Anodyne by Design; Measuring the Prevalence of Esoteric Designer Opioids in Pain Management Patients.

The recent increase in illicit opioids sold on the black market, cut into heroin and masqueraded as prescription pills prompts a significant public health concern. Most designer opioids possess unknown potencies and unknown pharmacokinetics and their unregulated, variable dosages lead to rashes of overdoses. Additionally, many of the designer opioids, especially the fentanyl analogs are significantly more potent than heroin. High-profile cases involving overdoses of U-47700 and carfentanil have been reported in the media; however, the true prevalence of these and other designer opioids is unknown. Independent LC-MS-MS screen and confirmation methods have been developed and validated to identify and quantify fentanyl, and 18 designer opioids and their metabolites; methods were then exercised on urine specimens from contract pain management clients. Assuming patients in a pain management program may have a higher probability to seek out self-medication, samples from pain management patients were investigated for designer opioids. Similarly, pain management patients identified as using heroin may be more likely to experiment with or be accidentally exposed to designer opioids, specimens screening positive for the heroin metabolite 6-acetylmorphine were specifically chosen for designer opioid screening. Within this small group of pain management and heroin-positive samples, nine designer opioids were detected at a total prevalence of 25%. When screening random pain management samples not positive for heroin, a considerably lower percentage of samples (<1%) were identified as positive for designer opioids. Furanyl fentanyl, fluorobutyryl fentanyl and acetylfentanyl were the most prevalent designer opioids detected in both test groups.

Medical Narrative and the Rhetoric of Identification: The Many Faces of Anna White Dildane.

When Anna White Dildane, a prostitute and heroin addict, was committed to the Laboratory of Social Hygiene (LSH) in 1917, she was treated by a staff that anticipated the methods of the biopsychosocial model later developed by Engel. That is to say, the staff members believed that Anna's rehabilitation was contingent on a scientific diagnosis of the physical, mental, and social factors that underlay her condition. However, using Anna and the LSH as a case study, we draw from Latour to show the limitations of this "modern" method of diagnosis and treatment that persists today. Using Burke, we advocate for a pragmatic orientation focused on creating rhetorically oriented narratives whose aim is to help patients make judgments about their health and future, namely, by bringing about the experience of "form" capable of constituting new types of identification. Effective medical rhetoric thus adopts a method of persuasion that begins with the narrative and self-understanding of the patient, links aspects of that narrative with the technical expertise of physicians and other health care providers, and crafts a new, more specialized narrative attentive to the desires and constraints of a patient's form of identification that is ultimately the seat of judgment.

Understanding prolonged cessation from heroin use: findings from a community-based sample.

BACKGROUND: There is abundant literature describing heroin initiation, co-morbidities, and treatment. Few studies focus on cessation, examining the factors that motivate and facilitate it. METHODS: The CHANGE study utilized mixed methods to investigate heroin cessation among low-income New York City participants. This paper describes findings from qualitative interviews with 20 former and 11 current heroin users. Interviews focused on background and current activities, supports, drug history, cessation attempts, and motivators and facilitators to cessation. RESULTS: Participants found motivation for cessation in improved quality of life, relationships, and fear of illness, incarceration and/or death. Sustained cessation required some combination of treatment, strategic avoidance of triggers, and engagement in alternative activities, including support groups, exercise, and faith-based practice. Several reported that progress toward goals served as motivators that increased confidence and facilitated cessation. Ultimatums were key motivators for some participants. Beyond that, they could not articulate factors that distinguished successful from unsuccessful cessation attempts, although data suggest that those who were successful could describe more individualized and concrete-rather than general-motivators and strategies. CONCLUSIONS: Our findings indicate that cessation may be facilitated by multifaceted and individualized strategies, suggesting a need for personal and comprehensive approaches to treatment.

Prevalence of heroin markers in urine for pain management patients.

Surveys of current trends indicate heroin abuse is associated with nonmedical use of pain relievers. Consequently, there is an interest in evaluating the presence of heroin-specific markers in chronic pain patients who are prescribed controlled substances. A total of 926,084 urine specimens from chronic pain patients were tested for heroin/diacetylmorphine (DAM), 6-acetylmorphine (6AM), 6-acetylcodeine (6AC), codeine (COD), and morphine (MOR). Heroin and markers were analyzed using liquid chromatography tandem mass spectrometry (LC-MS-MS). Opiates were analyzed following hydrolysis using LC-MS-MS. The prevalence of heroin use was 0.31%, as 2871 were positive for one or more heroin-specific markers including DAM, 6AM, or 6AC (a known contaminant of illicit heroin). Of these, 1884 were additionally tested for the following markers of illicit drug use: 3,4-methylenedioxymethamphetamine (MDMA), 3,4-methylenedioxyamphetamine (MDA), methamphetamine (MAMP), 11-nor-9-carboxy-Δ(9)-tetracannabinol (THCCOOH), and benzoylecgonine (BZE); 654 (34.7%) had positive findings for one or more of these analytes. The overall prevalence of heroin markers were as follows: DAM 1203 (41.9%), 6AM 2570 (89.5%), 6AC 1082 (37.7%). MOR was present in 2194 (76.4%) and absent (

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.

Prospective validation of substance abuse severity measures from administrative data.

BACKGROUND: Severity measures for clients in substance abuse treatment programs are becoming increasingly important as funders adopt payment systems linked to agency performance. Recently, two severity measures based on administrative data have been developed. This study validated these measures using prospective data. METHODS: Subjects were participants in the Drug Abuse Treatment Outcomes Study (adult or adolescent components) or the Substance Abuse and Mental Health Services Administration Medicaid Managed Behavioral Healthcare and Vulnerable Populations project (adult or adolescent chemical dependency components). Severity measures were calculated based on data obtained at entry into substance abuse treatment. The baseline severity measures were included along with age, gender, and race/ethnicity in logistic regression models predicting abstinence at follow-up for alcohol use, marijuana use, cocaine use, or heroin use. RESULTS: For adults, the severity measures were highly statistically significant (p<0.001) for all models in both data sets, indicating that adults with higher severity were more likely (and much more likely in many cases) to use alcohol, marijuana, cocaine, or heroin at the follow-up interview than were those with lower severity. For adolescents, the severity measure was highly statistically significant (p<0.001) for marijuana in both data sets and for alcohol in the Medicaid data set. CONCLUSIONS: Baseline severity measures were powerful predictors of abstinence at follow-up. These measures, derived from routinely available electronic records, appear to have noteworthy predictive validity. The severity indicators can be used for administrative purposes such as risk-adjustment when examining treatment agency performance.

Alcohol dependence: international policy implications for prison populations.

BACKGROUND: In light of the emphasis on drug abuse, this study explored the relative prevalence of substance use disorders among United Kingdom (UK) prison inmates in the context of findings from a general inmate population in the United States (US). The lead author of the report conducted a structured diagnostic interview with 155 new admissions to one of two prisons in the UK using the CAAPE (Comprehensive Addiction And Psychological Evaluation), a structured diagnostic interview, to ensure consistent assessments. The US sample consisted of 6,881 male inmates in a state prison system evaluated with an automated version of the SUDDS-IV (Substance Use Disorder Diagnostic Schedule-IV) interview. RESULTS: Alcohol dependence emerged as the most prevalent substance use disorder in both UK prisons and in the US sample. Relative frequencies of abuse and dependence for alcohol and other drugs revealed that dependence on a given substance was more prevalent than abuse ad defined by the current diagnostic criteria. CONCLUSION: Despite the emphasis on drugs in correctional populations, alcohol dependence appears to be the most prominent substance use disorder among the incarcerated in both the US and UK and must be considered in developing treatment programs and policy priorities.

Impact of program services on treatment outcomes of patients with comorbid mental and substance use disorders.

OBJECTIVE: This study examined the outcomes of individuals with co-occurring disorders who received drug treatment in programs that varied in their integration of mental health services. Patients treated in programs that provided more on-site mental health services and had staff with specialized training were expected to report less substance use and better psychological outcomes at follow-up. METHODS: Participants with co-occurring disorders were sampled from 11 residential drug abuse treatment programs for adults in Los Angeles County. In-depth assessments of 351 patients were conducted at treatment entry and at follow-up six months later. Surveys conducted with program administrators provided information on program characteristics. Latent variable structural equation models revealed relationships of patient characteristics and program services with drug use and psychological functioning at follow-up. RESULTS: Individuals treated in programs that provided specific dual diagnosis services subsequently had higher rates of utilizing mental health services over six months and, in turn, showed significantly greater improvements in psychological functioning (as measured by the Brief Symptom Inventory and the RAND Health Survey 36-item short form) at follow-up. More use of psychological services was also associated with less heroin use at follow-up. African Americans reported poorer levels of psychological functioning than others at both time points and were less likely to be treated in programs that provided mental health services. CONCLUSIONS: Study findings support continued efforts to provide specialized services for individuals with co-occurring disorders within substance abuse treatment programs as well as the need to address additional barriers to obtaining these services among African Americans.

Receipt of disability payments by substance users: mental and physical health correlates.

Since 1997, substance users have received disability benefits only for impairments apart from their substance use disorders. It is hypothesized that substance users currently receiving disability benefits would be more severely compromised, medically and/or psychiatrically, than those not receiving disability. Enrolling a community sample of 330 heroin and cocaine users between January 2002 and January 2004, it was found that individuals who were not receiving disability payments had similar mental health scores, current depressive symptoms scores, and lifetime rates of major depression compared to those receiving payments, but significantly lower rates of bipolar or psychotic disorders and psychiatric hospitalization (p < .01). Physically disabled persons had lower physical function scores and were more likely to be HIV-infected or taking medications regularly (p < .001). The authors conclude that schizophrenia, bipolar disorders, and chronic physical illness, but not major depression, are qualifying substance users for disability benefits. Longitudinal studies of disability status and its effects on the lives of substance users are warranted.

The predictive validity of the university of rhode island change assessment questionnaire in a heroin-addicted polysubstance abuse sample.

The purpose of this investigation was to examine the predictive utility of the stages-of-change scales of the University of Rhode Island Change Assessment (URICA; E. A. McConnaughy, J. O. Prochaska, & W. F. Velicer, 1983) questionnaire in a heroin-addicted polysubstance-abusing treatment sample. Ninety-six participants completed the URICA at the beginning of a 29-week treatment period that required thrice-weekly urine drug screens. Multivariate multiple regression analysis indicated that after controlling for demographic variables, substance abuse severity, and treatment assignment, the stages-of- change scales added significant variance to the prediction of heroin- and cocaine-free urine samples. The Maintenance scale was positively related to cocaine-free urines and length in treatment. The implications of these findings for treatment and for measuring readiness among individuals using multiple substances while taking maintenance medications are discussed.

A 33-year follow-up of narcotics addicts.

BACKGROUND: This study examined longitudinal patterns of heroin use, other substance use, health, mental health, employment, criminal involvement, and mortality among heroin addicts. METHODS: The sample was composed of 581 male heroin addicts admitted to the California Civil Addict Program (CAP) during the years 1962 through 1964; CAP was a compulsory drug treatment program for heroin-dependent criminal offenders. This 33-year follow-up study updates information previously obtained from admission records and 2 face-to-face interviews conducted in 1974-1975 and 1985-1986; in 1996-1997, at the latest follow-up, 284 were dead and 242 were interviewed. RESULTS: In 1996-1997, the mean age of the 242 interviewed subjects was 57.4 years. Age, disability, years since first heroin use, and heavy alcohol use were significant correlates of mortality. Of the 242 interviewed subjects, 20.7% tested positive for heroin (with additional 9.5% urine refusal and 14.0% incarceration, for whom urinalyses were unavailable), 66.9% reported tobacco use, 22.1% were daily alcohol drinkers, and many reported illicit drug use (eg, past-year heroin use was 40.5%; marijuana, 35.5%; cocaine, 19.4%; crack, 10.3%; amphetamine, 11.6%). The group also reported high rates of health problems, mental health problems, and criminal justice system involvement. Long-term heroin abstinence was associated with less criminality, morbidity, psychological distress, and higher employment. CONCLUSIONS: While the number of deaths increased steadily over time, heroin use patterns were remarkably stable for the group as a whole. For some, heroin addiction has been a lifelong condition associated with severe health and social consequences.

The use of artificial neural networks methodology in the assessment of "vulnerability" to heroin use among army corps soldiers: a preliminary study of 170 cases inside the Military Hospital of Legal Medicine of Verona.

This article describes a preliminary study of screening/diagnostic instruments for prediction for large-scale application in the military field at the Neuropsychiatric Department of the Military Hospital of Legal Medicine of Verona and for the prevention of self-destructive behaviors, particularly through the use of drugs. 170 subjects divided into three subsamples were examined. The first subsample was characterized by a strong tendency towards normalcy, the second by a strong tendency towards pathology, and the third by a great variety of expressions of psychological and social problems, which were not necessarily related to drug use. These subjects were administered a questionnaire designed according to Squashing Theory principles (Buscema, 1994a). Answers were processed by an Artificial Neural Network created by Semeion in Rome (Buscema, 1996) and were compared with a standard clinical psychiatric assessment report and with the results of psychodiagnostic tests. Results document ANNs' remarkable ability to recognize subjects with declared, in exordium and "at risk" pathological behaviors. Blind results on learning and trial samples show a very high predictive capacity (over 90%). A comparison with the examined subjects' clinical report and the results of the first follow-up also document very high agreements. The broad variation of answers obtained in the third subsample allows further methodological reflections on the contribution of Artificial Neural Networks and Squashing Theory to the study of deviance, for both sociologists and clinicians, and not only for those in the field of drug addiction.

Empirical assessment of the self-medication hypothesis among dually diagnosed inpatients.

The aim of this study was to empirically determine the expected effects of drugs of abuse on the psychiatric symptoms of individuals dependent on alcohol and other drugs to assess the validity of the self-medication hypothesis, defined as motivation of patients to seek a specific drug for relief of a particular set of symptoms. Eight-three inpatients in a large metropolitan hospital with an axis I diagnosis of one drug dependence and an axis II diagnosis of personality disorder completed the Hopkins Symptom Checklist-Revised (HSCL-90-R) and the Neuropsychological Impairment Scale (NIS). They also reported the effect of their drug of choice on each of the symptoms included in both tests. Heroin addicts reported that heroin improved some of their psychiatric symptoms and all of their cognitive dysfunctions. Both cocaine and alcohol users reported that their drug of choice worsened their psychiatric and cognitive symptoms. No relationship was found between frequency or severity of symptoms and drug choice. We concluded that attempts at self-medication may have occurred among heroin addicts, but were unlikely among alcoholics and cocaine addicts. We found no evidence in support of the self-medication hypothesis as a necessary reinforcer of continued drug use.

Nutritional status assessment of HIV-positive drug addicts.

Since human immunodeficiency virus (HIV) is known to lead to modifications of immune function and interrelationships among malnutrition, anergy and drug addiction have been shown, the aim of this work was to assess the nutritional status of 36 male heroin addicts under a period of detoxication (3 months). They were divided into two groups: (1) HIV negative (n = 20) and (2) HIV positive (n = 16); heights, weights and serum albumin concentration were measured and immune function was tested, using delayed hypersensitivity skin tests containing 7 antigens. No significant differences in anthropometric measurements were found between both groups, but anthropometric improvement was shown in every patient after the detoxication period. Serum albumin, often used as a classical index of malnutrition, remained within the normal values in both groups. The whole response to skin tests was depressed in both groups and no significant differences were shown between them. Therefore, these results might suggest that in spite of the apparent anthropometric recovery and the normal values of albumin, a subclinical malnutrition was indicated by the depressed immune function, which was more noticeable in the HIV-positive group.

A computer feedback system for clinical research.

This paper presents a computerized data base management and information retrieval system for a heroin addiction research clinic, which has potential application for any type of clinical research. It describes data input checking programs, file structures, and output programs. The system contains several interesting features: built-in feedback error detection and correction; patient month matrix formatting and data compression; and a virtual blocking system to reduce the size of the files.

The quantitative assessment of physical dependence on opiates.

A procedure for administering naloxone to narcotic-dependent individuals and a technique for quantitating the ensuing acute withdrawal syndrome have been developed to assess the degree of physical dependence. Successive injections of increasing doses of naloxone produce a controlled increase in severity of withdrawal signs and symptoms as measured by a subjective and an objective assessment battery. There is good agreement between the subjective and objective assessments and a global reting of withdrawal severity. The objective measures are, however, most sensitive and produce a withdrawal syndrome score related to the duration of the current cycle of drug abuse. Hand tremor, trapezius electromyogram and heart rate are the most sensitive signs of withdrawal and can be used in combination to form the basis of a simplified and shortened antagonist assessment test for physical dependence.