Take-home Doses Research Articles

Irma: Florida OTP patients got take‐home methadone doses

Alcoholism & Drug Abuse WeeklyVolume 29, Issue 36 p. 4-5 Articles Irma: Florida OTP patients got take-home methadone doses Alison Knopf, Alison KnopfSearch for more papers by this author Alison Knopf, Alison KnopfSearch for more papers by this author First published: 18 September 2017 https://doi.org/10.1002/adaw.31706Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume29, Issue3618 September 2017Pages 4-5 RelatedInformation

Cognitive function is largely intact in methadone maintenance treatment patients

Objectives: To confirm our previous findings of less cognitive impairments (based on cognitive screening tools) among methadone maintenance treatment (MMT) patients who achieved take-home dose (THD) privileges.Methods: a random sample of 65 Israeli MMT patients were studied using computerised, age and education standardised, cognitive domains (attention, executive function, memory, motor skills), and non-computerised phonetic and semantic verbal fluency.Results: Cognitive scores were within ±1 standard deviation (SD) of average for most domains, including non-verbal IQ, attention and motor skills. Verbal fluency and memory were >1 SD below average (mean = 84; z = –1.1 for both). Females were younger than the males and had poorer motor skills (P = 0.005) but better verbal memory (P < 0.0005). Opiate usage duration correlated with reaction time (P = 0.05) and inversely with verbal memory (P = 0.01). Overall cognitive function was poorest among 25 (38.5%) current drug users, and 6 (9.2%) lifetime schizophrenia patients. Cognitive domains were comparable between THD privileges subgroups.Conclusions: Despite heterogeneity in MMT duration, abuse duration, substance use and psychiatric comorbidity, all performed within ±1 SD of average for age and education in most cognitive domains. Our findings challenge the notion of MMT as being synonymous with compromised cognition and may lead to reduced bias regarding cognitive function of MMT patients.

Methadone "callbacks" within a veterans affairs opioid treatment program: Detecting methadone misuse.

A "callback" requires patients to bring in take-home methadone doses for inspection. An opioid treatment program (OTP) quality-improvement project examined random versus "for-cause" callbacks. Eighty-two random callbacks and 60 for-cause callbacks were conducted among patients enrolled in an OTP (N = 183). Among patients with more take home doses, 6% of random callbacks versus 44% of for-cause callbacks were failed. Among patients with fewer take home doses, 36% of for-cause callbacks were failed. For-cause callbacks are more useful than random ones. For-cause callbacks based on clinical judgment detect methadone misuse. (Am J Addict 2017;26:50-52).

A Comparative Pre-Phase I Study of the Impact of Gel Vehicle Volume on Distal Colon Distribution, User Experience, and Acceptability.

For persons at risk of HIV infection who practice receptive anal intercourse (RAI), topical rectal microbicides represent a promising option for coitally dependent protection. The study compared colorectal distribution and user sensory experiences of two different volumes of rectal gel for suitability as rectal microbicide. Eight HIV-negative men with a history of recent RAI were enrolled into a two-period, sequence-randomized dosing study comparing 3.5 and 10 ml of radiolabeled (1 mCi 99mTc-DTPA) universal placebo, hydroxyethyl cellulose gel. Each participant received two doses in the research unit, one of each volume, separated by a washout period of at least 2 weeks. Each research unit dose was followed by a self-administered take-home dose in the context of preparing for RAI. Safety and gastrointestinal distribution were assessed after the research unit doses, safety, perceptibility, and acceptability, were assessed after take-home doses. There were no adverse effects of Grade 2 or higher and all resolved spontaneously. Both volumes were well tolerated and received high acceptability scores. Perceptibility scores showed meaningful effect size differences ranging from Cohen's d = 0.5 to d = 1.2. The 3.5 and 10 ml gel volumes distributed similarly (p > .2) within the rectosigmoid, ranging from 0.69 to 18.84 cm and 1.21 to 19.01 cm from the anorectal junction, respectively. Both volumes covered the typical gastrointestinal distribution of ejaculate following simulated intercourse based on other studies. Either of these gel volumes could reasonably be pursued for the next phase of development of rectal microbicides.

Methadone-related deaths. A ten year overview

Over the last 10 years we have registered in our district (about 500,000 inhabitants) 36 cases of fatal methadone poisoning, involving both patients on treatment and naive subjects: this is a significant increase of deaths due to methadone use, misuse or abuse compared with previous years.Twenty-four patients (66.7%) were on methadone maintenance programs for heroin detoxification, while 12 (33.3%) were taking the drug without a medical prescription. The average blood concentration of methadone in patients undergoing a maintenance program was 1.06mg/L (0.21–3.37mg/L), against 0.79mg/L (0.2–3.15mg/L) in those taking the non-prescribed drug. Since 111 heroin-related deaths were recorded in our district in the same period, the fact that there appear to be many methadone deaths (about a third of heroin-related deaths) cannot be overlooked. The aim of this work is to understand the possible reasons for such a large number of methadone-related deaths. On this subject, we have noticed that risks associated with methadone intake are often underestimated by clinicians prescribing the drug: sometimes methadone is prescribed without taking into account patient's tolerance to opiates, and a large number of subjects enrolled in methadone maintenance programs in Italy, have also been given take-home doses, thus increasing the risk of abuse and diversion.

Differences in Methylphenidate Abuse Rates Among Methadone Maintenance Treatment Patients in Two Clinics

Methylphenidate, an amphetamine-like prescription medication for attention deficit hyperactivity disorder (ADHD) was suspected as being abused among methadone maintenance treatment (MMT) patients. We tested its presence in the routine urine monitoring of all patients in both Tel Aviv and Las Vegas MMT clinics. Data on demographic and addiction history, ADHD (Wender Utah Rating Scale), cognitive impairment (Mini Mental State Exam), and lifetime DSM-IV-TR psychiatric diagnosis from admission were retrieved, and retention following 6months. None of the 190 patients in Las Vegas tested positive for methylphenidate, while 14.7% (45/306) did in Tel Aviv. Abusers were less educated (p=0.01), had higher ADHD scores (p=0.02), lower cognitive scores (p=0.05), and a higher benzodiazepine (BDZ) abuse rate (p<0.0005), with no difference in age, gender, duration in MMT, cannabis, opiates, and cocaine abuse and infectious disease. Of the methylphenidate abuse 42.2% have take-home methadone dose privileges. Not like opiate use, being methylphenidate positive did not relate to 6-months retention. Compared to Tel Aviv, Las Vegas patients were more educated, with lower BDZ, and cocaine abuse. The greater abuse of methylphenidate among ADHD subjects might indicate their using it as self-medication, raising a possible indication for its prescription for that subgroup of MMT patients. The high rate of methylphenidate abuse in Israel needs future study.

RCT of drug counseling and abstinence contingent buprenorphine in Malaysia

s / Drug and Alcohol Dependence 140 (2014) e169–e251 e199 ysis and reporting were supported by grants R01 AA0016407, R01 AA018352, P20 AA017831 and NIDA T32DA007292. http://dx.doi.org/10.1016/j.drugalcdep.2014.02.553 Review of human abuse potential study methodology for abuse-deterrent formulations Kerri A. Schoedel1, Beatrice Setnik2, Carl L. Roland2, G.C. Pixton2, M. Shram1, Naama Levy-Cooperman1 1 INC Research, Toronto, ON, Canada 2 Pfizer Inc., Cary, NC, United States Aims: Abuse/misuse of prescription drugs is a significant problem. Various novel approaches to mitigate such use incorporate abuseand tamper-deterrent features into higher risk products, e.g., opioids. Such products should be evaluated in humans prior to marketing to determine their abuse potential. Methodological issues with these products differ from those of new chemical entities and specific design considerations are needed. To provide review of methodology for clinical evaluation of ADFs. Methods: ADF approaches may include chemical or physical barriers, prodrugs or agonist/antagonist combinations.Many products aim to deter intranasal (IN) and/or intravenous (IV) use; some products may also deter oral abuse. Abuse potential studiesmust consider the physicochemical and pharmacological nature of the investigational product (IP), and clinical studies assessing the intended/unintended routes of administration (ROA) should be performed when safe or feasible. Subjects should be experienced recreational drug users, and should also have experiencewith tampering and/or the relevant ROA. Single doses of IP and comparator are generally used, as the effects of the drug substance are usually well-understood. Multiple doses of the IP and comparator may be needed for some products, e.g., those providing “overdose protection”. Studies should typically include placebo. One challenge is the manipulation of products, e.g., crushing for IN/lV use. Manipulations and administration must be carefully standardized. In addition, due to obvious (intended) differences in formulations, blindingmay present a challenge andmust be balanced against the need to evaluate the “real-world” nature of the product. A reduced battery of traditional study endpoints may be used, i.e., those most relevant to abuse and class of interest. Finally, standard statistical analysis is used and may incorporate a “responder” analysis. Conclusions: Traditional human abuse potential study design can be applied to the evaluation of ADFs; however, design modifications may be needed. Financial support: INC Research Toronto Inc and Pfizer Inc. http://dx.doi.org/10.1016/j.drugalcdep.2014.02.554 RCT of drug counseling and abstinence contingent buprenorphine in Malaysia Richard S. Schottenfeld1, Marek C. Chawarski1, M. Mazlan2 1 Psychiatry, Yale University Medical School, New Haven, CT, United States 2 Substance Abuse Center Muar, Muar, Malaysia Aims: To evaluate whether the efficacy of office-based buprenorphinemaintenance treatment (BMT) with brief physician management (PM) and weekly medication dispensing in Malaysia is improved by provision of weekly, individual behavioral drug and HIV risk reduction counseling (BDRC), abstinence-contingent provision of take-home doses of buprenorphine (ACB), or the combination of BDRC and ACB. Methods: Opioid-dependent individuals completing BMT induction (N=234) were randomly assigned to 26weeks of BMT+PM, BMT+PM+BDRC, BMT+PM+ACB, or BMT+PM+BDRC+ACB. PM was provided by 2 primary care physicians working in busy private practice clinics. BDRC was provided by specially trained nurses. Primary outcomes were proportions opioid-negative urine tests and proportions meeting criteria for protective transfer for persistent illicit opioid use. Results: Patients were all male; mean (SD) age 38.7 (10.5) years; 95% ethnic Malay; 93% less than high school education; 44% employed full time; 25% married; 38% current ATS use; 9% HIV positive; 70% Hepatitis C positive. There were no significant baseline differences among treatment conditions. Retention averaged 145 (51) days out of 182 of offered active treatment and did not differ significantly among groups. Proportions of opioidnegative tests across randomization cells were 50% for PM only, 57% for PM+BDRC, 62% for PM+ACB, and 75% for PM+BDRC+ACB (p<0.001); differences related to both treatment componentswere also statistically significant (ACB: p<0.002, BDRC: p<0.05). 25 patientsmet criteria for protective transfer: 14 assigned to PMonly, 4 to PM+BDRC, 5 to PM+ACB, and 2 to PM+BDRC+ACB (p<0.002). Conclusions: The study results support the feasibility and the efficacy of providing behavioral counseling (BDRC), simple contingency management using takehome medications to reinforce abstinence (ACB), and the combination of BDRC+ACBduring officebased BMT in busy primary care practices in Malaysia. Financial support: R01 DA014718; K24 DA00445; CMHC/DMHAS/State of Connecticut. http://dx.doi.org/10.1016/j.drugalcdep.2014.02.555 Impulsivity in substance dependence: A meta-analysis Christian G. Schutz, S. Sahoo, M. Krausz Psychiatry, Institute of Mental Health, Vancouver,

Review of human abuse potential study methodology for abuse-deterrent formulations

s / Drug and Alcohol Dependence 140 (2014) e169–e251 e199 ysis and reporting were supported by grants R01 AA0016407, R01 AA018352, P20 AA017831 and NIDA T32DA007292. http://dx.doi.org/10.1016/j.drugalcdep.2014.02.553 Review of human abuse potential study methodology for abuse-deterrent formulations Kerri A. Schoedel1, Beatrice Setnik2, Carl L. Roland2, G.C. Pixton2, M. Shram1, Naama Levy-Cooperman1 1 INC Research, Toronto, ON, Canada 2 Pfizer Inc., Cary, NC, United States Aims: Abuse/misuse of prescription drugs is a significant problem. Various novel approaches to mitigate such use incorporate abuseand tamper-deterrent features into higher risk products, e.g., opioids. Such products should be evaluated in humans prior to marketing to determine their abuse potential. Methodological issues with these products differ from those of new chemical entities and specific design considerations are needed. To provide review of methodology for clinical evaluation of ADFs. Methods: ADF approaches may include chemical or physical barriers, prodrugs or agonist/antagonist combinations.Many products aim to deter intranasal (IN) and/or intravenous (IV) use; some products may also deter oral abuse. Abuse potential studiesmust consider the physicochemical and pharmacological nature of the investigational product (IP), and clinical studies assessing the intended/unintended routes of administration (ROA) should be performed when safe or feasible. Subjects should be experienced recreational drug users, and should also have experiencewith tampering and/or the relevant ROA. Single doses of IP and comparator are generally used, as the effects of the drug substance are usually well-understood. Multiple doses of the IP and comparator may be needed for some products, e.g., those providing “overdose protection”. Studies should typically include placebo. One challenge is the manipulation of products, e.g., crushing for IN/lV use. Manipulations and administration must be carefully standardized. In addition, due to obvious (intended) differences in formulations, blindingmay present a challenge andmust be balanced against the need to evaluate the “real-world” nature of the product. A reduced battery of traditional study endpoints may be used, i.e., those most relevant to abuse and class of interest. Finally, standard statistical analysis is used and may incorporate a “responder” analysis. Conclusions: Traditional human abuse potential study design can be applied to the evaluation of ADFs; however, design modifications may be needed. Financial support: INC Research Toronto Inc and Pfizer Inc. http://dx.doi.org/10.1016/j.drugalcdep.2014.02.554 RCT of drug counseling and abstinence contingent buprenorphine in Malaysia Richard S. Schottenfeld1, Marek C. Chawarski1, M. Mazlan2 1 Psychiatry, Yale University Medical School, New Haven, CT, United States 2 Substance Abuse Center Muar, Muar, Malaysia Aims: To evaluate whether the efficacy of office-based buprenorphinemaintenance treatment (BMT) with brief physician management (PM) and weekly medication dispensing in Malaysia is improved by provision of weekly, individual behavioral drug and HIV risk reduction counseling (BDRC), abstinence-contingent provision of take-home doses of buprenorphine (ACB), or the combination of BDRC and ACB. Methods: Opioid-dependent individuals completing BMT induction (N=234) were randomly assigned to 26weeks of BMT+PM, BMT+PM+BDRC, BMT+PM+ACB, or BMT+PM+BDRC+ACB. PM was provided by 2 primary care physicians working in busy private practice clinics. BDRC was provided by specially trained nurses. Primary outcomes were proportions opioid-negative urine tests and proportions meeting criteria for protective transfer for persistent illicit opioid use. Results: Patients were all male; mean (SD) age 38.7 (10.5) years; 95% ethnic Malay; 93% less than high school education; 44% employed full time; 25% married; 38% current ATS use; 9% HIV positive; 70% Hepatitis C positive. There were no significant baseline differences among treatment conditions. Retention averaged 145 (51) days out of 182 of offered active treatment and did not differ significantly among groups. Proportions of opioidnegative tests across randomization cells were 50% for PM only, 57% for PM+BDRC, 62% for PM+ACB, and 75% for PM+BDRC+ACB (p<0.001); differences related to both treatment componentswere also statistically significant (ACB: p<0.002, BDRC: p<0.05). 25 patientsmet criteria for protective transfer: 14 assigned to PMonly, 4 to PM+BDRC, 5 to PM+ACB, and 2 to PM+BDRC+ACB (p<0.002). Conclusions: The study results support the feasibility and the efficacy of providing behavioral counseling (BDRC), simple contingency management using takehome medications to reinforce abstinence (ACB), and the combination of BDRC+ACBduring officebased BMT in busy primary care practices in Malaysia. Financial support: R01 DA014718; K24 DA00445; CMHC/DMHAS/State of Connecticut. http://dx.doi.org/10.1016/j.drugalcdep.2014.02.555 Impulsivity in substance dependence: A meta-analysis Christian G. Schutz, S. Sahoo, M. Krausz Psychiatry, Institute of Mental Health, Vancouver,

Are 2 Weeks of “Take-Home” Privileges Beneficial for Patients' Long-term Outcome in a Methadone Maintenance Treatment Program?

Patients in Israeli methadone maintenance treatment can achieve a maximum of 2 weeks of take-home dose (13-THD) privileges after at least 2 years since the achievement of 1-week privileges (6-THD). Patients who ever achieved 6-THD were characterized to predict achievement of 13-THD. All patients who ever achieved 6-THD and then achieved 13-THD were studied (December 2010-December 2012). Information on drugs in urine on admission, demographics, and addiction characteristics was retrieved from medical charts. Retention in treatment and duration with THD were calculated and analyzed by Kaplan-Meier and Cox model regression. Fifty-five of the 161 patients who achieved 6-THD also achieved 13-THD. No benzodiazepine abuse on admission (odds ratio [OR] = 2.3, 95% confidence interval [CI]: 1.1-4.7), being Israeli-born (OR = 2.3, 95% CI: 1.1-5.2), and less than 12 years of education (OR = 2.8, 95% CI: 1.1-7.1) predicted the 13-THD achievers. The time to achieve 6-THD was shorter for the 13-THD patients than for the 106 who achieved only 6-THD (1.7 ± 1.5 vs. 2.3 ± 2.0 years, P = 0.07). After losing THD privileges, the 13-THD group showed a worse outcome than the 6-THD group: 1 year after losing 6-THD (n = 92) or 13-THD (n = 27), 3.3% of the former left treatment versus 14.8% of the latter, whereas 83.7% versus 70.4%, respectively, succeeded in regaining any THD and 12.0% versus 14.8%, respectively, failed altogether. Patients who achieved 13-THD were characterized by more rapid progress in rehabilitation, but those who failed and lost 13-THD privileges were at a higher risk to deteriorate further than those who failed after achieving 6-THD.

Treatment Outcome Unaffected by Initiation of Full Weekend Closure of Methadone Maintenance Treatment Clinic

After changing the weekend closure of our methadone maintenance clinic from 1 to 2 days, we compared patients’ retention in treatment, discount payment privileges, take-home doses, and rate of drugs in urine tests during the 6 months before and after the change. No differences were found in the 6-month retention rate (94.6% and 95.4%, respectively), take-home dose privileges (60.9% and 58%, respectively), or the rate of urines positive to all substance abuse. Expanding closure of the clinic for a 2-day weekend had no adverse effect on treatment parameters, suggesting that a methadone maintenance clinic may keep the same hours as other hospital's outpatient clinics.

Achievement of take-home dose privileges is associated with better-perceived sleep and with cognitive status among methadone maintenance treatment patients

Objectives. Methadone maintenance treatment (MMT) patients may achieve up to a 2-week privilege of methadone take-home doses (THD), which is associated with considerable responsibility. MMT patients are characterized as having poor sleep quality and low cognitive states. We studied sleep indices and cognitive status with respect to THD privileges. Methods. A sample of 123 MMT patients stratified by THD groups was studied. Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and the cognitive Clock Drawing Test (CDT) were performed. Results. Thirty-one of 123 patients never had any THD and 92 did (25 had the maximum of 2 weeks). The never THD had history of longer duration of opiate usage and a shorter period in MMT. They had the highest rates of poor sleep (80.6%, PSQI > 5), daily sleepiness (“fall asleep while talking”) (41.9%), and impaired cognitive status (58.1%, CDT < 3), while those who had 2-week privileges had the lowest (56, 8, and 28%, respectively). Logistic regression characterized THD patients as no-benzodiazepine and no-cocaine, short opiate usage duration, low ADHD scores, and no cognitive impairment (CDT = 3) and its interaction with treatment duration. Conclusion. Privileges that reflect patients’ abstinence and rehabilitation were also expanded to be associated with better cognitive states. These finding confirm the THD dispensing performance. Including CDT as part of the decision for dispensing THD may be considered.

Evaluation of Take‐Home Exposure and Risk Associated with the Handling of Clothing Contaminated with Chrysotile Asbestos

The potential for para-occupational (or take-home) exposures from contaminated clothing has been recognized for the past 60 years. To better characterize the take-home asbestos exposure pathway, a study was performed to measure the relationship between airborne chrysotile concentrations in the workplace, the contamination of work clothing, and take-home exposures and risks. The study included air sampling during two activities: (1) contamination of work clothing by airborne chrysotile (i.e., loading the clothing), and (2) handling and shaking out of the clothes. The clothes were contaminated at three different target airborne chrysotile concentrations (0-0.1 fibers per cubic centimeter [f/cc], 1-2 f/cc, and 2-4 f/cc; two events each for 31-43 minutes; six events total). Arithmetic mean concentrations for the three target loading levels were 0.01 f/cc, 1.65 f/cc, and 2.84 f/cc (National Institute of Occupational Health and Safety [NIOSH] 7402). Following the loading events, six matched 30-minute clothes-handling and shake-out events were conducted, each including 15 minutes of active handling (15-minute means; 0.014-0.097 f/cc) and 15 additional minutes of no handling (30-minute means; 0.006-0.063 f/cc). Percentages of personal clothes-handling TWAs relative to clothes-loading TWAs were calculated for event pairs to characterize exposure potential during daily versus weekly clothes-handling activity. Airborne concentrations for the clothes handler were 0.2-1.4% (eight-hour TWA or daily ratio) and 0.03-0.27% (40-hour TWA or weekly ratio) of loading TWAs. Cumulative chrysotile doses for clothes handling at airborne concentrations tested were estimated to be consistent with lifetime cumulative chrysotile doses associated with ambient air exposure (range for take-home or ambient doses: 0.00044-0.105 f/ccyear).

Methadone Dose, Take Home Status, and Hospital Admission Among Methadone Maintenance Patients

Among patients receiving methadone maintenance treatment (MMT) for opioid dependence, receipt of unobserved dosing privileges (take homes) and adequate doses (ie, ≥ 80 mg) are each associated with improved addiction treatment outcomes, but the association with acute care hospitalization is unknown. We studied whether take-home dosing and adequate doses (ie, ≥80 mg) were associated with decreased hospital admission among patients in an MMT. We reviewed daily electronic medical records of patients enrolled in one MMT program to determine receipt of take-home doses, methadone dose 80 mg or more, and hospital admission date. Nonlinear mixed-effects logistic regression models were used to evaluate whether take-home doses or dose 80 mg or more on a given day were associated with hospital admission on the subsequent day. Covariates in adjusted models included age, sex, race/ethnicity, human immunodeficiency virus status, medical illness, mental illness, and polysubstance use at program admission. Subjects (n = 138) had the following characteristics: mean age 43 years; 52% female; 17% human immunodeficiency virus-infected; 32% medical illness; 40% mental illness; and 52% polysubstance use. During a mean follow-up of 20 months, 42 patients (30%) accounted for 80 hospitalizations. Receipt of take homes was associated with significantly lower odds of a hospital admission (adjusted odds ratio [AOR] = 0.26; 95% confidence interval [CI], 0.11-0.62), whereas methadone dose 80 mg or more was not (AOR = 1.01; 95% CI, 0.56-1.83). Among MMT patients, receipt of take homes, but not dose of methadone, was associated with decreased hospital admission. Take-home status may reflect not only patients' improved addiction outcomes but also reduced health care utilization.

Predictive factors for treatment retention in methadone programs in Indonesia

This article presents the results of a 6-month prospective cohort study of methadone maintenance treatment (MMT) in Indonesia. The study aimed to investigate the predictor variables of retention in MMT in Indonesia. The duration of treatment (in days) was the main outcome of the study. For the study, program, client, social network, and accessibility factors were investigated as potential predictors of retention. The study analyzed the relative weight of each factor in predicting treatment retention. The sample consisted of 178 clients drawn from three participating clinics: Rumah Sakit Ketergantungan Obat and Tanjung Priok in Jakarta and Sanglah in Bali. The 3- and 6-month retention rates were 74.2% and 61.3%, respectively. These rates are comparable with previous studies conducted in developed countries. A survival analysis using a robust estimation for the Cox PH regression found that the strongest predictors of retention were methadone dose followed by an interaction between take-home dose and the experience of the clinic providing this treatment. Other significant predictor variables included age, perceived clinic accessibility, and client's belief in the program. The study concludes that MMT cannot solely rely on the pharmacology for retention but should also promote informed access to take-home doses.

Earning “Take-Home” Privileges and Long-Term Outcome in a Methadone Maintenance Treatment Program

This observational prospective study aimed to determine whether duration to the earning of privileges of "take-home" methadone doses (as a part of behavioral enforcement) reflects long-term outcome of patients in methadone maintenance treatment (MMT). All 657 former heroin addicts admitted to our MMT clinic between June 1993 and June 2008 were prospectively studied and followed up. Duration from admission to first take-home dose (until October 2008), to leaving (retention, until June 2009), and to dying (survival, until June 2008) was calculated. Most patients (n = 435; 66.2%) ever achieved take-home privileges. Retention was longest (10 years, 95% confidence interval [CI]: 8.8 to 11.2) for 110 patients who achieved their first take-home dose after 3 to 6 months, followed by 9 years (95% CI: 7.7 to 10.3) for 98 patients who achieved it after >6 months and ≤1 year, and 8.3 years (95% CI: 7.2 to 9.4) for 127 patients who managed to achieve it only after >1 year. Retention was lower among patients who were given exceptional take-home doses (not respecting policy regulations) <3 months since admission: 5.1 years (95% CI: 3.4 to 7.8) for 30 patients (who got it for medical reasons), 9 years (95% CI: 6.7 to 11.3) for 14 patients admitted from another MMT, and 6.3 years (95% CI: 5 to 7.6) for 56 patients who got it for unjustified (mistakes) reasons. The shortest retention in MMT was 2.2 years (95% CI: 1.8 to 2.7, P < 0.0005) for 222 patients who never managed to achieve any take-home privileges. Survival was longer among patients who ever versus never received take-home privileges (13.2 years [95% CI: 12.8 to 13.6] vs 12.3 years [95% CI: 11.5 to 13.1], respectively; P = 0.04) and longest (14.1 years [95% CI: 13.4 to 14.7]) among those who received take-home privileges after 3 to 6 months. The group with the shortest time (3 to 6 months) to the achievement of first take-home dose had the best outcome. Further studies are needed to characterize this group.

Opioid-Addiction Treatment: Maintenance or Abstinence Better?

Opioid-Addiction Treatment: Maintenance or Abstinence Better?

The virtual disappearance of injectable opioids for heroin addiction under the ‘British System’

Aims: Injectable opioids were prescribed unsupervised under the ‘British System’ for heroin dependence. National guidelines (1999 and 2003) confirmed that injectable opioids have a legitimate ‘limited clinical place’ and should be dispensed daily, with ‘mechanisms for supervision’. This study assesses whether national guidelines impacted on prescriptions of injectable opioids.Methods: A 25% random sample of community pharmacists (n = 2473) in England were surveyed by a questionnaire in 2005, with 95% response (n = 2349). Opioid maintenance prescription data for anonymous patients (n = 9620) were compared to the prescription data in 1995 (n = 3721) from a matched survey.Findings: Injectable opioid prescriptions reduced significantly from 10.5% (1995) to 1.8% (2005) of all opioid maintenance prescriptions. Daily doses significantly increased, as did daily dispensing from 28.8% (1995) to 57.8% (2005), whilst weekly dispensing reduced from 39.5% (1995) to 14.5% (2005). In 2005, injectable opioids accounted for 27.2% of private opioid prescriptions, versus 1.5% National Health Service (NHS) prescriptions. Private prescriptions were for larger take-home doses than NHS prescriptions. Regional variation was present.Conclusions: Injectable opioid maintenance treatment for heroin dependence under the unsupervised ‘British System’ is disappearing, although not extinct. If injectable opioids are prescribed, this is more in line with national guidelines. However, many prescriptions are less than daily instalments.

Abstinence-contingent reinforcement and engagement in non-drug-related activities among illicit drug abusers.

Methadone-maintained cocaine abusers (N = 78) were randomly assigned to 1 of the following 52-week interventions: (a) usual care only (UC), (b) take-home methadone doses contingent on cocaine- and opiate-negative results (THM), or (c) take-home methadone doses for cocaine- and opiate-negative results and monetary-based vouchers contingent on cocaine-negative urinalysis results (THM + V). Cocaine use was assessed by urinalysis on a thrice-weekly schedule. Frequency and enjoyability of non-drug-related activities were assessed with the Pleasant Events Schedule (PES) at baseline, midtreatment, and end of treatment. The THM + V condition achieved the greatest abstinence from cocaine and opiate use, followed by the THM and UC conditions. The THM + V condition had the highest PES frequency ratings at midtreatment and at the end of treatment, followed by the THM and UC conditions. There were significant differences between the THM + V and UC conditions on 10 of 12 PES-derived subscales. Analyses revealed that abstinence mediated the effects of treatment condition on frequency ratings. There were no significant differences in enjoyability ratings. These results suggest that when contingency-management interventions increase abstinence from drug abuse, they also increase engagement in non-drug-related activities in naturalistic settings.

Behavioral drug and HIV risk reduction counseling (BDRC) with abstinence-contingent take-home buprenorphine: A pilot randomized clinical trial

This pilot randomized clinical trial evaluated whether the efficacy of office-based buprenorphine maintenance treatment (BMT), provided with limited counseling or oversight of medication adherence is improved by the addition of individual drug counseling and abstinence-contingent take-home doses of buprenorphine. After a 2-week buprenorphine and stabilization period, heroin dependent individuals ( n = 24) in Muar, Malaysia were randomly assigned to Standard Services BMT (physician administered advice and support, and weekly, non-contingent medication pick-up) or Enhanced Services (nurse-delivered manual-guided behavioral drug and HIV risk reduction counseling (BDRC) and abstinence-contingent take-home buprenorphine (ACB), 7 day supply maximum). Outcomes included retention, proportion of opioid-negative urine tests, self-reported drug use, and self-reported HIV risk behaviors. 12/12 (100%) of Enhanced Services and 11/12 (92%) of Standard Services participants completed the entire protocol. The proportion of opioid-negative urine tests increased significantly over time for both groups ( p < 0.001), and the reductions were significantly greater in the Enhanced Services group ( p < 0.05); Enhanced Services group achieved higher overall proportions of opiate negative urine toxicology tests (87% vs. 69%, p = 0.04) and longer periods of consecutive abstinence from opiates (10.3 weeks vs. 7.8 weeks, p = 0.154). Both groups significantly reduced HIV risk behaviors during treatment ( p < 0.05), but the difference between Enhanced and Standard Services (26% vs. 17% reductions from the baseline levels, respectively) was not statistically significant ( p = 0.9). Manual-guided behavioral drug and HIV risk reduction counseling and abstinence-contingent take-home buprenorphine appear promising for adding to the efficacy of office-based BMT provided with limited drug counseling and medication oversight.

A 12-month controlled trial of methadone medical maintenance integrated into an adaptive treatment model

Methadone medical maintenance (MMM) reduces the reporting schedule for stable and well-functioning methadone maintenance patients to once a month, with counseling provided by medical staff. We report on the 12-month outcomes of 92 highly stable methadone maintenance patients randomly assigned to one of three study conditions: routine care, MMM at the methadone maintenance program, and MMM at a physician's office. Methadone medical maintenance patients received a 28-day supply of methadone, whereas routine care patients received five or six take-home methadone doses each week. All patients performed a medication recall once a month and submitted two urine samples each month. An adaptive stepped-care system of treatment intensification was used for patients who failed recall or who had drug-positive urine specimens. Seventy-seven patients completed the 12-month study period. Dropout was caused primarily by problems with handling methadone and disliking the recall frequency. There were low rates of drug use or failed medication recall. Treatment satisfaction was high in all groups, but the MMM patients initiated more new employment or family/social activities than did routine care patients over the study period. The stepped-care approach was well tolerated and matched patients to an appropriate step of service within a continuum of treatment intensity.