Curb Heroin In Plants (C.H.I.P.): Revisiting a Mid-1970s Intervention Into Workplace Heroin Addiction Created and Led by Detroit Autoworkers.

This article analyzes archival records to revisit Curb Heroin In Plants (C.H.I.P.), a public health intervention focusing on drug dependence that was created and led by Detroit, Michigan, autoworkers during the mid-1970s. Responding to widespread heroin use in Detroit auto plants, C.H.I.P. combined methadone maintenance with counseling on and off the job to treat heroin dependence while supporting autoworkers in continuing in employment and family life. Although C.H.I.P. ultimately failed, it was a promising attempt to transcend medical/punitive approaches and treat those with substance use disorder in a nonstigmatizing way, with attention to the workplace dimensions of their disorder and recovery. I argue that revisiting C.H.I.P. speaks to current public health debates about the intersection between the workplace and harmful drug use and how to create effective interventions and policies that are mindful of this intersection. For historians, C.H.I.P. is a valuable example of the crucial role of workplace actors in the early war on drugs and of an early methadone program that was not strongly concerned with crime reduction but incorporated social externalities (specifically job performance) to measure success.

Cannabinoid CB1 receptor neutral antagonist AM4113 inhibits heroin self-administration without depressive side effects in rats.

Cannabinoid CB1 receptors (CB1Rs) have been shown to be a promising target in medication development for the treatment of addiction. However, clinical trials with SR141716A (rimonabant, a selective CB1R antagonist/inverse agonist) for the treatment of obesity and smoking cessation failed due to unwanted side effects, such as depression, anxiety, and suicidal tendencies. Recent preclinical studies suggest that the neutral CB1R antagonist AM4113 may retain the therapeutic anti-addictive effects of SR141716A in nicotine self-administration models and possibly has fewer unwanted side effects. However, little is known about whether AM4113 is also effective for other drugs of abuse, such as opioids and psychostimulants, and whether it produces depressive side effects similar to SR141716A in experimental animals. In this study, we demonstrated that systemic administration of AM4113 (3 and 10 mg/kg) dose-dependently inhibited the self-administration of intravenous heroin but not cocaine or methamphetamine, whereas SR141716A (3 and 10 mg/kg) dose-dependently inhibited the self-administration of heroin and methamphetamine but not cocaine. In the electrical brain-stimulation reward (BSR) paradigm, SR141716A (3 and 10 mg/kg) dose-dependently increased the BSR stimulation threshold (i.e., decreased the stimulation reward), but AM4113 had no effect on BSR at the same doses, suggesting that SR141716A may produce aversive effects while AM4113 may not. Together, these findings show that neutral CB1R antagonists such as AM4113 deserve further research as a new class of CB1R-based medications for the treatment of opioid addiction without SR141716A-like aversive effects.

Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic.

OBJECTIVES: To estimate health outcomes of policies to mitigate the opioid epidemic. METHODS: We used dynamic compartmental modeling of US adults, in various pain, opioid use, and opioid addiction health states, to project addiction-related deaths, life years, and quality-adjusted life years from 2016 to 2025 for 11 policy responses to the opioid epidemic. RESULTS: Over 5 years, increasing naloxone availability, promoting needle exchange, expanding medication-assisted addiction treatment, and increasing psychosocial treatment increased life years and quality-adjusted life years and reduced deaths. Other policies reduced opioid prescription supply and related deaths but led some addicted prescription users to switch to heroin use, which increased heroin-related deaths. Over a longer horizon, some such policies may avert enough new addiction to outweigh the harms. No single policy is likely to substantially reduce deaths over 5 to 10 years. CONCLUSIONS: Policies focused on services for addicted people improve population health without harming any groups. Policies that reduce the prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation.

Opioid substitution treatment and heroin dependent adolescents: reductions in heroin use and treatment retention over twelve months.

BACKGROUND: Opioid dependence is a major health concern across the world and does also occur in adolescents. While opioid substitution treatment (OST) has been thoroughly evaluated in adult populations, very few studies have examined its use in adolescents. There are concerns that OST is underutilised in adolescents with heroin dependence. We sought to measure changes in drug use among adolescents receiving OST and also to examine treatment attrition during the first 12 months of this treatment. METHODS: We included all heroin dependent patients aged under 18.5 years commencing OST at one outpatient multidisciplinary adolescent addiction treatment service in Dublin, Ireland. Psycho-social needs were also addressed during treatment. Drug use was monitored by twice weekly urine drugs screens (UDS). Change in the proportion of UDS negative for heroin was examined using the Wilcoxon signed rank test. Attrition was explored via a Cox Regression multivariate analysis. RESULTS: OST was commenced by 120 patients (51% female and mean age 17.3 years). Among the 39 patients who persisted with OST until month 12, heroin abstinence was 21% (95% confidence interval [CI] = 9-36%) at month three and it was 46% (95% CI = 30-63%) at month 12. Heroin use declined significantly from baseline to month three (p < 0.001) and from month three to month 12 (p = 0.01). Use of other drugs did not change significantly. People using cocaine during month 12 were more likely to be also using heroin (p = 0.02). Unplanned exit occurred in 25% patients by 120 days. The independent predictors of attrition were having children, single parent family of origin, not being in an intimate relationship with another heroin user and evidence of cocaine use just before treatment entry. CONCLUSIONS: We found that heroin dependent adolescent patients achieved significant reductions in heroin use within three months of starting OST and this improved further after a year of treatment, about half being heroin abstinent at that stage. Patient drop out from treatment remains a challenge, as it is in adults. Cocaine use before and during treatment may be a negative prognostic factor.

A randomized, open label trial of methadone continuation versus forced withdrawal in a combined US prison and jail: Findings at 12 months post-release.

Recently, incarcerated individuals are at increased risk of opioid overdose. Methadone maintenance treatment (MMT) is an effective way to address opioid use disorder and prevent overdose; however, few jails and prisons in the United States initiate or continue people who are incarcerated on MMT. In the current study, the 12 month outcomes of a randomized control trial in which individuals were provided MMT while incarcerated at the Rhode Island Department of Corrections (RIDOC) are assessed. An as-treated analysis included a total of 179 participants-128 who were, and 51 who were not, dosed with methadone the day before they were released from the RIDOC. The results of this study demonstrate that 12 months post-release individuals who received continued access to MMT while incarcerated were less likely to report using heroin and engaging in injection drug use in the past 30 days. In addition, they reported fewer non-fatal overdoses and were more likely to be continuously engaged in treatment in the 12-month follow-up period compared to individuals who were not receiving methadone immediately prior to release. These findings indicate that providing incarcerated individuals continued access to MMT has a sustained, long-term impact on many opioid-related outcomes post-release.

Effect of initiating drug treatment on the risk of drug-related poisoning death and acquisitive crime among offending heroin users.

BACKGROUND: A recent Cochrane review of randomised trials identified a lack of evidence for interventions provided to drug-using offenders. We use routine data to address whether contact with treatment services reduces heroin users' likelihood of a future acquisitive offence or drug-related poisoning (DRP) death. METHODS: Heroin-users were identified from probation assessments and linked to drug-treatment, mortality and offending records. The study cohort was selected to ensure that the subject was not: in prison, in treatment or had recently left treatment. Subjects were classed as initiators if they attended a triage appointment within two weeks of their assessment; non-initiators otherwise. Initiator and non-initiators were compared over a maximum of one year, with respect to their risk of recorded acquisitive offence or DRP-death. Balance was sought using propensity score matching and missing data were accounted for using multiple imputation. RESULTS: Nine percent of assessments identified for analysis were classed as initiators. Accounting for observed confounding and missing data, there was a reduction in DRPs associated with initiator assessments, however there was uncertainty around this estimate such that a null-effect could not be ruled out (HR: 0.42, 95% CI 0.17-1.04). There was no evidence of a decrease in the recidivism risk, in fact the analysis showed a small increase (HR: 1.10, 95% CI 1.02-1.18). CONCLUSION: For heroin-using offenders, initial contact with treatment services does not appear to reduce the likelihood of a future acquisitive offence.

Patterns of HIV testing, drug use, and sexual behaviors in people who use drugs: findings from a community-based outreach program in Phnom Penh, Cambodia.

BACKGROUND: People who use drugs are an important priority for HIV programs. However, data related to their utilization of HIV services are limited. This paper reports patterns of HIV testing, drug use, and risk and service perception among people who use drugs. Study participants were receiving HIV and harm reduction services from a community-based program in Phnom Penh, comprised of itinerant peer-led outreach and static drop-in centers. METHODS: This was a mixed-methods study conducted in 2014, comprising of a quantitative survey using a structured questionnaire, followed by two focus group discussions among a sub-sample of survey participants. Participants were recruited from hotspots in five HIV high-burden communes using a two-stage cluster sampling method. Quantitative descriptive analyses and qualitative thematic analyses were performed. RESULTS: This study included 151 people who use drugs with a mean age of 31.2 (SD = 6.5) years; 77.5% were male and 39.1% were married. The most common drugs used were methamphetamines (72.8%) and heroin (39.7%), and 38.0% injected drugs in the past 3 months. Overall, 83.3% had been tested for HIV in the past 6 months, of whom 62.5% had been tested by peers through community-based outreach. However, there were ongoing HIV risks: 37.3% were engaging in sex on drugs, only 35.6% used a condom at last sexual intercourse, and 10.8% had had a sexually transmitted infection in the last 6 months. Among people who reported injecting drugs in the past 3 months, 27.5% reported re-using needles/syringes. Almost half (46.5%) perceived themselves as being at lower risk of HIV compared to the general population. Qualitative results contextualized the findings of low perception of HIV risks and suggested that although services were often unavailable on weekends, at night, or during national holidays, peer-led community-based outreach was highly accepted. CONCLUSIONS: A peer-led community-based approach was effective in reaching people who use drugs with HIV and harm reduction interventions. To mitigate ongoing HIV risks, expanding access to combination prevention interventions and implementing strategies to enable people who use drugs to objectively assess their HIV risks are required. Additionally, community-based programs should collect data along the care continuum, to enable decentralized tracking of progress towards 90-90-90 goals at local levels.

Today's fentanyl crisis: Prohibition's Iron Law, revisited.

More than a decade in the making, America's opioid crisis has morphed from being driven by prescription drugs to one fuelled by heroin and, increasingly, fentanyl. Drawing on historical lessons of the era of National Alcohol Prohibition highlights the unintended, but predictable impact of supply-side interventions on the dynamics of illicit drug markets. Under the Iron Law of Prohibition, efforts to interrupt and suppress the illicit drug supply produce economic and logistical pressures favouring ever-more compact substitutes. This iatrogenic progression towards increasingly potent illicit drugs can be curtailed only through evidence-based harm reduction and demand reduction policies that acknowledge the structural determinants of health.

Opioid analgesics and heroin: Examining drug misuse trends among a sample of drug treatment clients in Kentucky.

BACKGROUND: In an effort to mitigate Kentucky's prescription drug misuse, legislative intervention efforts were introduced in 2012 and 2013 to better regulate pain clinics, prescribed use of opioid analgesics, and to expand the monitoring of opioid prescriptions. The focus of this paper is primarily on opioid analgesics and heroin and the relationship of use/misuse patterns of these drugs to state drug policy initiatives. METHODS: A secondary data analysis of drug treatment clients (N=52,360) was conducted to project illicit drug use trends in Kentucky. This study describes temporal and geographic trends of self-reported illicit drug use among individuals in state-funded treatment in Kentucky between fiscal year 2010 and fiscal year 2013. RESULTS: Significant reductions in the prevalence of illicit opioid use, declined from fiscal year 2010 to fiscal year 2013 (p<.01, CI=-.298 to -.215). However, heroin use rates significantly increased over the years studied, suggesting there may be a transition from prescription opioids to heroin (p<.01, CI=.143 to .178). The analysis suggests these trends may continue. CONCLUSIONS: Findings suggest Kentucky's legislative efforts were effective in reducing illicit prescription opioid use, but heroin use has increased. One possible explanation for this relationship is that as prescription opioids became more difficult to obtain, users turned to heroin as a substitute. The finding of rising heroin use suggests a need for further policy initiatives to reduce heroin use, but the potential effectiveness of this policy remains unclear. Understanding trends may help to guide future policy efforts and pain management treatment strategies to where they might have their greatest impact.

A single administration of the hallucinogen, 4-acetoxy-dimethyltryptamine, prevents the shift to a drug-dependent state and the expression of withdrawal aversions in rodents.

Despite several studies suggesting the therapeutic use of 5-hydroxytryptamine receptors type 2A (5-HT2A ) agonists in the treatment of substance use disorders, the neurobiological basis accounting for such effects are still unknown. It has been observed that chronic exposure to drugs of abuse produces molecular and cellular adaptations in ventral tegmental area (VTA) neurons, mediated by brain-derived neurotrophic factor (BDNF). These BDNF-induced adaptations in the VTA are associated with the establishment of aversive withdrawal motivation that leads to a drug-dependent state. Growing evidence suggests that 5-HT2A receptor signaling can regulate the expression of BDNF in the brain. In this study, we observed that a single systemic or intra-VTA administration of a 5-HT2A agonist in rats and mice blocks both the aversive conditioned response to drug withdrawal and the mechanism responsible for switching from a drug-naive to a drug-dependent motivational system. Our results suggest that 5-HT2A agonists could be used as therapeutic agents to reverse a drug dependent state, as well as inhibiting the aversive effects produced by drug withdrawal.

Is the New Heroin Epidemic Really New? Racializing Heroin.

Heroin abuse as an outcome of the prior use of painkillers increased rapidly over the past decade. This "new epidemic" is unique because the new heroin users are primarily young White Americans in rural areas of virtually every state. This commentary argues that the painkiller-to-heroin transition could not be the only cause of heroin use on such a scale and that the new and old heroin epidemics are linked. The social marketing that so successfully drove the old heroin epidemic has innovated and expanded due to the use of cell-phones, text messaging and the "dark web" which requires a Tor browser, and software that allows one to communicate with encrypted sites without detection. Central city gentrification has forced traffickers to take advantage of larger and more lucrative markets. A second outcome is that urban black and Latino communities are no longer needed as heroin stages areas for suburban and exurban illicit drug distribution. Drug dealing can be done directly in predominantly white suburbs and rural areas without the accompanying violence associated with the old epidemic. Denial of the link between the new and old heroin epidemics racially segregates heroin users and more proactive prevention and treatment in the new epidemic than in the old. It also cuts off a half-century of knowledge about the supply-side of heroin drug dealing and the inevitable public policy measures that will have to be implemented to effectively slow and stop both the old and new epidemic.

Environmental enrichment as a potential intervention for heroin seeking.

BACKGROUND: Heroin-related cues can trigger craving and relapse in addicts or heroin seeking in rats. In the present study we investigated whether environmental enrichment (EE) implemented after heroin exposure can reduce cue-induced reinstatement of heroin seeking and expression of heroin conditioned place preference. METHODS: In Experiment 1, male Long Evans rats that already acquired a heroin self-administration habit, were housed in enriched or non-enriched environments, underwent extinction training and later were tested for cue-induced reinstatement of heroin seeking. In Experiment 2, rats were conditioned with heroin in one compartment of a CPP apparatus and saline in the other, exposed to 30days of enrichment or no enrichment and were later tested for heroin CPP. RESULTS: The results showed that exposure to EE significantly reduced responding during the reinstatement test (Experiment 1) and prevented the expression of heroin CPP (Experiment 2). CONCLUSION: Our findings suggest that EE can be an effective behavioral approach to diminish the effects of conditioned cues on heroin seeking.

Factors Associated with Relapse among Heroin Addicts: Evidence from a Two-Year Community-Based Follow-Up Study in China.

BACKGROUND: Many countries including China are facing a serious opiate dependence problem. Anti-drug work effectiveness was affected by the high relapse rate all over the world. This study aims to analyze the factors influencing heroin addict relapse, and to provide evidence for generating relapse prevention strategies. METHODS: A community-based follow-up study was conducted in China between October 2010 and September 2012. A total of 554 heroin addicts in accordance with the inclusion criteria from 81 streets in 12 districts of Shanghai, China were divided into 4 groups: group 1--daily dosage taken orally of 60 mL of methadone or under combined with psychological counseling and social supports (n = 130); group 2--daily dosage taken orally of over 60 mL of methadone combined with psychological counseling and social supports (n = 50); group 3--JTT (Jitai tablets) combined with psychological counseling and social supports (n = 206); group 4--JTT combined with social supports (n = 168). RESULTS: Log-rank test results showed that the cumulative relapse rate differences among four groups during the two-year follow-up period were not statistically significant (χ² = 5.889, p = 0.117). Multivariate Cox regression analysis results showed that only three independent variables were still statistically significant, including compliance with participation in psychological counseling (OR = 3.563, p = 0.000), the years of drug use (OR = 1.078, p = 0.001)and intervention model. CONCLUSIONS: Using the detoxification medications combined with appropriate psychological counseling and social support measures will help improve the effectiveness of relapse prevention, which is a kind of alternative community detoxification pattern. Appropriate and standard psychological counseling is very important for anti-drug treatment. The longer the drug addiction lasts, the longer the anti-drug treatment takes.

Harm reduction as a complex adaptive system: A dynamic framework for analyzing Tanzanian policies concerning heroin use.

Contrary to popular belief, policies on drug use are not always based on scientific evidence or composed in a rational manner. Rather, decisions concerning drug policies reflect the negotiation of actors' ambitions, values, and facts as they organize in different ways around the perceived problems associated with illicit drug use. Drug policy is thus best represented as a complex adaptive system (CAS) that is dynamic, self-organizing, and coevolving. In this analysis, we use a CAS framework to examine how harm reduction emerged around heroin trafficking and use in Tanzania over the past thirty years (1985-present). This account is an organizational ethnography based on of the observant participation of the authors as actors within this system. We review the dynamic history and self-organizing nature of harm reduction, noting how interactions among system actors and components have coevolved with patterns of heroin us, policing, and treatment activities over time. Using a CAS framework, we describe harm reduction as a complex process where ambitions, values, facts, and technologies interact in the Tanzanian sociopolitical environment. We review the dynamic history and self-organizing nature of heroin policies, noting how the interactions within and between competing prohibitionist and harm reduction policies have changed with patterns of heroin use, policing, and treatment activities over time. Actors learn from their experiences to organize with other actors, align their values and facts, and implement new policies. Using a CAS approach provides researchers and policy actors a better understanding of patterns and intricacies in drug policy. This knowledge of how the system works can help improve the policy process through adaptive action to introduce new actors, different ideas, and avenues for communication into the system.

LEADING THE FIGHT TO REVERSE THE OPIOID EPIDEMIC.

In August I had the opportunity to attend a meeting in Des Moines entitled, Iowa Opiate Abuse and Heroin Addiction: A Community Crisis Summit. This summit brought together stakeholders, subject matter experts, state officials, and people personally impacted by the opioid epidemic for a meaningful discussion about the problem and the next steps we can take to thwart the evolving public health crisis and growing number of personal tragedies. The meeting, sponsored by the Drake University College of Pharmacy and Health Sciences and the US Attorney's Offices for the Northern and Southern Districts of Iowa, was both sobering and enlightening.