Opiate Agonist Treatment Research Articles

The Role of Adverse Childhood Experiences on People in Opiate Agonist Treatment: The Importance of Feeling Unloved

Introduction: Adults in opiate agonist treatment (OAT) often have a background of adverse childhood experiences (ACEs) and are more likely to be exposed to a variety of risks that may trigger post-traumatic stress disorder (PTSD). Summative ACE scores are often used to identify individuals at risk of PTSD and continued substance use. What has not been addressed is whether specific ACE factors are exerting a greater influence on the individual. This study investigated whether specific ACEs predicted PTSD, and current continued substance use among adults in long-term OAT. Methods: An analysis of data that were collected at the follow-up stage of a study among 131 adults who attended OAT was conducted. Participants attended one of six OAT settings, covering 45% (n = 890) of clients in a defined area of Dublin, Ireland in 2017. Interviews were conducted with 104 participants, 66 males (63%) and 38 females (37%), with an average age of 43 years (SD = 7.4). The Adverse Childhood Questionnaire (ACQ); PTSD checklist (PCL-5); heroin; tranquilliser; cannabis; alcohol; and cocaine used in the previous 28 days were measured using the quantity used score within the Opiate Treatment Index. Socio‐demographics and age of first use of these four substances were also collected. The analysis has focussed on relating ACEs to PTSD, age of first drugs use, and current drug use of the participants. Results: Bivariate analysis showed that the summative ACQ score was significantly correlated with age of first opiate use (p = 0.004). Multiple regression analysis showed that the summative ACQ score and tranquilliser use predicted higher levels of PTSD (R2 = 0.50). Four specific ACEs predicted 54% of the variance in PTSD, these were feeling unloved (β = 0.328) living with a household member who had a problem with alcohol or used illicit street drugs (β = 0.280); verbal abuse (β = 0.219); and living with a person who had a mental illness (β = 0.197). Conclusions: While a summation of all ten ACEs predicted higher levels of PTSD, the factor “feeling unloved” as a child provided the single strongest predictor and may represent an overarching risk of PTSD and continued substance use in later life among adults in treatment for an opiate use disorder.

A cross-section observational study on the seroprevalence of antibodies to COVID-19 in patients receiving opiate agonist treatment.

IntroductionThe HSE National Drug Treatment Centre is an inner city drug treatment centre in Dublin which provides opiate agonist treatment (OAT) to approximately 565 patients, many of whom have complex care needs.ObjectiveThis study was conducted to determine seropositivity to the COVID-19 virus in patients attending NDTC, and to establish if patients tested had any clinical symptoms of this disease since March 2020.MethodAll patients attending for OAT were invited to participate and 103/565 patients agreed. The patients were tested for the presence of serum antibodies to COVID-19 in a single sample collected over a 4-month period (July–October 2020). A questionnaire was administered at the same time as sample taking.ResultsResults showed that the majority of patient samples (100; 97%) tested were negative for the presence of antibodies to COVID-19. There were only two confirmed positive results (1.9%) and one equivocal result (1%). None of the approximately 565 attendees at the HSE NDTC presented with serious illness indicative of COVID-19 throughout the three waves of the pandemic, nor were any deaths due to COVID-19 reported. ConclusionThese findings indicate (a) possible low level of exposure to COVID-19 among this patient cohort or (b) that those patients who have been exposed have not developed or maintained detectable antibody levels, nor developed symptoms of the disease. Public health measures could explain the low level of COVID-19 in this cohort. The findings are also consistent with the possibility of a protective effect of OAT medications on development of the disease.

Mobile telephone delivered contingency management for encouraging adherence to supervised methadone consumption: feasibility study for an RCT of clinical and cost-effectiveness (TIES)

BackgroundPrescription methadone or buprenorphine enables people with opioid use disorder to stop heroin use safely while avoiding withdrawal. To ensure methadone is taken as prescribed and to prevent diversion onto the illicit market, people starting methadone take their daily dose under a pharmacist’s supervision. Many patients miss their daily methadone dose risking withdrawal, craving for heroin and overdose due to loss of heroin tolerance. Contingency management (CM) can improve medication adherence, but remote delivery using technology may be resource-light and cost-effective. We developed an innovative way to deliver CM by mobile telephone. Software monitors patients’ attendance and supervised methadone consumption through an internet self-login at the pharmacy and sends reinforcing text messages to patients’ mobile telephones. A linked system sends medication adherence reports to prescribers and provides early warning alerts of missed doses. A pre-paid debit card system provides financial incentives.MethodsA cluster randomised controlled trial design was used to test the feasibility of conducting a future trial of mobile telephone CM to encourage adherence to supervised methadone in community pharmacies. Each cluster (drug service/3 allied pharmacies) was randomly allocated to provide patient’s presenting for a new episode of opiate agonist treatment (OAT) with either (a) mobile telephone text message CM, (b) mobile telephone text message reminders, or (c) no text messages. We assessed acceptability of the interventions, recruitment, and follow-up procedures.ResultsFour drug clinics were approached and three recruited. Thirty-three pharmacists were approached and 9 recruited. Over 3 months, 173 individuals were screened and 10 enrolled. Few patients presented for OAT and high numbers were excluded due to receiving buprenorphine or not attending participating pharmacies. There was 96% consistency in recording medication adherence by self-login vs. pharmacy records. In focus groups, CM participants were positive about using self-login, the text messages, and debit card. Prescribers found weekly reporting, time saving, and allowed closer monitoring of patients. Pharmacists reported that the tablet device was easy to host.ConclusionMobile telephone CM worked well, but a planned future trial will use modified eligibility criteria (existing OAT patients who regularly miss their methadone/buprenorphine doses) and increase the number of participating pharmacies.Trial registrationThe trial is retrospectively registered, ISRCTN 58958179.

The Healthy Addiction Treatment Recovery Model: Developing a Client-Driven, Nurse-Led Addiction Nursing Model.

The current model of nursing within international addiction services has been described as task oriented and reactive. Yet, it is known that nursing models should be led by client need and operate within the domain of the client and their wider environment. The aim of this study was to address this gap within addiction nursing and to develop an evidence-based addiction nursing model.To objectively assess the needs of clients, a cross-sectional survey was implemented within a representative selection of six drug treatment clinics and a sample of clients in receipt of opiate agonist treatment in Dublin, Ireland. The Opiate Treatment Index with the General Health Questionnaire embedded was used to measure heroin use, polydrug use, infectious disease risk, physical health, psychological adjustment, criminality and social well-being. To develop the addiction model, a mapping of relevant features of potential nursing models was conducted by nurses working in addiction services.The key finding from the client assessments was a lack of psychological adjustment; a cutoff score of 4 was recommended. The mean score among women was 11 (95% CI [8, 14]), and that among men was 8 (95% CI [6, 10]). Findings from the mapping of models highlighted the benefits of the BRENDA, FRAMES, and Tidal models. A focus on practical implementation and measurable outcomes was stressed. Results informed the development of the Healthy Addiction Treatment Recovery Model. The model refocused services on clients' objective needs and eradicated entrenched practices.

Factors and HCV treatment outcomes associated with smoking among people who inject drugs on opioid agonist treatment: secondary analysis of the PREVAIL randomized clinical trial

BackgroundCigarette smoking has emerged as a leading cause of mortality among people with hepatitis C virus (HCV). People who inject drugs (PWID) represent the largest group of adults infected with HCV in the US. However, cigarette smoking remains virtually unexplored among this population. This study aimed at (1) determining prevalence and correlates of cigarette smoking among HCV-infected PWID enrolled in opiate agonist treatment programs; (2) exploring the association of smoking with HCV treatment outcomes including adherence, treatment completion and sustained virologic response (SVR); and 3) exploring whether cigarette smoking decreased after HCV treatment.MethodsParticipants were 150 HCV-infected PWID enrolled in a randomized clinical trial primarily designed to test three intensive models of HCV care. Assessments included sociodemographics, presence of chronic health and psychiatric comorbidities, prior and current drug use, quality of life, and HCV treatment outcomes.ResultsThe majority of the patients (84%) were current cigarette smokers at baseline. There was a high prevalence of psychiatric and medical comorbidities in the overall sample of PWID. Alcohol and cocaine use were identified as correlates of cigarette smoking. Smoking status did not influence HCV treatment outcomes including adherence, treatment completion and SVR. HCV treatment was not associated with decreased cigarette smoking.ConclusionsThe present study showed high prevalence of cigarette smoking among this population as well as identified correlates of smoking, namely alcohol and cocaine use. Cigarette smoking was not associated with HCV treatment outcomes. Given the detrimental effects that cigarette smoking and other co-occurring, substance use behaviors have on HCV-infected individuals’ health, it is imperative that clinicians treating HCV also target smoking, especially among PWID. The high prevalence of cigarette smoking among PWID will contribute to growing morbidity and mortality among this population even if cured of HCV. Tailored smoking cessation interventions for PWID along with HCV treatment may need to be put into clinical practice.Trial registrationNCT01857245. Registered May 20, 2013.

Treatment with buprenorphine prior to EcoHIV infection of mice prevents the development of neurocognitive impairment.

Approximately 15-40% of people living with HIV develop HIV-associated neurocognitive disorders, HAND, despite successful antiretroviral therapy. There are no therapies to treat these disorders. HIV enters the CNS early after infection, in part by transmigration of infected monocytes. Currently, there is a major opioid epidemic in the United States. Opioid use disorder in the context of HIV infection is important because studies show that opioids exacerbate HIV-mediated neuroinflammation that may contribute to more severe cognitive deficits. Buprenorphine is an opioid derivate commonly prescribed for opiate agonist treatment. We used the EcoHIV mouse model to study the effects of buprenorphine on cognitive impairment and to correlate these with monocyte migration into the CNS. We show that buprenorphine treatment prior to mouse EcoHIV infection prevents the development of cognitive impairment, in part, by decreased accumulation of monocytes in the brain. We propose that buprenorphine has a novel therapeutic benefit of limiting the development of neurocognitive impairment in HIV-infected opioid abusers as well as in nonabusers, in addition to decreasing the use of harmful opioids. Buprenorphine may also be used in combination with HIV prevention strategies such as pre-exposure prophylaxis because of its safety profile.

Cost-effectiveness of Hepatitis C Virus Treatment Models for People Who Inject Drugs in Opioid Agonist Treatment Programs.

Many people who inject drugs in the United States have chronic hepatitis C virus (HCV). On-site treatment in opiate agonist treatment (OAT) programs addresses HCV treatment barriers, but few evidence-based models exist. We evaluated the cost-effectiveness of HCV treatment models for OAT patients using data from a randomized trial conducted in Bronx, New York. We used a decision analytic model to compare self-administered individual treatment (SIT), group treatment (GT), directly observed therapy (DOT), and no intervention for a simulated cohort with the same demographic characteristics of trial participants. We projected long-term outcomes using an established model of HCV disease progression and treatment (hepatitis C cost-effectiveness model: HEP-CE). Incremental cost-effectiveness ratios (ICERs) are reported in 2016 US$/quality-adjusted life years (QALY), discounted 3% annually, from the healthcare sector and societal perspectives. For those assigned to SIT, we projected 89% would ever achieve a sustained viral response (SVR), with 7.21 QALYs and a $245 500 lifetime cost, compared to 22% achieving SVR, with 5.49 QALYs and a $161 300 lifetime cost, with no intervention. GT was more efficient than SIT, resulting in 0.33 additional QALYs and a $14 100 lower lifetime cost per person, with an ICER of $34 300/QALY, compared to no intervention. DOT was slightly more effective and costly than GT, with an ICER > $100 000/QALY, compared to GT. In probabilistic sensitivity analyses, GT and DOT were preferred in 91% of simulations at a threshold of <$100 000/QALY; conclusions were similar from the societal perspective. All models were associated with high rates of achieving SVR, compared to standard care. GT and DOT treatment models should be considered as cost-effective alternatives to SIT.

Death Ambivalence and Treatment Seeking: Suicidality in Opiate Addiction

Rates of suicide and opiate overdose have recently skyrocketed in the United States. In light of impulsivity and impaired motivation common in people with substance use disorders, suicidality is common in addiction. Chart review surveys indicate two primary suicidal populations that are important to distinguish for clinical practice and healthcare policy. One group is heavily composed of people with SUDs, in whom chronic compulsive use fosters a numb ambivalence about death (low death intentionality). Many of these individuals with opiate use disorder (OUD) exaggerate suicidality to get prompt psychiatric care to treat the OUD. The second group is composed of those who have co-morbid psychiatric disorders and/or chronic pain who have a higher intent to die consistent with traditionally understood suicide risk factors. We contend that easier access to outpatient opiate agonist treatment would avoid unnecessary hospitalizations for death-ambivalent OUD patients, and for OUD patients in either group. First line treatment with an opioid agonist has high potential to effectively treat suicidal ideation as a secondary benefit.

Opiate agonist treatment to improve health of individuals with opioid use disorder in Lebanon

BackgroundOpioid agonist therapy has been widely used to reduce harms among individuals with opioid use disorder but its effectiveness has not been evaluated in the Middle East North African (MENA) region. This study aims to evaluate the effectiveness of a program using opioid agonist therapy in combination with psychosocial support on improving psychological and social well-being, reducing arrest, and reducing risky behavior in individuals with opioid use disorder in Lebanon.MethodsA one-group pre-test post-test design study was performed at SKOUN Lebanese Addiction Centre between January 2013 and December 2014. Eighty-six out of 181 patients agreed to participate and completed the 3-month assessment and 38 concluded the 12-month assessment. Psychological (depression and anxiety, quality of life), substance dependence/abuse, behavioral (injecting behavior, sharing needles and paraphernalia), and social outcomes were evaluated at baseline, 3, and 12 months post-treatment.ResultsRemarkable statistical significance improvements were observed 3 months after treatment in most outcome variables including quality of life, anxiety, substance dependence, overdose, employment, and injecting behavior. Improvements were sustained 12 months after treatment.ConclusionResults support expanding the access to opioid agonist therapy in other MENA countries to treat substance dependence and reduce harms among individuals with opioid use disorder.

Neuropsychological function is improved among opioid dependent adults who adhere to opiate agonist treatment with buprenorphine-naloxone: a preliminary study

BackgroundAmong persons with opioid use disorder (OUD), neuropsychological dysfunction is associated with depression, and better neuropsychological function is associated with opioid abstinence. However, it is unknown whether depressive symptomatology or adherence to opiate agonist treatment are associated with neuropsychological change over time.MethodsWe recruited 20 buprenorphine/naloxone-treated adults with OUD (M Age = 45.2 years [SD = 8.1]; 25% female) to complete baseline and 6 month visits containing a neuropsychological test battery and self-reported measures of depressive symptomatology and medication adherence.ResultsDepressive symptomatology was not significantly related to neuropsychological change (p’s > .05). Greater adherence to buprenorphine/naloxone was associated with improvements in learning, memory, and global functioning (r’s = .52–60; p’s < .05).ConclusionsAmong OUD patients, greater adherence to buprenorphine/naloxone is associated with improved neuropsychological functioning over time. In contrast, depressive symptomatology is not associated with neuropsychological functioning over time. Supporting adherence to buprenorphine/naloxone may improve and/or preserve learning and memory functioning in individuals treated for OUD.Trial registrationNCT01108679. Registered 21 April 2010.

Opiate addiction and overdose: experiences, attitudes, and appetite for community naloxone provision.

More than 200 opiate overdose deaths occur annually in Ireland. Overdose prevention and management, including naloxone prescription, should be a priority for healthcare services. Naloxone is an effective overdose treatment and is now being considered for wider lay use. To establish GPs' views and experiences of opiate addiction, overdose care, and naloxone provision. An anonymous postal survey to GPs affiliated with the Department of Academic General Practice, University College Dublin, Ireland. A total of 714 GPs were invited to complete an anonymous postal survey. Results were compared with a parallel GP trainee survey. A total of 448/714 (62.7%) GPs responded. Approximately one-third of GPs were based in urban, rural, and mixed areas. Over 75% of GPs who responded had patients who used illicit opiates, and 25% prescribed methadone. Two-thirds of GPs were in favour of increased naloxone availability in the community; almost one-third would take part in such a scheme. A higher proportion of GP trainees had used naloxone to treat opiate overdose than qualified GPs. In addition, a higher proportion of GP trainees were willing to be involved in naloxone distribution than qualified GPs. Intranasal naloxone was much preferred to single (P<0.001) or multiple dose (P<0.001) intramuscular naloxone. Few GPs objected to wider naloxone availability, with 66.1% (n = 292) being in favour. GPs report extensive contact with people who have opiate use disorders but provide limited opiate agonist treatment. They support wider availability of naloxone and would participate in its expansion. Development and evaluation of an implementation strategy to support GP-based distribution is urgently needed.

Prospects for people who use drugs: Maintenance, recovery or progress? An analysis of motivation to change in individuals attending for opioid agonist prescribing (OAP) in a general practice setting

Aims: To evaluate the characteristics and potential for change in a group of opiate dependent patients. Methods: A convenience sample of individuals receiving a prescription for an opiate substitute were recruited during a consultation with their general practitioner in an NHS practice located in a city in Central Scotland with a high incidence and prevalence of opiate drug use. Participants completed a standardised questionnaire (Christo Inventory for Substance Misuse) and self-allocated to a motivational group representing willingness to consider change of prescription. Findings: The group had a high level of comorbidity and a low interest in change of prescription. Stability of drug use was found to be common even in the presence of frequent mental and physical health problems. Unemployment was high in a largely male population who had a high need but low uptake for psychological help. Conclusions: For study participants, potential for change seems limited with medium to long-term continuation of an opiate agonist treatment plan appropriate. They represent a high risk group for death from various causes and may be protected by their current situation. Engagement with other health and social care professions is poor. Implications for clinical practice are that OAP is, for many, a longer term prospect and that recovery, or progress, should be assessed by a wider range of measures than just drug intake.

A combined opiate agonist and antagonist treatment reduces prolactin secreting pituitary tumor growth

Prolactin secreting pituitary adenomas (prolactinomas) is the most common pituitary tumors in humans. Animal studies have identified aggressive prolactinoma development in fetal alcohol exposed rats. We have recently identified a combination treatment of a μ opioid receptor antagonist naltrexone and a δ opioid receptor agonist D-Ala2-,N-Me-Phe4,Gly-ol Enkephalin (DPDPE) increases innate immune function. In this study, we tested whether naltrexone and DPDPE combination therapy is useful to control pituitary tumor growth. Fetal alcohol exposed and control Fischer 344 female rats at 60days of age were ovariectomized and received an estrogen implant to induce prolactinomas. Six weeks after the estrogen implant, these animals received treatments of naltrexone and DPDPE or saline. The growth of the pituitary tumor prior to and after opioidergic agent treatments was visualized using magnetic resonance imaging (MRI). At the end of the treatment, pituitary weights, plasma prolactin and splenic levels of cytotoxic factors were determined. Both imaging data and weight data indicated that the volume and the weight of the pituitary were increased more after estrogen treatment in animals exposed to fetal alcohol than control. Naltrexone and DPDPE treatment reduced the weight and volume of the pituitary gland and plasma levels of prolactin in both fetal alcohol exposed and control-fed animals. The treatment of opioidergic agents also increased the levels of cytotoxic factors in the spleen. These data provide a novel possibility in treating pituitary tumors using a combination therapy of naltrexone and DPDPE.

Some of the people, some of the time: field evidence for associations and dissociations between stress and drug use.

Stress's role in drug use is supported by retrospective interview and laboratory studies, but prospective data confirming the association in daily life are sparse. This study aims to assess the relationship between drug use and stress in real time with ambulatory monitoring. For up to 16weeks, 133 outpatients on opiate agonist treatment used smartphones to report each time they used drugs or felt more stressed than usual. They rated stress-event severity on a 10-point scale and as a hassle, day spoiler, or more than a day spoiler. For analysis, stress reports made within 72h before a reported use of cocaine or opioid were binned into 24-h periods. Of 52 participants who reported stress events in the 72-h timeframe, 41 reported stress before cocaine use and 26 before opioid use. For cocaine use, the severity of stressors, rated numerically (r effect = 0.42, CL95 0.17-0.62, p = 0.00061) and percent rated as "more than a day spoiler" (r effect = 0.34, CL95 0.07-0.56, p = 0.0292)], increased linearly across the three days preceding use. The number of stressors did not predict cocaine use, and no measure of stress predicted opioid use. In ecological momentary assessment (EMA) from the whole sample of 133, stress and drug use occurred independently and there was no overall relationship. EMA did not support the idea that stress is a necessary or sufficient trigger for cocaine or heroin use after accounting for the base rates of stress and use. But EMA did show that stressful events can increase in severity in the days preceding cocaine use.

Efforts to Reduce Overdose Deaths

The recent article by Schwartz et al. addresses the intersection of two important public health issues: opiate substitution therapy and fatal heroin overdose.1 In the United States, drug overdose is responsible for more than 36 000 deaths annually2 and is the leading cause of death among illicit drug users. Baltimore, Maryland, has one of the highest per capita heroin addiction rates in the nation, with an estimated prevalence of heroin use in 10% of the population.3 Schwartz et al. conducted a 15-year ecological analysis in Baltimore and found that increases in buprenorphine and methadone treatment with concurrent decreases in overdose deaths, controlling for heroin purity. Along with previous research,4 this study demonstrates the far-reaching benefits of opiate agonist treatment. In Baltimore, an estimated 34% of 68 000 drug users were in drug treatment in 2011, with heroin being the primary drug of abuse.5 The magnitude of out-of-treatment drug users in Baltimore and in the United States underscores the need for overdose prevention efforts targeting this population. Furthermore, out-of-treatment, long-term injection drug users (IDUs) are at greatest risk for overdose.6,7 As Schwartz et al. noted, periods of abstinence resulting from recent incarceration or drug treatment are chief overdose risk factors, given associated decreases in tolerance.8,9 These facts speak to the importance of overdose prevention among active IDUs. Capital City Care, a medical marijuana dispensary, is shown in Washington, DC, on April 15, 2013, prior to the store's opening. Three years after Washington, DC, legalized medical marijuana, three stores are set to open, allowing patients with HIV/AIDS, ... As of 2012, there were an estimated 188 overdose prevention education and naloxone distribution programs (OPEND) in the United States.2 OPEND programs train peer drug users how to prevent overdoses and administer naloxone in the event of an overdose. Naloxone is a short-acting opiate antagonist that reverses the effects of respiratory depression commonly caused by opiate overdose.7 Since 2004, Baltimore’s OPEND program, Staying Alive, has reached 35 000 individuals including an estimated 10 000 IDUs, 1200 medical and drug treatment providers, and 8500 jail inmates. Staying Alive has distributed 4000 vials of naloxone, and 250 reversals have been reported. Between 2003 and 2009 (half of the study period examined in Schwartz et al.), Staying Alive distributed 1263 naloxone vials and 196 reversals were reported. We commend Schwartz et al. for their study, which highlighted important public health programs that appear to reduce overdose mortality. We believe that both OPEND and increased availability of opiate substitution therapy have contributed to decreases in overdose mortality in Baltimore. We think that both are necessary for a holistic approach to the issue of overdose.

Exercise as an Adjunct Treatment for Opiate Agonist Treatment: Review of the Current Research and Implementation Strategies

ABSTRACT Opiate dependence is a significant public health concern linked to poor quality of life, comorbid psychiatric disorders, and high costs to society. Current opiate agonist treatments are an effective but limited intervention. Adjunctive interventions could improve and augment opiate agonist treatment outcomes, including drug abstinence, quality of life, and physical health. This article reviews exercise as an adjunctive intervention for opiate agonist treatment, especially in regards to improving mood and overall quality of life, while reducing other substance use. Poor adherence and dropout frequently prevent many individuals from garnering the many physical and mental health benefits of exercise. Strategies for implementing an exercise intervention, including safety considerations, are discussed.

Mu Opioid Receptor from the Zebrafish Exhibits Functional Characteristics as Those of Mammalian Mu Opioid Receptor

The functional characterization of the mu opioid receptor from the zebrafish (zfMOR) is reported here. After transfection in HEK-293 cell line, using both peptidergic and nonpeptidergic opioid ligands in the competition and saturation-binding experiments, in addition to the functional assays of (35)S-GTPgammaS-binding assays and intracellular 3'-5'-cyclic adenosine monophosphate (cAMP) level determinations, we demonstrate that zfMOR exhibits a pharmacological profile similar to that of the mammalian MOR. Besides, the internalization process of zfMOR after opiate agonist treatment (morphine, DAMGO, etorphine) resembles the pattern observed for its mammalian counterpart. These similarities suggest that the zebrafish is a good model for the study of the opioid effects in development.

Dissolution of a harm reduction track for opiate agonist treatment: Longitudinal impact on treatment retention, substance use and service utilization

Background There is great need to sustain harm reduction programmes for opiate-dependent persons, given variable retention of opioid agonist treatment (OAT) enrolees. Resource challenges may lead some health organizations to discontinue such programmes, though just as programmatic evaluation may determine efficacy and cost-effectiveness so to does it aid in examining impacts of programme dissolution. Methods This retrospective evaluation investigated impacts of the dissolution of a ‘Minimal Services’ (MS) harm reduction programme for substance-abusing OAT clientele at an urban U.S. Veterans Affairs Medical Centre. Targeted clinical data concerning treatment retention, substance use and service utilization was abstracted from medical records of MS-assignees ( N = 32) and a matched comparison group of standard OAT enrolees. Chart reviewers gathered data for a two-year period encompassing baseline, transitional, and dissolution study phases. Results Relative to matched-controls, MS-assignees exhibited: (1) disproportionately poor treatment retention over the two-year period; (2) high and temporally stable rates of documented substance use across study phases, and (3) increased utilization of resource-laden VAMC services after MS dissolution. Conclusion Collective results suggest MS programme dissolution was associated with adverse conditions for assignees and the larger treatment setting, and reinforce the need for pragmatic, humane treatment policies to facilitate retention of opiate-dependent persons.

Predictors of opiate agonist treatment retention among injection drug users referred from a needle exchange program

Aims The aim of this study was to examine the effect of a case management intervention on retention in opiate agonist therapy among injection drug users (IDUs) referred from a needle exchange program (NEP). Design, intervention, participants, and setting A randomized trial of a strengths-based case management intervention versus passive referral (control) was conducted among NEP attendees requesting and receiving referrals to subsidized, publicly funded opiate agonist treatment programs in Baltimore, MD. Measurements Multivariable Cox regression models were used to identify predictors of treatment retention using an ecological model approach, taking into account factors at the individual, social, and environmental level. Findings Of 245 IDUs, 127 (51.8%) entered opiate agonist treatment, for whom median retention was 7.9 months. The intervention was not associated with longer retention ( p = .91). Individual-level factors predictive of shorter retention included being employed and greater levels of psychiatric distress. Participants who had prior treatment experience and multiple treatment requests were retained significantly longer. Social factors adversely affecting treatment retention included unstable housing and buying drugs for others. Living further away from the treatment site was an environmental barrier that negatively affected treatment retention. Conclusions Multilevel interventions that address individual, social, and environmental factors are necessary to improve substance abuse treatment retention and treatment outcomes among IDUs referred from NEP.

The impact of opiate agonist maintenance therapy on drug use within social networks of injecting drug users.

This study examined whether participation in opiate drug treatment is associated with changes in drug use and injecting drug use within the social networks of injecting drug users. Participants were 245 injecting drug users who attended the Baltimore Needle Exchange Program during 2002-2004 and requested treatment and received a referral for opiate agonist treatment as part of an intervention to improve treatment outcomes. Data included interviews at baseline, 3, 6, 12, and 18 months and drug treatment program agency records. The mean age of participants was 42.2 years; 77% were African American, 69% were male, and 48% entered treatment. Final generalized estimating equations (GEE) models indicated that participants that entered opiate drug treatment exhibited approximately a 20% decrease in the proportional odds of having friends that used drugs (p = 0.04). Additionally, participants that entered opiate drug treatment exhibited a 26% decrease in the proportional odds of having friends that injected drugs (p = 0.01). These findings contribute evidence to further understand the dynamics between opiate drug treatment, changes in social network risk, and treatment outcomes, as well as suggest an important role for peer-based interventions to support entry and retention in opiate drug treatment.