Prescription Opioid Injection among HIV-Positive People Who Inject Drugs in a Canadian Setting

Prescription opioids (POs) are commonly prescribed to patients living with HIV/AIDS, while the illicit use of POs remains a major public health concern throughout Canada and the United States. 

We sought to identify the prevalence and correlates of PO injection among HIV-positive people who inject drugs (PWID) in Vancouver, Canada, where HIV/AIDS treatment and care is offered at no cost. We examined data from 634 individuals from an ongoing prospective cohort of HIV-positive PWID. 

Between December 2005 and November 2013, the median prevalence of recent PO injection was 24.2% [interquartile range (IQR): 21.5-25.8 %]. 

In a multivariable generalized estimating equation model, 

• Caucasian ethnicity, 
• heroin injection, 
• and drug dealing were positively associated with PO injection, 

While older age and methadone maintenance treatment were negatively associated with PO injection (all p < 0.05). Engagement on antiretroviral therapy was inversely associated with PO injection in a bivariable analysis, but did not remain significant after adjusting for heroin injection. 

These findings describe a particularly vulnerable sub-group of PWID who may benefit from targeted efforts to both minimize drug-related risk behaviors and support HIV/AIDS treatment.

Purchase full article at:   http://goo.gl/k7Eozb

By:  Lake S^1,2, Kerr T^1,3, Buxton J², Guillemi S¹, Parashar S¹, Montaner J^1,3, Wood E^1,3, Milloy MJ^4,5.

¹British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.

²School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, V6T 1Z3, Canada.

³Department of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.

⁴British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. uhri-mjsm@cfenet.ubc.ca.

⁵Department of Medicine, St. Paul's Hospital, University of British Columbia, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. uhri-mjsm@cfenet.ubc.ca.

AIDS Behav. 2016 May 5. [Epub ahead of print] 

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Correlates of Cocaine Use During Methadone Treatment: Implications for Screening & Clinical Management

BACKGROUND:

Cocaine use is frequent in patients receiving methadone maintenance treatment (MMT) and can jeopardize their treatment response. Identifying clinical predictors of cocaine use during methadone treatment can potentially improve clinical management. We used longitudinal data from the ANRS Methaville trial both to describe self-reported occasional and regular cocaine use during MMT and to identify clinical predictors.

METHODS:

We selected 183 patients who had data on cocaine (or crack) use at months 0 (M0), M6, and/or M12, accounting for 483 visits. The outcome was "cocaine use" in three categories: "no," "occasional," and "regular" use. To identify factors associated with the outcome over time, we performed a mixed multinomial logistic regression.

RESULTS:

Time on methadone was significantly associated with a decrease in occasional but not in regular cocaine use from 14.7 % at M0 to 7.1 % at M12, and from 10.7 % at baseline to 6.5 % at M12, respectively. After multiple adjustments, opiate injection, individuals screening positive for attention deficit hyperactivity disorder (ADHD) symptoms, and those presenting depressive symptoms were more likely to regularly use cocaine.

CONCLUSIONS:

Although time on MMT had a positive impact on occasional cocaine use, it had no impact on regular cocaine use. Moreover, regular cocaine users were more likely to report opiate injection and to present ADHD and depressive symptoms. Early screening of these disorders and prompt tailored pharmacological and behavioral interventions can potentially reduce cocaine use and improve response to MMT.

Below:  Cocaine use in methadone patients: M0, M6, and M12 visits

Full article at:  http://goo.gl/A4p5Dp

By:  Roux P1,2,3, Lions C4,5,6, Vilotitch A4,5,6, Michel L7,8,9, Mora M4,5,6, Maradan G4,5,6, Marcellin F4,5,6, Spire B4,5,6, Morel A10, Carrieri PM4,5,6; ANRS Methaville study group.

• 1INSERM, UMR_S 912, Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale (SESSTIM), 27 bd Jean Moulin, 13385, Marseille, France. perrine.roux@inserm.fr.
• 2Aix Marseille Université, UMR_S 912, IRD, Marseille, France. perrine.roux@inserm.fr.
• 3ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France. perrine.roux@inserm.fr.
• 4INSERM, UMR_S 912, Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale (SESSTIM), 27 bd Jean Moulin, 13385, Marseille, France.
• 5Aix Marseille Université, UMR_S 912, IRD, Marseille, France.
• 6ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France.
• 7INSERM, Research Unit 669, Paris, France.
• 8Univ Paris-Sud and Univ Paris Descartes, UMR-S0669, Paris, France.
• 9Centre Pierre Nicole, Paris, France.
• 10Oppelia, Paris, France. 
• Harm Reduct J. 2016 Apr 5;13(1):12. doi: 10.1186/s12954-016-0100-7

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The Impact of Enrolment in Methadone Maintenance Therapy on Initiation of Heavy Drinking among People Who Use Heroin

BACKGROUND:

There is equivocal evidence regarding whether people who use heroin substitute heroin for alcohol upon entry to methadone maintenance therapy (MMT). We aimed to examine the impact of MMT enrolment on the onset of heavy drinking among people who use heroin.

METHODS:

We derived data from prospective, community-based cohorts of people who inject drugs in Vancouver, Canada, between December 1, 2005, and May 31, 2014. Multivariable extended Cox regression analysis examined the effect of MMT enrolment on the onset of heavy drinking among people who used heroin at baseline.

RESULTS:

In total, 357 people who use heroin were included in this study. Of these, 208 (58%) enrolled in MMT at some point during follow-up, and 115 (32%) reported initiating heavy drinking during follow-up for an incidence density of 7.8 events (95% CI 6.4-9.5) per 100 person-years. The incidence density of heavy drinking was significantly lower among those enrolled in MMT at some point during follow-up compared to those who did not (4.6 vs. 16.2). MMT enrolment was not significantly associated with time to initiate heavy drinking (adjusted relative hazard after adjustment for relevant demographic and substance-use characteristics. Age and cannabis use were the only variables that were independently associated with the time to onset of heavy drinking.

CONCLUSION:

In this study, MMT enrolment did not predict heavy drinking and may even appear to decrease the initiation of heavy drinking. Our findings suggest younger age and cannabis use may predict heavy drinking. These findings could help inform on-going discussions about the effects of opioid agonist therapy on alcohol consumption among people who use heroin.

Purchase full article at:  http://goo.gl/W6rhty

By:  Klimas J1, Wood E, Nguyen P, Dong H, Milloy MJ, Kerr T, Hayashi K.

• 1British Columbia Centre for Excellence in HIV/AIDS, Vancouver, B.C., Canada.
• Eur Addict Res. 2016 Apr 6;22(4):210-214 

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Concurrent Heroin Use and Correlates among Methadone Maintenance Treatment Clients: A 12-Month Follow-up Study in Guangdong Province, China

Objective:

To assess concurrent heroin use and correlates among Methadone Maintenance Treatment (MMT) clients in Guangdong Province, China.

Method:

Demographic and drug use data were collected with a structured questionnaire, and MMT information was obtained from the MMT clinic registration system in Guangdong. Human immunodeficiency virus (HIV-) and hepatitis C virus (HCV) infected status and urine morphine results were obtained from laboratory tests. Logistic regressions were employed to investigate the factors associated with concurrent heroin use.

Results:

Among the 6848 participants, 75% continued using heroin more than once during the first 12 months after treatment initiation. Concurrent heroin use was associated with inharmonious family relationship, HIV positivity, having multiple sex partners, having ever taken intravenous drugs, higher maintenance dose and poorer MMT attendance. Among those who used heroin concurrently, the same factors, and additionally being older and female, contribute to a greater frequency of heroin use. 

Conclusions:

Concurrent heroin use was prevalent among MMT participants in Guangdong, underscoring the urgent needs for tailored interventions and health education programs for this population.

Full article at:  http://goo.gl/r6y8ol

By:  Xiaofeng Luo,1,2 Peizhen Zhao,3 Xiao Gong,1,2 Lei Zhang,4 Weiming Tang,3 Xia Zou,1,2 Wen Chen,1,2 and Li Ling1,2,*

¹Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, 74 Zhongshan Road II, Guangzhou 510080, China

²Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, 74 Zhongshan Road II, Guangzhou 510080, China

³Guangdong Center for Skin Guangdong Provincial Center for Skin Diseases and STIs Control, No. 2 Lujing Road, Guangzhou 510091, China;

⁴The Kirby Institute, University of New South Wales, Sydney NSW 2052, Australia

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Behavioral & Quality-of-Life Outcomes in Different Service Models for Methadone Maintenance Treatment in Vietnam

BACKGROUND:

Integrating HIV/AIDS and methadone maintenance treatment (MMT) services with existing health care delivery system is critical in sustaining efforts to fight HIV/AIDS in large injection-driven epidemics. However, efficiency of different integrative service models is unknown. This study assessed behavioral and health-related quality-of-life (HRQOL) outcomes of MMT in four service delivery models and explored factors associated with these outcomes of interest.

METHODS:

A cross-sectional survey was conducted in two HIV epicenters in Vietnam: Hanoi and Nam Dinh Province. All patients in five selected MMT clinics were invited to participate, and 1016 were interviewed (80-90 % response rate).

RESULTS:

Respondents had a mean age of 35.8, taken MMT for average 16.5 months and 3.3 % on MMT for 36-60 months. The MMT integrated with rural district health center (DHC) has the highest prevalence of concurrent drug use (11.3 %). The percentage of condom use (last sexual intercourse) with primary and casual partners was lowest in the MMT at urban DHCs. Patients at the rural DHC reported very high proportions of pain/discomfort (37.8 %), anxiety/depression (43.1 %), and mobility (13.3 %). In regression models, poorer HRQOL outcomes were found in MMT models in the rural areas or without general health care, and among those patients who were HIV positive, reported concurrent drug use, and had higher numbers of previous drug rehabilitation episodes. Mobility and anxiety/depression are factors that increased the likelihood of concurrent drug use among MMT patients.

CONCLUSIONS:

Outcomes of MMT were diverse across different integrative service models. Policies on rapid expansion of the MMT program in Vietnam should also emphasize on the integration with comprehensive health care services including psychological supports for patients.

History of drug use and rehabilitation

			MMT + VCT + ART + DGH
	MMT + VCT		Rural		Urban		MMT + RPC		All		p value
	Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD
History of drug use
Age first used drug	24.3	7.0	26.6	7.4	25.3	6.7	23.5	6.1	24.1	6.5	0.21
Time since first episode (year)	13.5	5.1	11.2	5.3	12.2	5.9	14.5	6.2	13.5	5.7	<0.01
Time since first drug injection (year)	10.9	4.4	7.9	3.9	9.2	4.6	11.0	5.5	10.9	4.9	0.02
Drug rehabilitation
Number of episodes	5.7	7.2	3.4	3.0	4.2	5.2	5.1	6.9	4.8	6.2	0.02
	N	%	N	%	N	%	N	%	N	%
Location of rehabilitation
Home, self-managed	213	85.9	103	75.7	132	68.8	226	61.8	674	71.6	<0.01
Voluntary centers	108	43.6	50	36.8	97	50.5	195	53.3	450	47.8	<0.01
Compulsory centers	74	29.8	13	9.6	32	16.7	137	37.4	256	27.2	<0.01
Reason for relapse
Boredom	91	36.7	31	22.8	80	41.7	162	44.3	364	38.6	<0.01
Peer inducement	115	46.4	67	49.3	106	55.2	189	51.6	477	50.6	0.30
Craving	107	43.2	62	45.6	96	50.0	168	45.9	433	46.0	0.56
Unemployment	11	4.4	3	2.2	6	3.1	29	7.9	49	5.2	0.02

Full article at:   http://goo.gl/gQ6GS4

By:  Tran BX1,2, Nguyen LH3,4, Nong VM3, Nguyen CT5, Phan HT6, Latkin CA7.

• 1Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam. bach@hmu.edu.vn.
• 2Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. bach@hmu.edu.vn.
• 3Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam.
• 4School of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam.
• 5Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam.
• 6Authority of HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam.
• 7Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. 
• Harm Reduct J. 2016 Feb 2;13(1):4. doi: 10.1186/s12954-016-0091-4.

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Impact of Blended Treatment Literacy & Psychoeducation on Methadone Maintenance Treatment Outcomes in Yunnan, China

BACKGROUND:

Outcomes of methadone maintenance treatment (MMT) in the management of opioid dependency can be impaired by poor adherence and retention, concomitant drug use, poor adjustment of methadone dosage, and low levels of awareness regarding methadone among drug users, among other factors. This study investigated the effects of intensive blended treatment literacy and psychoeducation on treatment compliance, methadone dose, and heroin use among MMT clients in China.

METHODS:

A total of 492 MMT clients who tested positive for urine morphine at least once during a 12-week intervention period preceding the study were recruited from 16 MMT clinics. Employing a client-centred approach, a blended treatment literacy and psychoeducation intervention was then implemented between March and June 2014, comprising (1) intensified methadone treatment literacy sessions; (2) participatory goal setting; (3) continuous adherence monitoring and support; and (4) engagement of both peers and doctors in delivering psychoeducation. Wilcoxon signed-rank test was used to compare urine morphine positive rates, daily methadone dosage, and the number of days that clients successfully accessed methadone before and during the intervention.

RESULTS:

During the intervention, urine morphine positive rates reduced to 27 % from 49.3 % previously; p < 0.001. In response to client needs, methadone dosages increased among 74 % of participants, remained unchanged among 12.0 %, and reduced among 13.4 % during the intervention. In addition, the average daily methadone dose increased from 63.0 to 72.6 mg; p < 0.001, while the average number of days that clients successfully accessed methadone increased from 69.4 to 73.9 over a period of 12 weeks; p < 0.001.

CONCLUSIONS:

Blended treatment literacy and psychoeducation delivered by a combination of peers and doctors was associated with reducedheroin use, improved treatment adherence, and higher methadone doses among our sample of MMT clients.

Full article at:   http://goo.gl/knbc2U

By:  Zhang B1, Cai T2, Yan Z3, Mburu G4,5, Wang B4, Yang L6.

• 1Yunnan Institute of Drug Abuse (YIDA), 300 Wujiadui, Xihuayuan, Xishan District, Kunming, Yunnan, China. zhangbo407@126.com.
• 2AIDS Care China, R 201, #17 Rongyuan, Jinjiang Residential Quarter, Bejing Road, Panlong District, Kunming, Yunnan, China. thomas@aidscarechina.org.
• 3AIDS Care China, R 201, #17 Rongyuan, Jinjiang Residential Quarter, Bejing Road, Panlong District, Kunming, Yunnan, China. zhyan@aidscarechina.org.
• 4International HIV/AIDS Alliance, 91-101 Davigdor Road, Hove, BN3 1RE, UK. gmburu@aidsalliance.org.
• 5Department of Health Research, Lancaster University, Lancaster, LA1 4YW, UK. gmburu@aidsalliance.org.
• 6Yunnan Institute of Drug Abuse (YIDA), 300 Wujiadui, Xihuayuan, Xishan District, Kunming, Yunnan, China. ylp412@126.com. 
• Harm Reduct J. 2016 Feb 26;13(1):8. doi: 10.1186/s12954-016-0097-y.

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Opioid Tolerance in Methadone Maintenance Treatment: Comparison of Methadone & Levomethadone in Long-Term Treatment

BACKGROUND:

This study aimed to investigate the development of opioid tolerance in patients receiving long-term methadone maintenance treatment (MMT).

METHODS:

A region-wide cross-sectional study was performed focusing on dosage and duration of treatment. Differences between racemic methadone and levomethadone were examined. All 20 psychiatric hospitals and all 110 outpatient clinics in Berlin licensed to offer MMT were approached in order to reach patients under MMT fulfilling the DSM IV criteria of opiate dependence. In the study, 720 patients treated with racemic methadone or levomethadone gave information on the dosage of treatment. Out of these, 679 patients indicated the duration of MMT.

RESULTS:

Treatment with racemic methadone was reported for 370 patients (54.5 %), with levomethadone for 309 patients (45.5 %). Mean duration of MMT was 7.5 years. We found a significant correlation between dosage and duration of treatment, both in a conjoint analysis for the two substances racemic methadone and levomethadone and for each substance separately. These effects remained significant when only patients receiving MMT for 1 year or longer were considered, indicating proceeding tolerance development in long-term treatment. When correlations were compared between racemic methadone and levomethadone, no significant difference was found.

CONCLUSIONS:

Our data show a tolerance development under long-term treatment with both racemic methadone and levomethadone. Tolerance development did not differ significantly between the two substances.

Full article at:   http://goo.gl/LsJZNb

By:  Gutwinski S1, Schoofs N2, Stuke H3, Riemer TG4, Wiers CE5, Bermpohl F6.

• 1Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. stefan.gutwinski@charite.de.
• 2Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. Nikola.Schoofs@charite.de.
• 3Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. Heiner.Stuke@charite.de.
• 4Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. t.riemer@alexius.de.de.
• 5Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. Corinde.Wiers@gmail.com.
• 6Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. Felix.Bermpohl@charite.de. 
• Harm Reduct J. 2016 Feb 16;13(1):7. doi: 10.1186/s12954-016-0095-0.

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