Methadone maintenance treatment and impulsivity: premature responding.

INTRODUCTION: Previous research showed that methadone maintenance treatment (MMT) is linked to impulsivity, with higher impulsivity levels being associated with for example, increased drug use. One aspect of impulsivity, most commonly studied in rodent research, is premature responding, the failure to wait for a starting signal. Premature responding is of high translational significance since it predicts the development of addiction-like behaviors in rodents. METHODS: We assessed 45 MMT patients and 46 demographically matched (age, sex, education, and handedness) healthy volunteers (HVs) on premature responding alongside action and inhibition of instructed and intentional trials using the Intentional Hand Task (IHT). RESULTS: The results showed markedly enhanced premature responses in the MMT vs. the HV group, which correlated positively with methadone dosage in the MMT patients. Throughout the task, MMT patients were faster across all trial parts and less accurate in response to instructed trials compared to HVs. CONCLUSIONS: The increase in premature motor reactions during variable waiting periods alongside increased motion speed and lower accuracy might reflect a specific motor inhibition deficit in MMT, a subcomponent of impulsivity not previously assessed in MMT. Incorporating an experimentally defined measure of impulsivity, such as premature responding, into existing test batteries used by clinicians might enable more tailored treatments addressing the increased impulsivity levels and associated dysfunctional behaviors in MMT.

Precarious Lives, Precarious Treatments: Making Drug Treatment Work in Northern Myanmar.

We explore how precarious livelihoods intersect with precarious treatments for heroin dependency in a setting affected by longstanding conflicts and an illicit drug economy as well as by recent events of pandemic and political change. Working with 33 qualitative interviews with people who inject drugs in Kachin State, northern Myanmar, we explore how drug dependency treatment, especially methadone substitution, is made to work in efforts to sustain everyday livelihoods. Our analysis attends to the work that is done to enable therapeutic trajectories to emerge as "generous constraints" in precarity. We trace methadone substitution as an emergent intervention of livelihood survival.

Estudio de seguimiento de 35 años de pacientes admitidos a tratamiento con metadona entre 1982-1984 en Asturias, España / A 35-year follow-up study of patients admitted to methadone treatment between 1982-1984 in Asturias, Spain

El objetivo fue evaluar el estado de una población dependiente a la heroína 35 años después de su primera inscripción en un tratamiento de mantenimiento con metadona (TMM). Se utilizó un protocolo ad hoc para evaluar morbilidad, consumo y tratamiento de la adicción en la muestra de supervivientes. Se calculó la razón de mortalidad estandarizada (RME) con un intervalo de confianza (IC) del 95%. Un total de 214 pacientes ingresaron en TMM entre 1982 y 1984 en el Servicio de Salud Pública de Asturias. Se recibió información sobre 195 sujetos, de los cuales 146 habían fallecido. Los hombres representaron el 77,5% de la cohorte del estudio. Durante el período de seguimiento de 35 años, la RME fue de 11,75 (IC 95% = 9,95 – 13,77). En la muestra de supervivientes, el 5,7% todavía estaba inscrito en TMM; el virus de inmunodeficiencia humana (VIH) se diagnosticó en un 38,77% y la hepatitis B/C en un 73,46%; el consumo actual de heroína se informó en un 4,1%. No hubo diferencias de género en la mortalidad o la condición de VIH y hepatitis B/C. Ninguna de las mujeres consumía heroína en el seguimiento de 35 años en comparación con el 5,26% de los hombres. En conclusión, nuestro estudio confirma la alta tasa de mortalidad a largo plazo, incluso después de la inscripción en TMM. (AU)

The objective was to evaluate outcomes in a heroin-dependent population 35 years after first enrolment in methadone maintenance treatment (MMT). An ad hoc protocol was used to assess drug misuse, treatment, and drug-related morbidity in the survivor sample. The standardized mortality ratio (SMR) and 95% confidence interval (CI) were calculated. A total of 214 heroin-dependent patients entered MMT between 1982 and 1984 in the Asturias Public Health Service. Information was received on 195 subjects, of whom 146 were deceased. Men accounted for 77.5% of the study cohort. Over the 35-year follow-up period, the SMR was 11.75 (95% CI = 9.95 – 13.77). In the survivor sample, 5.7% were still enrolled in MMT; human immunodeficiency virus (HIV) was diagnosed in 38.77% and hepatitis B/C in 73.46%. No differences were found between sexes in mortality or HIV and hepatitis B/C status. None of the female survivors were using heroin at the 35-year follow-up compared with 5.26% of males. In conclusion, our study confirms the high long-term mortality rate of heroin addicts, even after enrollment in MMT. (AU)

[Substitution treatments for opiate-dependent users. An experience of the Integrated Addiction Treatment Center in Dakar]. / Traitement de substitution des usagers dépendants des opiacés - L'expérience du Centre de prise en charge intégré des addictions de Dakar.

Methadone and buprenorphine are the two maintenance treatments in opiate addicts authorised in France since the end of the 1990's. More recently, some African countries such as Senegal have implemented a new health policy focused on reducing the risks by encouraging the use of methadone as maintenance treatment. The objectives of maintenance therapy are to reduce morbidity and mortality related to the consumption of heroin and other street opioids, to promote the integration of drug users into the healthcare system, and more generally, to improve their social integration. However, this strategy might have limitations in practice. Here, we report the experience of the Integrated Addiction Treatment Center in Dakar, Senegal, and discuss ethical considerations at both the individual and collective levels, which may improve care of opiate-dependent users in practice, especially in Africa.

Title: Traitement de substitution des usagers dépendants des opiacés - L'expérience du Centre de prise en charge intégré des addictions de Dakar. Abstract: La méthadone et la buprénorphine sont les deux traitements de substitution des opiacés autorisés en France depuis la fin des années 1990. Plus récemment, certains pays africains, comme le Sénégal, ont mis en place une nouvelle politique de santé axée sur la réduction des risques, en encourageant le recours aux traitements de substitution des opiacés. Les objectifs de la substitution sont de réduire la morbi-mortalité liée à la consommation d'héroïne ou d'autres opioïdes de rue, de favoriser l'insertion des usagers de drogue dans le système de soins, et, plus généralement, de faciliter leur insertion sociale. Cette nouvelle stratégie trouve néanmoins des limites dans la pratique. Nous rapportons dans cette revue l'expérience du Centre de prise en charge intégré des addictions de Dakar, au Sénégal, et proposons une réflexion éthique, tant individuelle que collective, afin d'améliorer le traitement de substitution des opiacés, notamment en Afrique.

Forensic pathological study of methadone-related deaths in the Genoa (Italy) district: A six-year study.

Methadone is a synthetic opioid, a pure agonist of the µ receptor. It is used for opioid maintenance therapy in heroin addiction. In recent years, Italian studies of incidence and prevalence have indicated an increase in the illegal sales of methadone and, consequently, an increase in deaths due to acute methadone intoxication as well. The present review is a prospective-observational study regarding epidemiological and toxicological analyses of methadone-related deaths recorded in the district of Genoa (Italy) from 2013 to 2018. The study includes a list of twenty-six people that have died from methadone toxicity: twenty-two males and four females. The concentration of methadone in the blood samples ranged from 181 to 4058.53 ng/mL, with an average of 964.29 ng/mL. Six subjects tested positive for methadone alone; twenty cases, however, presented drugs or substances in different concentrations in the blood samples. Illegal sales and consumption of methadone have a negative impact on the self-administration therapy of opioid addiction, inducing patients to increase their dosage or sell methadone in order to purchase illegal drugs. As shown in our study, this behaviour is associated with an increase in methadone-related deaths. Accordingly, careful monitoring of dosage administrated to patients is required in order to render the system safer.

Clinical characteristics and treatment outcomes of women with heroin dependence in Johannesburg, South Africa.

BACKGROUND: There has been a steady increase in the number of women with heroin dependence in South Africa (SA). Data from developed countries suggest that women with substance use disorder have unique treatment needs. There are limited SA data on women with heroin dependence and their response to treatment. OBJECTIVES: To describe the clinical and psychosocial characteristics of women entering inpatient rehabilitation for heroin dependence, determine the outcomes of treatment 3 and 9 months after rehabilitation, and compare these findings with male heroin users. METHODS: We conducted a longitudinal study of 44 women with heroin dependence who were admitted to a rehabilitation facility in the West Rand Municipality of Gauteng Province, SA. The participants were assessed during admission and 3 and 9 months after leaving inpatient rehabilitation. Structured interviews measured changes in drug use, psychopathology, social functioning, injecting and sexual behaviour, criminality and general health. Statistical analysis of these outcomes and comparison between women and men at 3 months and 9 months was performed by a generalised estimating equation. Fixed and time-varying covariates were included in the models. RESULTS: At baseline, 40% of female participants were HIV-positive, 50% engaged in sex work, 27% were injecting heroin users, and 75% were diagnosed with a comorbid mental illness. Thirty-seven (84%) and 30 (68%) were re-interviewed at the 3- and 9-month follow-up points, respectively. Of these, 6 were abstinent from all substances at 3 months and 2 at 9 months. Compared with males, females had a higher prevalence of HIV infection (p=0.006) and mental illness (p=0.0002) at enrolment. At 9 months, women had similar levels of drug use and criminality to men but scored significantly worse in terms of general health, social function and risky sexual behaviour. CONCLUSIONS: Women with heroin dependence in Johannesburg have high rates of HIV infection and comorbid mental illness and low rates of abstinence after inpatient detoxification and psychosocial therapy. Women fared worse than men in many domains of treatment outcome. This study builds evidence for the need for gender-sensitive substance rehabilitation facilities in SA.

Trajectories of heroin use predict relapse risk among heroin-dependent patients: A 5-year follow-up study.

OBJECTIVES: The relationship between past drug use trajectory and long-term relapse risk after rehabilitation among heroin-dependent patients remain understudied. The primary objectives were to identify longitudinal heroin use patterns of heroin-dependent patients, to determine the associative factors with trajectories and to investigate the impact of trajectory groups on relapse after finishing compulsory rehabilitation programs. MATERIALS AND METHODS: A total of 564 heroin-dependent patients were recruited from 4 compulsory rehabilitation facilities in Shanghai, China between 2007 and 2008. The baseline data was linked to participants' follow-up data on relapse from official records. Group-based trajectory model was used to identify distinctive drug use trajectory groups. The association between the identified group and heroin relapse risk was then analyzed to understand the role of past drug use trajectory on relapse. RESULTS: Five trajectory groups were identified in this cohort: (1) Rapid Decrease (9.9%); (2) Persistent High (32.0%); (3) Slow Decrease (34.1%); (4) Gradual Increase (4.5%); (5) Persistent Low (19.5%). Gender, age, education, and impulsivity were found to be different between the five groups. During the 5 years after discharged from the compulsory program, 291 (59.0%) individuals relapsed. Multivariate logistic regression analysis showed that the persistent high group (OR: 2.77 [1.46-5.24]), slow decrease group (OR: 2.31 [1.32-4.06]) and gradual increase group (OR: 3.50 [1.18-10.39]) was positively associated with the heroin relapse risk when compared to the persistent low group. CONCLUSIONS: Heroin use trajectories vary among heroin-dependent patients in China. The trajectories of heroin use before compulsory rehabilitation are associated with subsequent long-term relapse risk.

Factors predicting 6-month retention among people with opioid use disorders accessing outpatient methadone maintenance therapy in Tshwane, South Africa.

BACKGROUND: In South Africa (SA), increasing illicit opioid use and associated health challenges can be managed with opioid substitution therapy (OST), such as methadone, if the recommended dose and duration of use are prescribed. The Community Oriented Substance Use Programme (COSUP) provides free methadone to patients with opioid use disorder in Tshwane, SA, on need-based criteria. OBJECTIVES: To determine selected sociodemographic and substance use treatment factors associated with retention for at least 6 months among participants receiving methadone as part of OST in COSUP. METHODS: This was a retrospective cohort study using secondary data of patients treated with methadone at 8 COSUP sites. The factors associated with at least 6 months' retention for 575 participants from December 2016 to September 2018 were analysed. RESULTS: There were 91.3% males, 86.4% South Africans and 85.9% black Africans, with a median age of 30 years. At baseline, the majority were injecting heroin (55.5%) and were provided with free methadone (59.3%). The median dose of methadone at 6 months or on leaving the programme was 20 mg; 38.4% of participants were retained for at least 6 months. Of those not retained, the median duration on methadone was 56 days, whereas for those retained for at least 6 months, the median number of days on methadone were 254. After adjusting for sex and age, participants receiving methadone doses <50 mg had lower odds of being retained (0 - 20 mg: adjusted odds ratio (aOR) 0.25; p=0.002; 95% confidence interval (CI) 0.10 - 0.61; >20 - 40 mg: aOR 0.20; p<0.001; 95% CI 0.08 - 0.49) than those administered ≥50 mg. Participants who received free methadone had 3.75 the odds of being retained than those buying it themselves (p<0.001; 95% CI 2.47 - 5.70). Participants treated in the inner city had 5.19 the odds of being retained than those in a suburban setting (p<0.001; 95% CI 2.99 - 9.03). Compared with black African participants, white participants had 3.39 the odds of being retained (p=0.001; 95% CI 1.64 - 7.00). Injecting heroin users had 0.63 the odds of being retained (p=0.032; 95% CI 0.41 - 0.96). CONCLUSIONS: To maximise retention on OST, methadone should be free, with maintenance doses >50 mg. Reasons for lower retention among participants from periurban settings, those who inject and those from previously disadvantaged racial groups need to be explored, and findings used to inform programming.

Increases in methamphetamine use among heroin treatment admissions in the United States, 2008-17.

BACKGROUND AND AIMS: Due to their small sample sizes, geographic specificity and limited examination of socio-demographic characteristics, recent studies of methamphetamine use among people using heroin in the United States are limited in their ability to identify national and regional trends and to characterize populations at risk for using heroin and methamphetamine. This study aimed to examine trends and correlates of methamphetamine use among heroin treatment admissions in the United States. DESIGN: Longitudinal analysis of data from the 2008 to 2017 Treatment Episode Data Set. Descriptive statistics, trend analyses and multivariable logistic regression were used to examine characteristics associated with methamphetamine use among heroin treatment admissions. SETTING: United States. PARTICIPANTS: Treatment admissions of people aged ≥ 12 years whose primary substance of use is heroin. MEASUREMENTS: Primary measurement was heroin treatment admissions involving methamphetamine. Secondary measurements were demographics of sex, age, race/ethnicity, US census region, living arrangement and employment status. FINDINGS: The percentage of primary heroin treatment admissions reporting methamphetamine use increased each year from 2.1% in 2008 to 12.4% in 2017, a relative percentage increase of 490% and an annual percentage change (APC) of 23.4% (P < 0.001). During the study period, increases were seen among males and females and among all demographic and geographic groups examined. Among primary heroin treatment admissions reporting methamphetamine use in 2017, 47.1% reported injecting, 46.0% reported smoking, 5.1% reporting snorting and 1.8% reported oral/other as their usual route of methamphetamine use. CONCLUSIONS: Methamphetamine use among heroin treatment admissions in the United States increased from one in 50 primary heroin treatment admissions in 2008 to one in 8 admissions in 2017.

The Assessment of Recovery Capital (ARC) predicts substance abuse treatment completion.

Recovery from addiction requires various personal and environmental resources. The purposes of this study were to determine if the Assessment of Recovery Capital (ARC) scores measured at admission could predict substance abuse treatment (SAT) completion and to identify personal and environmental factors associated with ARC scores. Participants (N = 2265) comprised clients entering a Midwestern SAT facility (August 2015 - June 2017). Logistic regression was used to predict SAT completion using ARC scores. Nonparametric group comparisons were used for personal and environmental covariates. ARC scores significantly predicted successful SAT completion (OR = 1.05, 95% CI = 1.04, 1.05, Wald z = 12.9, p < 0.001). Employment had a positive relationship with ARC scores (Kruskal-Wallis χ2 = 215.96, df = 8, p < 0.001). ARC scores varied according to primary substance (Kruskal-Wallis χ2 = 101.10, df = 6, p < 0.001); alcohol and marijuana showed the highest scores and heroin the lowest. ARC scores decreased as number of problem substances increased (Kruskal-Wallis χ2 = 70.57, df = 2, p < 0.001, rS = -0.163, p < 0.001). Living arrangement was also significant (Kruskal-Wallis χ2 = 146.36, df = 8, p < 0.001); clients who were homeless had the lowest ARC scores. A number of personal and environmental covariates were associated with the ARC scores and potentially with the outcome. After adjustment, the ARC remained a strong predictor of SAT completion. The ARC should be used in SAT facilities to guide treatment decisions and to create individualized treatment plans for clients.

Smoking heroin with cannabis versus injecting heroin: unexpected impact on treatment outcomes.

BACKGROUND: In several countries, especially in Africa, the dominant method of heroin intake is smoking a joint of cannabis laced with heroin. There is no data exploring the impact of smoking heroin with cannabis on treatment outcomes. AIM: To compare treatment outcomes between people who inject heroin and people who smoke heroin with cannabis. METHODOLOGY: Three hundred heroin users were assessed on admission to inpatient rehabilitation and after treatment. We compared drug use, psychopathology, criminality, social functioning and general health between heroin injectors and heroin-cannabis smokers at treatment entry, and at 3 and 9 months after rehabilitation. RESULTS: The sample comprised 211 (70.3%) heroin-cannabis smokers and 89 (29.7%) heroin injectors. Eighty-four percent were followed up at 3 months and 75% at 9 months. At 9 months, heroin-cannabis smokers had a higher proportion of those who relapsed to heroin use compared with intravenous (IV) users (p = 0.036). The median number of heroin use episodes per day was lower for IV users than heroin-cannabis smokers at both follow-up points (p = 0.013 and 0.0019). A higher proportion of IV users was HIV positive (p = 0.002). There were no significant differences in psychopathology, general health, criminality and social functioning between IV users and heroin-cannabis smokers at all three time points. CONCLUSIONS: Heroin users who do not inject drugs but use other routes of administration may have increased risk for relapse to heroin use after inpatient rehabilitation and should therefore have equal access to harm reduction treatment services. Advocating a transition from injecting to smoking heroin in an African context may pose unique challenges.

Self-care habits among people who inject drugs with skin and soft tissue infections: a qualitative analysis.

BACKGROUND: Injection drug use is on the rise in the USA, and skin and soft tissue infections (SSTI) are a common complication, resulting in significant morbidity and mortality. Due to structural barriers to care-seeking, many people who inject drugs avoid formal care and resort to self-care techniques, but little is known about the nature of these techniques, or more generally about the accuracy or breadth of this population's knowledge of SSTIs. METHODS: Semi-structured qualitative interviews were conducted with 12 people who inject heroin in two metropolitan areas: Sacramento and Boston, USA. RESULTS: These interviews reveal a robust and accurate knowledge base regarding skin infections, including the progression from simple cellulitis to an abscess, and acknowledgment of the possibility of serious infections. Nonetheless, there remains a reticence to seek care secondary to past traumatic experiences. A step-wise approach to self-care of SSTI infections was identified, which included themes of whole-body health, topical applications, use of non-prescribed antibiotics, and incision and drainage by non-medical providers. CONCLUSIONS: The reported SSTI self-care strategies demonstrate resilience and ingenuity, but also raise serious concerns about inappropriate antibiotic consumption and complications of invasive surgical procedures performed without proper training, technique, or materials. Harm reduction agencies and health care providers should work to obviate the need for these potentially dangerous practices by improving healthcare access for this population. In the absence of robust solutions to meet the needs of this population, education materials should be developed to optimize the efficacy and minimize the harms of these practices, while empowering and supporting the autonomy of people who use drugs and providing clear guidance on when self-care should be abandoned in favor of formal medical care.

A prospective observational study of heroin users in Johannesburg, South Africa: Assessing psychiatric comorbidities and treatment outcomes.

BACKGROUND: Despite the rise in heroin use in sub Saharan-Africa opioid agonist maintenance treatment (OAMT) is still not state-funded in South Africa and many other African countries. In South Africa there has been little data published on the profile of heroin users and the outcomes of treatment for those who attend public treatment services. METHODS: 300 heroin users from two state-funded rehabilitation centres in Johannesburg were studied at entry into rehabilitation and 3-months after treatment. Treatment consisted of inpatient detoxification and inpatient psychosocial rehabilitation. Structured interviews measured changes in drug use, psychopathology and criminality post rehabilitation. RESULTS: Most (65.7%) smoked heroin in combination with cannabis while 29.7% were injecting users. Almost half the sample (49.3%) had at least one mental illness. Of the 252 (84%) participants seen at 3-month follow-up, 6.3% were abstinent of all substances (excluding tobacco), 65.5% had continued heroin use (CHU) and the balance used other substances. At follow-up there were significant decreases in heroin use (p<0.0001) and criminality (p<0.0001). There were however significant increases in alcohol use (p<0.0001), crystalmetamphetamine use (p=0.032) and the prevalence of current episode of major depression (p<0.0001). Just 11.9% received formal psychosocial treatment after leaving rehabilitation. None were on OAMT and only three participants were on psychotropic medication. None were tested for Hepatitis C during the study period and the majority (53%) did not know their HIV status. CONCLUSION: There are significant gaps in current treatment services for heroin users in South Africa. Retention in treatment and assessment and management of psychiatric and non-psychiatric comorbidities is low. Services need to be more integrated and should also include the provision of OAMT.

Injecting-related health harms and overuse of acidifiers among people who inject heroin and crack cocaine in London: a mixed-methods study.

BACKGROUND: Venous access is a priority for people who inject drugs (PWID). Damage and scarring of peripheral veins can exacerbate health harms, such as skin and soft tissue infections (SSTI), and promote transitions to femoral and subcutaneous injecting. Brown heroin available in Europe requires acidification for injection preparation. In this paper, we present mixed-methods data to explore our hypothesis of a link between overly acidic injection solutions, venous damage and SSTI risk. METHODS: We present a structured survey (n = 455) and in-depth qualitative interview (n = 31) data generated with PWID in London for the Care & Prevent study. Participants provided life history data and detail on injecting environments and drug preparation practices, including the use of acidifiers. Bivariate and multivariate analyses were conducted using a logistic regression for binary outcomes to explore associations between outcomes and excessive acidifier use. Grounded theory principles informed inductive qualitative analysis. Mixed-methods triangulation was iterative with results comparison informing the direction and questions asked of further analyses. RESULTS: Of the 455 participants, most (92%) injected heroin and/or crack cocaine, with 84% using citric as their primary acid for drug preparation. Overuse of acidifier was common: of the 418 who provided an estimate, 36% (n = 150) used more than ½ a sachet, with 30% (n = 127) using a whole sachet or more. We found associations between acidifier overuse, femoral injecting and DVT, but not SSTI. Qualitative accounts highlight the role of poor heroin quality, crack cocaine use, information and manufacturing constraints in acidifier overuse. Painful injections and damage to peripheral veins were common and often attributed to the use of citric acid. CONCLUSIONS: To reduce injecting-related injury and associated consequences, it is crucial to understand the interplay of environmental and practice-based risks underpinning venous damage among PWID. Overuse of acidifier is a modifiable risk factor. In the absence of structural supports such as safe injecting facilities or the prescribing of pharmaceutical diamorphine, there is an urgent need to revisit injecting paraphernalia design and distribution in order to alleviate health harms and distress among the most marginalised.

Factors impeding switching from methadone to buprenorphine in heroin users receiving methadone maintenance therapy - A naturalistic cohort study.

INTRODUCTION: Switching from methadone to buprenorphine/naloxone remains a challenge for heroin users receiving methadone maintenance treatment (MMT). The present study aimed to investigate the predictors for failed switching from methadone to buprenorphine/naloxone among patients receiving MMT. METHODS: This 5-year retrospective study included 168 individuals (138 males and 30 females) with opioid dependence who attempted to switch from methadone to buprenorphine/naloxone at our MMT clinics in Taiwan. We excluded patients with psychiatric comorbidity and other substance use disorders except nicotine. A univariate Cox proportional hazards regression model (Cox model) was used to estimate the potential factors of subsequent failed switching, followed by a multivariate Cox model to identify significant predictors after adjusting for other covariates. RESULTS: Seventy of the 168 participants (41.7%) failed switching from methadone to buprenorphine/naloxone. After forward selection in the Cox hazard regression model, a greater average dose of methadone (HR = 1.02; P = 0.01), greater maximal maintenance dose of MMT (HR = 1.02; P < 0.001), greater average dose of buprenorphine (HR = 1.10; P = 0.021), and lower average attendance rate during the three months before switching (HR = 0.09; P = 0.002) were significantly associated with failed switching. CONCLUSIONS: This study with limited participants showed that dose of methadone, dose of buprenorphine, and attendance rates were significantly associated with failed switching. Clinicians should discuss with their patients about tapering the dose of methadone and improving their attendance if they want to switch from methadone to buprenorphine. Further studies are necessary to verify whether our findings generalize to other populations.

Introducing hepatitis C virus healthcare pathways in addiction care in the Netherlands with a Breakthrough project: a mixed method study.

BACKGROUND: People who inject drugs (PWID) are disproportionally affected by the hepatitis C virus (HCV) infection. In the Netherlands, active HCV transmission in PWID has practically been halted but uptake of HCV testing and linkage to care remains insufficient in this risk group. A national HCV in Addiction Care (HAC) quality improvement project based on the Breakthrough methodology (i.e. Breakthrough project) aimed to secure proper linkage to care in PWID by introducing local HCV healthcare screening and treatment pathways in addiction care units. AIM: To qualitatively appraise the local HCV healthcare pathways; to evaluate the yield in terms of number of PWID screened, diagnosed, referred, and treated; and to identify best practices and barriers to successful participation in the HAC Breakthrough project. METHODS: Between 2013 and 2016, 12 units of addiction care centers throughout the Netherlands participated in two series of a HAC Breakthrough project. Local multidisciplinary teams created HCV healthcare pathways. Quality assessment of HCV healthcare pathways was performed retrospectively and data on screening results was collected. In-depth interviews were conducted to elucidate best practices and essential elements for successful participation. RESULTS: In total, six HCV healthcare pathways were submitted by ten teams of which 83% was judged to be of "good" or "sufficient" quality. Uptake of HCV-antibody screening was 40% (N = 487/1219) and uptake of HCV-RNA in HCV-antibody positives was 59% (N = 107/181). The project resulted in 76 (6%) newly detected cases of persistent HCV viremia. Of all HCV-RNA positives, 92% was referred to a hepatitis treatment center. In 39% (N = 27/70) of those referred, treatment initiation was documented and 82% (N = 22/27) achieved a sustained virological response. Teams identified several best practices including motivational counseling training, oral swabs for anti-HCV testing, facilitating complementary HCV RNA testing, and supervised hospital visits. CONCLUSION: The HAC Breakthrough project has brought about good quality HCV healthcare pathways in the majority of participating addiction care centers and has successfully linked PWID with ongoing HCV viremia to care. Uptake of HCV screening and treatment after referral were identified as the main gaps to be closed in the HCV cascade of care to achieve final HCV elimination in Dutch PWID (i.e. micro-elimination).

Abstinence Following a Motivation-Skill-Desensitization-Mental Energy Intervention for Heroin Dependence: A Three-year Follow-up Result of a Randomized Controlled Trial.

The high rate of relapse among heroin users remains a significant public concern in China. In the present study, we utilized a Motivation-Skill-Desensitization-Mental Energy (MSDE) intervention and evaluated its effects on abstinence and mental health. Eighty-nine male heroin users in a drug rehabilitation center were enrolled in the study. The participants in the MSDE intervention group (n=46) received MSDE intervention, which included motivational interviewing, coping skills training, eye movement desensitization and reprocessing, and mindfulness-based psychotherapy. The participants in the control group (n=43) received a series of lectures on skills training. A significant increase in Contemplation Ladder score (P<0.001) and decreases in scores on the Obsessive Compulsive Drug Use Scale (P<0.001), Beck Depression Inventory (P<0.001), and Aggression Questionnaire (P=0.033) were found immediately after intervention. Compared to the control group, the MSDE intervention group reported significantly higher abstinence rates (P=0.027) and retention rates (P<0.001) at follow-up. Overall, the MSDE intervention, which uses a combined strategy for relapse prevention, could be a promising approach for preventing relapse among heroin users in China.

In their own words: language preferences of individuals who use heroin.

BACKGROUND AND AIMS: Use of non-judgmental, respectful and uniform language to describe individuals with substance use disorders (SUD) is recommended to reduce stigma. However, existing research concerning the use of labels for substance use has largely focused on perspectives of treatment providers and the general public, and to a lesser degree of those in long-term recovery. This study aimed to examine and compare labels that individuals who use heroin and are initiating SUD treatment (1) use to describe themselves and when speaking with others who use drugs, with family and with treatment providers, and (2) prefer to be called and never want to be called. Design and Setting This was a cross-sectional survey study using a convenience sample of individuals initiating an in-patient managed withdrawal program in Massachusetts, USA. PARTICIPANTS: Between October 2017 and May 2018, 263 participants were enrolled. MEASURES: Participants completed a survey about (1) what labels they used to refer to self and when talking with others who use drugs, with providers, families and at 12-Step meetings and (2) to identify which label they preferred least and most for others to use when referring to them. FINDINGS: More than 70% of participants used the term 'addict' to describe themselves and when speaking with others. However, use of 'addict' varied by context, and was most common at 12-Step programs. Fewer than 15% reported using 'user' or slang terms, most commonly 'junkie', in any communications. The most-preferred label for others to call them was 'person who uses drugs', while the most common label that participants never wanted to be called was 'heroin misuser' or 'heroin-dependent'. CONCLUSION: Label preferences by individuals who use heroin and are in early recovery are consistent with general guidelines about use of first-person language and suggest avoidance of language indicative of drug misuse or dependence.

Facing the Growing Heroin Problem in Colombia: The New Methadone-assisted Treatment Programs. / Enfrentando el problema emergente de consumo de heroína en Colombia: los nuevos programas de tratamiento asistido con metadona.

OBJECTIVE: Colombia is facing a rising epidemic of intravenous heroin use. Knowledge of the methadone-assisted treatment programs in the country is crucial in order to propose improvement strategies. METHODS: 13 programmes from priority regions were surveyed. The demographic and clinical characteristics of the patients attending the programs, a description of the services offered, their methadone treatment protocols, the various barriers to treatment and the causes of treatment abandonment were reviewed. RESULTS: 12/13 questionnaires were analysed with a total of 538 active patients. Most of the patients attending these programs were men (85.5%) between 18 and 34 years-old (70%). Forty percent (40%) were intravenous drug users and 25% admitted sharing needles. The comorbidities associated with heroin use were mental illness (48%), hepatitis C (8.7%) and HIV (2%). Psychiatric comorbidity was more likely in patients attending the private sector (69.8% vs 29.7%; p<0.03). The initial average dose of methadone administered was 25.3±8.9mg/day, with a maintenance dose ranging from 41 to 80mg/day. Lack of alignment with primary care was perceived to be the most serious barrier to access, ahead of problems with insurance and prejudice towards treatment with methadone (p<0.05). Health Administration and insurance problems (p<0.003), together with the lack of availability of methadone (p<0.018) and relapse (p<0.014) were the most important reasons for abandonment of treatment. CONCLUSIONS: The treatment protocols of these programmes offer different levels of development and implementation. Some of the barriers to access and reasons for abandonment of treatment with methadone can be mitigated with better health administration.