Concurrent Heroin Use Research Articles

A quantitative LC-MS/MS method for investigation of polysubstance use involving heroin and cocaine

Concurrent use of heroin and cocaine (known as the “speedball”) prevails among substance use disorder populations, especially in opioid-dependent individuals, with severe consequences and a high fatality rate. Little is known about the patterns and correlations of the concurrent use of heroin and cocaine. It is vital to investigate such a polydrug use in both humans and animals to uncover concomitant toxicity and the cause of fatal overdose (death). In this study, we aimed to shed some light on the role of cocaine in the etiology of heroin-related deaths in the context of molecular pharmacokinetics (PK). For the purpose, a high-performance liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) method for simultaneous determination of heroin, cocaine, and their metabolites in whole blood was developed and fully validated in accordance with the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) guidelines. Then, this method was used to analyze heroin, cocaine, and their metabolites in blood from the rats intraperitoneally administered non-lethal 10 mg/kg heroin or 20 mg/kg cocaine alone, or their combination that is lethal with a proximal mortality of 33 %. The obtained results from the rats that experienced the lethal toxicity revealed that the concurrent use of heroin and cocaine significantly increased the risk of fatality from overdose. Heroin significantly slowed down the elimination of cocaine and its main metabolites in blood, while cocaine significantly enhanced heroin metabolism from 6-monoacetylmorphine (6-MAM) to morphine. Similar elimination half-lives for other heroin metabolites were observed. These findings are reported for the first time in this study, facilitating our understanding of the polysubstance metabolism and severe consequences produced by the polydrug use.

Predictors of concurrent heroin use among patients on opioid maintenance treatment in France: a multilevel study over 11 years

BackgroundConsistent reports from health professionals suggest that heroin is commonly used by patients undergoing opioid maintenance treatment (OMT) in France, potentially jeopardizing their recovery process. However, there has been no formal epidemiological assessment on the matter.MethodsWe use a yearly updated compendium retrieving information on patients admitted in treatment centres in France between 2010 and 2020. Given the hierarchical nature of the data collection, we conduct 2-level modified Poisson regressions to estimate the risks of past month heroin use among patients on OMT.ResultsDespite an overall decreasing trend over time, heroin use among patients on OMT is indeed common, with half of patients declaring concurrent use. Our study unveils differentiated risks of heroin use vary according to the type of OMT, with patients on methadone more likely to use heroin compared to those on buprenorphine. The use of multilevel-related measures also uncovers high heterogeneity among patients’ profiles, reflecting different stages in the treatment process, as well as differentiated practices across treatment centres.ConclusionOpioid maintenance treatment is associated with heroin use, in particular when methadone is involved. The heterogeneity among patients on OMT should be given particular attention, as it underscores the need for tailored interventions.

Heroin use among clients receiving methadone treatment in Dar es Salaam Tanzania: a qualitative study

Background: Simultaneous heroin use among methadone-maintained clients is a recognized phenomenon worldwide. Tanzania is the first sub-Saharan African country to offer methadone treatment. This study explored reasons for heroin use among clients on methadone treatment clinics in Dar es Salaam, Tanzania. Methods: This was exploratory cross-sectional study. Purposive sampling was used to select ten study participants. In in-depth interview guide was used to collect data. The interviews were conducted in Kiswahili and lasted for about sixty minutes. Audio-recordings of the interviews were transcribed verbatim and translated into English. Transcribed data was analysed and subjected to thematic analysis with the help of Nvivo 12 software. Results: Many reasons were mentioned for concurrent use of heroin and methadone among clients on methadone treatment. Some of the mentioned reasons were inadequate methadone dose, treatment, healthcare providers’ attitudes, and healthcare provision environment, lack of family support, peer influence homeless and easy availability of heroin. Conclusions: Different measures should be taken by methadone programs and stakeholders to overcome concurrent use of heroin and methadone among clients receiving methadone treatment.

A RARE CASE OF LUMBOSACRAL PLEXOPATHY SECONDARY TO SEVERE RHABDOMYOLYSIS FOLLOWING KRATOM, COCAINE, AND HEROIN USE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lumbosacral (LS) plexopathy can be difficult to diagnose as it is not commonly encountered in clinical practice. Disease severity is related to the underlying etiology however, progressive neurological deterioration is often seen if proper intervention is not executed promptly. LS plexopathy secondary to severe rhabdomyolysis has been reported in a small number of case reports. We present a rare case of LS plexopathy caused by severe rhabdomyolysis following concurrent use of kratom, cocaine, and heroin. CASE PRESENTATION: A 25 year old male with a history of schizophrenia presented to the emergency department (ED) after experiencing numbness and tingling in his lower extremities following cocaine, heroin and kratom use the day prior. On presentation, the patient became increasingly lethargic and sustained a cardiac arrest while in the ED. CPR was performed for 9 minutes before ROSC was achieved. Labs were remarkable for potassium of 8, BUN 35, creatinine 4.03, and creatine kinase of >100,000 consistent with rhabdomyolysis. The patient was also found to have compartment syndrome of his left lower extremity requiring emergent fasciotomy. He was admitted to the medical intensive care unit where he remained intubated and underwent hemodialysis for acute renal failure. On day 4 of admission, the patient was successfully liberated from the ventilator. At this point, flaccid paralysis and loss of sensation of his bilateral lower extremities were noted on exam. Work up including CT and MRI of the spine were significant for severe paraspinal edema and myonecrosis consistent with rhabdomyolysis. EMG of the lower extremities revealed mild chronic partial denervation with abnormal spontaneous activity in the proximal and distal right leg muscles. Oral Prednisone was initiated with improvement in the patient's lower extremity paralysis after five days of therapy. The patient completed a three week steroid taper with continued improvement in his exam. He was discharged to rehab. At one month follow-up, he showed near complete resolution of his neurologic deficits. DISCUSSION: The LS plexus includes a network of nerves that are formed by the anterior rami of the lumbar and sacral spinal cord which supply the lower back, pelvis and legs. LS plexopathy often presents with lower back and lower extremity weakness, pain, paresthesias, numbness and tingling. LS plexopathy is typically caused by trauma, diabetes, neoplasms and pregnancy. Complications of LS plexopathy may include progressive neurological deterioration, intractable pain, recurrent infections, joint contracture and bedsores. CONCLUSIONS: LS plexopathy secondary to severe rhabdomyolysis is rare, described in only a few case reports. Treatment often relies on addressing the underlying etiology and should be geared towards preventing further nerve damage as LS plexopathy can cause significant detriment to the quality of life of a patient. REFERENCE #1: Dydyk, A. (2021, February 07). Lumbosacral plexopathy. Retrieved April 29, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK556030/ REFERENCE #2: Jeon, H., Cho, B., Oh, S., & Park, S. (2007, December). Lumbosacral Plexopathy, COMPLICATING rhabdomyolysis in a 57-YEAR-OLD man, presented with sudden weakness in both legs. Retrieved April 29, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2588181/#:~:text=A%20diagnosis%20of%20lumbosacral%20plexopathy%2C%20complicating%20rhabdomyolysis%20was%20made.&text=Pelvic%20MRI%20is%20a%20helpful, with%20sudden%20weakness%20of%20legs. DISCLOSURES: No relevant relationships by Utku Ekin, source=Web Response No relevant relationships by Christopher Millet, source=Web Response No relevant relationships by Natalie Millet, source=Web Response No relevant relationships by Justin Thorson, source=Web Response

Concurrent Alcohol and Opioid Use Among Harm Reduction Clients

BackgroundHarm reduction services infrequently address alcohol use among clients using opioids, despite the evaluated risk of overdose or medical consequences for clients with viral infections. The purpose of this study is to assess concurrent alcohol and opioid use among syringe services and overdose prevention program participants predominately in southern Ohio and northern Kentucky. MethodsThis is a cross-sectional study using self-report data (n = 1,142) pooled across regional overdose prevention programs and a mobile syringe services program. The outcome variable was concurrent use categorized as no concurrent alcohol, prescription opioid or heroin use; alcohol and heroin or prescription opioid use; and alcohol, prescription opioid and heroin use in the past three months. ResultsThe sample was predominantly white (95%), 56% were male and the mean age was 33 years old. Forty-seven percent of the clients had no concurrent use of alcohol and opioids; 20.1% reported concurrent use of alcohol and either heroin or prescription opioids; and 33.4% reported concurrent use of alcohol, heroin and prescription opioids in the past 3 months. Lifetime suicidal ideation and non-opioid drug use were associated with concurrent alcohol and opioid use in the multivariable model. ConclusionHarm reduction clients with concurrent alcohol and opioid use may warrant enhanced overdose prevention services. Syringe services and overdose prevention program participants may benefit from education or a brief intervention on alcohol consumption.

Factors associated with concurrent heroin use among patients on methadone maintenance treatment in Vietnam: A 24-month retrospective analysis of a nationally representative sample

BackgroundMethadone maintenance treatment (MMT) is highly effective for reducing heroin use and HIV transmission among people who inject opioids. We sought to measure and understand factors associated with continued heroin use, a critical factor affecting treatment outcome among MMT patients in Vietnam. MethodWe collected data from medical charts of a nationally representative sample of patients who were on MMT from May 2008 to December 2013. We selected 10 MMT clinics using probability proportional to size and 50 patients/clinic by systematic random sampling. Concurrent heroin use was defined by self-report/positive urine test recorded in patient charts during month 3, 6, 12, and 24 after MMT initiation. We used multivariable logistic regression to identify factors associated with concurrent heroin use over the first 24 months in treatment. FindingsAll clients used heroin at baseline; concurrent heroin use was 55% at month 3; 19%, 14.6% and 15.2% at month 6, 12, and 24, respectively. Having no family emotional/financial support at baseline versus having this support (AOR = 2.03; 95% confidence interval [CI] = 1.17–3.53); using heroin for <15 years versus ≥15 years at baseline (AOR = 1.55; 95% CI = 1.01–2.38); being HIV-infected/not on antiretroviral treatment (ART; AOR = 1.79; 95% CI = 1.07–2.98) or being HIV infected/on ART (AOR = 2.39; 95% CI = 1.61–3.55), versus not being HIV infected; baseline methamphetamine use versus non-use (AOR = 2.68; 95% CI = 1.08–6.65), were associated with increased odds of concurrent heroin use among patients. ConclusionThe association between concurrent heroin use among MMT patients and lack of family emotional/financial support, highlights the critical importance of these types of support for successful treatment. Association with shorter heroin use history suggests motivational enhancement may reduce concurrent heroin use. Living with HIV, whether on ART or not, is associated with increased concurrent heroin use and suggests safe injection commodities and education, and drug–drug interaction management, are needed for this subgroup. Though few MMT clients reported baseline methamphetamine use, its association with later heroin use suggests the need for effective methamphetamine use interventions.

Family Related Factors and Concurrent Heroin Use in Methadone Maintenance Treatment in China

ABSTRACTBackground: The use of heroin during Methadone Maintenance Treatment (MMT) is a challenging problem that contributes to poor treatment outcomes. Families may play an important role in addressing concurrent heroin use during MMT, especially in collectivist societies such as China. Objectives: In this study, we explored the relationship between family-related factors and concurrent heroin use during MMT in China. Methods: This study was conducted at 68 MMT clinics in five provinces of China. There were 2,446 MMT clients in the analysis. Demographic information, MMT dosage, family members' heroin use status, family support of MMT, family problem, and self-reported heroin use were collected in a cross-sectional survey. The most recent urinalysis of opiate use was obtained from clinical records. Results: Of the 2,446 participants, 533 (21.79%) self-reported heroin use in the previous seven days or had a positive urine morphine test result in the clinic record. Participants whose family member[s] used heroin were 1.59 times (95% CI: 1.17, 2.15) more likely to use concurrently during treatment. Those with family members who totally support them on the MMT were less likely to use (AOR: 0.75, 95% CI: 0.60, 0.94). Having more family problems was positively associated with concurrent heroin use (AOR: 2.01, 95% CI: 1.03, 3.93). Conclusions: The results highlight the importance of the family's role in concurrent heroin use during MMT programs. The study's findings may have implications for family-based interventions that address concurrent heroin use.

Directly observed therapy for clozapine with concomitant methadone prescription: a method for improving adherence and outcome

A young male presented with many years of delusions and hallucinations, with concurrent heroin use and subsequent amphetamine uses. There were no depressive or manic symptoms and psychotic symptoms prior...

Transitioning illicit drug preferences and emerging user identities in Ohio: The proliferation of methamphetamine use among African Americans

ABSTRACTUnderstanding the social dynamics of local methamphetamine markets is critical to improving community health and reducing social costs associated with illicit drug use. We examine a local drug market in Summit County, Ohio, wherein methamphetamine users ascribe themselves different ethnic identities from those long associated with the drug elsewhere in the United States. Qualitative interviews with 52 study participants demonstrate that very poor and homeless White males and females are now using methamphetamine; however, even more surprising is that 31 of the participants identified themselves as poor or homeless, male or female African, Native, biracial, or multiracial Americans. The drug use trajectory of these 31 participants in particular involved a transition from a historical preference for crack to a present one for methamphetamine and, in some cases, a preference for concurrent use of methamphetamine and heroin. Many of these methamphetamine users also emphasized their ethnic identity to distinguish themselves as nonproducers of methamphetamine in comparison to Whites, who are commonly associated with methamphetamine production. Findings appear to suggest an emergent means of identity management resulting from the ethnic diversity of users in this methamphetamine market. These findings may have relevance in other communities with similar demographics and drug markets and may hold important implications for drug treatment, policy-making, and law enforcement professionals’ work associated with methamphetamine users, producers, and distributors.

Nonmedical Use of Prescription Opioids and Heroin Use Among Adolescents Involved in Competitive Sports

PurposeExamine the past-year prevalence of nonmedical use of prescription opioids (NUPOs), heroin use, and the concurrent NUPO and heroin in a sample of 12th graders involved in 16 different sports. MethodsA secondary analysis of nationally representative data from nine cohorts (2006–2014) of the Monitoring the Future study (n = 21,557). ResultsNo differences were found between 12th graders who participated in at least one competitive sport and nonparticipants with respect to past-year NUPO, heroin use, and concurrent NUPO and heroin use. Most of the 16 sports analyzed were not associated with the three drug use outcomes. However, 12th graders who participated in ice hockey had substantially greater odds of both past-year heroin use and concurrent NUPO and heroin, while those who participated in weightlifting (NUPO and heroin) and wrestling (NUPO) had slightly higher odds of using these drugs. ConclusionsThe study provides critical information to inform physicians, parents, and school officials of the risks associated with participating in certain high contact sports, particularly ice hockey.

Changes in dopamine transporter binding in nucleus accumbens following chronic self-administration cocaine: heroin combinations.

Concurrent use of cocaine and heroin (speedball) has been shown to exert synergistic effects on dopamine neurotransmission in the nucleus accumbens (NAc), as observed by significant increases in extracellular dopamine levels and compensatory elevations in the maximal reuptake rate of dopamine. The present studies were undertaken to determine whether chronic self-administration of cocaine, heroin or a combination of cocaine:heroin led to compensatory changes in the abundance and/or affinity of high- and low-affinity DAT binding sites. Saturation binding of the cocaine analog [(125) I] 3β-(4-iodophenyl)tropan-2β-carboxylic acid methyl ester ([(125) I]RTI-55) in rat NAc membranes resulted in binding curves that were best fit to two-site binding models, allowing calculation of dissociation constant (Kd ) and binding density (Bmax ) values corresponding to high- and low-affinity DAT binding sites. Scatchard analysis of the saturation binding curves clearly demonstrate the presence of high- and low- affinity binding sites in the NAc, with low-affinity sites comprising 85 to 94% of the binding sites. DAT binding analyses revealed that self-administration of cocaine and a cocaine:heroin combination increased the affinity of the low-affinity site for the cocaine congener RTI-55 compared to saline. These results indicate that the alterations observed following chronic speedball self-administration are likely due to the cocaine component alone; thus further studies are necessary to elaborate upon the synergistic effect of cocaine:heroin combinations on the dopamine system in the NAc.

Association between prescription drug misuse and injection among runaway and homeless youth

BackgroundThe nonmedical use of prescription drugs is the fastest growing drug problem in the United States, disproportionately impacting youth. Furthermore, the population prevalence of injection drug use among youth is also on the rise. This short communication examines the association between current prescription drug misuse (PDM) and injection among runaway and homeless youth. MethodsHomeless youth were surveyed between October 2011 and February 2012 at two drop-in service agencies in Los Angeles, CA. Prevalence ratios (PR) and 95% confidence intervals (CI) for the association between current PDM and injection behavior were estimated. The outcome of interest was use of a needle to inject any illegal drug into the body during the past 30 days. ResultsOf 380 homeless youth (median age, 21; IQR, 17–25; 72% male), 84 (22%) reported current PDM and 48 (13%) reported currently injecting. PDM during the past 30 days was associated with a 7.7 (95% CI: 4.4, 13.5) fold increase in the risk of injecting during that same time. Among those reporting current PDM with concurrent heroin, cocaine, and methamphetamine use, the PR with injection was 15.1 (95% CI: 8.5, 26.8). ConclusionsRunaway and homeless youth are at increased risk for a myriad of negative outcomes. Our preliminary findings are among the first to show the strong association between current PDM and injection in this population. Our findings provide the basis for additional research to delineate specific patterns of PDM and factors that enable or inhibit transition to injection among homeless and runaway youth.

Risk Factors of Erectile Dysfunction in Patients Receiving Methadone Maintenance Therapy

While methadone effectively treats opiate dependence, the side effect of erectile dysfunction (ED) may interfere with treatment adherence and benefits. To determine the rate of ED and the associated factors which predict ED in male patients on methadone maintenance therapy (MMT) in a Malaysian population. The main outcome measures were the International Index of Erectile Function-15 (IIEF-15) and the Beck Depression Inventory (BDI). A total of 108 participants diagnosed with heroin dependence were assessed. We used the Structured Clinical Interview for DSM-IV Axis-I Disorders (SCID-I) on subjects who received MMT, and they were assessed using the IIEF-15, the BDI, and measures of other clinical and sociodemographic variables. The rate of ED among men on MMT was 68.5% (mild ED, 36.1%; mild to moderate ED, 22.2%; severe ED, 3.7%). The mean age of the participants was 43.45 years. Older age (P = 0.002), concurrent illicit heroin use (P = 0.024), and having an older partner (P = 0.039) were significantly associated with ED. Following multivariate analysis, it was found that older age was the only significant predictor of ED, with an adjusted odds ratio of 1.07 (95% CI = 1.02-1.16). Methadone dose and duration of methadone treatment were not significantly associated with ED. ED was highly prevalent among male patients on MMT. This suggests that there is a need for routine assessment of sexual function in patients on methadone. Among the risk factors, age was the only factor that was significantly associated with ED. The current use of MMT in Malaysia in terms of dosage and duration did not pose a significant risk for ED.

A non‐rewarding, non‐aversive buprenorphine/naltrexone combination attenuates drug‐primed reinstatement to cocaine and morphine in rats in a conditioned place preference paradigm

Concurrent use of cocaine and heroin is a major public health issue with no effective relapse prevention treatment currently available. To this purpose, a combination of buprenorphine and naltrexone, a mixed very-low efficacy mu-opioid receptor agonist/kappa-opioid receptor antagonist/nociceptin receptor agonist, was investigated. The tail-withdrawal and the conditioned place preference (CPP) assays in adult Sprague Dawley rats were used to show that naltrexone dose-dependently blocked the mu-opioid receptor agonism of buprenorphine. Furthermore, in the CPP assay, a combination of 0.3 mg/kg buprenorphine and 3.0 mg/kg naltrexone was aversive. A combination of 0.3 mg/kg buprenorphine and 1.0 mg/kg naltrexone was neither rewarding nor aversive, but still possessed mu-opioid receptor antagonist properties. In the CPP extinction and reinstatement method, a combination of 0.3 mg/kg buprenorphine and 1.0 mg/kg naltrexone completely blocked drug-primed reinstatement in cocaine-conditioned rats (conditioned with 3 mg/kg cocaine, drug prime was 3 mg/kg cocaine) and attenuated drug-primed reinstatement in morphine-conditioned rats (conditioned with 5 mg/kg morphine, drug prime was 1.25 mg/kg morphine). These data add to the growing evidence that a buprenorphine/naltrexone combination may be protective against relapse in a polydrug abuse situation.

Concurrent heroin use among methadone maintenance clients in China

Background The study examined concurrent illicit heroin use among methadone maintenance clients in China and its association with clients' demographic characteristics, treatment experience, and personal social network. Methods Face-to-face surveys were conducted with 178 clients randomly recruited from six methadone maintenance treatment (MMT) clinics in Sichuan, China. Concurrent heroin use was measured based on self-report of heroin use during the past 30 days and a confirmatory urine morphine test. The participants' demographic characteristics and treatment factors were measured and examined. The drug use status of their family members and friends was also assessed. Results A total of 80 participants (44.9%) who either reported illicit heroin use in the past 30 days or had a positive urine test were defined as using heroin concurrently. Having drug-using friends was significantly associated with increased concurrent heroin use. Longer length of treatment (2 years or longer) was associated with increased concurrent heroin use. Among those who had both drug-using family members and friends, more women (71.4%) than men (50.0%) used heroin. For those who had no drug-using family members or friends, more men (34.8%) than women (20.8%) used heroin. Discussion Study findings indicate an urgent need to address concurrent illicit heroin use among MMT clients. Further examination of the influence of social networks on concurrent drug abuse behavior is encouraged. Results also highlight the importance of understanding gender differences in treatment seeking and behavioral changes, which is crucial to the development of gender-specific treatment strategies.

Benzodiazepine use among heroin users: Baseline use, current use and clinical outcome

Benzodiazepine use is associated with elevated levels of harm. The current study aimed to ascertain the long-term nature of the relationship between benzodiazepine use and clinical profile among heroin users. Longitudinal cohort, with follow-up at 3, 12, 24 and 36 months. Participants were 615 heroin users recruited for the Australian Treatment Outcome Study. At baseline, current benzodiazepine users were more likely to be committing crime, had poorer psychological health and poorer physical health. Baseline benzodiazepine use was not associated with the likelihood across follow-up of heroin use (P = 0.44), committing crime (P = 0.17), poorer psychological health (P = 0.31) or poorer physical health (P = 0.48). Current benzodiazepine use was, however, associated with a greater likelihood of concurrent heroin use (OR 2.77), crime (OR 2.04), poorer psychological health (beta = -4.47) and poorer physical health (beta = -2.33). Clinicians should be aware that reductions in benzodiazepine use are associated with reductions in harm, and that baseline benzodiazepine status does not equate to poor long-term outcome.

Drug withdrawal, cocaine and sedative use disorders increase the need for mechanical ventilation in medical patients

ABSTRACTAims Alcohol use disorders increase the need for mechanical ventilation (MV) in critically ill medical, surgical and trauma patients. Studies examining other drug use disorders (DUD) in trauma patients have not demonstrated heightened rates of intensive care unit (ICU) complications. Patients with asthma and concurrent cocaine or heroin use disorders have an increased need for MV. The objective of this study is to determine if the presence of DUD and drug withdrawal syndromes are associated with increased need for MV in medical patients.Design Analysis of a national database.Setting The Nationwide Inpatient Sample, the largest all‐payer in‐patient database was utilized for the years 2002–2004.Participants Adult patients with one of the six common diagnoses associated with medical ICU admission were included.Intervention None.Measurements Univariate analysis and multivariate logistic regression were performed to determine if DUD and drug withdrawal were associated independently with the use of MV.Findings A total 1 218 875 patients fulfilled one of the six diagnoses; 22 827 (1.9%) had DUD, and 102 841 (8.4%) underwent MV. Independent of the medical diagnosis, DUD was associated with an increased risk for requiring MV by univariate analysis (relative risk = 1.50, P &lt; 0.0001). By multivariate analyses, sedative and cocaine use disorders remained associated with increased need for MV. Independent of medical diagnosis and substance, drug withdrawal was associated with increased odds of MV by both univariate and multivariate analysis (odds ratio = 2.94, P &lt; 0.0001).Conclusions DUD are associated with increased need for MV in medical patients. This study demonstrates the importance of screening all medical patients for DUD.

Drug withdrawal, cocaine and sedative use disorders increase the need for mechanical ventilation in medical patients

Alcohol use disorders increase the need for mechanical ventilation (MV) in critically ill medical, surgical and trauma patients. Studies examining other drug use disorders (DUD) in trauma patients have not demonstrated heightened rates of intensive care unit (ICU) complications. Patients with asthma and concurrent cocaine or heroin use disorders have an increased need for MV. The objective of this study is to determine if the presence of DUD and drug withdrawal syndromes are associated with increased need for MV in medical patients. Analysis of a national database. The Nationwide Inpatient Sample, the largest all-payer in-patient database was utilized for the years 2002-2004. Adult patients with one of the six common diagnoses associated with medical ICU admission were included. None. Univariate analysis and multivariate logistic regression were performed to determine if DUD and drug withdrawal were associated independently with the use of MV. A total 1 218 875 patients fulfilled one of the six diagnoses; 22 827 (1.9%) had DUD, and 102 841 (8.4%) underwent MV. Independent of the medical diagnosis, DUD was associated with an increased risk for requiring MV by univariate analysis (relative risk = 1.50, P < 0.0001). By multivariate analyses, sedative and cocaine use disorders remained associated with increased need for MV. Independent of medical diagnosis and substance, drug withdrawal was associated with increased odds of MV by both univariate and multivariate analysis (odds ratio = 2.94, P < 0.0001). DUD are associated with increased need for MV in medical patients. This study demonstrates the importance of screening all medical patients for DUD.

Efficacy of naltrexone treatment with combined crack and opiate users: A descriptive study of a new treatment service in Bristol, UK

Naltrexone has been shown to be clinically effective in treating opioid dependence, although there are reports that it may be unsafe in treatment of unselected cases. Although there are no generally accepted pharmacological treatments for crack cocaine addiction alone, there is evidence that naltrexone can be useful in cases of concurrent cocaine and heroin use. In 2005 Bristol Specialist Drug Service initiated a naltrexone treatment programme targeted at pre-release offenders using both crack cocaine and heroin. Of 172 referrals, only 51 (30%) were inducted into treatment, and only 16% of these were retained at 3 months, and 4% at 9 months. There was evidence to support induction in prison, as 90% of those who were inducted there continued treatment on release. An integrated approach between criminal justice and community services is of primary importance in getting users into treatment. Interviews highlighted that the environment outside of prison can trigger relapse, and that community clinics need to separate clients on an abstinence programme from those who continue to use. Of clients interviewed, 52% reported that they use heroin to mitigate severe come down from crack, and it is suggested that naltrexone may be of use for these specialized combined users.

Micro-opioid receptor alkylation in the ventral pallidum and ventral tegmental area, but not in the nucleus accumbens, attenuates the effects of heroin on cocaine self-administration in rats.

The concurrent use of cocaine and heroin, often referred to as speedball, is a powerful reinforcer that has been reported in humans to sometimes result in heightened euphoria compared with either drug alone. Data from animal research indicate that the reinforcing efficacy of low doses of cocaine is potentiated by the addition of small amounts of heroin and that this potentiation is accompanied by synergistic increases in nucleus accumbens (NAc) extracellular fluid levels of dopamine. Although micro- and/or delta-opioid receptors may underlie this potentiation, the opioid receptor subtype or the loci responsible for this enhancement is not known. This experiment used intracranial administration of a selective micro-opioid receptor alkylating agent (beta-funaltrexamine (beta-FNA)) to assess the role of mu-opioid receptors in the NAc, ventral pallidum (VP), and ventral tegmental area (VTA) on the ability of heroin to alter cocaine self-administration. Rats were trained to self-administer cocaine, heroin, or their combination and were administered either vehicle or beta-FNA into one of each brain region and the effects upon drug intake assessed. beta-FNA administered into the VP or VTA shifted the dose-effect curve for the cocaine/heroin combination towards that maintained by cocaine alone. beta-FNA had no effect on self-administration of the combination of cocaine and heroin when injected into the NAc. These data suggest that heroin may attenuate feedback inhibition from the NAc to the VP and VTA when co-self-administered with cocaine, resulting in a positive modulation of the effects of cocaine.