Heroin-dependent Patient Research Articles

A Community-Based Investigation of Stigma Toward Individuals Receiving Methadone Maintenance Treatment in China: A Randomized Case Vignette Study.

Background: Even though methadone maintenance treatment (MMT) is effective and widely recommended, it is widely misunderstood and stigmatized. This study aimed to explore people's attitudes and beliefs toward MMT, and stigmatization of MMT patients in China.Methods: This randomized, vignette-based study enrolled 1,066 household respondents (552 males and 514 females, response rate is 88.83%, 86.00% in vignette 1 and 91.66% in vignette 2) from two communities in China. Respondents initially completed questionnaires on sociodemographic characteristics and their knowledge about methadone and MMT. They were then randomly assigned to vignette 1 (described a patient receiving MMT) or vignette 2 (described a patient receiving amlodipine treatment). The labeling, stereotyping, and social distance toward the individual described in the vignettes were evaluated.Results: In these two vignettes, respondents showed a significantly higher level of stigma and discrimination toward the patient receiving MMT than the patient receiving amlodipine treatment. Approximately 60% of respondents believed that methadone is a type of addictive drug and that participating in MMT is a way to get high. Over 60% of respondents labeled the heroin-dependent patient who is receiving MMT as an addict even though the patient has not used heroin for several years; about 80% of them believed that the patient has undesirable characteristics and expressed a strong desire for social distance.Conclusions: People's misunderstanding of MMT, and stigmatization of MMT patients were very common among populations in the communities in China. To maximize MMT patients benefiting from MMT programs, more efforts are needed to minimize the impact of MMT-related stigma.

Towards a common metric for assessing heroin-dependent patient satisfaction with medications: Testing methadone and buprenorphine-naloxone

BackgroundPatient satisfaction with methadone or buprenorphine-naloxone can be multidimensionally and specifically assessed by using, respectively, the Scale to Assess Satisfaction with Medications for Addiction Treatment–Methadone for Heroin addiction (SASMAT-METHER) or the SASMAT–Buprenorphine-Naloxone for Heroin addiction (SASMAT-BUNHER). The factor structures of the SASMAT-METHER and SASMAT-BUNHER show substantial commonalities. The objective of the present study is to evaluate the replicability of the SASMAT-METHER factor structure using data from the SASMAT-BUNHER development study in order to obtain an instrument that can be used to compare patient satisfaction with methadone vs. buprenorphine-naloxone. MethodSecondary analysis of SASMAT-BUNHER data provided by 205 participants in the original validation study of that scale (Pérez de los Cobos et al., 2018). Using the SASMAT-METHER component solution (17 items, 3 factors) as the target structure, a principal component analysis was performed on the data set comprised of the corresponding 17 SASMAT-BUNHER items using an oblique semi-specified Procrustean rotation. Additionally, Tucker congruence coefficients were computed to examine the correspondence between the two solutions. ResultThe factor structures of SASMAT-METHER and the 17-item version of the SASMAT-BUNHER can be considered equal given that the overall Tucker’s congruence coefficient of factorial similarity was 0.972, with individual component congruencies ranging from 0.960 to 0.995. ConclusionsThe SASMAT-METHER component solution can serve as a single common tool to compare methadone vs. buprenorphine-naloxone in terms of patient satisfaction. This finding supports the feasibility of using a common metric to specifically assess satisfaction with medications to treat heroin dependence.

Heroin-dependent patient satisfaction with methadone as a medication influences satisfaction with basic interventions delivered by staff to implement methadone maintenance treatment.

PurposeThe aim of the present study was to test a structural equation model of patient satisfaction with different key facets of methadone maintenance treatment (MMT). In this model, the three dimensions of patient satisfaction with methadone as a medication (ie, personal functioning and well-being, anti-addictive effect on heroin, and anti-addictive effect on non-opioid substances) were expected to predict satisfaction with the basic interventions delivered by the staff of treatment centers to implement MMT.Patients and methodsA sample of 210 heroin-dependent patients, resistant to MMT treatment (mean age =41.66 years, SD =6.50; 75.7% male), participated voluntarily in this study. Preliminary analysis based on exploratory structural equation modeling supported the expected three-factor measurement model of the scale to assess satisfaction with medications for addiction treatment – methadone for heroin addiction. Moreover, the 15 items measuring staff’s basic interventions were shown to be compatible with the expected single-factor measurement model. Then, both measurement models were included in a structural model.ResultsResults of this model show that patient satisfaction with the compatibility of methadone with personal functioning and well-being, as well as with the anti-addictive effects of methadone on non-opioid substances, predicts satisfaction with basic interventions conducted at methadone treatment centers (β=0.191 and β=0.152, respectively).ConclusionOur results provide further understanding regarding patient satisfaction with MMT, which could help professionals to better understand patient perspective and experience during MMT.

Development and validation of the scale to assess satisfaction with medications for addiction treatment – Buprenorphine-naloxone for heroin addiction (SASMAT-BUNHER)

BackgroundUntil now, no specific tool has been available to measure heroin-dependent patient satisfaction with buprenorphine-naloxone as a medication. The purpose of the present study was to develop the Scale to Assess Satisfaction with Medications for Addiction Treatment–Buprenorphine-Naloxone for Heroin addiction (SASMAT-BUNHER) and to examine its validity and reliability. MethodsThe SASMAT-BUNHER was developed from a pool of 44 self-administered items grouped into nine theoretical domains, as follows: Overall Satisfaction, Pharmacotherapy, Initiation, Anti-Addictive Effect on Heroin, Mental State, Physical State, Personal Functioning, Acceptability, and Anti-Addictive Effect on Secondary Substances. The Treatment Satisfaction Questionnaire for Medication 1.4 version (TSQM 1.4) was used for convergent validation. Participants were 316 heroin-dependent patients in maintenance treatment with buprenorphine-naloxone sublingual tablets at 16 different treatment centres. ResultsPrincipal component analysis of the SASMAT-BUNHER revealed a 5-factor structure that accounted for 65.1% of total variance. Based on similarities between empirically-obtained factors and theoretical domains, Factors 1 through 5 were named ‘Mental and Physical State’ (10 items), ‘Anti-Addictive Effect on Other Substances’ (5 items), ‘Anti-Addictive Effect on Heroin’ (4 items), ‘Personal Functioning’ (3 items), and ‘Acceptability’ (4 items). All factors showed acceptable internal consistency (Cronbach's alpha coefficients: 0.744–0.925) and test-retest reliability (intraclass correlation coefficients: 0.704–0.895). Correlation between SASMAT-BUNHER and TSQM 1.4 total scores was moderate (Pearson r = 0.552). Moreover, SASMAT-BUNHER total scores of patients reporting absence of buprenorphine-naloxone side effects were higher than those of their counterparts. ConclusionThese results support the validity and reliability of the SASMAT-BUNHER.

Addiction medicine ethics: relapse, no lapse and the struggle to treat addicts like everyone else.

Two case studies are presented as a focus for discussion of ethics in addiction medicine. The first is that of the alcohol-dependent patient who receives a liver transplant. The second is that of a heroin-dependent patient who continues to inject himself while in a general medical ward. I make some comments about the obligations of doctors to treat those who cause harm to themselves as they would treat those who are 'not responsible'.

A Case of Stercoral Perforation Detected on CT Requiring Proctocolectomy in a Heroin-Dependent Patient.

Stercoral perforation of the colon is rare but carries with it significant morbidity and mortality. Stercoral perforation usually occurs in elderly, immobile patients with chronic constipation. In this manuscript, we report the case of stercoral perforation in a patient due to chronic heroin dependence. We report the case of a 56-year-old male patient with stercoral perforation, diagnosed by computed tomography, secondary to heroin dependence, requiring proctocolectomy and an end ileostomy. There are very few reports in the literature describing cases of stercoral perforation and questions have been asked about the importance of preoperative cross-sectional imaging. In our case, the diagnosis of stercoral perforation was made only on CT. Although this is not the first such case to be reported, it is significant as preoperative CT imaging was influential not only in determining the aetiology of the abdominal distension seen on the plain film, but also in detecting the pneumoperitoneum which was not evident clinically or on plain radiographs.

P.1.a.011 Polymorphism of cytochrome P450 2D6 and its clinical significance in a sample of 73 consecutive patients

The activity of cytochrome P-450 enzyme 2D6 (CYP2D6) could be related to heroin-dependent patient satisfaction with methadone maintenance treatment. We sought to compare satisfaction with the usual methadone treatment in patients who are ultrarapid, extensive or poor metabolizers, according to CYP2D6 genotyping.Two hundred and five heroin-dependent patients filled out the Verona Service Satisfaction Scale for methadone maintenance treatment (VSSS-MT), before CYP2D6 genotyping.VSSS-MT overall scores were comparable in the poor metabolizer (N = 9) and extensive metabolizer (N = 185) groups, although they were higher in poor metabolizers and extensive metabolizers taken together than in the ultrarapid metabolizers (N = 11) (p < 0.003). Likewise, ultrarapid metabolizers scored higher than the rest of the sample on the VSSS-MT Basic Interventions subscale (p < 001). Regarding this subscale, no poor metabolizers felt dissatisfied, and ultrarapid metabolizer males (N = 7) reported lower satisfaction than ultrarapid metabolizer females (N = 4) (p < 0.022). Ultrarapid metabolizer genotype accounted for 4.2% of the variance on the VSSS-MT total scores, and 5.0% on the Basic Intervention scores.Heroin-dependent patients who are CYP2D6 ultrarapid metabolizers according to genotyping present deficient satisfaction with methadone maintenance treatment.

Heroin reduces startle and cortisol response in opioid-maintained heroin-dependent patients

Heroin dependence (HD) is a chronic relapsing brain disorder characterized by a compulsion to seek and use heroin. Stress is seen as a key factor for heroin use. Methadone maintenance and the prescription of pharmaceutical heroin [diacetylmorphine (DAM)] are established treatments for HD in several countries. The present study examined whether DAM-maintained patients and methadone-maintained patients differ from healthy controls in startle reflex and cortisol levels. Fifty-seven participants, 19 of each group matched for age, sex and smoking status, completed a startle session which included the presentation of 24 bursts of white noise while eye-blink responses to startling noises were recorded. Salivary cortisol was collected three times after awakening, before, during and after the startle session. DAM was administered before the experiment, while methadone was administered afterwards. Both heroin-dependent patient groups exhibited significantly smaller startle responses than healthy controls (P < 0.05). Whereas the cortisol levels after awakening did not differ across the three groups, the experimental cortisol levels were significantly lower in DAM-maintained patients, who received their opioid before the experiment, than in methadone-maintained patients and healthy controls (P < 0.0001). Opioid maintenance treatment for HD is associated with reduced startle responses. Acute DAM administration may suppress cortisol levels, and DAM maintenance treatment may represent an effective alternative to methadone in stress-sensitive, heroin-dependent patients.

Itraconazole Induced Torsade De Pointes in a Patient Receiving Methadone Substitution Therapy

Issues. Methadone, a pharmacological agent used to treat heroin dependence is relatively safe, but may cause cardiac arrhythmias in the concurrent presence of other risk factors. Approach and Key Findings. This case report highlights the risk of Torsade de Pointes, a life-threatening cardiac arrhythmia, in a heroin-dependent patient receiving methadone substitution therapy who was prescribed itraconazole for vaginal thrush. The patient presented to the accident and emergency department for chest discomfort and an episode of syncope following two doses of itraconazole (200 mg). Electrocardiogram monitoring at the accident and emergency department showed prolonged rate-corrected QT interval leading to Torsade de Pointes. The patient was admitted for cardiac monitoring, and electrocardiogram returned to normal upon discontinuation of methadone. Implication. This cardiac arrhythmia was most likely as a result of a drug interaction between methadone and itraconazole because the patient presented with no other risk factors. Conclusion. Given the benefits of methadone as a substitution treatment for heroin-dependent individuals, the association between methadone and cardiac arrhythmias is of great concern. Physicians treating heroin-dependent patients on methadone substitution therapy should therefore be cautious of the potential risk of drug interactions that may lead to fatal cardiac arrhythmias.

Itraconazole‐induced Torsade de Pointes in a patient receiving methadone substitution therapy

Methadone, a pharmacological agent used to treat heroin dependence is relatively safe, but may cause cardiac arrhythmias in the concurrent presence of other risk factors. APPROACH AND KEY FINDINGS: This case report highlights the risk of torsade de pointes, a life-threatening cardiac arrhythmia, in a heroin-dependent patient receiving methadone substitution therapy who was prescribed itraconazole for vaginal thrush. The patient presented to the accident and emergency department for chest discomfort and an episode of syncope following two doses of itraconazole (200 mg). Electrocardiogram monitoring at the accident and emergency department showed prolonged rate-corrected QT interval leading to torsade de pointes. The patient was admitted for cardiac monitoring, and electrocardiogram returned to normal upon discontinuation of methadone. This cardiac arrhythmia was most likely as a result of a drug interaction between methadone and itraconazole because the patient presented with no other risk factors. Given the benefits of methadone as a substitution treatment for heroin-dependent individuals, the association between methadone and cardiac arrhythmias is of great concern. Physicians treating heroin-dependent patients on methadone substitution therapy should therefore be cautious of the potential risk of drug interactions that may lead to fatal cardiac arrhythmias.

P01-55 The effect of topiramate in the treatment of opioid (Heroin) withdrawal

Objective:This study was carried out on 149 of Heroin dependent patient that admission for detoxification.Design:This study is a 10 days double blind placebo-controlled trial.Place &amp; duration of study:This study is a 10 days double blind placebo-controlled trial which was carried out on 149 of Heroin dependent patient that admission for detoxification in Mashhad Ebne-sina hospital in 1385-1386 Subjects were randomly divided into topiramate and placebo detoxification groups.Subjects &amp; methods:Topiramate group receive topiramate (max 200 mg) for 10 days. The placebo group received usual regimen and placebo. Withdrawal symptoms were assessed by Subjective and Objective Opiate Withdrawal Scale in days 1, 3, 5, 7, 10.information s analyzed by chi-square test for qualities variables and T-test &amp; Mann-Whitney for quantities variables in SPSS software.Results:22 subjects were excluded from the study. Both groups had no significant differences in age, sex, education, number of previous withdrawal and past history of other drug use. Result indicates decrease in objective withdrawal symptom significant in 3(p=0.000), 5 (p=0.004) and 7(p=0.026) day and subjective withdrawal symptom significant in 3 (p=0.000) day in topiramate groups.Conclusion:Topiramate can use for control of withdrawal symptom in patient with Heroin dependency.

Dr. Heilig Replies

Back to table of contents Previous article Next article Letters to the EditorFull AccessDr. Heilig RepliesMARKUS HEILIG M.D., Ph.D.,MARKUS HEILIG M.D., Ph.D.Search for more papers by this author,Published Online:1 Nov 2007https://doi.org/10.1176/appi.ajp.2007.07071058rAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To The Editor: Buprenorphine and methadone are both effective treatments for heroin dependence (1) . Counting studies on these medications is obviously not a valid method for comparing their efficacy. For retention in treatment, a meta-analysis yielded only a tendency-level advantage for methadone in high-dose studies (relative risk=0.79; 95% confidence interval [CI]=0.62–1.01) (1) . In flexible-dose studies, the relative risk was similar, but reached significance (relative risk=0.82; 95% CI=0.69–0.96). For drug use and criminality, the two treatments were reported to be equivalent. Thus, methadone provides a slight advantage over buprenorphine for retention in treatment, and the two medications are equivalent on other relevant outcomes. Methadone treatment is essential, but also has distinct limitations. As pointed out by Drs. Byrne and Wodak, methadone is “more toxic,” i.e., methadone has sufficient mu-opioid receptor activity to induce lethal respiratory suppression, whereas buprenorphine, a partial agonist, does not. Safety itself aside, the monitoring necessitated by methadone use somewhat detracts focus away from building a therapeutic alliance, which offsets the cost advantage of the medication.Given the complementary profiles of the two medications, pitching one against the other is not meaningful. The field needs rational ways of using both. In this context, we are unaware of any other therapeutic area in which a safer, albeit somewhat less effective medication, would be reserved for second-line treatment. Optimal balance between efficacy and safety is typically achieved by doing exactly the opposite. For example, few would consider using chloramphenicol for an infection before trying penicillin.But what if stepping up treatment as needed rather than giving everyone methadone right away led to losing more patients overall? That would indeed mean that the safety gains must be carefully weighed against efficacy losses, an exceedingly difficult tradeoff. Our study was designed to assess whether this is a concern and clearly showed that it is not. Nothing is lost by first trying the safer medication.In that perspective, the exact proportion of patients who ultimately transfer to methadone is irrelevant. But let us be correct. In our study, among 48 subjects randomly assigned to stepped treatment, 37 remained. Of those, 20 transferred to methadone. That is 54%, which is what we reported. The 65% given by Drs. Byrne and Wodak is a misrepresentation of our data.In summary, excellent outcomes can be achieved by starting every heroin-dependent patient with buprenorphine and progressing to methadone only if needed. These outcomes are as good as those achieved with the best possible methadone treatment. Among unselected individuals addicted to heroin who are retained in treatment, close to one-half do well without progressing to methadone. Each of these individuals represents a safety gain worth capturing. Finally, our study disclosed an unrestricted research grant from industry that accounted for approximately 25% of the budget. The remaining funding came from the Swedish Government and Stockholm County. It is unclear how this could invalidate our results. The reference cited (2) by Drs. Byrne and Wodak in support of this notion deals with meta-analyses, which our study clearly is not. Bethesda, Md. And Stockholm, SwedenDr. Heilig’s disclosures accompany the original article.This letter (doi: 10.1176/appi.ajp.2007.07071058r) was accepted for publication in July 2007.

Association of CYP2D6 ultrarapid metabolizer genotype with deficient patient satisfaction regarding methadone maintenance treatment

Objective The activity of cytochrome P-450 enzyme 2D6 (CYP2D6) could be related to heroin-dependent patient satisfaction with methadone maintenance treatment. We sought to compare satisfaction with the usual methadone treatment in patients who are ultrarapid, extensive or poor metabolizers, according to CYP2D6 genotyping. Methods Two hundred and five heroin-dependent patients filled out the Verona Service Satisfaction Scale for methadone maintenance treatment (VSSS-MT), before CYP2D6 genotyping. Results VSSS-MT overall scores were comparable in the poor metabolizer ( N = 9) and extensive metabolizer ( N = 185) groups, although they were higher in poor metabolizers and extensive metabolizers taken together than in the ultrarapid metabolizers ( N = 11) ( p < 0.003). Likewise, ultrarapid metabolizers scored higher than the rest of the sample on the VSSS-MT Basic Interventions subscale ( p < 001). Regarding this subscale, no poor metabolizers felt dissatisfied, and ultrarapid metabolizer males ( N = 7) reported lower satisfaction than ultrarapid metabolizer females ( N = 4) ( p < 0.022). Ultrarapid metabolizer genotype accounted for 4.2% of the variance on the VSSS-MT total scores, and 5.0% on the Basic Intervention scores. Conclusion Heroin-dependent patients who are CYP2D6 ultrarapid metabolizers according to genotyping present deficient satisfaction with methadone maintenance treatment.