Predicting biopsychosocial outcomes for heroin users in primary care treatment: a prospective longitudinal cohort study.

BACKGROUND: Opiate substitution treatment for heroin users reduces mortality, illicit drug use, crime, and risk-taking behaviour, and improves physical, mental and social functioning. Few extended studies have been carried out in UK primary care to study factors predicting recovery. AIM: To establish whether primary care opiate substitution treatment is associated with improvements in outcomes over 11 years, in delivering recovery, and to identify predictive factors. DESIGN AND SETTING: A prospective longitudinal cohort study, with repeated measures in the Primary Care Addiction Service, Sheffield, 1999-2011. METHOD: A total of 123 eligible patients were assessed using the Opiate Treatment Index at entry to treatment and at 1, 5, and 11 years. Clinical records were used to assess factors including employment and discharge status. RESULTS: At 11 years, there was a high rate of drug-free discharge (22.0%) and medically-assisted recovery (30.9%), and low mortality (6.5%). Continuous treatment was associated with being discharged drug free (P = 0.005). For those still in treatment, there were highly significant reductions in heroin use and injecting, and significantly improved psychosocial functioning. There were strong positive correlations between mental health, physical health, and social functioning. Patients in employment had significantly better psychological and social functioning (P = 0.017, P = 0.007, respectively). CONCLUSION: Opiate substitution treatment is associated over 11 years with full recovery, drug-free discharge and medically-assisted recovery. There is a strong association between the psychosocial variables, suggesting that intervention in any one of these areas may have extended benefits, by impacting on related variables and employment. The best predictor of a drug-free discharge was continuous uninterrupted treatment.

Can a targeted GP-led clinic improve outcomes for street sex workers who use heroin?

Female street sex workers in the UK are often addicted to heroin, and sex work may be a result of the economic drive to fund this addiction. This study looks at outcomes of a primary care drugs treatment intervention for street sex workers who use heroin, using prescribed maintenance treatment with intensive health and psychosocial support. Thirty-four sex workers entered the study and 100% were retained in the study at 1 year. After 1 year, only 33% of participants were still sex workers. Quality of life had improved significantly and heroin use had reduced.

The effect of time spent in treatment and dropout status on rates of convictions, cautions and imprisonment over 5 years in a primary care-led methadone maintenance service.

BACKGROUND: Methadone maintenance treatment (MMT) in primary care settings is used increasingly as a standard method of delivering treatment for heroin users. It has been shown to reduce criminal activity and incarceration over periods of periods of 12 months or less; however, little is known about the effect of this treatment over longer durations. AIMS: To examine the association between treatment status and rates of convictions and cautions (judicial disposals) over a 5-year period in a cohort of heroin users treated in a general practitioner (GP)-led MMT service. DESIGN: Cohort study. SETTING: The primary care clinic for drug dependence, Sheffield, 1999-2005. PARTICIPANTS: The cohort comprised 108 consecutive patients who were eligible and entered treatment. Ninety were followed-up for the full 5 years. INTERVENTION: The intervention consisted of MMT provided by GPs in a primary care clinic setting. MEASUREMENTS: Criminal conviction and caution rates and time spent in prison, derived from Police National Computer (PNC) criminal records. FINDINGS: The overall reduction in the number of convictions and cautions expected for patients entering MMT in similar primary care settings is 10% for each 6 months retained in treatment. Patients in continuous treatment had the greatest reduction in judicial disposal rates, similar to those who were discharged for positive reasons (e.g. drug free). Patients who had more than one treatment episode over the observation period did no better than those who dropped out of treatment. CONCLUSIONS: MMT delivered in a primary care clinic setting is effective in reducing convictions and cautions and incarceration over an extended period. Continuous treatment is associated with the greatest reductions.

Concomitant drugs of misuse and drug using behaviours associated with fatal opiate-related poisonings in Sheffield, UK, 1997-2000.

AIMS: To examine the degree of involvement of concomitant drugs of misuse and other previously identified behavioural risk factors in acute accidental opiate-related poisoning fatalities in Sheffield, 1997-2000. DESIGN: Retrospective analysis of coroners' records. SETTING: Sheffield, UK. PARTICIPANTS: All those who died from an acute accidental opiate-related poisoning in Sheffield between 1 January 1997 and 31 December 2000. MEASUREMENTS: Coronial data were collated under the headings: demographic characteristics, circumstances of death and toxicological findings. FINDINGS: Ninety-four deaths occurred over the study period. The majority of cases were regular users of illicit drugs. Approximately 20% of deaths were preceded by a period of abstinence from drug use, with imprisonment and hospitalization as the most common reasons. Sixty-one per cent of cases had concomitant drugs of misuse detected from toxicology most commonly benzodiazepines and/or alcohol. These were, however, found in relatively small concentrations and opiate blood concentrations were no lower in deaths where multiple substances were involved. Despite evidence to suggest that smoking is the preferred route of heroin administration in this region, the vast majority of cases involved injecting. CONCLUSIONS: Administration of an opiate via intravenous injection was the most consistent factor associated with these deaths over the period of this study. Co-administration of other central nervous system depressants, at least in lower quantities appear to be a feature rather than a risk factor per se in such fatalities.

Methadone maintenance treatment can be provided in a primary care setting without increasing methadone-related mortality: the Sheffield experience 1997-2000.

Methadone maintenance treatment has been shown in many studies to reduce mortality and morbidity among heroin users. However, there has been concern that widespread methadone prescribing will lead conversely to an increase in methadone-related deaths. This study in Sheffield shows no increase in methadone-related mortality over a two-year period, during which 400 untreated patients were recruited into primary care methadone treatment in the city.

Deaths from drugs of abuse in Sheffield 1997-1999: what are the implications for GPs prescribing to heroin addicts?

OBJECTIVE: Our aim was to examine the characteristics of drug abuse deaths in Sheffield between 1997 and 1999 with particular attention on the role of prescribed medication and the impact of increased methadone prescribing. METHODS: Information was made available on all deaths reported to the City of Sheffield Coroner between 1 January 1997 and 31 December 31 1999. These records were searched to identify individuals who died from a 'drug of abuse'-related poisoning. RESULTS: A total of 82 drug of abuse-related deaths occurred in Sheffield during the 3-year period. The number of deaths rose from 16 in 1997 to 34 in 1999 (112%), with the largest increase occurring between 1997 and 1998. The mean age over the period of study was 29.4 years (SD 7.5 years), the overwhelming majority of which were male (92%), single (89%) and unemployed (84%). Heroin on its own or in combination with other drugs was considered to be responsible for death in 70% of all cases. Deaths attributable either wholly or partially to methadone poisoning fell from 37% in 1997 to 18% in 1999. CONCLUSIONS: Given that the proportion of deaths involving methadone over this period fell against a background of increased prescribing, then it would appear that the availability of methadone is not a factor involved in the increase in the number of drug of abuse-related deaths in this study.