Discontinuing Methadone and Buprenorphine: A Review and Clinical Challenges.

This paper offers a review and recommendations for clinicians working with patients interested in discontinuing opioid agonist treatment. As buprenorphine/naloxone has gained widespread acceptance for opioid addiction, many treatment providers and patients have a range of hopes and expectations about its optimal use. A surprising number assume buprenorphine/naloxone is primarily useful as a medication to transition off illicit opioid use, and success is partially defined by discontinuing the medication. Despite accumulating evidence that a majority of patients will need to remain on medication to preserve their gains, clinicians often have to address a patient's fervent desire to taper. Using the concept of "recovery capital," our review addresses (1) the appropriate duration of opioid agonist treatment, (2) risks associated with discontinuing, (3) a checklist that guides the patient through self-assessment of the wisdom of discontinuing opioid agonist treatment, and (4) shared decision making about how to proceed.

PTSD / substance use disorder comorbidity: Treatment options and public health needs.

Purpose of Review: Posttraumatic stress disorder (PTSD) commonly co-occurs with substance use disorder (SUD) and is challenging to treat. We review all behavioral therapy models with at least one randomized controlled trial in a current PTSD/SUD population. We identify factors in selecting a model for clinical use, emphasizing a public health framework that balances the need for evidence with the need for feasibility in frontline settings. Recent Findings: Seven published models and 6 unpublished models are reviewed. Public health considerations for choosing a model include: whether it's been studied across a broad range of SUDs and in complex SUD patients; whether it can be conducted in group modality; its appeal to patients and providers; its cost; workforce requirements; and its ability to reduce substance use in addition to PTSD. Summary: There are two broad types of models: those that originated in the PTSD field versus the SUD field. Overall, the latter are stronger on public health factors and more feasible in SUD settings. Published models in this category include Relapse Prevention, BRENDA, and Seeking Safety. PTSD/SUD research is at an early stage and there is a need for methodology that quantifies "level of burden" (patients' socioeconomic disadvantages) across trials.

Women with methamphetamine dependence: research on etiology and treatment.

The epidemic of methamphetamine dependence is spreading eastward across the United States. Unlike the gender ratio associated with most other drugs of abuse, the proportion of woman methamphetamine users is nearly equal to men. This review will describe reasons why women begin use of methamphetamine, especially those that differ from the usual reasons for initiating drug use. The characteristics of women users at entry into treatment also differ from those of men, especially in regard to employment, psychological symptoms, and history of abuse and violence in their lives. Finally, the review will address treatment issues and options that can be responsive to the distinctive needs of women dependent on methamphetamine.

Integrating HCV services for drug users: a model to improve engagement and outcomes.

Although the majority of prevalent and incident cases of hepatitis C are related to injection drug use, drug users often find it difficult to access treatment services because of concerns about adherence and treatment candidacy. In response to the growing epidemic, OASIS, a nonprofit community clinic, developed a successful peer-based HCV group that allowed us to engage, educate, test, and treat hepatitis C in large numbers of drug users, the majority of whom have multiple potential barriers to intervention. Integrating services for hepatitis C, addiction, mental health, and psychosocial problems, the model involves a collaboration of medical providers and peer educators and incorporates elements of other proven behavioural models, including self-help groups, therapeutic communities, and peer interventions. Our results indicate that this peer-based model is successful at engaging, educating, and treating a diverse spectrum of chaotic drug users. We conclude that an integrated, peer-based approach to intervention can engage even the most challenging addicted patients with hepatitis C, and can facilitate their successful screening and treatment.

Addiction: selecting appropriate treatment and using the self-help system.

This chapter provides guidance for the occupational physician in identifying appropriate resources within the treatment and self-help system. Identifying resources to meet patient needs can be challenging in a climate where services are rapidly changing. Two inpatient or outpatient programs may have considerably different services, strengths, and limitations that can be difficult to precisely characterize. Degree of structure (e.g., inpatient versus outpatient) may be misleading in terms of the nature of the treatment provided. Knowledge and attitudes about the self-help system vary greatly, and it is important not to underestimate its potential or hold unrealistic expectations for what it can accomplish.

Abuse and violence history of men and women in treatment for methamphetamine dependence.

The Methamphetamine Treatment Project offers the opportunity to examine the history of abuse and violence in a sample of 1016 methamphetamine users participating in a multisite study between 1999-2001. Reporting of abuse and violence was extensive, with 80% of women reporting abuse or violence from a partner. Men were more likely to report experiencing violence from friends and others. A high percentage of study participants reported a variety of threatening or coercive experiences with their partners. Past and current interpersonal violence is a characteristic of the lifestyles of the majority entering treatment for methamphetamine dependence.

Psychiatric symptoms in methamphetamine users.

The Methamphetamine Treatment Project (MTP) offers the opportunity to examine co-occurring psychiatric conditions in a sample of 1016 methamphetamine users participating in a multisite outpatient treatment study between 1999-2001. Participants reported high levels of psychiatric symptoms, particularly depression and attempted suicide, but also anxiety and psychotic symptoms. They also reported high levels of problems controlling anger and violent behavior, with a correspondingly high frequency of assault and weapons charges. Findings continue to support the value of integrated treatment for co-occurring conditions, especially the importance of training counseling staff to handle psychotic symptoms when needed.