Opiate Substitution Treatment Research Articles

Effectiveness of opioid maintenance programs for treating drug dependence in prisons.

To evaluate the effectiveness of opioid maintenance programs in treating opioid dependence in Spanish prisons. A narrative bibliographic review was carried out on the following databases: PubMed; Cochrane; IBECS; LILACS; HealthCare. All clinical trials were chosen as a preference, along with systematic review articles and some articles that were considered relevant for their content. The time period was limited to between January 2011 and November 2021. The languages chosen were English, Spanish and Catalan. Repeated articles and those that were not related to the objectives were rejected. The search criteria were: "methadone AND prisons"; "opiate substitution treatment AND prisons"; "methadone AND buprenorphine"; "methadone OR buprenorphine"; "prisons AND Methadone AND buprenorphine". 20 articles were selected out of 647 items consulted after applying the corresponding filters and after discarding duplicates. There was a slightly greater effectiveness of buprenorphine versus methadone. The high prevalence of the program was highlighted, as well as the variety of adverse effects of methadone. Usefulness with regard to inmates' behavior showed a range of opinions. The possibility of new treatment alternatives with better pharmacological control is mentioned.

Predictive factors for acceptance of a long-acting opiate substitution treatment studied through social representations and internalized stigma

Opioid use disorder is a public health problem worldwide with a treatment gap partially due to sociocultural representation and stigma. Taking the opportunity of an authorization to a subcutaneous (SC) injectable solution of buprenorphine, the first and only injectable treatment for opioid dependence available in France, we investigate potential obstacles to its implementation in France. This study aimed to define the factors predicting the acceptance of a new SC form of opiate substitution treatment (OST) by comparing the social representations using an adapted version of the Explanatory Model Interview Catalogue (EMIC) and the internalized stigma of intravenous drug injection using the Internalized Stigma of Mental Illness Inventory (ISMI) between participants receiving OST likely to accept the SC form or not. We also observed whether the fear of an opiate withdrawal syndrome could influence this choice. Fifty OST patients were included, 54% of them accepted a new SC form of OST. Perceived causes of drug injection measured with EMIC were significantly lower among participants who would not accept the new SC form. No significant difference was found regarding the total score of the adapted ISMI or its items. The fear of opiate withdrawal syndrome did not seem to be statistically related to acceptance of a long-acting SC OST in either group. The most discriminating combination of factors in predicting patient acceptance of such treatment was related to the perceived causes of drug injection associated with a severe Diagnostic and Statistical Manual of Mental Disorders 5th version (DSM-5) diagnosis, and a lower alcohol consumption. We observed significant differences in social representations but not in internalized stigma between the two groups. Moreover, the predictive factors linked to the acceptance of a new SC form of OST suggest a multifactorial combination of elements that will have to be tested in a larger and prospective study delivering long-acting high-dose buprenorphine.

OS-004-YI - Community dispensed hepatitis C virus treatment for ‘hard to reach’ opiate substitution treatment service users in Dublin: an intervention to address HCV infection eradication

OS-004-YI - Community dispensed hepatitis C virus treatment for ‘hard to reach’ opiate substitution treatment service users in Dublin: an intervention to address HCV infection eradication

Anti-HCV testing acceptance and seroconversion rates among people who use drugs and are under opiate substitution treatment (Hippocrates Epidemic Detection System)

Anti-HCV testing acceptance and seroconversion rates among people who use drugs and are under opiate substitution treatment (Hippocrates Epidemic Detection System)

FORWARDS-1: an adaptive, single-blind, placebo-controlled ascending dose study of acute baclofen on safety parameters in opioid dependence during methadone-maintenance treatment—a pharmacokinetic-pharmacodynamic study

BackgroundTreatment of opiate addiction with opiate substitution treatment (e.g. methadone) is beneficial. However, some individuals desire or would benefit from abstinence but there are limited options to attenuate problems with opiate withdrawal. Preclinical and preliminary clinical evidence suggests that the GABA-B agonist, baclofen, has the desired properties to facilitate opiate detoxification and prevent relapse. This study aims to understand whether there are any safety issues in administering baclofen to opioid-dependent individuals receiving methadone.MethodsOpiate-dependent individuals (DSM-5 severe opioid use disorder) maintained on methadone will be recruited from addiction services in northwest London (NHS and third sector providers). Participants will be medically healthy with no severe chronic obstructive pulmonary disease or type 2 respiratory failure, no current dependence on other substances (excluding nicotine), no current severe DSM-5 psychiatric disorders, and no contraindications for baclofen or 4800 IU vitamin D (placebo). Eligible participants will be randomised in a 3:1 ratio to receive baclofen or placebo in an adaptive, single-blind, ascending dose design. A Bayesian dose-escalation model will inform the baclofen dose (10, 30, 60, or 90 mg) based on the incidence of ‘dose-limiting toxicity’ (DLT) events and participant-specific methadone dose. A range of respiratory, cardiovascular, and sedative measures including the National Early Warning Score (NEWS2) and Glasgow Coma Scale will determine DLT. On the experimental day, participants will consume their usual daily dose of methadone followed by an acute dose of baclofen or placebo (vitamin D3) ~ 1 h later. Measures including oxygen saturation, transcutaneous CO2, respiratory rate, QTc interval, subjective effects (sedation, drug liking, craving), plasma levels (baclofen, methadone), and adverse events will be obtained using validated questionnaires and examinations periodically for 5 h after dosing.DiscussionStudy outcomes will determine what dose of baclofen is safe to prescribe to those receiving methadone, to inform a subsequent proof-of-concept trial of the efficacy baclofen to facilitate opiate detoxification. To proceed, the minimum acceptable dose is 30 mg of baclofen in patients receiving ≤ 60 mg/day methadone based on the clinical experience of baclofen’s use in alcoholism and guidelines for the management of opiate dependence.Trial registrationClinicaltrials.gov NCT05161351. Registered on 16 December 2021.

Aggression towards clinicians within Opiate Substitution Treatment (OST) services: A survey of service providers

BackgroundHigh levels of aggression towards staff in healthcare settings have been reported. It seems likely that workers in Opioid Substitution Therapy (OST) would be at increased risk of adverse events and their consequences. ObjectivesThis study aimed to establish if practitioners who provide OST are experiencing negative outcomes, specifically aggression, distress, and burnout, and to identify if workload and professional affiliation were associated with these risks. MethodsA survey was conducted of OST practitioners in a single geographical region of New Zealand (population approx. 344,000). The survey asked for demographics (including caseloads), Perception of Patient Aggression Scale New Zealand Revision (POPAS-NZ), Kessler 10 (K10), Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), and Abbreviated Maslach Burnout Inventory (aMBI) and two qualitative questions asking about the best and worst aspects of working in OST. ResultsAll recorded OST workers in the region (n = 181) were invited to participate, 95 practitioners responded to the survey (52.4%). This group included pharmacists, doctors, nurses, social workers and addiction workers. Results indicated aggression, distress, and burnout were being experienced by practitioners. Number of patients seen by a practitioner significantly increased risk of aggression (F(1,90) = 14.14, p < 0.001). Psychiatrists were the most at risk profession (p = 0.016). Burnout responses were high for around 20% of practitioners, with low numbers meeting criteria for distress and PTSD. Positive things about working in OST were relationships with patients, appreciating patient outcomes and positive team environments. Negative aspects were patient behaviours, maintaining empathy, and, administration tasks. ConclusionsAggression was a workplace hazard for OST clinicians. Low rates of distress and PTSD symptoms were reported and some evidence of practitioner burnout. Practitioners reported positive relationships, making a difference and teamwork may have been improving this area of mental health work.

Community consumption of analgesic opioids and opiate substitution treatments in a self-employed workers health plan: trend, substitution effects and demographic factors

Objective: Our aim was to evaluate community consumption of strong prescription opioid treatments in France in 2015 and 2017.Methods: A nation-wide French health care insurance claims database was analyzed for opioids average annual cost, annual prevalence of dispensations and users by mean of two repeated retrospective cross sectional study in 2015 and 2017.Results: In 2015–2017 prevalence of users per 100 000 beneficiaries per year rose from 878 to 932 (+6%) for strong opioid analgesics and lowered from 160 to 150 (-6%) for opiate substitution treatments. Prevalence of users of oxycodone, fentanyl, morphine, hydromorphone, buprenorphine, and methadone shifted by +17%, -5%, +4%, -8%, -13%, and +10%, respectively (+20% for methadone capsules). Oxycodone moved from third place to first place in terms of number of dispensation. Highest prevalence were in the western half of France, age over 60 and female for strong analgesic opioids and the north-east quarter and the south-west quarter of France, age 30 to 49 and male for opiate substitution treatments. The factor most strongly associated with prevalencewas age in strong analgesic opioids and gender in opiate substitution treatments.Conclusions: In 2 years the use of analgesics progresses, especially for oxycodone, while that of the substitution drugs decreases. Despite its greater danger, methadone tends to replace buprenorphine and capsule form tends to replace the syrup. Regulatory changes or enhanced controls may have played a role. The age of strong analgesic opioids consumers highlights the issue of severe pain in the elderly.

Effectiveness of opiate substitution treatment in reducing HIV risk behaviors among African, Caribbean, and Black people: a systematic review.

The objective of this systematic review is to identify, appraise, and synthesize the best available evidence on the effectiveness of opioid substitution treatment in reducing HIV risk behavior among African, Caribbean, and Black people. Substance use plays an important role in HIV transmission among Black people by increasing risky sexual behavior and the risk of HIV acquisition. Opioid substitution treatment, such as methadone maintenance treatment and buprenorphine therapy, has been found to be an effective measure to minimize HIV transmission attributable to opioid addiction. The current review considered studies that included African, Caribbean, and Black adult patients, aged 18 years or over, who have used methadone maintenance treatment or buprenorphine therapies as part of the intervention for opioid use disorders and have been evaluated for sex- and drug-related HIV risk behaviors. This review considered studies that have evaluated the impact of methadone maintenance treatment or buprenorphine therapy on sex- and drug-related HIV risk behaviors. Multiple databases were searched, including Embase, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials, OpenGrey, Grey Matters, New York Academy of Medicine Grey Literature Report, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform. Two reviewers independently assessed all titles and abstracts, and potentially relevant studies were retrieved in full. Papers selected for retrieval were assessed by two independent reviewers for methodological validity. Data were then extracted from papers. Statistical pooling of quantitative data and meta-analysis was not possible due to heterogeneity of data. Five articles were included in this review: three randomized controlled trials, one cohort study, and one quasi-experimental study. Four studies focused on methadone maintenance treatment and one study discussed the effectiveness of buprenorphine intervention. All studies were from the United States. One study enrolled participants in methadone maintenance treatment for heroin injectors, of which 10% of the sample was HIV positive. These papers included studies that reported a significant reduction in sex-related HIV risk behavior, including having multiple sex partners, frequency of sexual intercourse, condom use, prostitution, and sex trade. Of the five studies, two reported on drug-related HIV risk behaviors, citing a reduction in drug-related HIV risk behaviors. Also, these papers showed unexpected outcomes relating to frequency of sexual intercourse, prostitution, and sex trade. One study reported a significantly higher number of sexual encounters among persons not participating in treatment. One study reported decreasing prostitution and sex trade among individuals receiving methadone maintenance treatment intervention. Methadone maintenance treatment or buprenorphine therapy can be effective in reducing sex- and drug-related HIV risk behaviors among African, Caribbean, and Black people. However, due to the weaknesses in the body of evidence and the quality of evidence, it is not possible to make strong conclusions about these interventions. Rigorous studies are necessary to generate more findings and reinforce the body of literature. PROSPERO CRD42019126954.

Methadone-Assisted Opiate Withdrawal and Subsequent Heroin Abstinence: The Importance of Psychological Preparedness.

Treatment guidelines emphasize patients' readiness for transitioning from opiate substitution treatment (OST) to opiate withdrawal and abstinence. Psychological preparedness indicators for this transition were examined. Patients (all male) were recruited from three treatment settings: prison, an inpatient detoxification unit, and an outpatient clinic. Time 1 (T1) was admission to methadone-assisted withdrawal in all settings. Time 2 (T2) was a 6-month follow-up. With n = 24 at T1 for each group (N = 72), a battery of instruments relevant to psychological preparedness was administered. At T1, inpatients had higher self-efficacy beliefs for successful treatment completion than prison patients. For patients contactable at T2, T1 self-efficacy positively predicted T2 opiate abstinence. No other variable improved prediction. T1 SOCRATES (Stages of Change Readiness and Treatment Eagerness Scale) ambivalence scores, age, and lifetime heroin use duration predicted maintenance of contact or not with treatment services and contactability by the researcher. Measures of mood did not differ between groups at T1 or predict T2 outcomes. Self-efficacy beliefs are a potentially useful indicator of readiness for transitioning from OST to a medically assisted opiate withdrawal and subsequent abstinence. Ambivalence regarding change, age, and lifetime heroin use duration are potentially useful predictors of patients maintaining contact with services, and of being retained in research. These findings advance existing literature and knowledge by highlighting the importance of self-efficacy in psychological preparedness for opiate abstinence, and the predictive utility to clinicians of this and other variables measurable at admission, in the clinical management of opiate users. (© 2020 The Authors. The American Journal on Addictions published by Wiley Periodicals LLC on behalf of The American Academy of Addiction Psychiatry). (Am J Addict 2021;30:11-20).

The fentanyl epidemic in Estonia: factors in its evolution and opportunities for a comprehensive public health response, a scoping review

BackgroundThe spread of illicitly manufactured fentanyl has the potential to greatly increase the fatal overdoses in many places in the world. The purpose of this paper is to analyse the evolution of fentanyl use epidemic in Estonia. Methodsthis scoping review is based on extensive review and synthesis of broad range of literature: research reports, newspaper, magazine, coverage of illicit fentanyl use; policy documents, position papers, reports released by government agencies, and surveillance data. ResultsFor an over a decade up to 2017, Estonia has had the highest overdose death mortality in Europe. The use of (injected) fentanyl is a major contributor to the Estonian overdose death epidemic. Shutting down a major producer and distributor of illicit fentanyl has been extremely effective in curbing the number of overdose deaths. Unfortunately, this supply-side intervention came ten years into the epidemic, and might be difficult to replicate in settings with decentralized production. In areas faced by fentanyl we would recommend large-scale implementation of opiate substitution treatment and naloxone distribution, syringe service programs to provide for safer injecting and link to other services (high frequencies of fentanyl injection create high risk for HIV and HCV transmission), and programs, such as “Break the Cycle,” to reduce initiation into injecting drug use. Further, the means of responding to emerging substances should match the world in which different substances can be rapidly introduced, and where people who use drugs can change preferences based on market availability. ConclusionAddressing illicitly manufactured fentanyl may serve as a public health learning experience for developing early detection and rapid response programs in rapidly changing drug use environments.

Continuation of Buprenorphine to Facilitate Postoperative Pain Management for Patients on Buprenorphine Opioid Agonist Therapy

Background: Acute pain management in patients on buprenorphine opioid agonist therapy (BOAT) can be challenging. It is unclear whether BOAT should be continued or interrupted for optimization of postoperative pain control. Objectives: To determine an evidence-based approach for pain management in patients on BOAT in the perioperative setting, particularly whether BOAT should be continued or interrupted with or without bridging to another mu opioid agonist and to identify benefits and harms of either perioperative strategy. Study Design: Systematic literature review with qualitative data synthesis. Setting: Hospital, perioperative. Methods: The study protocol was registered on PROSPERO (Registration number 9030276355). Medline via OVID, EMBASE, CINAHL, and the Cochrane CENTRAL register of trials were searched for prospective or retrospective observational or controlled studies, case series, and case reports that described perioperative or acute pain care for patients on BOAT. References of narrative and systematic reviews addressing acute pain management in patients on BOAT and references of included articles were hand-searched to identify additional original articles for inclusion. The full text of publications were reviewed for final inclusion, and data were extracted using a standardized data extraction form. Results were summarized qualitatively. Primary outcomes were postoperative pain intensity and total opioid use and identification of benefits and harms of perioperative strategies. Results: Eighteen publications presenting data on the perioperative management of patients on BOAT were identified: 10 case reports, 5 case series, and 3 retrospective cohort studies. Eleven articles reported continuation of BOAT, 2 concerned bridging BOAT, and 4 articles described stopping BOAT without planned bridging. In one retrospective cohort study, BOAT was continued in half and interrupted in half of patients. Patients on BOAT may have pain that is more difficult to treat than those who are not on OAT. There is no clear evidence that one particular strategy provides superior postoperative pain control, but interruption of BOAT may result in harm, including failure to return to baseline BOAT doses, continuing non-BOAT opioid use, or relapse of opioid use disorder. Limitations: There were a limited number of articles relevant to the study question consisting of case reports and retrospective observational studies. Some omitted relevant details. No prospective studies were found. Conclusions: There is no clear benefit to bridging or stopping BOAT but failure to restart it may pose concerns for relapse. We recommend continuing BOAT in the perioperative period when possible and incorporating an interdisciplinary approach with multimodal analgesia. Key words: Opioid use disorder, opiate substitution treatment, buprenorphine, buprenorphinenaloxone, buprenorphine opioid agonist therapy, postoperative pain, acute pain, multimodal analgesia

Effectiveness of opiate substitution treatment in reducing HIV risk behaviors among African, Caribbean and black people: a systematic review protocol.

This systematic review aims to identify, appraise and synthesize the best available evidence on the effectiveness of methadone maintenance treatment or buprenorphine therapy in reducing sex- and drug-related HIV risk among African, Caribbean and black people. Substance use plays an important role in HIV transmission and acquisition among African, Caribbean and black people by increasing risky sexual behavior and the risk of HIV acquisition. Pharmacological interventions targeting drug use, injection-related risk behaviors and HIV risk behaviors have been found to be effective measures in minimizing HIV transmission attributable to opioid addiction. This review will consider studies that have evaluated the impact of methadone maintenance treatment or buprenorphine therapy on sex- and drug-related HIV risks. All interventions conducted in any clinical setting will be included. Multiple sources of published and gray literature will be searched, including Embase, MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials, OpenGrey, Grey Matters, New York Academy of Medicine's Grey Literature Report, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform. All titles and abstracts identified will be reviewed independently by two reviewers and potentially relevant studies will be retrieved in full. Papers selected for retrieval will be assessed by two independent reviewers for methodological validity. Data will be extracted from papers and will include details about the interventions, populations, study methods and outcomes. PROSPERO CRD42019126954.

Combined treatment and prevention strategies for hepatitis C virus elimination in the prisons in New South Wales: a modelling study.

Australia is currently on track to meet the World Health Organization (WHO) global hepatitis C virus (HCV) elimination goals by 2030, reflecting universal subsidized access to testing and direct-acting antiviral (DAA) treatment. In New South Wales, DAA treatment in prisons has scaled-up substantially, with 1000 prisoners treated in 2017. However, HCV prevalence and incidence in this setting is high, which could undermine elimination efforts. This study aimed to test the preventative effects of DAA treatment scale-up, opiate substitution treatment (OST) and needle and syringe programme (NSP) strategies for prisons. Modelling study using an individual-based mathematical model of a typical prison setting. The model was calibrated against Australian epidemiological data sets and executed in-prison events for each individual daily, including movements between prisons, changes in risk behaviour and uptake of prevention measures such as OST and NSP, as well as DAA treatment. Scenarios were projected from 2018 to 2030. New South Wales prisons. New South Wales prisoners. Variables including prison populations, prevalence and incidence rate were calculated. Prisoners were described by demographic characteristics, HCV infection history, risk behaviours and accessing treatment and prevention measures in varied security settings. Increasing the number of prisoners treated for HCV to 2000 annually was projected to reduce the HCV incidence rate to 8.69 [95% confidence interval (CI) = 8.17, 9.20] per 100 person-years (100 p.y.). Combined treatment and prevention strategies were necessary to reduce the projected incidence rate to 5.22 (95% CI = 5.13, 5.52) per 100 p.y. Considering the expected reductions in the prevalence of chronic HCV in the Australian community, incidence rate was predicted to drop to 0.93 (95% CI = 0.92, 0.98) per 100 p.y. by 2030. This model, which simulates prison scenarios to inform Australia's national hepatitis C virus elimination efforts, suggests that continued direct-acting antiviral (coverage in the community combined with a moderate increase of direct-acting antiviral treatments in prisons, and introduction of improved harm reduction via opiate substitution treatment and/or needle and syringe programmes, makes hepatitis C virus elimination feasible in Australian prisons.

Adjunctive memantine for opioid use disorder treatment: A systematic review

Memantine is commonly used for the treatment of moderate-to-severe Alzheimer's disease. Due to its antagonism of the N-methyl-d-aspartate (NMDA) receptor, which has been shown to block rewarding and reinforcing effects of morphine, memantine has been investigated for potential utilization in opioid use disorder (OUD). The objective of this systematic review is to assess the evidence available to determine the safety and efficacy of memantine as treatment for OUD. Pubmed (1946-August 2019) and Embase (1947-August 2019) were queried using the following search terms: opioid-related disorders, opioids, substance withdrawal syndrome, withdrawal syndrome, opiate addiction, opiate, opiate dependence, opiate substitution treatment, managed opioid withdrawal, or drug withdrawal and memantine. After assessing studies appropriate for the objective, one single-blind and five double-blind, placebo-controlled trials were included. Of the included studies, four demonstrated beneficial effects of memantine either as monotherapy or adjunct to methadone or buprenorphine on reducing opioid cravings and methadone dose, increasing retention rates, and improving cognitive performance in patients with OUD. Two studies did not show benefit on patient retention rates with memantine adjunct to naltrexone. Study durations ranged from 3 to 13 weeks, and memantine dosing ranged from 5 to 60 mg/day. Memantine was well tolerated with similar rates of adverse effects between treatment groups. Based on the reviewed literature, memantine appears most beneficial as an adjunctive treatment for OUD when combined with methadone or buprenorphine, but not naltrexone. Larger studies with longer periods of treatment and follow-up are needed to support the use of memantine in the management of OUD.

The impact of opiate substitution treatment on mortality risk in drug addicts: a natural experiment study

Background Opiate substitution treatment (OST) is the main treatment for people addicted to heroin and other opioid drugs. However, there is limited information on how the delivery of this treatment affects mortality risk. Objectives To investigate the associations of mortality risk with periods during treatment and following cessation of treatment, medication type, co-prescription of other medication and dosing regimens during titration and detoxification. The trends with time of prescribed medication, dose and treatment duration were also explored. Design Prospective longitudinal observational study. Setting UK primary care between 1998 and 2014. Participants A total of 12,780 patients receiving methadone, buprenorphine or dihydrocodeine. Main outcome measures All-cause mortality relating to 657 deaths and drug-related poisoning relating to 113 deaths. Data sources Clinical Practice Research Datalink with linked information on cause of death from the Office for National Statistics. Results For both outcomes, the lowest mortality risk was observed after 4 weeks of treatment and the highest risk was observed in the first 4 weeks following cessation of treatment [e.g. for drug-related poisoning, incidence rate ratio (IRR) 8.15, 95% confidence interval (CI) 5.45 to 12.19]. There was evidence that the treatment period risks varied with OST medication. The largest difference in risk was for the first 4 weeks of treatment for both outcomes, with patients on buprenorphine being at lower risk than those on methadone (e.g. for drug-related poisoning, IRR 0.08, 95% CI 0.01 to 0.48). The co-prescription of benzodiazepines was associated with linearly increasing the risk of drug-related deaths by dose (IRR 2.02, 95% CI 1.66 to 2.47), whereas z-drugs (zolpidem, zopiclone and zaleplon) were associated with increased risk of both all-cause (IRR 1.83, 95% CI 1.59 to 2.12) and drug-related (IRR 3.31, 95% CI 2.45 to 4.47) mortality. There was weak evidence that higher initial and final doses were associated with increased all-cause mortality risk. In the first 4 weeks of treatment, the risk increased by 4% for each 5-mg increment in methadone dose (1-mg increase in buprenorphine) (hazard ratio 1.04, 95% CI 1.00 to 1.09). In the first 4 weeks after treatment ceased, a similar increment in final dose increased the risk by 3% (hazard ratio 1.03, 95% CI 0.99 to 1.07). There were too few deaths to evaluate the effects on drug-related poisoning. The proportion of OST patients receiving buprenorphine increased between 1998 and 2006. Median treatment duration was consistently shorter for buprenorphine than for methadone for each year studied (overall median duration of 48 and 106 days, respectively). Limitations As this was an observational study, the possibility remains of bias from unmeasured factors, which covariate adjustment and inverse probability weighting can eliminate only partially. Conclusions Using buprenorphine as an alternative to methadone may not reduce mortality overall despite resulting in lower IRRs from shorter treatment duration. Clinical guidance needs to consider strengthening warnings about the co-prescription of a range of drugs for OST patients. Future work Our analyses need to be replicated using other clinical data sets in the UK and in other countries. New interventions and trials are required to investigate improving the retention of OST patients in primary care. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Satisfaction with Life among Recipients of Opiate Substitution Treatment

Satisfaction with Life among Recipients of Opiate Substitution Treatment

Characterising opportunity to use heroin reveals new avenues for intervention: context, outcomes, and latency to initiation

Preceding initiation, opportunity to use heroin is the earliest necessary condition for heroin-related outcomes to occur. This study aimed to characterise first heroin use opportunity (prior to initiation) and to identify heroin-related outcomes associated with earlier age at first opportunity. Structured interviews were conducted with 93 opiate substitution treatment clients in UK drug and alcohol treatment clinics. The majority of participants (64.8%) reported initiating heroin use on the same day as being first presented with the opportunity to use heroin. Of those who reported early age at opportunity to use heroin, 77.4% reported this came from friends/partner/family compared with 59.3% of those who reported later opportunities. After adjustment, overdose was found to be more than twice as likely amongst those who reported first opportunity to use heroin at age 17 or under (AOR 2.82 95% CI 1.57–5.05). Findings indicate the early drug use environment is linked to later risk of overdose. Greater consideration of context surrounding heroin use opportunity may indicate mechanisms to disrupt or prevent initiation of heroin use and later drug-related harms. Given short latency to initiation, focus should be placed on preventing initiation of heroin use through injecting.

PMH20 - BUDGETARY IMPACT OF TREATING OPIOID ADDICTION IN THE DANISH MUNICIPAL SETTING

In Denmark, municipalities are responsible for providing opiate substitution treatment. There are around 13,000 injecting drug users in Denmark, although only 7,050 people received Opioid Agonist Therapy (OAT) in 2015. A budget impact model was created that considered both the costs to the municipalities as well as to the criminal justice system to estimate the budgetary impact of treating opioid addiction as well as having 50% of users outside the treatment system. Costs and outcomes were modelled over a one-year timeframe, in a population calculated based on the average size of a Danish municipality (n=55,000) and the prevalence of intravenous drug use in Denmark (0,23%). Direct treatment were based on published tariffs by third sector providers in the form of a daily rate charged to the municipality. Wider societal costs (additional healthcare, mental health, and criminal justice) were based on published analyses of Danish registry data. clinical parameters used in the model were: i. retention in treatment and ii. Proportion of urine samples which are free from illicit opioids (i.e. no ‘use on top’) from published clinical trial data. Total direct treatment costs to an average municipality were 2.19 mDKK for one year. Total healthcare costs were 5.5 mDKK (1.24 mDKK generated by patients in treatment). Costs associated with court decisions and imprisonment were 4.35 mDKK (1.66 mDKK from patients who had started treatment). If treatment access were increased by 10%, an average municipality, and its associated health care and criminal justice systems, would save approximately -219 kDKK, 146 kDKK and 150 kDKK respectively. Our model shows that savings generated by from addiction treatment far outweigh the cost of treatment itself. New treatment approaches, that address known treatment barriers, could generate substantial further savings. Further research is warranted to identify additional direct and indirect costs and savings in Denmark.

Incidence and spontaneous clearance of hepatitis C virus (HCV) in people who inject drugs at the Stockholm Needle Exchange-Importance for HCV elimination.

The major transmission route for hepatitis C virus (HCV) is through sharing of unsterile injection equipment among people who inject drugs (PWID). The WHO strategy for HCV elimination by 2030 proposes increased efforts to treat PWID populations that drive the HCV epidemic. Among participants in the Stockholm needle exchange programme (NEP), the HCV prevalence is 60%. We aimed to study HCV incidence, spontaneous HCV clearance rate, and predictors associated with new HCV infections and reinfections in NEP participants. All 2320 patients enrolled in the programme between 8 April 2013 and 23 September 2016 were tested for HCV at baseline, and responded to a questionnaire regarding sociodemographic data and injection risk behaviour. Tests for HCV were repeated at an interval of 3-6months. The anti-HCV prevalence in the NEP participants at baseline was 77%, and the prevalence of HCV RNA was 57%. 24% of the anti-HCV positive were HCV RNA negative with a spontaneously cleared HCV infection. The overall HCV incidence rate was 22/100 PY. The HCV incidence rate in the HCV naive group was 26/100 PY, and in the spontaneously cleared group 19/100. Although there were no significant differences in becoming HCV infected between the two groups (31% vs 29%), the rate of spontaneous HCV clearance was significantly lower in the HCV naive group, 20% vs 44%, (P<0.05). A high HCV incidence rate was noted among the PWID indicating that treatment needs to be scaled up in conjunction with harm reduction measures to achieve HCV elimination goals set by WHO. This includes high coverage needle exchange programmes and effective addiction treatment for substance users, including opiate substitution treatment.

Positive reinforcement targeting abstinence in substance misuse (PRAISe): Study protocol for a Cluster RCT & process evaluation of contingency management

There are approximately 256,000 heroin and other opiate users in England of whom 155,000 are in treatment for heroin (or opiate) addiction. The majority of people in treatment receive opiate substitution treatment (OST) (methadone and buprenorphine). However, OST suffers from high attrition and persistent heroin use even whilst in treatment. Contingency management (CM) is a psychological intervention based on the principles of operant conditioning. It is delivered as an adjunct to existing evidence based treatments to amplify patient benefit and involves the systematic application of positive reinforcement (financial or material incentives) to promote behaviours consistent with treatment goals. With an international evidence base for CM, NICE recommended that CM be implemented in UK drug treatment settings alongside OST to target attendance and the reduction of illicit drug use. While there was a growing evidence base for CM, there had been no examination of its delivery in UK NHS addiction services. The PRAISe trial evaluates the feasibility, acceptability, clinical and cost effectiveness of CM in UK addiction services. It is a cluster randomised controlled effectiveness trial of CM (praise and financial incentives) targeted at either abstinence from opiates or attendance at treatment sessions versus no CM among individuals receiving OST. The trial includes an economic evaluation which explores the relative costs and cost effectiveness of the two CM intervention strategies compared to TAU and an embedded process evaluation to identify contextual factors and causal mechanisms associated with variations in outcome. This study will inform UK drug treatment policy and practice.Trial registration ISRCTN 01591254.