Temporal changes in non-fatal opioid overdose patterns among people who use drugs in a Canadian setting.

Background and Aims: Little is known about how the expansion of opioid agonist therapy (OAT) and emergence of fentanyl in the illicit drug supply in North America has influenced non-fatal opioid overdose (NFOD) risk. Therefore, we sought to identify patterns of substance use and addiction treatment engagement (i.e., OAT, other inpatient or outpatient treatment) prior to NFOD, as well as the trends and correlates of each pattern among people who use drugs (PWUD) in Vancouver, Canada. Methods: Data were derived from participants in three prospective cohorts of PWUD in Vancouver in 2009-2016. Observations from participants reporting opioid-related NFOD in the previous six months were included. A latent class analysis was used to identify classes based on substances used at the time of last NFOD and addiction treatment engagement in the month prior to the last NFOD. Multivariable generalized estimating equations estimated the correlates of each class membership. Results: In total, 889 observations from 570 participants were included. Four distinct classes were identified: (1) polysubstance use (PSU) and addiction treatment engagement; (2) PSU without treatment engagement; (3) exposure to unknown substances, mostly without treatment engagement; and (4) primary heroin users without treatment engagement. The class of exposure to unknown substances appeared in 2015 and became the dominant group (76.9%) in 2016. In multivariable analyses, the odds of membership in the class of primary heroin users decreased over time (adjusted odds ratio [AOR]: 0.74, 95% confidence interval [CI]: 0.68-0.81). Conclusions: Changing profiles of PWUD reporting opioid-related NFOD were seen over time. Notably, there was a sudden increase in reports of overdose following exposure to unknown substances since 2015, the majority of whom reported no recent addiction treatment engagement. Further study into patterns of substance use and strategies to improve addiction treatment engagement is needed to improve and focus overdose prevention efforts.

Prevalence and treatment of opioid use disorders among primary care patients in six health systems.

BACKGROUND: The U.S. experienced nearly 48,000 opioid overdose deaths in 2017. Treatment of opioid use disorder (OUD) with buprenorphine is a recommended part of primary care, yet little is known about current U.S. practices in this setting. This observational study reports the prevalence of documented OUD and OUD treatment with buprenorphine among primary care patients in six large health systems. METHODS: Adults with ≥2 primary care visits during a three-year period (10/1/2013-9/30/2016) in six health systems were included. Data were obtained from electronic health record and claims data, with measures, assessed over the three-year period, including indicators for documented OUD from ICD 9 and 10 codes and OUD treatment with buprenorphine. The prevalence of OUD treatment was adjusted for age, gender, race/ethnicity, and health system. RESULTS: Among 1,368,604 primary care patients, 13,942 (1.0 %) had documented OUD, and among these, 21.0 % had OUD treatment with buprenorphine. For those with documented OUD, the adjusted prevalence of OUD treatment with buprenorphine varied across demographic and clinical subgroups. OUD treatment was lower among patients who were older, women, Black/African American and Hispanic (compared to white), non-commercially insured, and those with non-cancer pain, mental health disorders, greater comorbidity, and more opioid prescriptions, emergency department visits or hospitalizations. CONCLUSIONS: Among primary care patients in six health systems, one in five with an OUD were treated with buprenorphine, with disparities across demographic and clinical characteristics. Less buprenorphine treatment among those with greater acute care utilization highlights an opportunity for systems-level changes to increase OUD treatment.

Monitoring consumption of methadone and heroin in major Chinese cities by wastewater-based epidemiology.

BACKGROUND: Methadone maintenance treatment (MMT) services have been used in China for treatment of heroin dependence. But no study has been conducted to assess the appropriateness of MMT distribution and the potential abuse of methadone in China. This study aims to do that through a nationwide estimation of methadone consumption in China via wastewater-based epidemiology and subsequently compare it with MMT data and level of heroin abuse. METHODS: Wastewater samples were collected from 53 wastewater treatment plants in 27 major cities that cover all geographic regions of China. Methadone and pure heroin consumptions were estimated based on influent concentrations of methadone, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), morphine and codeine. RESULTS: Drug residues were detected in most samples. The ratio of EDDP/methadone was around 2 in influents and methadone and EDDP loads were strongly correlated, indicating that they originated from human consumption. Both influent methadone and EDDP loads in Southwest and Northwest China were significantly higher than those in other regions. The highest estimated consumptions of methadone and heroin in China were 22.0 ±â€¯2.1 mg/1000 in./d and 263.9 ±â€¯115.9 mg/1000 in./d, respectively. There was a significant positive correlation between methadone and heroin consumptions. CONCLUSIONS: Consumption of methadone in China was primarily from MMT services. The use of methadone and heroin displayed a clear geographical pattern: it is higher in the western inland regions than in the eastern regions. This study has shown that the distribution of MMT services is reflective of the level of heroin abuse in different regions of China.

Buprenorphine Use in Palliative Care.

Palliative care is encountering an increasing number of patients with opioid use disorder who are managed on medication-assisted treatment. Buprenorphine is US Food and Drug Administration approved for office-based management of opioid use disorder. As a partial opioid agonist, it can be used to manage pain in the palliative care setting but can also pose inherent challenges to the management of pain that necessitates full opioid agonists. This article uses a case example to highlight the management of substance use disorder and pain in a patient on buprenorphine along the full illness trajectory. In addition, an overview of buprenorphine pharmacology, unique aspects of the prescribing waiver, and pain management will be discussed.

Mixed methods to explore factors associated with the decline of patients in the methadone maintenance treatment program in Shanghai, China.

BACKGROUND: This study was to characterize the Methadone Maintenance Treatment (MMT) in Shanghai, China, and to explore factors associated with the decline of patients in MMT during 2005-2016. METHODS: Both qualitative and quantitative methods were used in this study. Based on the data from Shanghai Centers for Disease Control (CDC), we described the changes in the number of patients who received MMT, and new enrollment each year from 2005 to 2016. Focus groups were conducted with 22 patients, and in-depth interviews were conducted with 9 service providers. RESULTS: Quantitative data demonstrate that the number of new enrollment began to decline in 2009, and the number of patients receiving MMT began to decline in 2012. The main reasons for dropout include (1) discontinuing medication due to unknown reasons (25%), (2) criminal activities other than drug-related crimes (20%), (3) relapse to heroin use (16%), and (4) physical disease (10%). Qualitative assessment results indicate that the major reasons for the decline of patients in MMT are as follows: (1) the increase of Amphetamine-type stimulants (ATS) use in recent years, (2) limited knowledge about MMT in both patients and MMT staff, (3) complicated enrollment criteria, and (4) discrimination against drug use. CONCLUSION: Various reasons to explain the decline of patients in MMT in Shanghai, China, were identified. Government agencies, service providers, and other stakeholders need to work together and overcome identified barriers to support MMT programs in China.

Non-suicidal self-injury in Chinese heroin-dependent patients receiving methadone maintenance treatment: Prevalence and associated factors.

BACKGROUND: To date, there have been no studies examining non-suicidal self-injury (NSSI) in Chinese heroin-dependent patients (HDPs) receiving methadone maintenance treatment (MMT). This study determined the prevalence of NSSI and its methods in HDPs under MMT as well as factors significantly associated with NSSI. METHOD: We recruited a cross-sectional sample of 652 HDPs from three MMT clinics in Wuhan, China. In total, 603 HDPs (92.5%) completed standardized questionnaires concerning demographic, clinical, and psychosocial data. The presence and methods of NSSI were assessed with two standardized questions. RESULTS: The one-month prevalence of NSSI in Chinese HDPs receiving MMT was 13.8%. The most common three methods of NSSI were burning (59%), cutting (19.3%), and hitting (9.6%). Significant factors associated with NSSI in multiple logistic regression analysis were unemployment (OR [95%CI] = 2.54 [1.26, 5.10], P = 0.009), a short duration of MMT (OR [95%CI] = 1.04 [1.01, 1.09], P = 0.034), pain (OR [95%CI] = 2.31 [1.05, 5.35], P = 0.028), depression (OR [95%CI] = 4.32 [2.09, 9.00], P < 0.001), anxiety (OR [95%CI] = 3.74 [1.61, 8.70], P = 0.002), and loneliness (OR [95%CI] = 3.04 [1.27, 7.26], P = 0.012). CONCLUSIONS: NSSI is common among Chinese HDPs of MMT clinics. Services for HDPs in MMT settings should include periodic screening for NSSI, adequate pain treatment, and appropriate psychosocial treatment for depression, anxiety, and loneliness.

Factors associated with discontinuation of methadone maintenance therapy (MMT) among persons who use alcohol in Vancouver, Canada.

BACKGROUND: We sought to examine the factors associated with discontinuation of MMT among persons on methadone who use alcohol. METHODS: We evaluated the impact of drug-related and other factors on discontinuation of MMT among persons enrolled in MMT and who reported any use of alcohol versus those who were enrolled in two community-recruited prospective cohorts of people who use illicit drugs (PWUD). Extended Cox models with time-dependent variables identified factors independently associated with time to first MMT discontinuation. RESULTS: Between December 2005 and 2015, 823 individuals on MMT who also reported using alcohol at least once were included in these analyses. During the study period, 391 (47.5%) discontinued methadone. Daily heroin injection (Adjusted Hazard Ratio [AHR] = 2.67, 95% Confidence Interval [CI]: 2.10-3.40) and homelessness (AHR = 1.42, 95% CI: 1.10-1.83) were positively associated with MMT discontinuation, whereas receiving other concurrent addiction treatment in addition to MMT (AHR = 0.07, 95% CI: 0.05-0.08), as well as >60 mg methadone dose (AHR = 0.48, 95% CI: 0.39-0.60), Hepatitis C virus seropositivity (AHR = 0.65, 95% CI: 0.47-0.90), and HIV seropositivity (AHR = 0.72, 95% CI: 0.57-0.91) were negatively associated with MMT discontinuation. Any/heavy alcohol use was not independently associated with MMT discontinuation. CONCLUSIONS: This study reinforces the known risks of continued heroin injection and homelessness for MMT discontinuation among individuals who also consume alcohol and highlights the protective effect of both MMT dose and receipt of concurrent addiction treatment.

Orexin A in men with heroin use disorder undergoing methadone maintenance treatment.

Orexins have played a role in reward-seeking and addiction-related behavior. There are few reports in the literature on serum levels of orexins in patients with heroin use disorder (HUD) undergoing methadone maintenance treatment (MMT). The aim of this study was to investigate the serum levels of orexin A in HUD patients undergoing MMT. Fifty male HUD patients undergoing MMT and 25 healthy males were enrolled for this study. Serum orexin A were measured with assay kits. Using analysis of covariance (ANCOVA) with body mass index (BMI) adjustments, the serum levels of orexin A in HUD men undergoing MMT were found to be significantly higher than in healthy controls. In conclusion, our results suggest that MMT might increase orexin A levels in HUD patients.

A randomized, open label trial of methadone continuation versus forced withdrawal in a combined US prison and jail: Findings at 12 months post-release.

Recently, incarcerated individuals are at increased risk of opioid overdose. Methadone maintenance treatment (MMT) is an effective way to address opioid use disorder and prevent overdose; however, few jails and prisons in the United States initiate or continue people who are incarcerated on MMT. In the current study, the 12 month outcomes of a randomized control trial in which individuals were provided MMT while incarcerated at the Rhode Island Department of Corrections (RIDOC) are assessed. An as-treated analysis included a total of 179 participants-128 who were, and 51 who were not, dosed with methadone the day before they were released from the RIDOC. The results of this study demonstrate that 12 months post-release individuals who received continued access to MMT while incarcerated were less likely to report using heroin and engaging in injection drug use in the past 30 days. In addition, they reported fewer non-fatal overdoses and were more likely to be continuously engaged in treatment in the 12-month follow-up period compared to individuals who were not receiving methadone immediately prior to release. These findings indicate that providing incarcerated individuals continued access to MMT has a sustained, long-term impact on many opioid-related outcomes post-release.

General health of opioid substitution therapy clients.

Five common medical conditions among opioid substitution therapy (OST) clients were assessed during a health promotion event held at a tertiary hospital-based OST clinic in Sydney, Australia. Data were collected anthropometrically (body mass index and waist circumference), using spirometry, electrocardiogram, Pap test histories, Fibroscan and medical record review. Assessments were undertaken by specialised hospital staff. Abnormal results were found for 17% of those who underwent an electrocardiogram, 60% were anti-hepatitis C virus positive (40% were viraemic), fibrosis was detected in one-third (7% severe fibrosis and 18% cirrhosis), chronic obstructive pulmonary disease was detected among 30% of participants with 7% at Global Initiative for Chronic Obstructive Lung Disease stage II and 2% at stage III. Forty-seven percent of the female respondents reported that they had not had a Pap test in the previous 2 years. Findings indicate that OST clients suffer several health problems that OST clinics are well placed to identify and provide support for referrals.

From political controversy to a technical problem? Fifteen years of opioid substitution treatment in Finland.

BACKGROUND: The aim of the article is to analyze changes in opioid substitution treatments (OST) in Finland. OST spread in Finland in the late 1990s and early 2000s (Phase 1). Since then, OST has become an integrated part of Finnish drug policy and is provided in various substance abuse treatment units as well as in municipal health centers (Phase 2). METHODS: The paper analyses the policy around the implementation of opioid substitution treatment in Finland, focusing on identifying the key factors and the relations between them that have contributed to the implementation of OST in Finland. RESULTS: OST has become accepted in Finland during the past ten years as a crucial element of a harm reduction strategy. Present incentives behind this development are not as clearly related to drug-specific policies as in the late 1990s; rather, they stem from both the restructuring of health care services (e.g. cost-effectiveness) and the strengthening of the medical or technico-administrative approach to the development of OST. CONCLUSION: Since the early 2000s, the development of substitution treatment in Finland has not taken place under explicit drug-political guidance, but largely as a result of many differing intended and unintended effects. One of the unintended effects is the fact that buprenorphine has replaced heroin as the most commonly misused opioid in Finland.

Methadone, a contested substance: Danish methadone policy in the 1970s.

BACKGROUND: During the 1970s in Denmark, there was a great deal of controversy about the role of methadone in Danish drug policy. At stake were not just epistemological issues about how to explain drug problems or indeed technical issues about the best possible treatment for such problems, but also social issues about how drug problems and drug treatment affected and were affected by social change. The paper uses an analytical framework in which drugs are co-constructed with their social worlds. It uses this framework to investigate how conflicts emerged about the different ways of conceiving of the relationship between methadone and Danish society. METHODS: Documentary data from the archives of a pressure group of parents of children with drug problems, the archives of an addiction doctor, newspaper articles, and policy documents from that time were coded in order to identify and analyze central controversies. RESULTS: The methadone controversy of the 1970s was not just about the best treatment methods, but also a matter of the future of the Danish welfare state. The nation debated whether it should medicalise a social problem or solve it through social reform. CONCLUSION: Drug treatment is not just a technical issue, but also a political issue and this needs to be accounted for when making drug policy.

The trajectory of methadone maintenance treatment in Nepal.

There are about 28,500 people who inject drugs (PWID) in Nepal and HIV prevalence among this group is high. Nepal introduced harm reduction services for PWID much earlier than other countries in South Asia. Methadone maintenance treatment (MMT) was first introduced in Nepal in 1994. This initial small scale MMT programme was closed in 2002 but reopened in 2007 as an emergency HIV prevention response. It has since been scaled up to include three MMT clinics and continuation of MMT is supported by the Ministry of Home Affairs (MOHA; the nodal ministry for drug supply reduction activities) and has been endorsed in the recent National Narcotics policy. Pressure from drug user groups has also helped its reintroduction. Interestingly, these developments have taken place during a period of political instability in Nepal, with the help of strong advocacy from multiple stakeholders. The MMT programme has also had to face resistance from those who were running drug treatment centres. Despite overcoming such troubles, the MMT programme faces a number of challenges. Coverage of MMT is low and high-risk injecting and sexual behaviour among PWID continues. The finance for MMT is largely from external donors and these donations have become scarce with the current global economic problems. With a multitude of developmental challenges for Nepal, the position of MMT in the national priority list is uncertain. Ownership of the programme by government, a cost-effective national MMT scale up plan and rigorous monitoring of its implementation is needed.

New treatment gives hope to East Africa's drug users.

The United Republic of Tanzania is the first mainland sub-Saharan country to launch a national methadone programme as part of its battle to fight the twin epidemics of heroin addiction and HIV infection. Fumbuka Ng'wanakilala reports.

Drug control and public health: getting beyond stalemate. Interview with Robin Room by Fiona Fleck.

Robin Room is a member of a drugs policy modelling group that uses data to project what would happen to the harm caused by illicit drugs if policies or conditions changed. He talks to Fiona Fleck about alternative scenarios to today's illicit trade in drugs and the implications of different scenarios for public health.

Methadone maintenance treatment in Spain: the success of a harm reduction approach.

PROBLEM: During the 1980s, Spain had very strict laws limiting access to opioid agonist maintenance treatment (OAMT). Because of this, mortality among people who used illicit opioids and other illicit drugs was high. Spain was also the European country with the highest number of cases of acquired immunodeficiency syndrome transmitted through illicit drug injection. APPROACH: The rapid spread of human immunodeficiency virus (HIV) infection among people using heroin led to a shift from a drug-free approach to the treatment of opioid dependence to one focused on harm reduction. A substantial change in legislation made it possible to meet public health needs and offer OAMT as part of harm reduction programmes in the public health system, including prisons. LOCAL SETTING: Legislative changes were made throughout the country, although at a different pace in different regions. RELEVANT CHANGES: Legal changes facilitated the expansion of OAMT, which has achieved a coverage of 60%. A parallel reduction in the annual incidence of HIV infection has been reported. Reductions in morbidity and mortality and improved health-related quality of life have been described in patients undergoing OAMT. LESSONS LEARNT: The treatment of opioid dependence has been more heavily influenced by moral concepts and prejudices that hinder legislation and interfere with the implementation of OAMT than by scientific evidence. To fulfil public health needs, OAMT should be integrated in harm reduction programmes offered primarily in public facilities, including prisons. Longitudinal studies are needed to detect unmet needs and evaluate programme impact and suitability.

Trends and predictors in methadone maintenance treatment dropout in Shanghai, China: 2005-2011.

BACKGROUND: The methadone maintenance treatment (MMT) program has been implemented in Shanghai since 2005. This study aims to portray the trend of MMT dropout and identify predictive factors that may influence dropout in Shanghai MMT clinics, which could assist in the intervention strategy development. METHODS: A retrospective evaluation was used in the Shanghai component of the National MMT data management system between January 1, 2005 and December 31, 2011. The Cox model for recurrence events was employed to estimate hazard ratio (HR) predicting dropout during the follow-up period. RESULTS: Of all 6169 participants, 63% dropped out of the program at least once (ranging from 0 to 10 times), and 74% of them did not return by the end of this study. The average monthly incidence rate of dropout was 4.4% with a range from 0 to 9.3%. Adjusted analyses demonstrated that the individuals with methadone tapering didn't have a greater probability of dropping out compared to those with stable dosage (HR = 1.07, 95% CI: 0.90-1.27). However, there was a higher dropout rate among younger individuals (<30 years vs. ≥50 years old; HR = 1.41, 95% CI: 1.16-1.71), among those who were less educated (HR = 1.48, 95% CI: 1.17-1.87), among those who shared needles with others (HR = 1.29, 95% CI: 1.06-1.58), among those whose urine tested positive for opiates (HR = 1.69, 95% CI: 1.51-1.89), and among those who had a low average methadone dose at the initial stable stage of treatment (≤35 mg/day vs. >65 mg/day; HR = 1.39, 95% CI: 1.19-1.63). CONCLUSIONS: Shanghai has been facing the challenge of keeping a high MMT retention rate. Increasing the use of methadone tapering after a stable treatment stage with sufficient dosage could be attempted in the MMT program, as well as considering comprehensive interventions among specific populations, such as young, poorly educated, opiate-positive and needle sharing individuals.

Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995-2009.

OBJECTIVES: We examined the association between the expansion of methadone and buprenorphine treatment and the prevalence of heroin overdose deaths in Baltimore, Maryland from 1995 to 2009. METHODS: We conducted a longitudinal time series analysis of archival data using linear regression with the Newey-West method to correct SEs for heteroscedasticity and autocorrelation, adjusting for average heroin purity. RESULTS: Overdose deaths attributed to heroin ranged from a high of 312 in 1999 to a low of 106 in 2008. While mean heroin purity rose sharply (1995-1999), the increasing number of patients treated with methadone was not associated with a change in the number of overdose deaths, but starting in 2000 expansion of opioid agonist treatment was associated with a decline in overdose deaths. Adjusting for heroin purity and the number of methadone patients, there was a statistically significant inverse relationship between heroin overdose deaths and patients treated with buprenorphine (P = .002). CONCLUSIONS: Increased access to opioid agonist treatment was associated with a reduction in heroin overdose deaths. Implementing policies that support evidence-based medication treatment of opiate dependence may decrease heroin overdose deaths.