Treatment of Prescription Opioid Disorders in Canada: Looking at the 'Other Epidemic'?

The magnitude and consequences of prescription opioid (PO) misuse and harms (including rising demand for PO disorder treatment) in Canada have been well-documented. 

Despite a limited evidence-base for PO dependence treatment, opioid maintenance therapy (OMT) - mostly by means of methadone maintenance treatment (MMT) - has become the de facto first-line treatment for PO-disorders. For example in the most populous province of Ontario, some 50,000 patients - large proportions of them young adults - are enrolled in MMT, resulting in a MMT-rate that is 3-4 times higher than that of the United States. 

MMT in Ontario has widely proliferated towards a quasi-treatment industry within a system context of the public fee-payer offering generous incentives for community-based MMT providers. Contrary to the proliferation of MMT, there has been no commensurate increase in availability of alternative (e.g., detox, tapering, behavioral), and less intrusive and/or costly, treatments which may provide therapeutic benefits at least for sub-sets of PO-dependent patients. 

Given the extensive PO-dependence burden combined with its distinct socio-demographic and clinical profile (e.g., involving many young people, less intensive or risky opioid use), an evidence-based 'stepped-care' model for PO dependence treatment ought to be developed in Canada where MMT constitutes one, but likely a last resort or option, for treatment. Other, less intrusive treatment options as well as the best mix of treatment options should be systematically investigated and implemented. 

This case study has relevance and implications for evidence-based treatment also for the increasing number of other jurisdictions where PO misuse and disorders have been rising.

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

By:  Fischer B1,2,3,4, Kurdyak P5,6,7, Goldner E8, Tyndall M9,10, Rehm J11,12,13,14.

• 1Social and Epidemiological Research Department, Centre for Addiction & Mental Health (CAMH), Toronto, ON, M5S 2S1, Canada. bfischer@sfu.ca.
• 2Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada. bfischer@sfu.ca.
• 3Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, M5T 1R8, Canada. bfischer@sfu.ca.
• 4Centre for Applied Research in Mental Health & Addiction (CARMHA), Simon Fraser University, Vancouver, V6B 5K3, Canada. bfischer@sfu.ca.
• 5Social and Epidemiological Research Department, Centre for Addiction & Mental Health (CAMH), Toronto, ON, M5S 2S1, Canada. paul.kurdyak@camh.ca.
• 6Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada. paul.kurdyak@camh.ca.
• 7Mental Health and Addictions Program, Institute for Clinical Evaluative Science (ICES), Toronto, ON, M4N 3M5, Canada. paul.kurdyak@camh.ca.
• 8Centre for Applied Research in Mental Health & Addiction (CARMHA), Simon Fraser University, Vancouver, V6B 5K3, Canada. egoldner@sfu.ca.
• 9B.C. Centre for Disease Control (BCCDC), Vancouver, BC, V5Z 4R4, Canada. mtyndall@bccdc.ca.
• 10Department of Medicine, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada. mtyndall@bccdc.ca.
• 11Social and Epidemiological Research Department, Centre for Addiction & Mental Health (CAMH), Toronto, ON, M5S 2S1, Canada. jtrehm@gmail.com.
• 12Department of Psychiatry, University of Toronto, Toronto, ON, M5T 1R8, Canada. jtrehm@gmail.com.
• 13Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, M5T 1R8, Canada. jtrehm@gmail.com.
• 14Dalla Lana School of Public Health, University of Toronto, Toronto, ON, M5T 3M7, Canada. jtrehm@gmail.com.
• Subst Abuse Treat Prev Policy. 2016 Mar 8;11(1):12. doi: 10.1186/s13011-016-0055-4. 

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Cold Turkey: New Hampshire's Prison Detox

Via:  https://goo.gl/2YdzpE

Factors Associated with the Chronicity of Intimate Partner Violence Experiences among Pregnant Women in Detoxification Services

The purpose of this study was to assess factors associated with chronicity of intimate partner violence (IPV) among pregnant substance abusers. 

A total of 114 pregnant women entering an inpatient, detoxification unit voluntarily agreed to participate in a study about women’s health and well-being. Face-to-face interviews were used for data collection. A multiple linear regression assessed the relationship between background characteristics, substance use, and IPV chronicity. 

Protective factors, which were associated with reduced chronicity of IPV, included whether most recent/current intimate partner fathered pregnancy, whether the mother was currently in a relationship with most recent/current intimate partner, whether the mother received greater social support, and increasing age. 

Childhood sexual abuse was associated with increased chronicity of IPV. Results suggest important prevention, intervention, and treatment implications for this vulnerable population.

Purchase full article at:  http://goo.gl/C0XuFP

By:  Afton Jackson MPH^a* & Lisa Shannon PhD, MSW^a

• ^a Department of Sociology, Social Work, and Criminology, Morehead State University, Morehead, Kentucky, USA 

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Mortality among Individuals Accessing Pharmacological Treatment for Opioid Dependence in California, 2006-10

To estimate mortality rates among treated opioid-dependent individuals by cause and in relation to the general population, and to estimate the instantaneous effects of opioid detoxification and maintenance treatment (MMT) on the hazard of all-cause and cause-specific mortality.

Population-based treatment cohort study.

Linked mortality data on all individuals first enrolled in publicly-funded pharmacological treatment for opioid dependence in California, USA from 2006 to 2010.

32,322 individuals, among whom there were 1,031 deaths (3.2%) over a median follow-up of 2.6 years (interquartile range: 1.4 - 3.7).

The primary outcome was mortality, indicated by time to death, crude mortality rates (CMR), and standardized mortality ratios (SMR).

Individuals being treated for opioid dependence had a more than four-fold increase of mortality risk compared with the general population. Mortality risk was higher when individuals were out-of-treatment than in-treatment and during detoxificationthan during MMT, especially in the two weeks post-treatment entry. Detoxification and MMT both independently reduced the instantaneous hazard of all-cause and drug-related mortality. MMT preceded by detoxification was associated with lower all-cause and other-cause-specific mortality than MMT alone.

In people with opiate dependence, detoxification and methadone maintenance treatment both independently reduce the instantaneous hazard of all-cause and drug-related mortality.

Below: Crude mortality rates by cause of death according to in-treatment and out-of-treatment periods

ˆ overdose (accidental poisoning by alcohol or other drugs), other drug-related (harmful alcohol or drug use or dependence)

+ suicide (intentional self-harm or self-poisoning), homicide, injury (accidental injury, traffic accidents)

# cancer, respiratory disease, liver disease, diabetes, infections/parasites, endometriosis, digestive disease, renal disease, central nervous system, other, and unknown

See Appendix 1 for ICD-10 codes incldued in each category of mortality.

Full article at:  http://ht.ly/SJ2NG

By:  Elizabeth Evans,1 Libo Li,1 Jeong Min,2 David Huang,1 Darren Urada,1 Lei Liu,3 Yih-Ing Hser,1 and Bohdan Nosyk2,4

²British Columbia Centre for Excellence in HIV/AIDS

³Northwestern University Feinberg School of Medicine

⁴

1UCLA Integrated Substance Abuse Programs

2British Columbia Centre for Excellence in HIV/AIDS

3Northwestern University Feinberg School of Medicine

4Simon Fraser University, Faculty of Health Sciences

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Mortality among individuals accessing pharmacological treatment for opioid dependence in California, 2006 - 2010

Below: Crude mortality rates by cause of death according to in-treatment and out-of-treatment periods

The primary outcome was mortality, indicated by time to death, crude mortality rates (CMR), and standardized mortality ratios (SMR).

Individuals being treated for opioid dependence had a more than four-fold increase of mortality risk compared with the general population (SMR 4.5 95% CI: 4.2, 4.8). Mortality risk was higher (1) when individuals were out-of-treatment (SMR 6.1, 95% CI: 5.7, 6.5) than in-treatment (SMR 1.8, 95% CI: 1.6, 2.1) and (2) during detoxification (SMR 2.4, 95% CI 1.5, 3.8) than during MMT (SMR 1.8, 95% CI 1.5, 2.1), especially in the two weeks post-treatment entry (SMR 5.5, 95% CI 2.7, 9.8 versus SMR 2.5, 95% CI 1.7, 4.9). Detoxification and MMT both independently reduced the instantaneous hazard of all-cause and drug-related mortality. MMT preceded by detoxification was associated with lower all-cause and other-cause-specific mortality than MMT alone.

In people with opiate dependence, detoxification and methadone maintenance treatment both independently reduce the instantaneous hazard of all-cause and drug-related mortality.

Via:   http://ht.ly/O46n0  HT @UCLAHealth