New Resources and Events Available on ATForum.com

Have you visited ATForum.com lately? Over 30 new meetings, conferences, and webinars have been added to the site in addition to key new resources including the following on medication-assisted treatment.

Neonatal Abstinence Syndrome: How States Can Help Advance the Knowledge Base for Primary Prevention and Best Practices of Care
Association of State and Territorial Health Officials – March 2014.

Confronting the Stigma of Opioid Use Disorder—and Its Treatment
Journal of the American Medical Association – February 26, 2014.

Medication-Assisted Treatment With Methadone: Assessing the Evidence
Psychiatric Services – February 1, 2014.

Medication-Assisted Treatment With Buprenorphine: Assessing the Evidence
Psychiatric Services – February 1, 2014.

Medscape Ask the Pharmacist: Methadone or Buprenorphine for Maintenance Therapy of Opioid Addiction: What’s the Right Duration
Medscape – February 3, 2014. Note: A Medscape account is required to view this article. If you do not have a Medscape account you can create one for free.

Advancing Service Integration in Opioid Treatment Programs for the Care and Treatment of Hepatitis C Infection
International Journal of Clinical Medicine – January 2014.

Advancing Access to Addiction Medications Report
American Society of Addiction Medicine (ASAM) – December 2013.

Half of Veterans Prescribed Medical Opioids Continue to Use Them Chronically, Study Finds

“Of nearly 1 million veterans who receive opioids to treat painful conditions, more than half continue to consume opioids chronically or beyond 90 days, new research says. Results presented at the 30th Annual Meeting of the American Academy of Pain Medicine reported on a number of factors associated with opioid discontinuation with the goal of understanding how abuse problems take hold in returning veterans.

Of 959,226 veterans who received an opioid prescription, 502,634 (representing 52.4% of the total sample) used opioids chronically.

The preliminary analysis showed that certain factors were more likely to be present in veterans who continued to use opioids chronically. They include post-traumatic stress disorder, tobacco use, being married, having multiple chronic pain conditions, the use of multiple opioids and opioid dose above 100 mg per day.

Some findings did not align with previous research in the fields of pain and addiction.

The press release is available at: http://www.newswise.com/articles/half-of-veterans-prescribed-medical-opioids-continue-to-use-them-chronically-study-finds

Source: American Academy of Pain Medicine (AAPM) – March 7, 2014

Fewer Opioid Treatment Programs Offer HIV Testing

“According to a study, fewer opioid treatment programs are offering onsite testing for HIV and sexually transmitted infections (STIs), despite guidelines from the Centers for Disease Control and Prevention (CDC) recommending routine HIV testing in all health care settings.

The absolute number of programs offering testing for HIV, STIs, and HCV increased from 2000 to 2011. However, the percentage of programs offering HIV testing decreased significantly, by 18%, and the percentage of those offering testing for STIs fell by 13% throughout the study. Testing for each infection did not change over time in public programs, but HIV testing dropped by 20% among for-profit programs and 11% in nonprofit programs.

http://www.pharmacytimes.com/publications/issue/2014/February2014/Fewer-Opioid-Treatment-Programs-Offer-HIV-Testing

Source: PharmacyTimes.com - February 19, 2014

International Journal of Drug Policy Celebrates its 25th Anniversary – 25 Free Downloads Available from Past Issues

Articles of interest related to opioid dependence and addiction include:

  • Gender sameness and difference in recovery from heroin dependence: A qualitative exploration – September 2013
  • Interventions to prevent HIV and Hepatitis C in people who inject drugs: A review of reviews to assess evidence of effectiveness – August 2013
  • What has been achieved in HIV prevention, treatment and care for people who inject drugs, 2010–2012? A review of the six highest burden countries – October 2013
  •  
  • Syringe access, syringe sharing, and police encounters among people who inject drugs in New York City: A community-level perspective – August 2013
  • “I felt like a superhero”: The experience of responding to drug overdose among individuals trained in overdose prevention – August 2013
  • Brief overdose education can significantly increase accurate recognition of opioid overdose among heroin users – June 2013
  • Does informing people who inject drugs of their hepatitis C status influence their injecting behaviour? Analysis of the Networks II study – December 2013

http://www.ijdp.org/issues?issue_key=S0955-3959(13)X0007-6

Source: International Journal of Drug Policy – January 2014

New Mexico Jail Methadone Program Shows Mixed Results

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jail cropped“A recent study conducted by the University of New Mexico found that inmates in the methadone maintenance program, which provides a daily dose of methadone to inmates already enrolled in a community-based methadone program, spent almost 40 days longer out of jail than their opiate-addicted counterparts not enrolled in a methadone program. That amounts to per-inmate savings to taxpayers of almost $2,700, according to the study, as taxpayers shell out around $69 to house an inmate per day.

The study published in early December, however, contains another finding that erases the savings: Inmates enrolled in the methadone program tended to stay in jail 36 days longer than other inmates. It’s unclear what causes methadone inmates to stay longer, though the program’s directors and others have a couple guesses – that methadone-receiving inmates are more comfortable in jail than those addicted to heroin, and that inmates getting methadone tend to prefer serving their full sentences and leaving jail without probation.”

http://www.abqjournal.com/331644/news/methadone-program-shows-mixed-results.html

Source:  ABQJournal.com – January 6, 2014

Beating the Poppy Seed Defense: New Test Can Distinguish Heroin Use from Seed Ingestion

“Heroin is one of the most widely used illegal drugs in the world, but drug testing has long been challenged by the difficulty in separating results of illicit heroin users from those who have innocently eaten poppy seeds containing a natural opiate. Research in Drug Testing and Analysis explores a new test which may present a solution to this so-called ‘poppy seed defense.’

The team sought to identify an acetylated derivative which is known to be present in street heroin, but would not be found in either poppy seeds or medicines containing opiates. The authors identified a unique glucuronide metabolite (designated ‘ATM4G’) which could be used as a marker of street heroin use. A high frequency for the presence of ATM4G in urine strongly suggests that detection of this metabolite may offer an important advance in workplace drug testing and forensic toxicology, providing a potential solution to the poppy seed defense.

‘This research report addresses a longstanding analytical problem in forensic toxicology and workplace drug testing, by identifying a urinary marker that differentiates street heroin users from those whom have ingested morphine present in poppy seeds’ said Dr. Andrew Kicman, from the Department of Forensic and Analytical Science at King’s College, London.”

http://www.eurekalert.org/pub_releases/2014-01/w-btp010714.php

Source:  Eurekalert.org – January 7, 2014

Monitoring the Future Results Released

In mid-December, The National Institute on Drug Abuse (NIDA) announced the results of its 2013 Monitoring the Future (MTF) survey. The survey, conducted earlier in the year by scientists at the University of Michigan, tracks annual drug abuse trends of eighth, 10th, and 12th-grade students. NIDA is a component of the National Institutes of Health (NIH).

MTF is one of three major survey instruments the Department of Health and Human Services uses to monitor the nation’s substance abuse patterns among teens.

This year’s announcement focused on attitudes about and prevalence of marijuana use, as well as abuse of synthetic drugs, prescription medications, and tobacco.

Prescription Medications – There was mixed news regarding abuse of prescription medications. The survey shows continued abuse of Adderall, commonly used to treat attention deficit hyperactivity disorder, or ADHD, with 7.4 percent of seniors reporting taking it for non-medical reasons in the past year. However, only 2.3 percent of seniors report abuse of Ritalin, another ADHD medication. Abuse of the pain reliever Vicodin has shown a marked decrease in the last 10 years, now measured at 5.3 percent for high school seniors, compared to 10.5 percent in 2003.

Heroin – For cocaine and heroin, while there was no significant change from the 2012 rates, there continues to be a gradual decline in use, with both drugs at historic lows in all three grades. The 2013 rate for high school seniors for past year cocaine use is 2.6 percent, compared to a peak of 6.2 percent in 1999. Similarly, the reported use of heroin by 12th-graders is 0.6 percent this year, compared to a peak of 1.5 percent in 2000.

http://www.drugabuse.gov/related-topics/trends-statistics/monitoring-future

Source: National Institute on Drug Abuse – December 16, 2013

Among Prescription Painkillers, Drug Abusers Prefer Oxycodone

prescriiption pad“A nationwide survey of opioid drug abusers in rehab indicates that because of the high it produces, the prescription painkiller oxycodone is the most popular drug of choice. Hydrocodone, also prescribed to treat pain, is next in line. In all, some 75 percent of those surveyed rated one of these drugs as their favorite.

Researchers at Washington University School of Medicine in St. Louis and Nova Southeastern University in Miami questioned more than 3,500 people in 160 drug-treatment programs across the United States, asking which drugs they abuse and why. Oxycodone was favored by 45 percent, and hydrocodone was preferred by about 30 percent.

Although the drugs are meant to be taken orally, almost 64 percent of oxycodone abusers and just over one-quarter of hydrocodone abusers crushed the tablets and inhaled the drug, while one in five oxycodone abusers reported that they sometimes dissolved the drug in water and injected it. Less than 5 percent reported taking hydrocodone intravenously.

Personality, age and gender all played a role in drug preferences, the research showed. Oxycodone was attractive to those who enjoy taking risks and prefer to inject or snort drugs to get high. Young, male drug users tend to fit that profile.

In contrast, hydrocodone is the more popular choice among women, older people, people who don’t want to inject drugs and those who prefer to deal with a doctor or friend rather than a drug dealer.

The research is published in the current issue of the journal PAIN.

“Opioids are prescribed to treat pain, but their misuse has risen dramatically in recent years,” said principal investigator Theodore J. Cicero, PhD, a Washington University researcher who studies prescription drug abuse. “Our goal is to understand the personal characteristics of people who are susceptible to drug abuse, so we can detect problems ahead of time.”

Among those surveyed, 54 percent said the quality of the high was considered much better for oxycodone, compared with 20 percent who preferred the high they got from hydrocodone.

“Among the reasons addicts prefer oxycodone is that they can get it in pure form,” Cicero said. “Until recently, all drugs with hydrocodone as their active ingredient also contained another product such as acetaminophen, the pain reliever in Tylenol. That turns out to be very important because addicts don’t like acetaminophen.”

Acetaminophen causes considerable irritation when it’s injected, and when taken orally in large amounts, it can cause severe liver damage, he explained.

“Interestingly, addicts, while they’re harming their health in one respect by taking these drugs, report being very concerned about the potentially negative side effects of acetaminophen,” said Cicero, a professor of neuropharmacology in psychiatry.

Those side effects, combined with a preference for the high provided by oxycodone, have led drug abusers to seek out that drug, either on the street or by visiting physicians and attempting to convince doctors that they have pain severe enough to warrant a prescription pain killer.

Cicero is concerned with the U.S. Food and Drug Administration’s (FDA) recent approval of a new, pure form of hydrocodone without acetaminophen, a formulation he expects will be attractive to abusers.

The study also found that even among people in treatment for drug dependence, there seems to be little appetite for moving to stronger prescription narcotics such as fentanyl or various derivatives of morphine.”

The press release can be accessed at: http://news.wustl.edu/news/Pages/26204.aspx

Source: Washington University School of Medicine – November 25, 2013

 

Keeping OTP Patients in Treatment Longer: Methadone vs. Buprenorphine

hour glass1Data from the first large randomized U.S. trial comparing treatment retention of methadone and buprenorphine patients confirm what a Cochrane review—generally considered the Gold Standard—and other studies have found: treatment retention is much higher with methadone than with buprenorphine, although  the two are equally effective in suppressing illicit opioid use.

The current study is actually a secondary analysis, using data from a large, multisite, open-label study assessing liver function in individuals treated for opioid dependence. The original study enrolled participants from nine opioid treatment programs (OTPs) between 2006 and 2009, randomized to receive either methadone or buprenorphine (as buprenorphine/naloxone). Buprenorphine patients in that study were more than 50 percent less likely than methadone patients to remain in treatment for 24 weeks.

The data were gathered from 529 methadone and 738 buprenorphine patients. (Investigators changed the original 1:1 ratio to 2:1 because of a higher number of buprenorphine dropouts.) Measurements included patient characteristics at baseline, medication dose and urine drug screens at baseline and weekly, days in treatment, and treatment completion.

The goal of the study was to examine patient and medication characteristics associated with treatment retention and continued illicit opioid use in patients given methadone vs. buprenorphine/naloxone.

Study Group

  • Average age 37 years; two-thirds were male
  • 71% white, 12% Hispanic, 9% African American
  • About 90% smoked cigarettes, 27% used alcohol, 69% had injected drugs during the previous 30 days
  • Positive test results for drugs other than opioids: cocaine, 37%; amphetamine, 9%; marijuana, 24%

Patients were told to abstain from opioids for 12 to 24 hours before study onset, to achieve mild-to-moderate opioid withdrawal.

Key Findings

  • Significantly more buprenorphine patients than methadone patients (25% vs. 8%) dropped out within the first 30 days
  • Significantly more methadone than buprenorphine patients completed treatment (74% vs. 46%)
  • Completion rate was even higher with higher daily doses
    • For methadone: 80% or higher with 60 mg or more; 91% or higher with 120 mg or more
    • For buprenorphine (which showed a linear dose-relationship): 60% with 30 to 32 mg, the study maximum
    • Factors associated with higher dropout rates included being younger, being Hispanic (relative to white), and using heroin, cannabinoids, cocaine, or amphetamine during treatment
    • Higher medication dose was related to lower opiate use, especially in the buprenorphine group

Average maximum daily doses for methadone were 93.1 mg (range, 5 to 397 mg), and for buprenorphine, 22.1 mg (range, 2 to 32 mg).

Investigators noted three important findings about buprenorphine retention:

  • About 25% of buprenorphine patients dropped out during the first 30 days, “suggesting a critical period calling for special efforts in retaining these participants”
  • During the first 9 weeks, positive opiate urine results were significantly lower among those receiving buprenorphine, confirming the drug’s advantage of a much shorter induction time
  • A linear positive relationship between dose and treatment completion rate suggested “the benefit of dosing greater than the common practice of a maximum dose of 16 mg”

Buprenorphine Doses and Treatment Outcomes

Even patients taking 30 to 32 mg buprenorphine daily, the maximum for this study, had a retention rate lower than the methadone group (60 percent vs. 74 percent), and about 30 percent continued opioid use. “These findings suggest that participants may yet fare better with [buprenorphine] doses higher than the 32 mg used in this study,” the authors said. They commented on the generally high safety profile of buprenorphine: “We believe with proper monitoring safety will not be a clinical concern in such an effort.”

The authors cited a large investigation (Di Petta) linking daily buprenorphine doses as high as 56 mg with a retention rate of over 92 percent at 30 months. They also drew a comparison to the previous long-standing practice of limiting daily methadone doses to 40 mg—later shown to be highly inadequate, with most patients needing 60 to 120 mg or more.

(Although many sources cite a maximum daily dose of 32/8 mg buprenorphine/naloxone, this is not the first clinical study to investigate higher doses. Studies such as this are based on clinical evidence, designed with safety checks in place, and approved by an institutional review board.)

*   *   *

Reference

Hser YI, Saxon AJ, Huang D, et al. Treatment retention among patients randomized to buprenorphine/naloxone compared to methadone in a multi-site trial. [Epub ahead of print August 20, 2013.]  Addiction. doi: 10.1111/add.12333.

 Resources

Di Petta G, Leonardi C. Buprenorphine high-dose, broad spectrum, long-term treatment: A new clinical approach to opiate alkaloid dependency. Heroin Add & Rel Clin Probl. 2005;7(3):21-26.

Kakko J, Grönbladh L, Dybrandt Svanborg K, et al. A stepped care strategy using buprenorphine and methadone versus conventional methadone maintenance in heroin dependence: a randomized controlled trial. Am J Psychiatry. 2007;164:797-803. doi:10.1176/appi.ajp.164.5.797.

Mattick RP, Kimber J, Breen C, Davoil M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2008;16(2):CD002207. doi: 10.1002/14651858.CD002207.pub3.

Pinto H, Maskrey V, Swift L, Rumball D, Wagle A, Holland R. The SUMMIT trial: a field comparison of buprenorphine versus methadone maintenance treatment. J Subst Abuse Treat. 2010;39(4):340-352. doi: 10.1016/j.jsat.2010.07.009. PMID: 20817384.

Longer-Term Buprenorphine Tapering Improved Opioid Abstinence

“Outpatients addicted to prescription opioids may benefit from a 4-week taper regimen followed by naltrexone maintenance, according to data published in JAMA Psychiatry.

Compared with prescription opioid-dependent adults who were tapered off for 1 or 2 weeks, those who were tapered off for 4 weeks experienced greater abstinence from opioids.

The double blind, 12-week randomized trial included 70 adult outpatients addicted to prescription opioids. Participants were randomly assigned to a buprenorphine tapering regimen of 1, 2 or 4 weeks, plus naltrexone therapy. The intervention was split into two phases: phase 1 occurred between 1 and 5 weeks from randomization, during which time participants attended the outpatient clinic daily; phase 2 occurred between weeks 6 and 12, and participants attended the clinic three times per week. Behavioral therapy and urine toxicology tests were provided during both phases of the trial.”

http://www.healio.com/psychiatry/substance-use-disorders/news/online/%7B7dfc4c9b-288c-4375-86f0-ac05ebef9c68%7D/longer-term-buprenorphine-tapering-improved-opioid-abstinence

Source: Healio.com – October 23, 2013

Almost Half of Hospitalized Heroin Users Self-Report Good Health

hospital sign purchasedshutterstock_33280960“Nearly half of heroin users who are hospitalized for medical or surgical treatment perceive themselves to be in good, very good, or excellent health, “underlining a disconnect between addiction and perceived health status,” according to a study of 112 patients.

The apparent disparity between self-reported health and disease burden suggests that “perceptions of health status may not actually reflect physical health but a different construct altogether,” Lidia Z. Meshesa and her colleagues wrote.

The investigators enrolled 112 non–treatment-seeking hospitalized heroin users in the study. The average age of the participants was 40 years, and 72% were male, reported Ms. Meshesa, of the Clinical Research and Education (CARE) Unit at Boston Medical Center, and her coauthors (Addict. Behav. 2013;38:2884-7). None was currently in treatment for substance abuse. All the participants completed a standard questionnaire on health-related quality of life and were asked detailed questions about their drug use and mental and physical health histories.”

http://www.clinicalpsychiatrynews.com/news/neurology/single-article/almost-half-of-hospitalized-heroin-users-self-report-good-health/572f62cb339ce00cb34f0fd033eb9228.html

Source: ClinicalPsychiatryNews.com – October 21, 2013

Death From Drugs Like Oxycodone Linked to Economically Disadvantaged Neighborhoods, Family Fragmentation

Death from analgesic overdose, including oxycodone and codeine, is more concentrated in economically disadvantaged neighborhoods with fragmented families than other types of deaths from unintentional causes, according to new research from the American Journal of Public Health. Yet, compared to heroin overdose deaths, analgesic overdoses were found to occur in higher-income neighborhoods.

Researchers analyzed data from the Office of the Chief Medical Examiner of New York City, to understand the role of neighborhood characteristics, including income distribution, quality of built environment and family fragmentation, in analgesic overdose deaths. Analgesic overdose fatalities were compared against heroin overdoses and non-overdose accidental deaths, which included instances like drownings, poisonings, falls and other accidents.

http://www.medicalnewstoday.com/releases/267428.php

Source: MedicalNewsToday.com – October 17, 2013

National Safety Council Report: Only Three States Adequately Addressing Prescription Drug Abuse

NSCThe National Safety Council (NSC) released its report, Prescription Nation: Addressing America’s prescription drug abuse epidemic showing 47 states must improve existing standards if they are to reduce the number of deaths involving prescription drug overdoses. NSC is calling on states to take immediate action to improve the prescribing, monitoring, treatment and availability of opioid pain relievers.

Prescription drug abuse is a growing public health epidemic. Forty-five people die every day from overdoses of prescription pain relievers, accounting for more deaths than cocaine and heroin combined. Enough pain killers were prescribed in 2010 to medicate every American adult around the clock for one month.

“For the first time since WWII, something other than motor vehicle crashes is the leading cause of unintentional injury deaths for Americans ages 25-64,” said John Ulczycki, vice president of strategic initiatives at NSC. “Countless lives already have been lost. NSC will be working to confront this issue on a national level.”

In the report, NSC examined state efforts in four areas: state leadership and action, prescription drug monitoring programs, responsible painkiller prescribing and overdose education and prevention programs.

Kentucky, Vermont and Washington were the only states that met standards in all four areas.

Fourteen states - Arizona, Delaware, Hawaii, Idaho, Iowa, Kansas, Maine, Missouri, Nebraska, New Hampshire, Pennsylvania, South Carolina, South Dakota and Wyoming – failed to meet standards.

Visit nsc.org/rxreport to receive the full report and learn more about solutions to this growing epidemic. Note: Registration is required to access the report. NSC also developed an infographic illustrating the scope of the problem. The infographic can be downloaded at nsc.org/rxnation.

http://www.prnewswire.com/news-releases/nsc-report-only-three-states-adequately-addressing-prescription-drug-abuse-227719161.html

Source: PRNewsWire.com – October 14, 2013

National Survey Shows Continued Reduced Levels Of Prescription Drug Use Among Young Adults

The rate of past month nonmedical use of prescription drugs among young adults aged 18 to 25 in 2012 was 5.3 percent – similar to rates in 2010 and 2011, but significantly lower than the rate from 2009 (6.4 percent), according to a new report by the Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA issued its 2012 National Survey on Drug Use and Health (NSDUH) report in conjunction with the 24th annual national observance of National Recovery Month.

Overall, the use of illicit drugs among Americans aged 12 and older remained stable since the last survey in 2011. The NSDUH report shows that 23.9 million Americans aged 12 or older were current (past month) illicit drug users – (9.2 percent of the population 12 and older).

Marijuana continues to be the most commonly used illicit drug. In 2012, 7.3 percent of Americans were current users of marijuana – up from 5.8 percent in 2007. Although past month use of marijuana rose in nearly every age group between 2007 and 2012, it did drop among those aged 12 to 17 from 7.9 percent in 2011 to 7.2 percent in 2012.

 In addition to marijuana, the use of heroin also rose significantly. The number of people aged 12 and older who used heroin in the past year rose from 373,000 in 2007 to 669,000 in 2012.

 “Reducing the impact of drug use and its consequences on our Nation requires a robust public health response coupled with smart on crime strategies that protect public safety,” said Gil Kerlikowske, Director of the Office of National Drug Control Policy. “For the first time in a decade, we are seeing real and significant reductions in the abuse of prescription drugs in America, proving that a more comprehensive response to our drug problem can make a real difference in making our nation healthier and safer. Expanding prevention, treatment, and support for people in recovery for substance use disorders will be our guide as we work to address other emerging challenges, including the recent uptick in heroin use shown in this survey.”

 The 2012 report also showed that many Americans needing treatment for a substance use disorder are still not receiving specialty treatment. According to the report 23.1 million Americans aged 12 or older needed treatment for an illicit drug or alcohol use problem in 2012 and only 2.5 million (or 10.8 percent of those in need) received it in a specialized treatment setting.

 NSDUH is a scientifically conducted annual survey of approximately 70,000 people throughout the country, aged 12 and older. Because of its statistical power, it is a primary source of statistical information on the scope and nature of many substance abuse and mental health issues affecting the Nation.

The press release can be accessed at: http://www.samhsa.gov/newsroom/advisories/1309033910.aspx

The report and detailed tables can be accessed at: http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/Index.aspx

Source: SAMHSA – September 4, 2013

POLL QUESTION: Should Methadone Programs Include Birth Control?

question boxUniversity of Maine researcher Marie Hayes says she has been criticized for her opinion that methadone programs should incorporate birth control for addicted women.

“That sounds like you’re saying, ‘These defective people shouldn’t reproduce,’ so I’ve been attacked by social workers for that position [who say] ‘Why can’t they have a family like everyone else?’ And the answer is they can, as soon as they get their health back.”

She did not suggest that methadone programs should incorporate sterilization.”

As of July 25, there 656 total votes and 83.24% voted yes.

http://bangordailynews.com/2013/07/16/health/should-methadone-programs-include-birth-control/

Source: BangorDailyNews.com – July 16, 2013

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