Using Client's Routine Urinalysis Records From Multiple Treatment Systems to Model Five-Year Opioid Substitution Treatment Outcomes

BACKGROUND:

At global, national, and local level, the need for ongoing, timely and cost efficient, comprehensive drug treatment monitoring, and evaluation systems have clearly been well recognized.

OBJECTIVES:

To test the feasibility of linking laboratory data and client intake data and its usefulness for modeling retrospectively, for the first time, 5-year longitudinal drug treatment outcomes in an Irish opiate treatment setting.

METHODS:

A multisite, retrospective, longitudinal cohort study was implemented to evaluate outcomes for opiate users based on 1.7 million routine urinalysis results collected from 4,518 individuals presenting for opioid substitution treatment in Ireland from January 2006 to December 2010.

RESULTS:

Analysis of opiates, cocaine, benzodiazepine, and cannabis use at treatment intake, 6 months and at 1-5 year follow-ups revealed differences in urinalysis protocols; significant differences in age of first drug use between those using and not using opiates at 5 years; significant decreases in opiate use; increases in benzodiazepine use and significant increasing effects of concurrent cocaine and benzodiazepine use on the odds of using opiates. Time series analysis of weekly proportions opiate positive predicted 16% (95% confidence interval: 7%-25%) of clients would be opiate positive 5 years postinitial intake. 

CONCLUSIONS: 

Underutilized urinalysis data can be used to address the need for cost effective, efficient evidence of drug-treatment outcomes across time, place, and systems. Linking and matching the cross-sectional data across sites and times also revealed where improvements in electronic records could be made.

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By:  Comiskey CM1, Snel A1.

• 1 School of Nursing and Midwifery, Trinity College, University of Dublin , Dublin , Ireland.
• Subst Use Misuse. 2016 Mar 20;51(4):498-507. doi: 10.3109/10826084.2015.1126738. Epub 2016 Mar 4. 

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Substance Use among Homeless Individuals with Schizophrenia and Bipolar Disorder

Mental illness and substance use are over represented within urban homeless populations. This paper compared substance use patterns between homeless individuals diagnosed with schizophrenia spectrum (SS) and bipolar disorders (BD) using the Mini-International Neuropsychiatric Interview. 

From a sample of 497 subjects drawn from Vancouver, Canada who participated in the At Home/Chez Soi study, 146 and 94 homeless individuals were identified as BD and SS, respectively. In the previous 12 months, a greater proportion of BD homeless reported greater use of cocaine, amphetamines, opiates, hallucinogens, cannabinoids, and tranquilizers compared to SS. Cocaine and opiates were significantly associated with BD homeless. 

The present study illustrates the relationship between substance use and BD in a vulnerable urban population of homeless, affected by adverse psychosocial factors and severe psychiatric conditions.

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By:  Maremmani AG1, Bacciardi S, Gehring ND, Cambioli L, Schütz C, Jang K, Krausz M.

• 1*"Vincent P. Dole" Dual Diagnosis Unit, Department of Clinical and Experimental Medicine, University of Pisa; †Association for the Application of Neuroscientific Knowledge to Social Aims (AU-CNS), Pietrasanta, Lucca, Italy; ‡Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada; §Medical University of Vienna, Neuroimaging Labs, Austria; ∥Institute of Mental Health, Department of Psychiatry, and ¶Department of Psychiatry, University of British Columbia; #Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital; and **School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada. 

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Impact of Cannabis Use During Stabilization on Methadone Maintenance Treatment

Background and Objectives

Illicit drug use, particularly of cannabis, is common among opiate-dependent individuals, and has the potential to impact treatment in a negative manner.

Methods

To examine this, patterns of cannabis use prior to and during methadone maintenance treatment (MMT) were examined to assess possible cannabis-related effects on MMT, particularly during methadone stabilization. Retrospective chart analysis was used to examine outpatient records of patients undergoing MMT (n=91), focusing specifically on past and present cannabis use and its association with opiate abstinence, methadone dose stabilization, and treatment compliance.

Results

Objective rates of cannabis use were high during methadone induction, dropping significantly following dose stabilization. History of cannabis use correlated with cannabis use during MMT, but did not negatively impact the methadone induction process. Pilot data also suggested that objective ratings of opiate withdrawal decrease in MMT patients using cannabis during stabilization.

Conclusions and Scientific Significance

The present findings may point to novel interventions to be employed during treatment for opiate dependence that specifically target cannabinoid-opioid system interactions.

Full article at:   http://goo.gl/hFf8AP

By:  Jillian L. Scavone, PhD,1 Robert C. Sterling, PhD,2 Stephen P. Weinstein, PhD,2 and Elisabeth J. Van Bockstaele, PhD1

¹Department of Neuroscience, Farber Institute for Neurosciences (http://www.jefferson.edu/university/farber_institute.html), Thomas Jefferson University, Philadelphia, Pennsylvania

²Department of Psychiatry and Human Behavior, Thomas Jefferson University, Philadelphia, Pennsylvania

Address correspondence to Dr. Sterling, Division of Substance Abuse Programs, 1021 S 21st St, 2nd Floor, Philadelphia, PA 19146. Email:ude.nosreffej@gnilrets.treboR

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A More In‐Depth Look at Prescription Opioids

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By:  http://goo.gl/WUevak and http://goo.gl/kjharo

Psychiatric Comorbidity and Substance Use Outcomes in an Office-Based Buprenorphine Program Six Months Following Hurricane Sandy

BACKGROUND:

On October 2012, Hurricane Sandy struck New York City, resulting in unprecedented damages, including the temporary closure of Bellevue Hospital Center and its primary care office-based buprenorphine program.

OBJECTIVES:

At 6 months, we assessed factors associated with higher rates of substance use in buprenorphine program participants that completed a baseline survey one month post-Sandy (i.e. shorter length of time in treatment, exposure to storm losses, a pre-storm history of positive opiate urine drug screens, and post-disaster psychiatric symptoms).

METHODOLOGY:

Risk factors of interest extracted from the electronic medical records included pre-disaster diagnosis of Axis I and/or II disorders and length of treatment up to the disaster. Factors collected from the baseline survey conducted approximately one month post-Sandy included self-reported buprenorphine supply disruption, health insurance status, disaster exposure, and post-Sandy screenings for PTSD and depression. Outcome variables reviewed 6 months post-Sandy included missed appointments, urine drug results for opioids, cocaine, and benzodiazepines.

RESULTS:

129 (98%) patients remained in treatment at 6 months, and had no sustained increases in opioid-, cocaine-, and benzodiazepine-positive urine drug tests in any sub-groups with elevated substance use in the baseline survey. Contrary to our initial hypothesis, diagnosis of Axis I and/or II disorders pre-Sandy were associated with significantly less opioid-positive urine drug findings in the 6 months following Sandy compared to the rest of the clinic population.

CONCLUSION:

These findings demonstrate the adaptability of a safety net buprenorphine program to ensure positive treatment outcomes despite disaster-related factors.

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By:  Tofighi B1, Grossman E2, Goldfeld KS1, Williams AR1,3, Rotrosen J3, Lee JD1,2.

• 1a Department of Population Health , New York University School of Medicine , New York , New York , USA.
• 2b Division of General Internal Medicine , New York University School of Medicine , New York , New York , USA.
• 3c Department of Psychiatry , New York University School of Medicine , New York , New York , USA. 

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Short-Term Outcomes for Opiate and Crack Users Accessing Treatment: The Effects of Criminal Justice Referral and Crack Use

BACKGROUND/AIMS:

The English drug treatment population doubled in size between 1998 and 2008, increasingly characterised by crack cocaine use and criminal justice system (CJS) referral. We assessed short-term (median 3.5 month) behaviour changes following participation in drug treatment and the moderating effect of CJS referral/crack use.

METHODS:

Opiate and/or crack cocaine users (n = 1,267) were recruited from 342 agencies. Outcome effects were assessed via interaction term regression, clustered at participant level, controlling for client characteristics. Treatment retention effects were tested via Cox proportional hazard models.

RESULTS:

Statistically significant improvements in health, drug use and offensive behaviour were observed (e.g. heroin use from 87 to 51%, acquisitive offending from 47 to 23%). Referral route was not associated with variation in outcomes. Crack use at baseline was associated with a greater chance of non-fatal overdose at follow-up but a greater reduction in offending income (p = 0.002, 95% CI £104-£419).

CONCLUSION:

Despite changes in the English drug treatment population, equivalent short-term improvements in client behaviour were observed a decade earlier. Outcomes for CJS-referred clients were comparable to non-CJS. Crack use at treatment entry offered some scope for greater improvements in offending but may be a barrier to cessation of mortality-associated risky behaviour.

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By:   Jones A1, Hayhurst KP, Millar T, Pierce M, Dunn G, Donmall M.

• 1Centre for Epidemiology, Institute of Population Health, University of Manchester, Manchester, UK. 

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Frequency of Hepatitis B & C Viruses & HIV among Drug Addicts in the Eastern Anatolia, Turkey

Hepatitis B, hepatitis C and HIV infections constitute serious healthcare problems worldwide.

There are a limited number of studies regarding the prevalence of hepatitis B, hepatitis C and HIV infections among the drug addicts in Turkey; hence, the current study aimed to determine the frequency of these infections among 235 drug addicts treated in a drug addiction treatment centre/Elazig, Turkey.

HBsAg, anti-HBs, anti-HCV and anti-HIV tests in 235 drug addicts were studied by ELISA technique. Urine samples obtained from drug addicts were analyzed for cannabis, opiate and cocaine metabolites.

All the 235 drug users were males, and their mean age was 30.69 ± 9.494 years; 112 (47.7%) of them were in the age group ranging 20 - 29 years (P < 0.05). Of 235 drug addicts, 113 (48.1%) and 115 (48.9%) were only cannabis and opiate users, respectively. In urine samples of seven (3%) drug addicts both cannabis and opiate metabolites were detected. Cocaine was detected in none of the urine samples. The frequencies of HBsAg, anti-HBs and anti-HCV among drug addicts were 2.6%, 38.3%, and 9.4%, respectively. None of the drug addicts was positive for HIV. Anti-HCV was more prevalent in opiate users than in cannabis users: 15.7% vs. 1.8% (P < 0.001).

The obtained results showed that HCV infection was an alarming problem among opiate users in the eastern part of Turkey. It is suggested to rapidly diagnose the infected persons; thus preventive measures and appropriate control may limit further transmission of these infections.

Table 1.

Distribution of HBV, HCV Markers, Cannabis and Opiate Users Regarding the Age a

Characteristics	No Tested	HBsAg Positive	Anti-HBs Positive	Anti-HCV Positive	Cannabis Positive	Opiate Positive
Overall	235	6 (2.6)	90 (38.3 )	22 (9.4)	113 (48.1)	115 (48.9)
Age, y
< 20	14 (6)	0	10 (11.1 )	0	4 (3.5)	10 (8.7)
20 - 29	112 (47.7)	2 (33.3)	35 (38.9 )	5 (22.7)	70 (61.9)	42 (36.5)
30 - 39	68 (28.9)	2 (33.3 )	25 (27.8 )	7 (31.8)	27 (23.9)	38 (33)
40 - 49	26 (11.1)	1 (16.7 )	13 (14.4 )	5 (22.7)	7 (6.2)	17 (14.8)
50 - 59	15 (6.4)	1 (16.7 )	7 (7.8 )	5 (22.7)	5 (4.4)	8 (7)

a Data are presented as No (%).

Table 2.

Frequency of HBV and HCV Markers in Cannabis and Opiate Users a

HBV and HCV Markers	Cannabis Users, n= 113	Opiate Users, n= 115	P Value
HBsAg
Negative	109 (96.5)	113 (98.3)
Positive	4 (3.5)	2 (1.7)	> 0.05
Anti-HBs
Negative	68 (60.2)	74 (64.3)
Positive	45 (39.8)	41 (35.7)	> 0.05
Anti-HCV
Negative	111 (98.2)	97 (84.3)
Positive	2 (1.8)	18 (15.7)	< 0.001

a Data are presented as No (%).

Full article at: http://goo.gl/gWoJlM

By: Nuran Karabulut,1,* Yasemin Bulut,2 and Selda Telo3

²Department of Medical Microbiology, Medical Faculty, Firat University, Elazig, Turkey

³

Department of Medical Microbiology, Mental Health Hospital, Elazig, Turkey

1Department of Medical Microbiology, Mental Health Hospital, Elazig, Turkey

  

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Clinical Needs of Patients with Problem Drug Use

Illicit drug use is a serious public health problem associated with significant co-occurring medical disorders, mental disorders, and social problems. Yet most individuals with drug use disorders have never been treated, though they often seek medical treatment in primary care. The purpose of this study was to examine the baseline characteristics of people presenting in primary care with a range of problem drug use severity to identify their clinical needs.

We examined sociodemographic characteristics, medical and psychiatric comorbidities, drug use severity, social and legal problems, and service utilization for 868 patients with drug problems. These patients were recruited from primary care clinics in a medical safety net setting. Based on Drug Abuse Screening Test results, individuals were categorized as having low, intermediate, or substantial/severe drug use severity.

Patients with substantial/severe drug use severity had serious drug use (opiates, stimulants, sedatives, intravenous drugs); high levels of homelessness (50%), psychiatric comorbidity (69%), and arrests for serious crimes (24%); and frequent use of expensive emergency department and inpatient hospitals. Patients with low drug use severity were primarily users of marijuana, with little reported use of other drugs, less psychiatric comorbidity, and more stable lifestyles. Patients with intermediate drug use severity fell in between the substantial/severe and low drug use severity subgroups on most variables.

Patients with the highest drug use severity are likely to require specialized psychiatric and substance abuse care, in addition to ongoing medical care that is equipped to address the consequences of severe/substantial drug use, including intravenous drug use. Because of their milder symptoms, patients with low drug use severity may benefit from a collaborative care model that integrates psychiatric and substance abuse care in the primary care setting. Patients with intermediate drug use severity may benefit from selective application of interventions suggested for patients with the highest and lowest drug use severity. Primary care safety net clinics are in a key position to serve patients with problem drug use by developing a range of responses that are locally effective and that may also inform national efforts to establish patient-centered medical homes and to implement the Affordable Care Act.

Full article at: http://goo.gl/9PHMze

By: Krupski A1, West II2, Graves MC2, Atkins DC2, Maynard C2, Bumgardner K2, Donovan D2, Ries R2, Roy-Byrne P2.

• 1From the Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington at Harborview Medical Center, Seattle (AK, IIW, MCG, DCA, KB, DD, RR, PR-B); the Department of Health Services, University of Washington School of Public Health, Seattle (CM); and the Alcohol & Drug Abuse Institute, University of Washington, Seattle (DD). krupski@uw.edu.
• 2From the Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington at Harborview Medical Center, Seattle (AK, IIW, MCG, DCA, KB, DD, RR, PR-B); the Department of Health Services, University of Washington School of Public Health, Seattle (CM); and the Alcohol & Drug Abuse Institute, University of Washington, Seattle (DD). 

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A Review of Ethylphenidate in Deaths in East & West Scotland

Ethylphenidate is a psychostimulant and analogue of methylphenidate. Interestingly it is also produced as a metabolite from the co-ingestion of methylphenidate and alcohol (ethanol). In the UK, between April and June 2015, ethylphenidate and 6 other methylphenidate based novel psychoactive substances (NPS) were subjected to a temporary class drug order under the Misuse of Drugs Act 1971. Ethylphenidate is being abused by both novel and habitual drug users, more prominently in the East of Scotland. What is unknown in the literature is the contribution of ethylphenidate in deaths. 

A search was conducted for an 18 month period (July 2013 to December 2014) to identify cases where ethylphenidate was detected during post-mortem toxicological analysis. Nineteen cases were identified and these cases were examined with regards to case circumstances, pathology findings, toxicology results and adverse effects. 

The individuals ranged in age from 20 to 54 (median 37) and the majority were male (n=14) and from the East of Scotland (n=16), more specifically Edinburgh and surrounding area. Current or previous heroin abuse was a common theme in these cases (n=16) and injection was a common route of administration of "legal highs" or "burst". 

The concentration of ethylphenidate in the cases ranged from 0.008mg/L to over 2mg/L in post-mortem femoral blood (median 0.25mg/L, average 0.39mg/L). Other drugs commonly detected were benzodiazepines (n=15), followed by opiates (n=11, 4 of which were positive for 6-monoacetylmorphine) and then methadone (n=8). All 19 cases received a full post-mortem examination and there were 10 cases where drug toxicity was the sole or potentially contributory factor to the cause of death. 

Ethylphenidate was specifically mentioned in the cause of death for 5 cases, chronic intravenous (IV) drug use was named as part of the cause of death for 2 cases and in 6 cases there was evidence of complications and infections through IV drug use. As far as it is known to the authors, this is the first review of post-mortem cases involving the use of ethylphenidate in East and West Scotland. 

This study can be used as a guide for toxicologists and pathologists when interpreting cases which are positive for ethylphenidate.

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By: Parks C1, McKeown D2, Torrance HJ3.

• 1Forensic Medicine and Science, University of Glasgow, Glasgow G12 8QQ, United Kingdom.
• 2Forensic Medicine and Science, University of Glasgow, Glasgow G12 8QQ, United Kingdom
• 3Forensic Medicine and Science, University of Glasgow, Glasgow G12 8QQ, United Kingdom

Quantifying Crime Associated with Drug Use among a Large Cohort of Sanctioned Offenders in England & Wales

To assess the relationship between testing positive for opiates and/or cocaine and prior offending.

139,925 persons (107,573 men) identified from a saliva test for opiate and cocaine metabolites following arrest in England and Wales, 1 April 2005-31 March 2009, were case-linked with 2-year recorded offending history. 

• The relationship between testing positive for opiates and cocaine and prior two-year offending was greater for women than men. 
• The association was weaker for those testing positive for opiates only. 
• Men testing positive for cocaine only had a lower rate of prior offending, women had a higher rate. 
• The strongest associations were for non-serious acquisitive crimes (e.g. dually-positive: prostitution (women-only); shoplifting; women). 
• Testing positive for opiates and cocaine was associated with violent offences among women.

Among drug-tested offenders, opiate use is associated with elevated prior offending and the association is stronger for women than men. Cocaine use is associated with prior offending only among women.

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Via: Pierce M1, Hayhurst K2, Bird SM3, Hickman M4, Seddon T5, Dunn G6, Millar T7.

• 1Centre for Mental Health and Risk, University of Manchester, 4th Floor, Ellen Wilkinson Building, Oxford Road, M13 9PL Manchester, UK.
• 2Centre for Mental Health and Risk, University of Manchester, 4th Floor, Ellen Wilkinson Building, Oxford Road, M13 9PL Manchester, UK.
• 3MRC Biostatistics Unit, Institute of Public Health, University Forvie Site, Robinson Way, CB2 0SR Cambridge, UK.
• 4School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, BS8 2PS Bristol, UK.
• 5School of Law, University of Manchester, 4.46A Williamson Building, Oxford Road, M13 9PL Manchester, UK.
• 6Centre for Biostatistics, University of Manchester, Jean McFarlane Building (First Floor), Oxford Road, Manchester M13 9PL, UK
• 7Centre for Mental Health and Risk, University of Manchester, 4th Floor, Ellen Wilkinson Building, Oxford Road, M13 9PL Manchester, UK 
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