Increased somatic morbidity in the first year after leaving opioid maintenance treatment: results from a Norwegian cohort study.

BACKGROUND/AIMS: Some patients on opioid maintenance treatment (OMT) leave treatment temporarily or permanently. This study investigated whether patients interrupting their OMT differed from non-interrupters in sociodemographic and drug-use characteristics and examined acute/sub-acute somatic morbidity among the interrupters, prior to, during, and after OMT. METHODS: Cohort design. OBSERVATION PERIOD: 5 years prior to, up to first 5 years during, and up to 5 years after interruption of OMT. PARTICIPANTS: The sample (n = 200) comprised 51 OMT interrupters and 149 non-interrupters. Data on patient characteristics were obtained from interviews and OMT register information. Data on somatic morbidity were gathered from hospital records. MEASUREMENTS: Key patient characteristics among OMT interrupters and non-interrupters. Incidence rates of acute and sub-acute somatic disease incidents leading to hospital treatment (drug-related/non-drug-related/injuries) prior to/during/after OMT. RESULTS: Interrupters and non-interrupters did not differ in sociodemographic characteristics, while longer duration of amphetamine and benzodiazepine dependence predicted OMT interruption. Interrupters scored significantly higher on drug-taking and overdose during OMT but still had a significant 41% reduction in drug-related treatment, episodes. After interruption of treatment, such episodes increased markedly and were 3.6 times more frequent during the first post-OMT year compared to the pre-OMT period (p < 0.001). This increase was highest during the first months after OMT interruption. 2-5 years after interruption there was no significant increase. CONCLUSIONS: Increased somatic morbidity was found among OMT interrupters during the first year after OMT, and especially during the immediate post-treatment period.

Changes in neuropsychological functioning during alcohol detoxification.

This study investigates changes in neuropsychological functioning during early abstinence from alcohol. 30 alcohol-dependent inpatients were tested at intake (day 4 of admission) and post detoxification (day 26), using a test-retest design. The neuropsychological battery included measures of pre-morbid IQ, full-scale IQ, verbal and non-verbal measures of memory and executive function. IQ was within the normal range at intake and comparable with age-adjusted normative values and there were some impairments in memory and executive function. There were significant increases in performance scores post detoxification in working memory, verbal fluency and verbal inhibition but not in non-verbal executive function tasks (mental flexibility and planning ability). Despite increased scores on tests of verbal and memory skills after 3 weeks of abstinence, complex executive abilities showed little change. These may have a negative impact on engagement and response to treatment and compromise clinical outcomes, heightening the risk of relapse.

In-patient detoxification procedures, treatment retention, and post-treatment opiate use: comparison of lofexidine + naloxone, lofexidine + placebo, and methadone.

OBJECTIVE: In-treatment and post-treatment outcomes were compared for three detoxification procedures (lofexidine+naloxone, lofexidine+placebo naloxone, and methadone). SAMPLE AND DESIGN: The sample was 137 opiate dependent in-patients. Detoxification treatments were 6-day lofexidine+naloxone (n=45), lofexidine+placebo naloxone (n=46), or 10-day methadone reduction (n=46). A cohort study design was used with double-blind random allocation to lofexidine+naloxone versus lofexidine+placebo. Patients who did not consent to, or who were excluded from randomisation received methadone. RESULTS: Outcome differences between treatment groups at follow-up were generally associated with length of stay post-detoxification rather than detoxification procedure. Among patients who were not opiate abstinent throughout follow-up (n=85), those who received lofexidine+naloxone detoxification reported a longer interval to first heroin use, with an interaction between detoxification medication and subsequent retention in treatment also identified. CONCLUSIONS: Detoxification medication may influence medium-term opiate use outcomes via its effect upon retention in treatment.

Induction of patients with moderately severe methadone dependence onto buprenorphine.

Current clinical practice allows patients with low levels of physiological dependence on opioids (equivalent to methadone doses of 30 mg/d or less) to be transferred to buprenorphine. This study investigated the response of opioid-dependent patients receiving doses of methadone between 30-70 mg/d when transferred to buprenorphine at doses between 12-16 mg/d. Twenty-three patients receiving inpatient opioid detoxification agreed to take part in a trial of facilitated transfer to buprenorphine. Following the last morning dose of methadone, buprenorphine was substituted in doses increasing from 4 mg to a maximum of 16 mg, with adjunctive lofexidine (maximum of 2.4 mg/d). All except two patients successfully completed transfer to buprenorphine. To investigate the effect of initial methadone dose, the group was split into intermediate dose (ID; 30 - 49 mg/d; n = 10) and high dose (HD; 50-70 mg/d; n = 11) groups. Average stabilisation dose of buprenorphine for the sample who completed transfer was 14.0 mg/d (SD 2.3) and average daily lofexidine dose during transfer was 0.57 mg (SD 0.39). The HD group used significantly more lofexidine to complete transfer compared to the ID group. Increased opioid withdrawal symptoms, of mild severity as measured by the Short Opiate Withdrawal Scale (SOWS), were found in the HD group compared with the ID group during the first and last day of buprenorphine stabilisation. However, average SOWS scores for the whole of the period of transfer were not significantly different from those during the period of stabilisation on buprenorphine in either the ID or HD groups. This study suggests that transfer to buprenorphine is relatively uncomplicated from daily methadone doses of 30-70 mg in an inpatient setting and may be facilitated by use of lofexidine. This procedure may allow a larger proportion of opioid-dependent patients access to buprenorphine treatment.

Reduced injection risk and sexual risk behaviours after drug misuse treatment: results from the National Treatment Outcome Research Study.

This paper investigates injecting, shared use of needles/syringes and sexual risk behaviours at intake to treatment and at one-year follow-up among 753 drug users recruited to the National Treatment Outcome Research Study (NTORS). Injecting, sharing and having unprotected sex were substantially reduced among clients admitted to methadone programmes and among those admitted to residential treatments. The overall levels of risk fell after treatment, and the majority of those who were engaged in high risk behaviours at intake had stopped at follow-up. The results also show the variability of individual outcomes. A minority persisted with their risk behaviour, and others who were not at risk at intake who had started to engage in risky behaviours at follow-up. The behaviour of these clients creates a focal point for risk as well as being a threat to public health. Several social and psychological factors were predictive of health risk behaviours. These included frequency and duration of heroin use, polydrug use, alcohol use, gender, ethnicity, having a drug-using partner, anxiety and depression. The results indicate the important role that can be played by treatment services in helping to reduce the risk of blood-borne infections. We suggest that risk reduction interventions are an important and effective component of treatment programmes.

A double-blind randomized placebo-controlled trial of lofexidine in alcohol withdrawal: lofexidine is not a useful adjunct to chlordiazepoxide.

Lofexidine is an alpha-adrenoceptor agonist which has proved useful in opiate withdrawal and which, through its attenuation of noradrenergic activity, might be a valuable adjunct in the management of alcohol withdrawal. The objective of this study was to compare the clinical effectiveness and patient retention with adjunctive lofexidine versus placebo in the treatment of alcohol withdrawal under chlordiazepoxide cover. This was done in a prospective double-blind randomized placebo-controlled trial with 72 alcohol-dependent adults referred and admitted for in-patient alcohol detoxification. The adjunctive lofexidine group experienced significantly more severe withdrawal symptoms, greater hypotensive problems, more adverse effects, and no better rates of retention in treatment. Lofexidine provides no discernible benefit as an adjunctive medication (to chlordiazepoxide) in alcohol detoxification and, on the basis of our study, appears to be contra-indicated.

Are the Twelve Steps more acceptable to drug users than to drinkers? A comparison of experiences of and attitudes to Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) among 200 substance misusers attending inpatient detoxification.

The present study is a cross-sectional interview-based investigation comparing experiences of and attitudes towards Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) in a sample of 200 patients attending inpatient substance misuse detoxification services. Two hundred consecutive admissions were recruited; 100 each from one drug and one alcohol in-patient treatment service in which attendance at AA/NA was a voluntary adjunct to a generic treatment programme. Although there were no differences in the history of AA/NA attendance, the drug users (who were on average younger) reported significantly more positive attitudes towards AA/NA, more willingness to attend during their in-patient treatment and greater intention to attend following completion of their detoxification. In particular, despite no differences in spiritual/religious orientation, the drug users reported more positive views of the Twelve Steps. As AA/NA remain popular and accessible forms of substance misuse support, it is critical that we develop a clearer understanding of their impact and of the scope for their integration with generic forms of substance misuse treatment.

The impact of naloxone/lofexidine combination treatment on the opiate withdrawal syndrome.

Clinical studies in opiate-dependent patients suggest that detoxification treatment with opiate antagonists may accelerate the resolution of the opiate withdrawal syndrome, permitting early induction onto naltrexone maintenance treatment. The present open study compared the clinical efficacy of daily naloxone injections in conjunction with lofexidine, with conventional lofexidine monotherapy, in 49 polysubstance-misusing opiate-dependent patients. Overall, the addition of naloxone did not confer substantial benefit over lofexidine monotherapy, although area-under-the-curve analysis showed that withdrawal severity in the naloxone/lofexidine combination group was significantly less than in the lofexidine monotherapy group, who experienced more severe withdrawal symptoms on days 4, 7, 9 and 13 of treatment. There were no significant differences in rates of completion of detoxification. Blood pressure remained within normal limits in both groups. Naltrexone maintenance treatment acceptability was low; only four patients continued with treatment for 5 or more days. The modest benefit of adding naloxone to lofexidine compared to the findings of previous opiate antagonist detoxification treatment studies is discussed in the context of the hypothesis that a critical level of opiate receptor occupancy is required to accelerate resolution of opiate withdrawal; the neurochemical mechanisms which may promote this are discussed.

Outcomes after methadone maintenance and methadone reduction treatments: two-year follow-up results from the National Treatment Outcome Research Study.

This paper provides a detailed analysis of the 2-year outcomes for 351 drug misusers allocated on an intention-to-treat basis to methadone maintenance or methadone reduction treatments. Both groups showed substantial reductions in their use of illicit drugs and in other outcome areas. However, whereas most methadone maintenance patients received maintenance, only about one third of those allocated to methadone reduction received methadone reduction, and many actually received a form of methadone maintenance. Reduction patients were more likely to receive low doses of methadone, and were less likely to remain in treatment. For maintenance patients, higher doses and retention in treatment were both associated with improvements in illicit heroin use at 2 years. For the reduction patients, the more rapidly the methadone was reduced, the worse the heroin use outcomes. For patients in both treatment conditions, reductions in heroin use were associated with improvements in other outcome areas. The more severely dependent patients showed better outcomes in methadone maintenance. Methadone reduction treatment processes were associated with poor outcomes, and many patients who were allocated to methadone reduction treatment did not receive reduction treatment as intended. This calls into question the appropriateness of either the initial treatment planning process or the treatment delivery process, or both. A clearer distinction should be made between methadone maintenance and methadone reduction. Treatment goals should be made explicit both to the patient and to the clinical staff at the start of treatment. We suggest the need for a reappraisal of the goals and procedures of methadone reduction treatment.

High dose cocaine use in São Paulo: a comparison of treatment and community samples.

This cross-sectional study investigates patterns of drug use and associated problems among 332 cocaine users from treatment and community samples in São Paulo, Brazil. Data were collected using a structured questionnaire and the Severity of Dependence Scale (SDS). The majority were regular users of high doses of smoked cocaine. After controlling for severity of cocaine use, users in the community were found to be more involved in illegal activities, more likely to report adverse effects of cocaine, to be involved in prostitution, and to have lived on the streets. Better methods are required to provide interventions to tackle the problems and risk behaviors of these cocaine users.

Fiabilidad del "Maudsley addiction profile" (MAP, ERIT-version) y del "Treatment perceptions questionaire" (TPQ) en Italia, España y Portugal para la evaluación de tratamientos / Fiability of the Maudsley Addiction Profile ERIT Version (MAP) and the Treatment Perceptions Questionaire (TPQ) in Italy, Spain and Portugal for the evaluation of treatments

Se describe el control que se ha llevado a cabo sobre dos nuevas herramientas destinadas a la investigación sobre evaluación de tratamientos -el "MAUDSLEY ADDICTION PROFILE" (MAP, ERIT-Version) y el "TREATMENT PERCEPTIONS QUESTIONNAIRE" (TPQ) en Italia, Portugal y España. El MAP y el TPQ se desarrollaron en el Reino Unido como herramientas rápidas previsiblemente valiosas para la investigación de la población adulta que presenta desórdenes derivados del consumo de sustancias psicoactivas. El objetivo de dicho trabajo era validar la aplicación de estas herramientas en el contexto del continente europeo y la fiabilidad interna y test-retest de los ítem. En el estudio se incluyeron 206 sujetos en total (hubo 124 que participaron en el test- retest de MAP, y 95 que completaron el TPQ). Otros trece sujetos se sometieron a los dos, tanto al MAP como al TPQ. Los resultados del estudio indican que el MAP puede ser aplicado en 15 minutos, o menos incluso; que se ha comprobado la fiabilidad interna y test-retest del MAP y del TPQ, y que ambos resultan idóneos tanto para la validación del tratamiento como para otras relevantes propuestas de investigación que se desarrollen en la Unión Europea (AU)

Health care professionals referred for treatment of alcohol and drug problems.

This study reports on 62 health care professionals referred to a specialist drug and alcohol treatment service. Most patients used more than one type of substance. Health problems were common, but were seldom reasons for referral. Self-referral was infrequent. Referral was often subsequent to intoxication at work or persistent absenteeism. Just over half of admissions completed treatment. Multiple drug use was a poor prognostic indicator with fewer multiple drug users engaging with, or completing, treatment.

Peer-initiated overdose resuscitation: fellow drug users could be mobilised to implement resuscitation.

Research interviews about overdose experiences were conducted with 115 patients attending a methadone maintenance clinic in south London, UK. While almost half (49.6%) reported having experienced overdose personally (on an average of four occasions each), almost all (97.4%) reported that they had witnessed overdoses (on an average of six occasions each). This represents a total of 706 overdoses witnessed, of which 106 had resulted in fatalities. The vast majority of patients (86/97) reported that they had taken actions when they had witnessed overdoses with those acting taking an average of nearly threee different actions on the last occasion on which they had seen someone overdosing. Most respondents reported that they would be willing to act, even if they did not know the overdose victim personally and that they had not been deterred from acting by the previous response from the emergency services. Fear of punishment was not a strong deterrent from acting certainly not for this sample, with many participants also expressing an interest in expanding their repertoire of overdose interventions, for example through training in resuscitation techniques and by keeping naloxone at home for use in overdose emergency.

Routes of drug administration and multiple drug misuse: regional variations among clients seeking treatment at programmes throughout England.

AIMS: To investigate regional variations across England in routes of administration for heroin, non-prescribed methadone, non-prescribed benzodiazepines, cocaine powder, crack cocaine and amphetamines. DESIGN, SETTING, PARTICIPANTS: A survey of 1053 clients recruited to 54 residential and community drug misuse programmes. MEASUREMENTS: Structured face-to-face interviews conducted with clients at admission to treatment. FINDINGS: Routes of administration included injecting, smoking, snorting and oral use. For some drugs (methadone and benzodiazepines) one main route of administration was used. For other drugs (heroin, amphetamines and cocaine powder) there were marked variations in route. For all drugs except benzodiazepines, there were regional differences in routes of administration. Heroin injectors were more likely also to use other drugs by injection. CONCLUSIONS: The differences in routes of administration of different drugs, and the regional differences in routes of use, have implications for the provision of preventive and treatment services. Interventions to prevent transitions to injecting may be especially appropriate in areas where injecting is not prevalent. Hepatitis B vaccination continues to be advisable in both areas of high and low injecting prevalence. Needle exchange schemes and interventions targeted at drug overdose may be more suitable in areas of high injecting prevalence. Further research into regional differences in routes of drug use should be conducted with non-clinical samples.

Variation between and within drug treatment modalities: data from the National Treatment Outcome Research Study (UK).

This paper describes treatment practices in 54 drug treatment programmes taking part in the National Treatment Outcome Research Study (NTORS). Programmes were representative of the 4 main treatment modalities in the UK: in-patient, residential rehabilitation, methadone maintenance and methadone reduction. Distinguishing features of these forms of treatment were identified. Substantial variations in treatment practices were also observed within each modality, particularly for detoxification and prescribing arrangements, counselling and non-drug treatment services, and planned duration of treatment. Many programmes reported extensive waiting lists. These findings are discussed in the context of the growing international evidence of the association between patient outcome and the manner in which programme services are delivered.

New European instruments for treatment outcome research: reliability of the maudsley addiction profile and treatment perceptions questionnaire in Italy, Spain and Portugal.

This report describes the field testing of two recently developed instruments for treatment evaluation research - the Maudsley Addiction Profile (MAP) and the Treatment Perceptions Questionnaire (TPQ) - in Italy, Portugal and Spain. The MAP and TPQ have been developed in the United Kingdom as brief instruments which contain measures of high face validity for research applications with the adult psychoactive substance use disorder population. The present study assesses the application of these instruments in the continental European context and assesses the internal and test-retest reliabilities of the items. A total of 206 subjects participated in the study (124 subjects participated in the MAP test-retest study, and 95 clients completed the TPQ). Thirteen subjects completed both the MAP and the TPQ questionnaires. Results of the study indicated that the MAP can be administered to clients in 15 min or less. The internal and test-retest reliabilities of the MAP and TPQ are satisfactory. Both instruments are suitable for treatment evaluation and other relevant research purposes in the European Union.

Patterns of improvement after methadone treatment: 1 year follow-up results from the National Treatment Outcome Research Study.

One year outcomes for substance use behaviours, health and criminal behaviour, and variation in treatment response, are reported for patients recruited to methadone maintenance and methadone reduction treatment programmes as part of NTORS. Significant reductions in the use of all illicit target drugs were found at follow-up for patients recruited to the methadone maintenance and methadone reduction modalities. Because of similarities in the treatments received by clients in the two modalities we caution against interpreting these findings as showing that methadone maintenance and reduction treatments lead to similar outcomes. At this stage, it is suggested that these outcomes be regarded as reflective of exposure to some general methadone substitution treatment. Further investigation of the outcomes for the two modalities will be conducted. Cluster analyses were used to classify patients according to level of improvement in drug use. Four groups were identified. Two groups (59% of cases) showed substantial reductions in their illicit drug use and criminality as well as reduced physical and psychological symptoms. Twenty two percent of cases showed poor outcomes across a range of measures. Results for alcohol consumption were less satisfactory for patients in all groups. A majority of patients achieved widespread improvements across a range of outcome measures after treatment in existing methadone treatment services. These changes represent important clinical benefits to the individual clients, to their families and to society.