U.S. Attorney General Holder Urges Use of Drug to Help In Heroin ODs

Attorney General Eric Holder declaring heroin addiction is an “urgent and growing public health crisis,” urged first responders to carry the drug naloxone that helps resuscitate victims from an overdose.

“Addiction to heroin and other opiates — including certain prescription pain-killers — is impacting the lives of Americans in every state, in every region, and from every background and walk of life — and all too often, with deadly results,” Holder said in a video message posted Monday on the Justice Department website.”

http://www.usatoday.com/story/news/politics/2014/03/10/holder-heroin-overdose-help/6247281/

Source: USAToday.com – March 10, 2014

National Institute on Drug Abuse (NIDA) Updated Research Report on Heroin

Message from AATOD Regarding the Death of Philip Seymour Hoffman

AATOD“Philip Seymour Hoffman’s death has attracted national media attention as most celebrity deaths do, especially when they relate to a drug overdose. We have seen this phenomenon shortly after the deaths of Anna Nicole Smith and Michael Jackson. There was an immediate flurry of media attention, and then other stories took center stage.

For many addiction treatment professionals and patient advocates, the issues surrounding celebrity deaths represent the daily struggles that must be confronted by a wary public. A number of issues naturally come to surface during such times about opioid addiction and treatment.”

The AATOD message addresses:

  • Changing Social Attitudes
  • Changing Federal and State Oversight
  • The Opportunity to Educate

“The tragedy of Mr. Hoffman’s death will inevitably be revisited by another celebrity death in the future. We will engage once again in the flurry of media stories which typically have a limited lifespan. Ultimately, we need to work effectively to change America’s perceptions about the safety and danger of prescription opioids, the danger of heroin (which is obviously not an FDA approved drug), and the value of prevention and early intervention in providing access to care. Mr. Hoffman’s death is a stark reminder of the dangers of using heroin. It is not, nor has ever been, a safe drug. The user simply does not know what the drug has been cut with or its potency.

Many people who have worked in the addiction treatment community for many years know that heroin has been adulterated with all sorts of dangerous chemicals which can lead to death. We need to continually educate the public about these issues and work with patient advocates and public policy officials to ensure that the message is consistent and sticks.”

http://www.aatod.org/news/message-from-aatod-regarding-the-death-of-philip-seymour-hoffman/

Source: The American Association for the Treatment of Opioid Dependence – February 11, 2014

Wider Use of Antidote Could Lower Overdose Deaths by Nearly 50%

“Distributing naloxone and training people to use it can cut the death rates from overdose nearly in half, according to a new study.

The new study, published in the BMJ, followed the expansion of Overdose Education and Naloxone Distribution (OEND) programs in Massachusetts.  The programs were offered at emergency rooms, primary care centers, rehabilitation centers, support groups for families of addicted people and other places that might attract those at risk.

The study involved 2912 people in 19 different Massachusetts communities — each of which had had at least 5 opioid overdose deaths between 2004 and 2006.  The participants were trained to recognize overdose, call 911 and administer naloxone using a nasal inhaler.  If the naloxone didn’t work, they were instructed to try another dose and perform rescue breathing until help arrived.

During that time, 153 naloxone-based rescues were reported for which there was data on outcomes, and in 98% of those cases, the drug revived the victim.

There are still practical barriers however, to widely distributing naloxone and implementing more OEND type programs. Advocates have argued that the medication should be made available over-the-counter since it has little potential for abuse and is nontoxic. The Centers for Disease Control (CDC), the director of the National Institute on Drug Abuse and even the drug czar’s office support making it more widely available, and unlike the case with needle exchange programs, there has been no organized opposition to OEND. But the Food and Drug Administration (FDA) has no precedent for allowing over-the-counter sales of such a drug: naloxone is a generic medication approved in an injectable form. Without a company to submit an application for its use in the intranasal version, the agency isn’t likely to OK over-the-counter sales.”

http://healthland.time.com/2013/02/05/wider-use-of-antidote-could-lower-overdose-deaths-from-by-nearly-50/

Source: HealthlandTime.com – February 5, 2014

From NIDA Notes: Medications That Treat Opioid Addiction Do Not Impair Liver Health

A trial that compared buprenorphine/naloxone (Bup/Nx) to methadone produced no evidence that either medication damages the liver. Researchers concluded that Bup/Nx and methadone are equally safe for the liver, and Bup/Nx may be considered a first line alternative to the more established medication for treating opioid addiction.

Dr. Andrew Saxon at the Veterans Affairs Puget Sound Health Care System in Seattle, and Dr. Walter Ling at the University of California, Los Angeles Integrated Substance Abuse Program, conducted the trial with colleagues in the NIDA Clinical Trials Network. Dr. Saxon’s team randomly assigned 1,269 new patients in 8 U.S. opioid treatment programs to therapy with either Bup/Nx or methadone. The study findings reflect the experiences of 731 patients who provided blood samples for liver function tests at baseline, completed the 24 weeks of active treatment, and submitted blood for at least 4 of 8 scheduled tests of liver function during treatment. These tests include measuring the levels of two enzymes (alanine aminotransferase and aspartate aminotransferase) that the liver releases when it is injured.

Most trial participants maintained enzyme levels that indicate healthy liver function throughout the study. In 15.5 percent, enzyme levels increased to higher than twice the upper end of the normal range, indicating some ongoing liver injury. A few patients developed extreme elevations to 10 times the upper limit of normal or had other laboratory signs of severe liver injury.

The percentages of Bup/Nx and methadone patients who experienced each outcome were so close as to be statistically equivalent, warranting the conclusion that both medications were similarly safe. Although the researchers could not definitively rule out the possibility that the medications contributed to some of the observed worsening of liver function, their analysis produced no evidence to this effect. Instead, they say the changes most likely resulted from hepatitis, the toxicity of illicit drugs, and impurities in those drugs. Infection with hepatitis B or C doubled a patient’s odds of a significant change in enzyme levels and was the only predictor of worsening liver function. Most extreme increases in enzyme levels occurred when a patient seroconverted to hepatitis B or C, or used illicit drugs during the study.

The researchers note that about 44 percent of those screened for the study did not meet its enrollment criteria, suggesting that the participant group was healthier than many who visit clinics for addiction treatment. The ineligible population was also older, had a higher rate of stimulant use, and was less likely to be white than patients in the enrolled group, suggesting that the evaluable patient group might not be representative of all opioid-dependent patient groups.

Graphs available at: http://www.drugabuse.gov/news-events/nida-notes/2013/12/medications-treat-opioid-addiction-do-not-impair-liver-health

Source: National Institute on Drug Abuse (NIDA) Notes – December 2013

Supreme Court: Heroin Dealer Can’t be Given Longer Sentence Because Client Died

Pg8_law“The U.S. Supreme Court unanimously ruled a heroin dealer cannot be held liable for a client’s death and given a longer sentence if heroin only contributed to the death, and was not necessarily the only cause.

The ruling is likely to result in a shorter sentence for Marcus Burrage, who received 20 extra years in prison because of his client’s death, according to USA Today. The decision is also likely to make it more difficult in the future for prosecutors to extend drug sentences, the article notes.”

MAT With Methadone or Buprenorphine: Assessing the Evidence for Effectiveness

evidenceIt’s not surprising that a thorough review of the efficacy of medication-assisted treatment (MAT) with methadone or buprenorphine reveals  a high level of evidence for the positive impact of MAT in keeping patients in treatment and reducing or eliminating illicit opioid use.

What is surprising is that the stigma against MAT persists—even though evidence suggests that methadone maintenance treatment (MMT) has a positive impact on drug-related HIV risk behaviors and criminal activity—and thus could make clinic neighborhoods safer, rather than less desirable.

The research findings on MMT and buprenorphine or buprenorphine-naloxone maintenance treatment (BMT) were published in November 2013 in two peer-reviewed articles (see References) as part of the Assessing the Evidence Base (AEB) Series sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA).

The Assessing the Evidence Base Series

SAMHSA sponsored the AEB Series to help guide providers’ decisions about which behavioral health services public and commercially funded plans should cover. The Affordable Care Act (ACA) greatly expands health care coverage and provides the opportunity “for federal and state agencies to work with private and nonprofit sectors to transform the American health care system” by developing a comprehensive set of community-based, recovery-oriented, and evidence-based services for people with mental and substance use disorders. The ACA doesn’t specify specific treatments, leaving the decision to federal, state, and local agencies, managed care organizations, and commercial and private insurers.

Deciding which services have verified effectiveness isn’t an easy task. To help in the decision-making process, the AEB Series provides a literature evaluation for 14 behavioral health services. For people with substance use disorders, they include, in addition to MMT and BMT, residential treatment, peer-recovery support, and intensive outpatient programs. The goal of the AEB Series is “to provide a framework for decision makers to build a modern addictions and mental health service system for the people who use these services and the people who provide them.”

The Studies

Authors of the MMT and BMT studies searched major databases and other sources to review meta-analyses, reviews, and individual studies from 1995 through 2012.

In brief, the studies found that with adequate dosing, MMT (> 60 mg) and BMT (16 mg-32 mg) caused a similar reduction in illicit opioid use, but MMT was associated with better treatment retention and BMT with a lower risk of adverse events. In pregnancy, MMT and BMT (without naltrexone) showed similar efficacy, but MMT was better than BMT in retaining pregnant women in treatment, and BMT was associated with improved maternal and fetal outcomes, compared to no MAT.

MMT and BMT showed similar occurrence rates of neonatal abstinence syndrome, “but symptoms were less severe for infants whose mothers were treated with BMT.” BMT is associated with a lower risk of adverse events, and has the advantage of greater availability (office facilities improve access and provide earlier care). MMT may be needed for patients who require high doses of opioid agonist treatment, and has the advantage of a possible positive effect on mortality, drug-related HIV risk behaviors, and criminal activity.

The authors advise that MMT “should be a covered service available to all individuals,” and that BMT “should be considered for inclusion as a covered benefit.”

Sprinkled within the two articles are qualifiers such as “possible,” “associated with,” and “suggestive.” That’s because the statistical significance shown in some large, well-designed studies tends to disappear when data from individual studies are merged. Merging changes drug dosages, length of treatment, patient characteristics of the group, and other data; these changes may make reaching statistical significance impossible.

Areas for Future Research

The authors identified several areas where additional data would be helpful. For methadone, these include the impact of MMT on secondary outcomes, the efficacy and safety tradeoffs of doses > 100 mg, and confirmation of results of interim treatment for improved outcome. (In interim treatment, patients receive methadone daily under supervision for up to 120 days, and emergency counseling, while awaiting placement in a program.)  Another research area: the use of MMT in subpopulations—racial and ethnic minority groups, and people who misuse prescription drugs.

For buprenorphine, suggested research areas include the impact of BMT on secondary outcomes, appropriate dosing to enhance outcomes, and confirmation of stepped-care results. (Stepped-care involves gradually increasing buprenorphine doses to 32 mg—higher doses “do not provide additional efficacy;” patients requiring more medication are switched—“stepped-up”—to high-dose methadone.) Other research areas: the use of BMT in subpopulations (described above), and improved induction protocols to minimize retention problems.

A box in each publication summarizes the authors’ findings for each treatment. We reproduce them below, as they appeared in print.

 

Evidence for the effectiveness of MMT: high

Evidence clearly shows that MMT has a positive impacta on:

  • Retention in treatment
  • Illicit opioid use

Evidence is less clear but suggestive that MMT has a positive impact on:

  • Mortality
  • Illicit drug use (non-opioid)
  • Drug-related HIV risk behaviorsb
  • Criminal activity

Evidence suggests that MMT has little impact on:

  • Sex-related HIV risk behaviorsc

 

a Compared with placebo, detoxification, drug-free rehabilitation, or wait-listing
b Sharing injection equipment.
c Having unprotected sexual relations.

 

Evidence for the effectiveness of BMT: high

Evidence clearly shows that BMT has a positive impact compared with placebo on:

  • Retention in treatment
  • Illicit opioid use

Evidence is mixed for its impact on:

  • Non-opioid illicit drug use

 

Regarding retention in treatment and illicit opioid use, BMT had a positive effect compared to placebo, while MMT had a positive effect compared to placebo, detoxification, drug-free protocols, or wait-listing protocols.

Closing Statements

The authors note the importance of MAT, especially considering the poor success rates of abstinence-based treatments, and recognize both MMT and BMT as important treatment options. Below are summaries of their closing statements.

Methadone: The authors point out the need for educating providers, consumers, and family members about the benefits of MMT and ways to avoid the significant adverse events that can occur (referring to respiratory depression and cardiac arrhythmias). They also note the need for education about “appropriate doses to improve efficacy” and “appropriate initiation to minimize adverse events.”

They close with: Because of MMT’s relative efficacy, efforts should be made to increase access to MMT for all individuals who struggle with opioid use disorders. Directors of state mental health and substance abuse agencies and community health organizations should look for methods to increase access to MMT, and purchasers of health care services should cover appropriately monitored MMT.”

Buprenorphine: Noting the key advantage of buprenorphine—its availability—and the “limited access to and more restrictive safety profile of MMT,” the authors consider BMT an important treatment for opioid dependence. “Policy makers have reason to promote access to BMT for patients in substance use treatment who may wish to choose BMT as a potentially safer alternative to MMT.

They close with: “Administrators of substance use treatment programs, community health centers, and managed care organizations and other purchasers of health care services, such as Medicare, Medicaid, and commercial insurance carriers, should give careful consideration to BMT as a covered benefit.”

#     #     #

References

Fullerton CA, Kim M, Thomas CP, et al. Medication-assisted treatment with methadone: assessing the evidence. Psychiatric Services in Advance. November 18, 2013; doi: 10.1176/appi.ps.201300235.

Thomas CP, Fullerton CA, Kim M, et al. Medication-assisted treatment with buprenorphine: Assessing the Evidence. Psychiatric Services in Advance. November 18, 2013; doi: 10.1176/appi.ps.201300256.

Dougherty RH, Lyman DR, George P, Ghose SS, Daniels AS, Delphin-Rittmon ME.

Assessing the Evidence Base for Behavioral Health Services: Introduction to the Series.

Psychiatric Services. 2014; doi: 10.1176/appi.ps.201300214

http://ps.psychiatryonline.org/article.aspx?articleID=1759202

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

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

Barriers to HCV Care Include Lack of Physical Symptoms, Treatment Side Effects

“Barriers to hepatitis C care for patients enrolled in opioid substitution treatment included the perception of being physically well and concerns about adverse effects associated with interferon-based hepatitis C virus treatment, according to results from the ETHOS study.

“Integrating treatment for hepatitis C within settings that provide treatment for drug dependence minimizes some of the barriers for clients wishing to undertake hepatitis C treatment,” study researcher Carla Treloar, PhD, deputy director of the Centre for Social Research in Health at the University of New South Wales, Australia, told Infectious Disease News. “However, treatment remains an unattractive option for some patients. Providing ways for those without hepatitis C symptoms to be assessed for liver damage may be important to open up alternative conversations about hepatitis C care.”

http://www.healio.com/infectious-disease/hepatitis-resource-center-2013/barriers-to-hcv-care-include-lack-of-physical-symptoms-treatment-side-effects

Source: Healio.com – December 11, 2013

Heroin Addiction Warps Brain’s Ability to Change

brain“In a study of heroin abusers’ post-mortem brains, longer duration of heroin use was associated with changes in the shape and packaging of DNA in the brain in the ventral and dorsal striatum, areas of the brain associated with drug addiction, according to Yasmin Hurd, PhD, of the Icahn School of Medicine at Mount Sinai Hospital in New York, N.Y., and colleagues.

The DNA of these patients’ brains became more “open” to gene expression and overactive, which may mean that a treatment that helps “close” this gap and reduce over activity may help temper addiction, Hurd told MedPage Today during an oral presentation at the Society for Neuroscience meeting.”

http://www.medpagetoday.com/MeetingCoverage/SFN/42901

Source: MedPageToday.com – November 14, 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

Role of Police in Responding to Overdoses Often Unclear: Study

hospital sign“The role of police officers in responding to overdoses is often unclear, according to a new study. Researchers say training officers in administering the overdose antidote naloxone could have a significant impact on the death rate from drug-related fatalities.

The study found that while police officers often serve as medical first responders, it is often unclear what police can or should do at the scene of an overdose, PsychCentral.com reports.

The researchers interviewed 13 law enforcement officials in Connecticut and Rhode Island communities experiencing high rates of drug overdoses. They found officials were supportive of being involved in overdose prevention, but they expressed hesitancy about laypersons administering naloxone. Officers said they were frustrated with their current overdose response options, the lack of accessible drug treatment, the cycle of addiction and the pervasiveness of easily accessible prescription opioid medications in their communities.”

http://www.drugfree.org/join-together/community-related/role-of-police-in-responding-to-overdoses-often-unclear-

Source: JoinTogether.org – September 30, 2013

Locked Up in America Infographic

jail croppedThe Criminal Justice Degree Hub has developed an infographic that shows that 46.8% of federal prisoners are incarcerated for drug offenses. Other statistics include yearly correctional spending by state and the number of prisoners by year.

http://www.criminaljusticedegreehub.com/locked-up-in-america/

Source: CriminalJusticeDegreeHub.com – October 2013

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