Current trends in Finnish drug abuse: Wastewater based epidemiology combined with other national indicators.

No single measure is able to provide a complete picture of population- or community-level drug abuse and its current trends. Therefore, a multi-indicator approach is needed. The aim of this study was to combine wastewater-based epidemiology (WBE) with data from other national indicators, namely driving under the influence of drugs (DUID) statistics, drug seizures, and drug use surveys. Furthermore, drug market size estimates and a comparison of confiscated drugs to drugs actually consumed by users were performed using the WBE approach. Samples for wastewater analysis were collected during one-week sampling periods in 2012, 2014 and 2015, with a maximum of 14 cities participating. The samples were analysed with a validated ultra-high-performance liquid chromatography-mass spectrometric (UHPLC-MS/MS) methodology for various common drugs of abuse. The results were then compared with data from other national indicators available. Joint interpretation of the data shows that the use of amphetamine and MDMA has increased in Finland from 2012 to 2014. A similar trend was also observed for cocaine, although its use remains at a very low level compared to many other European countries. Heroin was practically absent from the Finnish drug market during the study period. The retail market for the most common stimulant drugs were estimated to have been worth EUR 70 million for amphetamine and around EUR 10 million for both methamphetamine and cocaine, in 2014 in Finland.

Use of illicit stimulant drugs in Finland: a wastewater study in ten major cities.

Estimations of drug use at the national level are generally based on various sources of information, such as drug seizures, socio-scientific studies, toxicological data and hospital records. Nevertheless, all of these approaches have limitations that cannot be overcome, even if conclusions are drawn from combined data retrieved from different sources. Drug epidemiology through wastewater analysis has the potential to provide unique perspectives, internationally comparable data, and up-to-date information on the use of both traditional illicit drugs and new psychoactive substances (NPSs). In Finland, no large-scale studies on regional illicit drug consumption, based on a wastewater approach, have been reported. In this study, 24-h influent composite samples were collected during two 1-week study periods from ten different wastewater treatment plants in May and November-December 2012. The cities included in the study represent the geographical areas throughout Finland and cover 40% of the Finnish population. The samples were analyzed with an in-house validated, ultra high-performance liquid-chromatography mass spectrometric (UHPLC-MS/MS) method for various common illicit drugs and some NPS type stimulant drugs. The results were also compared with available statistics, information on drug seizures and laboratory-confirmed toxicological data, as well as other studies available based on wastewater analysis. The data show that illicit stimulant drug use is more common in the larger cities of Southern Finland. Amphetamine was the most commonly used drug in all 10 cities during both collection periods (excluding the collection period in May in Lappeenranta). Cocaine consumption remains very low in Finland in comparison to other European countries; it was concentrated in the biggest cities in Southern Finland. This study shows interesting temporal and spatial differences in drug use in Finland, as well as the possibilities of using wastewater analytics to reveal local hotspots of NPS consumption.

Extended-release methylphenidate for treatment of amphetamine/methamphetamine dependence: a randomized, double-blind, placebo-controlled trial.

AIMS: To assess the efficacy of methylphenidate as a substitution therapy for amphetamine/methamphetamine dependence in Finland and New Zealand. DESIGN: Parallel-group, double-blind, randomized placebo-controlled trial. SETTING: Out-patient care. PARTICIPANTS: Amphetamine-/methamphetamine-dependent, aged 16-65 years. MEASUREMENTS: The primary outcome measure was presence/absence of amphetamine/methamphetamine in urine samples collected twice weekly. Secondary measures included treatment adherence, alterations in craving scores and self-reported use. Primary analysis was by intention-to-treat (ITT). The study drug, methylphenidate (as Concerta(®) ), was up-titrated over 2 weeks to a maximum dose of 54 mg daily and continued for a further 20 weeks. Doses were given under daily supervision at the clinics. FINDINGS: Seventy-nine participants were randomized (40 methylphenidate; 39 placebo); 76 received allocated treatment and 27 completed the trial. ITT analysis (n = 78) showed no statistically significant difference in the percentage of positive urines between the methylphenidate and placebo arms (odds ratio: 0.95, 95% confidence interval: 0.83-1.08). However, there was a significant difference (P < 0.05) between the active and placebo arms in retention, the placebo arm displaying a significantly lower retention from 6 weeks that persisted until the end of the trial. CONCLUSIONS: The trial failed to replicate earlier findings suggesting that methylphenidate was superior to placebo. The low retention rate confounded the ability to draw firm conclusions about efficacy. The higher retention rate was observed in the methylphenidate arm. Any replication of this work would need to consider alternatives to the rigid clinic attendance criteria, and consider an increased dose.

Naltrexone implant for the treatment of polydrug dependence: a randomized controlled trial.

OBJECTIVE: The majority of drug addicts are polydrug dependent, and no effective pharmacological treatment is currently available for them. The authors studied the overall real-world effectiveness of naltrexone implant in this patient population. METHOD: The authors assessed the effectiveness of a naltrexone implant in the treatment of coexisting heroin and amphetamine polydrug dependence in 100 heroin- and amphetamine-dependent outpatients in a 10-week randomized, double-blind, placebo-controlled trial. The main outcome measures were retention in the study, proportion of drug-free urine samples, and improvement score on the Clinical Global Impressions Scale (CGI). Analyses were conducted in an intent-to-treat model. RESULTS: At week 10, the retention rate was 52% for patients who received a naltrexone implant and 28% for those who received a placebo implant; the proportions of drug-free urine samples were 38% and 16%, respectively, for the two groups. On the CGI improvement item, 56% of the patients in the naltrexone group showed much or very much improvement, compared with 14% of those in the placebo group (number needed to treat=3). CONCLUSIONS: Naltrexone implants resulted in higher retention in the study, decreased heroin and amphetamine use, and improved clinical condition for patients, thus providing the first evidence of an effective pharmacological treatment for this type of polydrug dependence.

Addiction research centres and the nurturing of creativity: the Department of Alcohol, Drugs and Addiction at the National Institute for Health and Welfare in Finland: diverse problems, diverse perspectives.

The Department of Alcohol, Drugs and Addiction started operations on 1 January 2009, when the National Institute of Public Health (KTL) and the National Research and Development Centre for Welfare and Health (STAKES) were merged. The newly formed institute, called the National Institute for Health and Welfare (THL), operates under the Finnish Ministry of Social Affairs and Health. The scope of the research and preventive work conducted in the Department covers alcohol, drugs, tobacco and gambling issues. The two main tasks of the Department are (i) to research, produce and disseminate information on alcohol and drugs, substance use, addictions and their social and health-related effects and (ii) to develop prevention and good practices with a view to counteracting the onset and development of alcohol and drug problems and the damaging effects of smoking and other addictions. The number of staff hovers at approximately 60 people. The Department is organized into three units, one specialized in social sciences (the Alcohol and Drug Research Unit), another in laboratory analytics (the Alcohol and Drug Analytics Unit) and the third primarily in preventive work (the Addiction Prevention Unit). These units incorporate a rich variety and long traditions of both research and preventive work. The mixture of different disciplines creates good opportunities for interdisciplinary research projects and collaboration within the Department. Also, the fact that in the same administrative context there are both researchers and people specialized in preventive work opens up interesting possibilities for combining efforts from these two branches. Nationally, the Department is a key player in all its fields of interest. It engages in a great deal of cooperation both nationally and internationally, and among its strengths are the high-quality, regularly collected long-term data sets.

Alcohol-induced psychotic disorder and delirium in the general population.

BACKGROUND: Epidemiological data on alcohol-induced psychotic disorder and delirium (alcohol-induced psychotic syndrome, AIPS) are scarce. AIMS: To investigate the epidemiology of AIPS, the risk factors for developing AIPS among people with alcohol dependence, and mortality associated with alcohol dependence with or without AIPS, in a sample drawn from the general population of Finland. METHOD: A general population sample of 8028 persons were interviewed with the Composite International Diagnostic Interview and screened for psychotic disorders using multiple sources. Best-estimate diagnoses of psychotic disorders were made using the Structured Clinical Interview for DSM-IV Axis I Disorders and case notes. Data on hospital reatments and deaths were collected from national registers. RESULTS: The lifetime prevalence was 0.5% for AIPS and was highest (1.8%) among men of working age. Younger age at onset of alcohol dependence, low socioeconomic status, father's mental health or alcohol problems and multiple hospital treatments were associated with increased risk of AIPS. Participants with a history of AIPS had considerable medical comorbidity, and 37% of them died during the 8-year follow-up. CONCLUSIONS: Alcohol-induced psychotic disorder is a severe mental disorder with poor outcome.

Workplace drug testing in a military organization: results and experiences from the testing program in the Finnish Defence Forces.

In the military environment drug abuse is a particular risk for occupational safety. In the Finnish Defence Forces a drug testing program was conducted in 2002-2005; soldiers, professional civilians, and military students were tested when applying for a work or right to study; furthermore, annually 5% of the personnel were subjected to random testing. In total, over 2000 urine samples were analyzed in an accredited laboratory for cannabis, opiates, amphetamines, or cocaine. In this article, the drug testing program as a part of the anti-drug strategy of the Finnish Defence Forces is described, and the findings including practical experiences and financial expenses are reported. Only one person applying for a civilian post tested positive for amphetamine and cannabis. In seven other samples codeine and morphine were detected; these were, however, due to prescribed medication, not drug abuse. In the execution of the program, no particular difficulties were reported. In conclusion, it seems that the use of illicit drugs in the Finnish military is extremely rare, at least partly due to the successful anti-drug strategy. After an elaborate planning, even an extensive drug testing program can be executed without substantial setbacks. In the future, the effectiveness of drug testing programs as a means of improving occupational safety needs to be investigated in controlled studies using comparative design.

Lifetime prevalence of psychotic and bipolar I disorders in a general population.

CONTEXT: Recent general population surveys of psychotic disorders have found low lifetime prevalences. However, this may be owing to methodological problems. Few studies have reported the prevalences of all specific psychotic disorders. OBJECTIVE: To provide reliable estimates of the lifetime prevalences of specific psychotic disorders. DESIGN: General population survey. SETTING AND PARTICIPANTS: A nationally representative sample of 8028 persons 30 years or older was screened for psychotic and bipolar I disorders using the Composite International Diagnostic Interview, self-reported diagnoses, medical examination, and national registers. Those selected by the screens were then re-interviewed with the Structured Clinical Interview for DSM-IV. Best-estimate DSM-IV diagnoses were formed by combining the interview and case note data. Register diagnoses were used to estimate the effect of the nonresponders. MAIN OUTCOME MEASURES: Diagnosis of any psychotic or bipolar I disorder according to the DSM-IV criteria. RESULTS: The lifetime prevalence of all psychotic disorders was 3.06% and rose to 3.48% when register diagnoses of the nonresponder group were included. Lifetime prevalences were as follows: 0.87% for schizophrenia, 0.32% for schizoaffective disorder, 0.07% for schizophreniform disorder, 0.18% for delusional disorder, 0.24% for bipolar I disorder, 0.35% for major depressive disorder with psychotic features, 0.42% for substance-induced psychotic disorders, and 0.21% for psychotic disorders due to a general medical condition. The National Hospital Discharge Register was the most reliable of the screens (kappa = 0.80). Case notes supplementing the interviews were essential for specific diagnoses of psychotic disorders. CONCLUSIONS: Multiple sources of information are essential for accurate estimation of lifetime prevalences of psychotic disorders. The use of comprehensive methods reveals that their lifetime prevalence exceeds 3%.

A comparison of aripiprazole, methylphenidate, and placebo for amphetamine dependence.

OBJECTIVE: Problems related to illegal amphetamine use have become a major public health issue in many developed countries. To date, evidence on the effectiveness of psychosocial treatments has remained modest, and no pharmacotherapy has proven effective for amphetamine dependence. METHOD: Individuals meeting DSM-IV criteria for intravenous amphetamine dependence (N=53) were randomly assigned to receive aripiprazole (15 mg/day), slow-release methylphenidate (54 mg/day), or placebo for 20 weeks. The study was terminated prematurely due to unexpected results of interim analysis. An intention-to-treat analysis was used. The primary outcome measure was the proportion of amphetamine-positive urine samples. RESULTS: Patients allocated to aripiprazole had significantly more amphetamine-positive urine samples than patients in the placebo group (odds ratio=3.77, 95% CI=1.55-9.18), whereas patients who received methylphenidate had significantly fewer amphetamine-positive urine samples than patients who had received placebo (odds ratio=0.46, 95% CI=0.26-0.81). CONCLUSIONS: Methylphenidate is an effective treatment for reducing intravenous drug use in patients with severe amphetamine dependence.

Predictors of benzodiazepine discontinuation in subjects manifesting complicated dependence.

We described characteristics of subjects with benzodiazepine dependence that was typically complicated by harmful and hazardous alcohol use or high benzodiazepine doses, and assessed predictors of successful discontinuation of benzodiazepines for this group. Seventy-six patients who participated in a randomized clinical trial of two different gradual withdrawal treatment approaches were assessed. The trial was conducted between February 1995 and July 1999. The mean age +/- SD of subjects was 40.0 +/- 9.6 years, 55% were male, 38% were married or cohabiting, and 70% had received more than nine years of education. The median benzodiazepine dose was 35 mg/day (range 2.5-180) in diazepam equivalents. The median duration of benzodiazepine use was 84 (range 8-360) months. Subjects with lower benzodiazepine doses and no previous withdrawal attempts were more successful at benzodiazepine discontinuation. Cluster B personality/borderline personality disorder was associated with an inability to stop benzodiazepine use and with "dropping out" of treatment. Alcohol use-related disorders or other psychiatric diagnoses were not associated with outcome. Further studies on predictors of successful benzodiazepine discontinuation in different populations are required. Patients manifesting cluster B personality/borderline personality disorder and benzodiazepine dependence may need concomitant treatment for their personality disorders to benefit from benzodiazepine discontinuation treatment.

Symptom severity and quality of life after benzodiazepine withdrawal treatment in participants with complicated dependence.

The aims of the present study were to assess changes in psychopathology and quality of life after withdrawal treatment in participants with benzodiazepine dependence that was in most cases complicated by harmful and hazardous alcohol use or high benzodiazepine doses. Seventy-six participants with benzodiazepine dependence (DSM-III-R) who participated in a randomized clinical trial of two different gradual withdrawal treatment approaches were initially assessed by Symptom Checklist-90 (SCL-90), visual analogue scales (VASs), and the Health-Related Quality of Life battery (HRQOL). The assessments were repeated after treatment ended and again after a follow-up averaging 11 months. During the study, all measurements for the participants with clinically significant (over 50%) benzodiazepine-dose decreases improved more than those for the participants with smaller decreases, and differences in the HRQOL energy/vitality, home management, and life satisfaction scores were significant. Our data indicate that in participants with complicated benzodiazepine dependence, clinically significant dose decreases are associated with improvements in their self-rated quality of life.

Seizures induced by low-dose right unilateral and bifrontal electroconvulsive stimuli.

The duration of electroconvulsive therapy (ECT) seizures of depressive patients has been found to be inversely related to titrated right unilateral (RUL) and bilateral (BL) seizure threshold (ST) levels. This inverse relationship is thought to reflect those neural processes determining seizure duration. The relation between seizure duration and titrated ST level in bifrontal (BF) ECT, which has not been previously studied, is examined here in addition to RUL ECT. We found an inverse relationship in RUL ECT but no relationship in BF ECT. Eighteen percent of RUL patients seized at the first stimulus level versus 40% of BF patients. Compared with previous studies, both our starting dose and the increments between stimuli were greater in BF ECT (50.4 mC) than in RUL ECT (25.2 mC). A relationship between stimulus dose and seizure length may have also been present in BF ECT had similar titration schedules been used for both electrode placements. Future studies using titration schedules with a lower initial dose and finer gradations between stimulus levels are needed to evaluate whether a relationship between stimulus dose and seizure duration exists in BF ECT.

Long-term outcome after benzodiazepine withdrawal treatment in subjects with complicated dependence.

BACKGROUND: The study aimed to monitor subjects with benzodiazepine (BZ) dependence after withdrawal treatment in order to evaluate long-term outcome and predictors of remaining BZ-free. Subjects with high-dose dependence or co-occurring alcohol problems were not excluded. METHOD: Seventy-six participants in an earlier, randomized, controlled trial of outpatient BZ discontinuation were interviewed, and documents from their treatment settings obtained, along with urine and serum samples for BZ use. Long-term outcomes for a cognitive-behavioral treatment group and a treatment-as-usual group were measured. RESULTS: BZ discontinuation treatment outcomes were maintained in both treatment groups. No between-group differences were found. At the end of the study 25% of the subjects were BZ-free, and the median dose decrease from pre-treatment levels was 16.1 mg in diazepam equivalents. Subjects with pre-treatment doses exceeding 40 mg were able to maintain their doses at therapeutic levels through the follow-up. Pre-treatment low BZ dose, no previous withdrawal attempts, and high life satisfaction predicted success in staying BZ-free. CONCLUSIONS: In subjects with complicated BZ dependence, the benefits of BZ discontinuation treatment may persist, but more studies are needed.

Treatment of out-patients with complicated benzodiazepine dependence: comparison of two approaches.

AIMS: To evaluate whether gradual benzodiazepine taper combined with cognitive-behavioural treatment is more effective than standard treatment for patients with dependence in out-patient clinics. DESIGN: A randomized, controlled clinical trial, using standard questionnaires and serum and urine tests. SETTINGS: Four public-sector out-patient clinics for alcohol and drug abusers in Helsinki. PARTICIPANTS: Seventy-six patients with benzodiazepine dependence (DSM-III-R). Patients taking high doses of the drug or with alcohol use disorders were included to obtain a subject group representative of usual clinical practice. INTERVENTION: Subjects received gradual benzodiazepine taper combined with cognitive-behavioural therapy (experimental group) or standard withdrawal treatment not scheduled by the researchers (control group). MEASUREMENTS: The outcome was measured in terms of attaining a state of abstinence or by a decrease in the dosage during the study period of up to 12 months' duration. FINDINGS: No statistically significant differences in the outcomes were observed between the groups. A total of 13% of the experimental group and 27% of the control group were able to discontinue drug use. In addition 67% of the experimental group and 57% of the control group were able to decrease the dose. CONCLUSIONS: The search continues for improved methods of helping patients with complicated benzodiazepine dependence.

Right unilateral and bifrontal electroconvulsive therapy in the treatment of depression: a preliminary study.

The short-term outcome of electroconvulsive therapy (ECT) was studied in 24 patients with a current major depressive episode (DSM-IV). Patients were randomized to high dose (400% above the seizure threshold) right unilateral (RUL) ECT, to moderate dose (150% above seizure threshold) RUL ECT, and to low dose (just above seizure threshold) bifrontal (BF) ECT. Primary outcome measures included number of treatments, Hamilton Depression Rating Scale score, and Mini-Mental State Examination score. High dose RUL ECT was associated with a significantly faster response to treatment than low dose BF ECT. Moreover, there was a tendency to a higher response rate with high dose RUL ECT compared with either moderate dose RUL ECT or BF ECT.

Differential response to right unilateral ECT in depressed patients: impact of comorbidity and severity of illness [ISRCTN39974945].

BACKGROUND: Recent electroconvulsive therapy (ECT) efficacy studies of right unilateral (RUL) ECT may not apply to real life clinics with a wide range of patients with major depressive episodes. METHODS: The study included two groups of patients. In addition to a homogeneous group of patients with major depression according to DSM-IV criteria with severity of the major depressive episode > 16 scores on 17-item Hamilton Rating Scale for Depression (HDRS) (Group 1, n = 16), we included a heterogeneous group of patients with less severe major depressive episodes or with a variety of comorbid conditions (Group 2, n = 24). We randomly assigned the patients to an RUL ECT treatment dosed at 5 or 2.5 times seizure threshold with an intent-to-treat design. The outcomes measured blindly were HDRS, number of treatments, and Mini-Mental State Examination (MMSE). The patients were considered to have responded to treatment if the improvement in HDRS score was at least 60% and they had a total score of less than ten. RESULTS: The Group 2 patients responded poorer (8% vs. 63%), and had more often simultaneous worsening in their MMSE scores than Group 1 patients. The differences in the outcomes between the two different doses of RUL ECT treatment were not statistically significant. CONCLUSIONS: ECT effectiveness seems to be lower in real-life heterogeneous patient groups than in homogeneous patient samples used in experimental efficacy trials.