adapted CM intervention for routine use in UK drug services was moderately effective in encouraging heroin abstinence compared with no CM only when targeted at attendance. CM targeted at abstinence was not effective. TRIAL REGISTRATION NUMBER: ISRCTN 01591254.

Influence of the dose on the severity of opiate withdrawal symptoms during methadone detoxification.

AIM: This study investigates factors influencing the severity of opiate withdrawal symptoms, focusing on the relationship between methadone dose and withdrawal severity among opiate-dependent in-patients receiving methadone detoxification. METHODS: The sample comprised 48 opiate-dependent patients admitted to a specialist in-patient drug treatment service and withdrawn from opiates, using a 10-day methadone reduction schedule. The severity of withdrawal symptoms was assessed daily using the Short Opiate Withdrawal Scale. RESULTS: Patients withdrawn from higher doses of methadone and those reporting higher levels of anxiety reported more severe withdrawal symptoms. No relationship was found between methadone dose and completion of detoxification or length of hospital stay. CONCLUSIONS: Although patients on higher doses of methadone reported more severe opiate withdrawal symptoms than patients on lower doses, the dose effect accounted for only a small percentage of the total variance. Nonetheless, the finding of a dose-response effect supports one of the basic principles of clinical practice during detoxification, namely the matching of the medication withdrawal schedule to the pre-admission opiate dose.

The relationship between cognitive inhibition and psychotic symptoms.

Cognitive models of schizophrenia have highlighted deficits of inhibitory attentional processes as central to the disorder. This has been investigated using "negative priming" (S. P. Tipper, 1985), with schizophrenia patients showing a reduction of negative priming in a number of studies. This study attempted to replicate these findings, but studied psychotic symptoms rather than the broad diagnostic category of schizophrenia. Psychotic individuals exhibiting positive symptoms were compared with asymptomatic psychiatric patients and with a normal control group. As predicted, the symptomatic group failed to show the usual negative priming effect, which was present in the asymptomatic and normal groups. A modest but significant correlation was found between negative priming and delusions. Neither diagnosis, nor affective or negative symptoms, nor chronicity, nor medication, was related to negative priming. These data replicate previous findings that positive symptoms are related to a reduction in cognitive inhibition, although considerable variability was observed among the psychotic patients.

Clinical features and management of gamma-hydroxybutyrate (GHB) withdrawal: a review.

AIM: To examine the clinical course of gamma-hydroxybutyrate (GHB) withdrawal and generate management guidelines. DESIGN: Review and analysis of all published reports of GHB or GHB precursor withdrawal identified from electronic searches. FINDINGS: In total, 38 cases of GHB (n = 28) or GHB precursor (n = 10) withdrawal were identified, 36 of which were from the US. A rapidly deteriorating course into delirium (53% of cases) was typical for heavily dependent users. Symptoms were broadly similar to alcohol withdrawal but often occurred earlier in usage with delirium being associated with severe dependence as determined by more frequent ingestion. High dose benzodiazepines were effective in pharmacological management of GHB withdrawal. In benzodiazepine refractory cases withdrawal responded to other sedative agents, mainly pentobarbital or chloral hydrate. No withdrawal seizures but one death was recorded. CONCLUSIONS: GHB withdrawal is potentially life threatening and requires vigorous clinical management, preferably as an inpatient for severe cases. A management algorithm is proposed.

Benzodiazepine co-dependence exacerbates the opiate withdrawal syndrome.

Patients seeking treatment for opiate withdrawal are commonly also dependent on benzodiazepines, although the interactions between benzodiazepine and opiate dependence and withdrawal syndromes have been subject to little systematic investigation. This is the first study comparing type, severity and course of opiate withdrawal symptoms between opiate dependent patients with, and without, concurrent benzodiazepine dependence. Patients dependent only on opiates (n = 39), and patients dependent on both opiates and benzodiazepines (n = 22), were recruited from consecutive admissions to an in-patient drug treatment unit. Quantity and duration of prior opiate use was similar for both groups. Patients completed daily self-ratings of opiate withdrawal (SOWS) for the duration of a standard in-patient detoxification treatment. Co-dependent patients were detoxified from benzodiazepines and opiates concurrently. Co-dependent patients reported a more severe withdrawal symptoms than patients withdrawing from opiates alone. Co-dependent patients had significantly more severe opiate withdrawal symptoms. Concurrent benzodiazepine withdrawal exacerbates opiate specific withdrawal symptoms. Possible psychological and neurophysiological mechanisms for the observed sensitisation are discussed.

Understanding barriers to sexual health service access among substance-misusing women on the South East coast of England.

OBJECTIVES: Evidence suggests substance-misusing women (SMW) experience disproportionate sexual health morbidity and poor uptake of interventions including contraception and cervical screening, yet there has been little investigation of sexual health service access issues for this population. METHODS: Twenty women with problem drug use in Hastings in South East England, UK participated in a one-to-one interview with a researcher to explore experiences and beliefs surrounding access to a range of sexual health service interventions. Transcripts were open-coded and themes were elicited and organised concerning barriers to access. RESULTS: Drug-use lifestyles, trauma and low self-worth framed the lives of SMW and hindered sexual health service access through: depleted practical and emotional resources to enable attendance; high perceived emotional cost of discussing sexual histories, and coping with tests and unfavourable results; and low anticipated value of sexual health interventions due to low perception and minimisation of risk and perceived incompatibility between drug use and sexual well-being. CONCLUSIONS: A range of practical, social and emotional barriers to sexual health service access exist for this population, presenting a context from within which use of services may come at considerable personal cost to SMW. Interventions addressing anticipated stigma and emotional, hygiene and fiscal concerns are warranted for this population.

Comparison of buprenorphine and methadone in the treatment of opiate withdrawal: possible advantages of buprenorphine for the treatment of opiate-benzodiazepine codependent patients?

The study is a preliminary investigation to compare the effectiveness of buprenorphine and methadone as opiate detoxification treatments. The sample comprised 123 drug misusers who were dependent upon opiates only or who were codependent upon opiates and benzodiazepines. Drug misusers dependent upon methadone doses up to 70 mg were eligible for the study. Detoxification took place within a specialist inpatient drug-dependence unit. Withdrawal symptom severity was assessed on a daily basis by means of the Short Opiate Withdrawal Scale. Outcome was assessed for reductions in severity of withdrawal symptoms, treatment retention, and treatment completion. Buprenorphine detoxification was associated with less severe opiate withdrawal symptoms than methadone. Opiate/Benzodiazepine codependent patients reported less severe withdrawal symptoms during treatment with buprenorphine than with methadone and were also more likely to complete detoxification when treated with buprenorphine.

Within-patient variability in clinical presentation of gamma-hydroxybutyrate withdrawal: a case report.

The emergence of gamma-hydroxybutyrate (GHB) dependence in the UK is described, with specific reference to a case study of serial episodes of GHB withdrawal. Symptoms are broadly similar to those for alcohol withdrawal, and rapid deterioration into delirium is common in severe dependence. This case report reflects the variability in clinical presentation of GHB withdrawal and response to treatment, even within the same patient. It is concluded that GHB withdrawal requires vigorous clinical management, preferably on an elective basis, in an inpatient setting if dependence is severe.