Blood Oxygenation and Heart Rate Changes After Diamorphine Intravenous Injection During Opioid Agonist Treatment for Outpatients With Heroin Dependence.

OBJECTIVES: More than 60 million people use opioids each year, and many countries have declared an opioid overdose crisis. Heroin, one of the most commonly used opioids, has depressant effects on autonomic functioning; however, few studies have been able to examine the effects of heroin or its pharmaceutically prepared equivalent, diamorphine, in human clinical populations. The present study examined heart rate and oxygen saturation in the minutes immediately after acute diamorphine administration in outpatients with heroin dependence. METHODS: The sample was a subset of participants (N = 36) in the German Project of Heroin Assisted Treatment of Opiate Dependent Patients Trial in Bonn, Germany. Patients were given 3 daily doses of intravenous diamorphine. Doses were determined on an individual basis by study physicians. Pulse oximetry was recorded at baseline and at 30-second intervals from 0 to 450 seconds after diamorphine administration. RESULTS: Heart rate was significantly higher than baseline at 30 seconds after diamorphine administration and significantly lower than baseline at 270 seconds onward. Oxygen saturation was significantly lower than baseline at 60 seconds onward. CONCLUSIONS: Results are consistent with other studies in which depressant effects of opioids were observed. Our findings suggest that even therapeutic doses of diamorphine may have rapid and significant-predominantly depressant-effects on oxygenation and heart rate in populations that frequently use opioids. Monitoring of potential adverse opioid effects would be beneficial even in populations presumed to have developed physiological tolerance.

ADHD Prevalence among Outpatients with Severe Opioid Use Disorder on Daily Intravenous Diamorphine and/or Oral Opioid Maintenance Treatment.

(1) Background: Attention deficit hyperactivity disorder (ADHD) is a common comorbid condition in opioid use disorder (OUD) and is associated with a more severe course of substance use. Patients with severe OUD who have not responded to oral opioid maintenance treatment can be treated with intravenous diamorphine up to three times per day. Here, we investigated the prevalence of ADHD among patients undergoing either daily diamorphine maintenance treatment or daily oral opioid maintenance treatment. (2) Methods: We assessed all participants with the WURS-k and the ADHD-SR. The Diagnostic Interview for ADHD in Adults (DIVA) was performed with all participants who met the cut-off in the WURS-k and/or ADHD-SR. (3) Results: The overall prevalence of ADHD was 17.9%. Prevalence of ADHD among patients undergoing daily diamorphine maintenance treatment was 14.3%. Prevalence of ADHD among patients undergoing daily oral opioid maintenance treatment was 20.3%. The combined presentation of ADHD was the most prevalent condition. In urine samples of participants with comorbid ADHD, heroin was detected the most and cocaine the least frequently. (4) Conclusions: Almost one out of five patients with OUD suffered from comorbid ADHD. In 83.3%, ADHD had not been diagnosed prior to participation in this study. Thus, patients with SUD could benefit from being routinely screened for ADHD.

Benzodiazepine use among patients in heroin-assisted vs. methadone maintenance treatment: findings of the German randomized controlled trial.

Benzodiazepine (BZD) use has been found to be associated with poorer psychosocial adjustment, higher levels of polydrug use and more risk-taking behaviors among opioid dependent patients. The aim of this paper is to analyze the correlation between BZD use, BZD prescription and treatment outcome among participants in the German trial on heroin-assisted treatment. 1015 patients who participated in the study comparing heroin-assisted and methadone maintenance treatment (HAT & MMT) for 12 months were included in the analysis. Analyses were carried out to assess the association of treatment outcome with baseline BZD use, with ongoing BZD use and with different patterns of BZD prescription. Baseline BZD use correlated with lower retention rates but not with poorer outcome. Ongoing BZD use correlated with poorer outcomes. Significantly better outcomes were found in the course of phobic anxiety symptomatology for those with regular prescription of BZD. The percentage of BZD positive urine tests decreased more in HAT than in MMT. Poorer outcome for benzodiazepine users may be mediated by a higher severity of addiction. Cautious prescribing of benzodiazepines may be beneficial due to the reduction of overall illicit use.

Successful treatment of chronic hepatitis C virus infection in severely opioid-dependent patients under heroin maintenance.

BACKGROUND: Severely opioid-dependent patients are at high risk of both acquiring and spreading the hepatitis C virus (HCV). It is uncertain, however, whether these patients are possible candidates for HCV treatment. We therefore explored treatment retention and adherence as well as sustained viral response in co-morbid severely opioid-dependent subjects under heroin maintenance, who previously failed in conventional substitution treatment or were not in any drug treatment. METHODS: All patients in heroin maintenance in the German heroin trial, who received standard antiviral HCV therapy with pegylated interferon and ribavirin, were included. Co-consumption of licit and illicit drugs was tolerated as long as it did not interfere with treatment. RESULTS: Twenty-six patients in heroin maintenance were treated for chronic HCV infection. Both the Global Severity Index of the Symptom Checklist 90-R (average score 65.9) and the Opiate Treatment Index (average score 16.6) indicated relevant co-morbidity. Twenty-one patients (81%) were retained in treatment; the adherence rate was 92%. Eighteen patients (69%) achieved a sustained viral response, with a 100% response rate for genotype 2, 90% for genotype 3, and 42% for genotype 1. DISCUSSION: This is the first study that investigates the feasibility of antiviral HCV treatment in a well-defined sample of co-morbid severely opioid-dependent subjects in heroin maintenance treatment. Viral response rates are comparable to non-drug-user populations. Within a need-adapted treatment setting, HCV treatment may even be extended to difficult-to-treat opioid-dependent patients.

Long-term effects of heroin-assisted treatment in Germany.

AIMS: Trials in Switzerland, the Netherlands and Spain have found that heroin-assisted treatment (HAT) as maintenance treatment for opioid-dependent patients reduces illicit drug use. A German trial also found diamorphine treatment to be superior to methadone treatment. The present study describes the association between 2 years of heroin treatment and improvements in health and social stabilization, as well as illicit drug use. DESIGN: A prospective cohort study design. PARTICIPANTS: A total of 515 patients were assigned to diamorphine treatment; 278 patients remained in the study treatment for the entire period of 24 months (54.8%). MEASUREMENTS: The results on physical (Opiate Treatment Index Health Symptoms Scale) and mental (Symptom Checklist 90-Revised Global Severity Index) health and illicit drug use (number of days with drug use within the last month-European Addiction Severity Index) were examined by repeated-measures analyses. FINDINGS: Symptoms of physical (Pillai's trace = 0.837, df = 4, P < 0.001) and mental health (Pillai's trace = 0.450, df = 4, P < 0.001) improved during treatment. Street heroin use declined rapidly (Pillai's trace = 0.836, df = 4, P < 0.001), as did cocaine use (Pillai's trace = 0.280, df = 4, P < 0.001). CONCLUSIONS: HAT is associated with improvements in mental and physical health in the long term.

Pregnancy and birth under maintenance treatment with diamorphine (heroin): a case report.

BACKGROUND: Heroin-assisted treatment (HAT) is a new form of treatment for heroin-dependent patients not responding to conventional interventions such as methadone maintenance treatment. No pregnancies or births under HAT have been reported until now. CASE: The pregnancy course of a 31-year-old severely dependent multi-morbid woman receiving HAT and the birth of a healthy baby after premature delivery is described. HAT helped to reduce the use of illicit substances both before and during pregnancy. The neonatal abstinence syndrome was clinically well compensated. CONCLUSION: HAT seems to be feasible in pregnant women and normal birth is possible under HAT, which therefore may act as a harm reduction measure for polydrug-using pregnant women not responding to methadone maintenance treatment.