Linkage to Primary Care for Persons First Receiving Injectable Naltrexone During Inpatient Opioid Detoxification

HIGHLIGHTS

• XR-NTX begun during opioid detoxification can be continued in primary care settings.
• 55% of XR-NTX recipients link to primary care for continued treatment.
• We found no predictors of XR-NTX continuation in primary care.

INTRODUCTION:

Opioid use disorders commonly require ongoing medication-assisted treatment to reduce relapse following discharge from inpatient detoxification programs. Naltrexone, an opioid antagonist, is an increasingly popular treatment option in its once-monthly injectable form (XR-NTX). The aim of this study was to examine the follow-up rates of persons who received an initial injection during inpatient detoxification and scheduled for receipt of a first outpatient injection in the primary care setting.

METHODS:

We reviewed the electronic health records of 62 consecutive opioid dependent adults who received an initial injection of XR-NTX during extended inpatient detoxification at Stanley Street Treatment and Resources (SSTAR) in Fall River, Massachusetts, from March 2013 to August 2015, and were referred to the adjacent SSTAR primary care health center for their second injection 1month later. Demographic information, drug use and opioid treatment history, and aftercare planning were assessed.

RESULTS:

Participants averaged 32.4 (±7.8) years of age, 90.3% were non-Latino Caucasian, 35.5% were homeless, 21.3% reported a drug overdose in the last year, and 53.2% had been in detoxification within the last year. Of the 62 participants referred to primary care, 34 (54.8%) followed up to receive their second XR-NTX injection. Twenty of these persons received at least a third XR-NTX injection. No demographic, treatment history, substance use behaviors, or aftercare plan variables were associated with receipt of a second injection (p<.20).

CONCLUSION:

Predicting, and therefore improving, XR-NTX continuation during the transition from inpatient detoxification to primary care may be difficult in this population.

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By:  Stein MD1, Risi MM2, Bailey GL3, Anderson BJ2.

• 1General Medicine Research Unit, Butler Hospital, Providence, RI, 02906; Warren Alpert Medical School of Brown University, Providence, RI, 02912. Electronic address: michael_stein@brown.edu.
• 2General Medicine Research Unit, Butler Hospital, Providence, RI, 02906.
• 3Warren Alpert Medical School of Brown University, Providence, RI, 02912; Stanley Street Treatment and Resources, Inc., Fall River, Massachusetts, 02720. 
• J Subst Abuse Treat. 2016 May;64:44-6. doi: 10.1016/j.jsat.2016.01.007. Epub 2016 Feb 23.

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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

Nalmefene for the Treatment of Alcohol Use Disorders: Recent Data & Clinical Potential

Few pharmacotherapies are available for alcoholism. Numerous studies indicate the involvement of the opioid-endorphin system in mediating the reinforcing effects of alcohol via dopaminergic neurons. The opioid antagonist naltrexone was found to be effective in alcohol treatment and the European Medicines Agency has now approved the mu-opioid antagonist und partial kappa agonist nalmefene. Areas covered: 

This article presents background information on the chemistry of nalmefene and pre-clinical and clinical findings. The three relevant Phase III studies, all of which followed a harm-reduction, "as needed" approach and found reduced alcohol consumption with nalmefene 18 (20) mg, are discussed in detail. 

Expert opinion: The integration of the "as needed" approach into conventional psychosocial alcohol therapies may be challenging but offers the opportunity to reach otherwise not treated patients. Nalmefene is the first medication to be approved specifically in this indication and seems to be most suitable for patients with alcohol misuse or a rather low physical dependence on alcohol who do not require immediate detoxification or inpatient treatment. 

Although a categorical distinction between patients who want to stop heavy drinking or drinking at all over time may be somewhat hypothetical, nalmefene offers new treatment options to patients with alcohol use disorder.

Purchase full article at:   http://goo.gl/f9ej1w

By:  Soyka M1,2.

• 1 Department of Psychiatry and Psychotherapy , Ludwig Maximilian University , Munich , Germany.
• 2 Privatklinik Meiringen , Meiringen , Switzerland.
• Expert Opin Pharmacother. 2016 Jan 25.

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Veterans' Service Utilization Patterns After Alcohol and Opioid Detoxification in VHA Care

OBJECTIVE:

This study aimed to examine detoxification-related service utilization in the Veterans Health Administration (VHA).

METHODS:

VHA data for 266,908 patients were used to examine rates and predictors of receiving detoxification, attending post-detoxification appointments, and entering specialty treatment. Multilevel, mixed-effects logistic regressions were used to examine associations between patient and facility characteristics and service utilization.

RESULTS:

Nationally, 8.0% of VHA patients with alcohol or opiate dependence received detoxification in fiscal year 2013 (facility range=.1%-20.4%); 43.1% of detoxified patients received follow-up (11.1%-76.4%), and 49.9% entered specialty treatment (13.0%-77.2%). In adjusted analyses, detoxification was more likely among male, younger, white, and homeless patients with documented alcohol or opiate disorders and comorbid general medical conditions but without previous addiction treatment. Detoxification was also more likely in facilities with fewer vacant addiction therapist positions. Follow-up and specialty treatments were more likely among younger, healthier homeless patients with previous addiction treatment and a documented alcohol use disorder.

CONCLUSIONS:

Detoxification-related service utilization was highly variable across the VHA. Interventions are needed to optimize use.

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By:  Timko C1, Gupta S1, Schultz N1, Harris AH1.

• 1The authors are with Health Services Research and Development (HSR&D), U.S. Department of Veterans Affairs, Menlo Park, California (e-mail: christine.timko@va.gov ).
• Psychiatr Serv. 2016 Jan 14:appips201400579. 

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Gender Differences among Alaska Native People Seeking Alcohol Withdrawal Treatment

BACKGROUND:

Few studies focus on gender differences among patients who utilize detoxification services; even fewer focus on detoxification for Alaska Native people. This analysis focused on gender differences at admission among a sample of Alaska Native patients seeking alcohol withdrawal treatment.

METHODS:

The sample included 383 adult Alaska Native patients admitted to an inpatient alcohol detoxification unit during 2006 and 2007. Logistic regression was used to estimate unadjusted and adjusted associations with gender.

RESULTS:

Women were 88% more likely to have stable housing than men. Women were 87% less likely to be seasonal workers and 50% less likely than men to be seeking employment at admission. Women had more than 5 times the odds of having children in the home at admission and almost 3 times the odds of experiencing physical abuse than men. Additionally, women were 50% less likely to accept a referral to substance abuse treatment following detoxification.

CONCLUSIONS:

The study found significant differences based upon gender. For instance, women are in need of services that accommodate women with children and services that address histories of physical abuse. Conversely men are in need of housing and employment opportunities. Post detoxification follow-up, case-management, and transition to care should include gender as a factor in treatment planning.

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By:  Bear UR1, Beals J1, Novins DK1,2, Manson SM1.

• 1 University of Colorado Anschutz Medical Campus, Centers for American Indian and Alaska Native Health, Colorado School of Public Health , Aurora , CO , USA.
• 2 University of Colorado Anschutz Medical Campus , Department of Psychiatry , Aurora , CO , USA
• Subst Abus. 2016 Jan 5:0.  

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Gender Differences in the Life Concerns of Persons Seeking Alcohol Detoxification

Highlights

• Mental health, smoking, and finances are the most prevalent life concerns
• Gender affects the life concerns of persons with alcohol use disorders
• Men more concerned than women about money and drug use problems
• Men reported greater concern than women in most domains assessed

Background

This study explored the life concerns of persons seeking alcohol detoxification, a group with multiple life and psychosocial challenges. Gender may be an important contributor to the particular life concerns of persons with alcohol use disorders.

Methods

Using a 32-item, previously-validated life concerns survey that captures ten conceptual domains, we interviewed persons entering inpatient alcohol detoxification asking them to rate their level of concern about health and welfare items.

Results

Participants (n = 189) were 27% female, with a mean age of 43.5 years. Overall, concern about alcohol problems was perceived as the most serious, followed by mental health, cigarette smoking, financial, and relationship problems. Men were significantly more concerned than women about six of the ten domains including money, drug use, transmissible diseases, and physical illness.

Conclusions

Recognition of the daily worries of persons seeking inpatient alcohol detoxification persons could allow providers to better tailor their services to the context of their patients’ lives. Focusing on pressing life concerns such as mental health, financial, relationship problems, and other drug use may influence detoxification services and aftercare treatment choices.

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By:   Michael D. Stein, Megan M. Risi, Jessica N. Flori, Micah T. Conti, Bradley J. Anderson, Genie L. Bailey

Affiliations

General Medicine Research Unit, Butler Hospital, Providence, RI, 02906

Warren Alpert Medical School of Brown University, Providence, RI, 02912

Correspondence

Corresponding author at: Health Services, Policy & Practice, Alpert School of Medicine at Brown University, Butler Hospital, 345 Blackstone Blvd., Providence, RI 02906. Tel.: +401 455 6646; fax: +401 455 6685.

Michael_Stein@brown.edu

DOI: http://dx.doi.org/10.1016/j.jsat.2015.12.005

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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.

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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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Release from Incarceration, Relapse to Opioid Use & the Potential for Buprenorphine Maintenance Treatment: A Qualitative Study of the Perceptions of Former Inmates with Opioid Use Disorder

The United States has the highest rate of incarceration in the world (937 per 100,000 adults). Approximately one-third of heroin users pass through correctional facilities annually. Few receive medication assisted treatment (MAT; either methadone or buprenorphine) for opioid use disorder during incarceration, and nearly three-quarters relapse to heroin use within 3 months of release. This qualitative study investigated barriers to and facilitators of buprenorphine maintenance treatment (BMT) following release from incarceration (“re-entry”).

We conducted 21 semistructured interviews of former inmates with opioid use disorder recruited from addiction treatment settings. Interviews were audio-recorded, transcribed, and analyzed using a grounded theory approach. Themes that emerged upon iterative readings of transcripts were discussed by the research team.

Participants reported adverse re-entry conditions, including persistent exposure to drug use and stressful life events, which were perceived to contribute to opioid relapse and affected addiction treatment decisions during re-entry. Themes that emerged relating to BMT included: 1) reliance on willpower; 2) fear of dependency on medications; 3) variable exposure to buprenorphine; and 4) acceptability of BMT following relapse. Willpower was perceived to be more important for recovery than medications. Many participants experienced painful withdrawal from methadone during incarceration and were fearful that using MAT would lead to opioid tolerance and painful withdrawal again in the future. Participants reported both positive and negative experiences taking illicit buprenorphine, which affected interest in BMT. Overall, BMT was perceived to be a good treatment option for opioid use disorder that could reduce the risk of re-incarceration.

BMT was perceived to be acceptable, but former inmates with opioid use disorder may be reluctant to utilize BMT upon re-entry. Factors limiting utilization of BMT could be mitigated though policy change or interventions. Policies of the criminal justice system (e.g., forced detoxification) may be dissuading former inmates from utilizing effective treatments for opioid use disorder. Interventions that improve education and access to BMT for former inmates with opioid use disorder could facilitate entrance into treatment. Both policy changes and interventions are urgently needed to reduce the negative consequences of opioid relapse following re-entry.

Table 1

Sociodemographic characteristics of former inmates with opioid use disorder

Characteristic	N (%)
Age, median years (IQR)	49 (46–52)
Male	17 (81)
Race/Ethnicity
Hispanic	13 (62)
Non-Hispanic Black	8 (38)
English-speaking	20 (95)
Medicaid	19 (90)
High school diploma or equivalency	11 (52)
Ever injected drugs	15 (71)
Current substance usea
Heroin	6 (29)
Other opioid analgesics	2 (10)
Cocaine	3 (14)
Lifetime substance useb
Heroin	21 (100)
Other opioid analgesics	9 (43)
Cocaine	17 (81)
Treatment history
MMT	13 (62)
Nonpharmacologic treatment	20 (95)
BMT	8 (38)
Any opioid addiction treatment	21 (100)

aWithin the previous 30 days.

bRegular use within lifetime.

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

By:  Aaron D Fox, Jeronimo Maradiaga, Linda Weiss, Jennifer Sanchez, Joanna L Starrels, and Chinazo O Cunningham

Albert Einstein College of Medicine, Bronx, NY 10461 USA

Montefiore Medical Center, Bronx, NY 10467 USA

New York Academy of Medicine, New York, NY 10029 USA

Aaron D Fox, Email: gro.eroifetnom@xofda.

Contributor Information.

Corresponding author.

 

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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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