Opioid Substitution Treatment Programs Research Articles

"It can save your life, that's all I know," barriers and facilitators for engagement in take-home naloxone for people receiving opioid substitution treatment in regional Australia: An explorative study.

Engagement in take-home naloxone (THN) programs by people receiving opioid substitution treatment (OST) in Australia is low despite methadone being a significant contributor to opioid overdose deaths. Our aim was to explore barriers and facilitators for OST patients to engage in THN. We used a descriptive qualitative design with thematic analysis to gain insight into naloxone uptake by people engaged in an OST program in regional Australia. Eleven participants were interviewed; eight had previously engaged with THN. Barriers to THN included limited knowledge and understanding, lack of information, and not personally experiencing an overdose. Facilitators included having a traumatic experience of overdose, knowledge and understanding of THN and overdose, empowerment in carrying naloxone, and expanding THN programs. Support for the expansion of THN programs is desired among participants, and widespread peer distribution is understood to be the key to success. This study found that prior traumatic experience of overdose facilitates acceptance of THN, and being offered THN was the most important factor in engagement. Less clear is how to engage people who lack a traumatic overdose experience.

Linkage to hepatitis C treatment in two opioid substitution treatment units in Gothenburg, Sweden: a retrospective cohort study

BackgroundChronic infection with the hepatitis C virus (HCV) is common in people with former or current injection drug use. Among the patients in the opioid substitution treatment (OST) program in Gothenburg, Sweden, more than 50% had been infected with HCV. However, many patients did not have any follow-up for their infection and the linkage to treatment could be improved.MethodsA model of care for HCV was introduced at an OST unit in Gothenburg, Sweden, in 2017. The aim was to increase testing and linkage to HCV treatment. A nurse and a medical doctor, both specialized in infectious diseases, performed on-site testing at the OST unit with transient liver elastography (Fibroscan) to evaluate the fibrosis stage and initiated HCV treatment. This study retrospectively reviewed the patients’ medical records to assess information regarding participation in the model of care, hepatitis C status, linkage to treatment and treatment outcome.ResultsAmong the 225 patients enrolled in OST at baseline, 181 were still in the OST program at the end of study (December 31st, 2018). In total, 29 patients, most of whom did not attend the Clinic of Infectious Diseases, were referred to the model of care. By the end of study, 17 patients (100% of those treated) reached sustained virologic response. In parallel, an additional 19 patients got treatment directly at the Clinic of Infectious Diseases.ConclusionIntegrating HCV screening and examination in an OST unit successfully linked patients to treatment. However, not all patients received treatment. To reach the goal of eliminating HCV, different models of care are needed.

Direct-acting antiviral treatment for chronic hepatitis C in people who use drugs in a real-world setting.

BackgroundDirect-acting antivirals (DAAs) offer high cure rates in people who inject drugs (PWID) with hepatitis C virus (HCV) infection. There are concerns regarding lower response rates among PWID in real life. We evaluated the outcome of DAA therapy in PWID in a real-world setting and the factors that affect it.MethodsWe performed a retrospective analysis of 174 PWID with chronic hepatitis C who started DAAs in a Greek liver clinic in collaboration with an addiction program. Patients who did not return for reassessment were considered as lost to follow up (LTFU). A logistic regression model was used to assess factors associated with a sustained virological response 12 weeks after treatment completion (SVR12) and LTFU.ResultsPatients’ mean age was 48±9.2 years and 91/174 (52.3%) were attending opioid substitution treatment programs. Overall, 144/174 (82.8%) patients completed therapy and presented for SVR12 testing, 8/174 (4.6%) did not complete treatment and 22/174 (12.6%) were LTFU. Overall SVR12 was 79.9% (139/174). For those with an available SVR12 test the response rate reached 96.5% (139/144). Regression analysis did not indicate any significant association between patient characteristics and SVR12. Age <45 years and genotype 3 were independent predictors of LTFU. Parallel use was found to have a trend towards LTFU.ConclusionsHCV treatment by hepatologists and addiction specialists is feasible, effective and safe in a real-world setting. However, as 12% of patients appear to be LTFU, more emphasis should be placed on interventions guaranteeing follow up for SVR testing and general care.

Patient Dropout from Opioid Substitution Treatment

Opioid Substitution Treatment (OST) is an established treatment for opioid dependence. In New Zealand, OST programs are regulated by the Ministry of Health (2014) and Methadone and Buprenorphine/Naloxone (Suboxone) are the primary medications. Retention on OST is a key indicator for stabilisation of patients with opioid dependence. The purpose of the present research was to study dropout rates and identify factors associated with the dropout of patients from OST at the Community Alcohol and Drug Service (CADS), Hamilton, from 1st January 2013 to 30th April 2014. A retrospective clinical audit of patients on OST was conducted. There were 150 patients on OST in Hamilton under the CADS team during the period of study. Nine patients dropped out during the study period. Sixty-four patients were randomly selected from the remaining 141 patients who remained on treatment as a comparison group and for the study sample to be approximately half of the overall population of 150 patients. File review was conducted and potential predictors of dropout were identified. Thirty-five independent variables were selected and dropout was the dependent variable. The statistical programme SPSS22 was used to analyse the data. Fisher’s exact test was used and four variables were identified as being associated with dropout: history of intravenous drug use; (Fisher’s exact p = 0.05); history of lifetime imprisonment (Fisher’s exact p =0.05); other medications prescribed, (Fisher’s exact p = 0.04); and opioid type prescribed during the study, i.e. methadone or Suboxone. Patients on Suboxone dropped out more than those on methadone, (Fisher’s exact p = 0.00). The overall dropout rate was 6%, which was less than the rates of 15-85% found in previous studies. The limitations of the study were that it was retrospective and the number of dropouts was small. Furthermore, only patient factors associated with dropout were included in the study and service factors were not included.

Comparative study between prison- and community-based treatment satisfaction for opioid use disorder in Lebanon.

Opioid substitution treatment (OST), such as Buprenorphine, has become a well-established evidence-based approach for the treatment of inmates with opioid use disorder (OUD) in most of the developed world. However, its application in Lebanon remains mainly as a community-based intervention. The purpose of this paper is to highlight the need of its implementation within the Lebanese correctional system. The work is a pilot cross-sectional study that compares two groups: 30 male adult prisoners with OUD convictions receiving symptomatic treatment and 30 male adult community patients with OUD receiving Buprenorphine. The objective was to measure the difference in the patients' general perception and satisfaction of the treatments available. OUD was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria and the level of satisfaction was measured by "Treatment Perceptions Questionnaire (TPQ)." The prison group reported significantly lower satisfaction when compared to the community group (total TPQ mean scores: M=34.73, SD =4.12 and M=16.67, SD =4.78, respectively, with t (56.76) =15.68, p=0.000). Furthermore, age, marital status, education level and elapsed time in treatment had no significant interactions with the total TPQ score. The major principles of the ethics of care and evidence-based safe practices will be proposed for the introduction of Buprenorphine to Lebanese prisons. This work provides an opportunity for the expansion of the Lebanese OST program and consequently other countries in the region could benefit from this experience.

Factors associated with health-related quality of life in a large national sample of patients receiving opioid substitution treatment in Germany: A cross-sectional study

BackgroundKnowledge of health-related quality of life (HRQOL) of patients receiving opioid substitution treatment (OST) is limited and fragmented. The present study examines the HRQOL of a large national sample of OST patients in Germany and sociodemographic and clinical correlates.MethodsCross-sectional data on the HRQOL of 2176 OST patients was compared with German general population norms. Patients were recruited from 63 OST practices across Germany. To identify correlates of HRQOL, as measured with the SF-12, we performed bi- and multivariate analyses with sociodemographic and clinical variables, including patient- and clinician-reported outcomes on physical and mental health.ResultsPatients’ HRQOL was significantly poorer than in the general population, especially their mental HRQOL. Factors associated with lower physical HRQOL were older age, longer duration of opioid dependence, hepatitis C virus infection, and HIV infection. Benzodiazepine use was associated with lower mental HRQOL, and amphetamine use with higher physical HRQOL, compared to non-use of these substances. For both mental and physical HRQOL, the factor with the strongest positive association was employment and the factors with the strongest negative associations were physical and mental health symptom severity, psychiatric diagnosis, and psychopharmacological medication.ConclusionsCompared to the general population, we found substantially lower HRQOL in OST patients, especially in their mental HRQOL. OST programs can benefit from further improvement, particularly with regard to mental health services, in order to better serve their patients’ needs. Clinicians may consider the use of patient-reported outcome measures to identify patients’ subjective physical and psychological needs. Further research is needed to determine if employment is a cause or consequence of improved HRQOL.Trial registrationClinicalTrials.gov: NCT02395198, retrospectively registered 16/03/2015

A cross-national analysis of the association between years of implementation of opioid substitution treatments and drug-related deaths in Europe from 1995 to 2013.

Data at the individual-level provide evidence that opioid substitution treatment (OST) programs protect against mortality for opioid dependent populations. Prior research has not examined the merits of national implementation of opioid substitution programs for reducing mortality at the country-level. This study elucidates longitudinal associations between country-level implementation of opioid substitution treatment programs on mortality rates of drug related deaths (DRD) from 1995 to 2013 in 30 European nations. Cases of DRD were measured using National Definitions for each country from official sources of data. Preliminary analysis of dispersion of cases of DRD using means and variances justified use of the negative binomial regression model with a population offset. Year and country-level fixed effects negative binomial regression models investigated the association between years of implementation of methadone maintenance therapy (MMT), OST in prison, and high dose buprenorphine treatment (HDBT) implementation and mortality rates from drug related deaths after adjusting for unemployment rates, heroin seizures and per capita expenditures on health. Beta coefficients were converted to Incidence Rate Ratios (IRR) and standard errors bootstrapped using non-parametric methods to adjust for bias (SDbs). The mean mortality rate of DRD was 1.81 from 1995 to 2013. In adjusted models, each additional year of MMT (IRR=.61, SD=.04, p<.001; SDbs=.08, p<.001), prison OST (IRR=.90, SD=.01, p<.001; SDbs=.02, p<.001), and HDBT (IRR=.09, SD=.02, p<.001; SDbs=.02, p<.01) was significantly associated with lower rates of DRDs after adjusting for country and year fixed effects. Implementation of OST programs in the general population and in prison settings may have protected against mortality from drug use at the country-level in Europe from 1995 to 2013.

Collaborative pharmacist prescribing within the opioid substitution treatment program in South Australia: Patient and pharmacist views.

There is a shortage of medical practitioners able and/or willing to prescribe OST. This qualitative study investigated an alternative model of care where by pharmacists co-prescribed with an accredited doctor for OST patients. Semi-structured face-to-face interviews with 14 OST patients were conducted at a state government drug and alcohol clinic about their views on pharmacist prescribing OST for them. In the second phase of the study, three focus group interviews with 18 pharmacists were conducted to explore their views on a policy proposal which would allow them to co-prescribe for OST patients. Transcripts were analysed using the five-step framework approach with the support of the software package NVivo. In general, both patients and pharmacists supported co-prescribing. Improved patient continuity of care and convenience were regarded as the main benefits of having a pharmacist co-prescriber. Continued doctor involvement with patient was supported under a co-prescribing model, but not all pharmacists may desire or be suitable to fulfil the role of a co-prescriber. Changes to health care relationships and provisions to ensure adequate support of pharmacist co-prescribers were important consideration factors in moving forward with this proposed new model of care.

Commentary on Mounteney et al. (2016): What drug monitoring systems need in 2015.

Keywords: Epidemiology; Europe; illicit drug monitoring; new psychoactive substances; trends; prevalence; harms

Opioid substitution treatment in Ukraine: review of the peer-reviewed literature.

Objective: To review published peer-reviewed papers regarding opioid substitution treatment (OST) in Ukraine and to describe the research agenda that has been in parallel with the development of opioid substitution treatment program in Ukraine. Further, to understand research gaps and future directions of scientific efforts concerning the OST implementation in Ukraine. Methods: Literature search using standardized research terms of PubMed, Science Direct, and Google Scholar was supplemented with consultations with relevant in-country researchers to identify any additional publications that were not found through on-line search. Original literature search has been conducted during August, 2013, two refreshment searches were conducted during October, 2013 and February, 2014. The literature search and eligible papers selection were conducted applying PRISMA guidelines. Results: Eight papers were published in peer reviewed journals specifically scrutinizing the features of the OST program or patients’ outcomes in Ukraine. Demonstrating the feasibility of buprenorphine and methadone maintenance treatment in Ukraine was core aim of majority of the papers. Few discussed TB and HIV treatment outcomes and health-related quality of life (QoL). Program description and cost-effectiveness of OST in Ukraine were the topic of two other papers. Decreased injection risk behavior and high retention rates were reported for Ukrainian methadone and buprenorphine patients. Other treatment indicators (TB treatment outcomes, HIV initiation, and services utilizations) have been higher among those on substitution treatment compared to those who were not. QoL besides health-related indicators have been understudied among Ukrainian OST patients. Conclusions: Published papers provide evidence to conclude that OST in Ukraine is effective in terms of patients’ retention on treatment and decreasing self-reported HIV-related risk behaviors and also provides a background for wide scale-up of the program. Further research is needed to understand how the program could be improved to better meet the needs of the opioid dependent drug users accounting for Ukrainian context.

Design and baseline findings of a large-scale rapid response to an HIV outbreak in people who inject drugs in Athens, Greece: the ARISTOTLE programme.

To (i) describe an intervention implemented in response to the HIV-1 outbreak among people who inject drugs (PWIDs) in Greece (ARISTOTLE programme), (ii) assess its success in identifying and testing this population and (iii) describe socio-demographic characteristics, risk behaviours and access to treatment/prevention, estimate HIV prevalence and identify risk factors, as assessed at the first participation of PWIDs. A 'seek, test, treat, retain' intervention employing five rounds of respondent-driven sampling. Athens, Greece (2012-13). A total of 3320 individuals who had injected drugs in the past 12 months. ARISTOTLE is an intervention that involves reaching out to high-risk, hard-to-reach PWIDs ('seek'), engaging them in HIV testing and providing information and materials to prevent HIV ('test') and initiating and maintaining anti-retroviral and opioid substitution treatment for those testing positive ('treat' and 'retain'). Blood samples were collected for HIV testing and personal interviews were conducted. ARISTOTLE recruited 3320 PWIDs during the course of 13.5 months. More than half (54%) participated in multiple rounds, resulting in 7113 visits. HIV prevalence was 15.1%. At their first contact with the programme, 12.5% were on opioid substitution treatment programmes and the median number of free syringes they had received in the preceding month was 0. In the multivariable analysis, apart from injection-related variables, homelessness was a risk factor for HIV infection in male PWIDs [odds ratio (OR) yes versus no = 1.89, 95% confidence interval (CI) = 1.41, 2.52] while, in female PWIDS, the number of sexual partners (OR for > 5 versus one partner in the past year = 4.12, 95% CI = 1.93, 8.77) and history of imprisonment (OR yes versus no = 2.76, 95% CI = 1.43, 5.31) were associated with HIV. In Athens, Greece, the ARISTOTLE intervention for identifying HIV-positive people among people who inject drugs (PWID) facilitated rapid identification of a hidden population experiencing an outbreak and provided HIV testing, counselling and linkage to care. According to ARISTOTLE data, the 2011 HIV outbreak in Athens resulted in 15% HIV infection among PWID. Risk factors for HIV among PWID included homelessness in men and history of imprisonment and number of sexual partners in women.

Diversion of Methadone and Buprenorphine from Opioid Substitution Treatment: The Importance of Patients’ Attitudes and Norms

AimsMethadone and buprenorphine diversion by patients in opioid substitution treatment (OST) is a poorly understood phenomenon. We study the norms and attitudes on diversion among OST patients, including the role these norms and attitudes play as diversion risk factors. We also study whether perceived quality of care, social bonds to treatment staff, and deterrence can be associated with diversion. MethodsStructured interviews were conducted with 411 patients from eleven OST programs. In total, 280 interviews were done on site by the researchers, while 131 interviews were conducted through peer interviewing by specially trained patients. The data was analyzed through frequency- and averages-calculations, cross-tabulations, and logistic regression analysis. ResultsMost patients consider diversion as mostly positive (83.7%), morally right (76.8%), and without any significant risk of detection (66.9%). Individual differences in norms and risk perceptions may play a role in explaining variations in diversion; patients who consider it right to share medication with friends report higher treatment-episode diversion than other patients (OR 1.455, p=0.016). Patients who perceive control measures as effective report lower diversion than other patients (OR=0.655, p=0.013). Furthermore, data indicate that patients who are satisfied with the care and service are less prone to engage in diversion. Social bonds with treatment staff seem to be less importance. ConclusionsThe norm system described by patients resemble Bourgois’ ‘moral economy of sharing’ concept—not sharing drugs with friends in withdrawal is considered unethical. Efforts to decrease diversion may focus on lifestyle-changing interventions, and reducing black market demand for illicit medications by expanding access to treatment.

Past-year gambling behaviour among patients receiving opioid substitution treatment.

BackgroundSubstance abuse and gambling problems are associated, however, studies on gambling problems among opioid substitution treatment (OST) patients are scarce. The aims of this study are to explore the association of gender, age, treatment medication and treatment program with gambling behaviour, including gambling participation and gambling problems, among OST patients.FindingsAll OST patients (n = 244) in three Finnish outpatient clinics were recruited in March - April 2014. The response rate was 64.3%. OST programs included two choices of orientation (rehabilitative/harm reduction) and two choices for treatment medication (methadone/buprenorphine-naloxone). Of 144 respondents, 70.1% had gambled during the past year and 12.5% were identified as potential past-year problem gamblers. Gambling was statistically significant more commonly among males (79.8%) compared with females (53.7%). Similarly patients in the rehabilitative program gambled (75.9%) more than those in the harm reduction program (50.0%). Gender, age, treatment medication or treatment program was not associated with past-year gambling problems.ConclusionsGambling participation of the OST patients seemed to be somewhat similar compared with the Finnish general population, but gambling problems were more common among OST patients. Gender and age may not be very strong indicators of risk while screening problem gamblers among OST patients. Institution of a problem gambling screening program is recommended, and additional intervention for gambling problems should be implemented for that need as a part of OST.

Diversion of Methadone and Buprenorphine from Opioid Substitution Treatment: Patients who Regularly Sell or Share Their Medication

Diversion—the practice of patients selling or sharing their medication—is a much debated problem of opioid substitution treatment. Regular diversion by patients was studied at 11 opioid substitution treatment programs in the south of Sweden. Using quantitative and qualitative data, it was investigated whether those patients differ from other patients, their motives for and means of diversion, and who the recipients are. Regular diverters are a small, yet heterogeneous group. Continued illicit drug use, however, stands out as a common risk factor. Pecuniary need and a desire to help friends are other important motives. The client base mainly consists of people from the regular diverters’ own drug milieus.

Evaluation of opioid withdrawal after maintenance on extended-release tramadol

s / Drug and Alcohol Dependence 140 (2014) e86–e168 e163 motivational interventionmaybe sufficient for substantially reducing unmotivated, non-treatment seeking individuals use of ecstasy. Financial support: Australian Government Department of Health and Ageing under the National Psychostimulants Initiative. http://dx.doi.org/10.1016/j.drugalcdep.2014.02.458 Opioid substitution treatment enrollment and outcomes in California: 1991–2011 Bohdan Nosyk1,2, E. Evans2, Libo Li2, Darren Urada2, M.J. Milloy1, Evan Wood1, R. Rawson2, Y. Hser2 1 BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada 2 UCLA Integrated Substance Abuse Programs, Los Angeles, CA, United States Aims: To provide a descriptive analysis of the opioid substitution treatment (OST) delivery system, we examine trends in demographic anddrug use characteristics of patients accessingOST in California over the past 20 years. Methods: Statewide administrative datawas obtained from the California Alcohol & Drug Data System (CADDS; 1991–2005) and CaliforniaOutcomeMeasurementSystem(CalOMS;2006–2011)on all patients admitted to publicly funded OST programs from 1991 to 2011. Univariate trends in demographic, drug use characteristics and treatment outcomes were considered. Cochran-Armitage tests were applied to confirm observed trends. Results: The study sample consisted of 240,225 individuals and 689,192 treatment episodes. Individuals had amedian 2 (IQR: 1–5) OST episodes during the study period. The annual number of new OST admissions peaked in 1994 (51,902) and fell to 18,480 in 2011; within these years, detoxification treatment admissions fell from 88.0% to 41.4% (p 20 of the last 30 days, and meeting DSM-IV criteria for current opioid dependence with observed withdrawal. After random assignment to ER tramadol (0, 100 or 300mg bid for 7 days; n=12/group), all groups crossed over to placebo for 6 additional days of monitoring. Four breakthrough withdrawal medications were available. Primary outcomes were: (1) number of breakthrough withdrawal medication doses taken and (2) subject-rated opioid withdrawal. Secondary outcomes included observer-rated withdrawal ratings, physiologic and cognitive measures, and serious adverse events. Results: Amount of breakthrough withdrawal medication differed significantly among groups (p<0.001) over the 6-day placebo-dosing period whereby the 600mg tramadol group requested significantly more rescue doses on days 2–4 (Dunnet p<0.05) versus the placebo-assigned group. Specifically, more acetaminophenwasused in the600mg transfer group thanplacebo ondays2–4 (Dunnetp<0.05). Therewerenostatistically significant increases on subject-rated withdrawal measures. Observer-rated withdrawal scores for the 600mg group increased modestly from days 2–3 and then decreased to values similar to the 200mg and placebo groups. There were no serious adverse events. Conclusions: Abrupt cessation of repeated dosing with ER tramadol 600, but not 200mg, produced opioid withdrawal as evidenced primarily by increased use of rescue medications. Financial support: NIDA R01 DA027068 (MRL), T32 DA007304 and NCRR and NCATS UL1RR033173. http://dx.doi.org/10.1016/j.drugalcdep.2014.02.460

Post-Soviet Central Asia: A summary of the drug situation

BackgroundThe paper aims to provide a snapshot of the drug situation in Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan using the EU methodology of “harmonised indicators of drug epidemiology.” MethodsMost of the data reported here were gathered and analysed within the framework of the EU-funded CADAP project in 2012. Together with members of CADAP national teams, we conducted extraction from the databases of national institutions in the field of (public) health and law enforcement, issued formal requests for the provision of specific information to national governmental authorities, and obtained national grey literature in Russian. In specific cases, we leaned on the expert opinions of the national experts, gathered by means of simple online questionnaires or focus group. In the rather scarce cases where peer-reviewed sources on the specific topics exist, it is used for comparisons and discussion. ResultsAll the post-Soviet Central Asian countries lack information on drug use in the general population. School surveys are relatively well developed in Kazakhstan, and Kyrgyzstan benefited from an international survey project on health in schools organised by private donors in 2009. For Tajikistan and Uzbekistan, the most recent available data on drug use in the school population are from 2006 and as such are of little relevance. Problem drug use is widespread in Central Asia and estimates of its prevalence are available for all four countries. All the post-Soviet Central Asian countries use a rather outdated system of narcological registers as the only source of data on drug users who are treated (and those investigated by the police), which was inherited from Soviet times. The availability of treatment is very low in all the countries reported on here except Kyrgyzstan; opioid substitution treatment (OST) was introduced first in Kyrgyzstan; Kazakhstan and Tajikistan are piloting their OST programmes but the coverage is extremely low, and in Uzbekistan the OST pilot programme has been abolished. HIV and hepatitis C virus (HCV) infections are concentrated in injecting drug users (IDUs) in Central Asia, with the situation in Kazakhstan having stabilised; HIV is on the increase among Kyrgyz IDUs. The sharp decrease in HIV and VHC seroprevalence among IDUs in Uzbekistan and Tajikistan still awaits an explanation. The system for monitoring of fatal drug overdoses needs substantial improvement in all the countries reported on here. Overall mortality studies of drug users registered in the narcological registers were performed in Uzbekistan, Kazakhstan, and Tajikistan; the highest excess mortality among registered drug users was found in Uzbekistan, and in all three countries, it was substantially higher for women than men. The seizures of illegal drugs are by far the highest in Kazakhstan; however, wild-growing cannabis represents 90% of these seizures. Uzbekistan was the country with the highest number of drug arrests. In Kazakhstan, after the decriminalisation of drug use in 2011, the number of reported drug-related offences dropped to below 50% of the figure for the previous year. ConclusionThe drug situation monitoring system in the four post-Soviet countries of Central Asia still needs substantial improvement. However, in its current state it is already able to generate evidence that is useful for the planning of effective national and regional drug policies, which would be of the utmost importance in the forthcoming years of the withdrawal of the International Security Assistance Force from Afghanistan.

Changes in quality of life (WHOQOL-BREF) and addiction severity index (ASI) among participants in opioid substitution treatment (OST) in low and middle income countries: An international systematic review

BackgroundOpioid substitution treatment (OST) can increase quality of life (WHOQOL-BREF) and reduce addiction severity index (ASI) scores among participants over time. OST program participants have noted that improvement in quality of life is one of the most important variables to their reduction in drug use. However, there is little systematic understanding of WHOQOL-BREF and ASI domain changes among OST participants in low and middle-income countries (LMIC). MethodsUtilizing PRISMA guidelines we conducted a systematic literature search to identify OST program studies documenting changes in WHOQOL-BREF or ASI domains for participants in buprenorphine or methadone programs in LMIC. Standardized mean differences for baseline and follow-up domain scores were compared along with relationships between domain scores, OST dosage, and length of follow-up. ResultsThere were 13 OST program studies with 1801 participants from five countries eligible for inclusion in the review. Overall, statistically significant changes were noted in all four WHOQOL-BREF domain and four of the seven ASI domain scores (drug, psychological, legal, and family) documented in studies. Dosage of pharmacologic medication and length of follow-up did not affect changes in domain scores. ConclusionWHOQOL-BREF and ASI domain scoring is a useful tool in measuring overall quality of life and levels of addiction among OST participants. Coupled with measurements of blood-borne infection, drug use, relapse, and overdose, WHOQOL-BREF and ASI represent equally important tools for evaluating the effects of OST over time and should be further developed as integrated tools in the evaluation of participants in LMIC.

Shouting through bullet-proof glass: Some reflections on pharmacotherapy provision in one Australian clinic

The Opioid Substitution Treatment Program in New South Wales and Australia has a serious impact on the day to day lives of many people. The program and those consumers who rely upon it are seen with ambivalence by many in the wider community, and many consumers are discriminated against. It seems, to those of us who are engaged in it, that the system itself is confusing and sometimes arbitrary, and that a range of priorities other than clinical need dominate our experience of treatment. These pressures can manifest for us consumers as a punitive and unresponsive treatment experience that, rather than assisting us to live our lives, actually places barriers in our way and ties us up in knots that will take a long time to unravel.

Participation in opioid substitution treatment reduces the rate of criminal convictions: Evidence from a community study

ObjectivePositive outcomes associated with opioid substitution treatment include reduced illicit opioid use and lower risk of HIV and other blood-borne infections. The effect on the reduction of criminal activity remains unclear. Our aim was to investigate the impact of treatment on criminal activity using conviction register data. MethodThis observational retrospective study included all new patients (N=169) enrolled in an opioid substitution treatment program in the Helsinki University Central Hospital Clinic for Addiction Psychiatry between 2000 and 2005. Psychiatric and psychosocial services were provided as part of the program. Patient treatments were followed up for 18months. Data on criminal convictions were collected for approximately 3years before and after the start of treatment. ResultsMean rates of convictions decreased significantly during treatment. The effects were similar for total convictions, drug convictions, and property crime convictions. Although the numbers of violence and drunk driving convictions were too small to be analysed separately, on a bivariate level there was no indication of reduction in these crime types. Patients with amphetamine co-dependence fared best. Sex, age, other co-dependences or psychiatric diagnoses, negative urine analyses during the treatment, and dropping out from treatment had little impact on the outcomes. ConclusionsOpioid substitution treatment seems to reduce criminal activity effectively. However, more information is needed to determine how treatment influences different types of criminality and which types of patients benefit most.

Combined effects of law enforcement and substitution treatment on heroin mortality

To explore the combined effects of street-level law enforcement and substitution treatment programs on drug-related mortality, taking into account prevalence of heroin use and changes in injecting behaviour. Time trend analysis using annual police reports and case register data of opioid substitution treatments in Switzerland, 1975-2007. Drug-related mortality increased during times of more intense street-level law enforcement [odds ratio (OR) 1.32, 95% confidence interval (95% CI) 1.15-1.51], and the number of drug-related deaths predicted the number of heroin possession offences 2 years later (r = 0.97, P < 0.001). Substitution treatment had a protective effect on drug-related mortality (OR 0.23, 95% CI 0.18-0.30). Surprisingly, the number of drug-related deaths was substantially biased by an oscillation period of 14 years (OR 1.24, 95% CI 1.17-1.32). Our analysis revealed that the amount of police resources allocated to law enforcement was determined rationally, however, on biased grounds and with untoward consequences. Substitution treatment of heroin users reduced drug-related mortality in the long run, but different factors masked its impact for several years. Therefore, the introduction-or the expansion-of opioid substitution treatment programs should not be promoted with the argument of an immediate reduction of drug-related deaths in a country.