We wanted to find out whether continued use of drugs or alcohol impedes addiction treatment with methadone. We looked at the dose and things that make people stop treatment.
How was the study done?
Between 2005 and 2015, we talked to 823 people receiving methadone who said they used alcohol at least once. We asked about their experiences with interrupting methadone treatment and their drug use.
The VIDUS study involves people who use illicit drugs. The ACCESS study involves people living with HIV who use illicit drugs, mostly living in Vancouver’s Downtown Eastside neighbourhood. Researchers work with participants to look at how social, economic, physical, policy, and individual factors impact the health and well-being of HIV-positive illicit drug users. All participants do an interviewer-administered survey, and a clinic visit with a study nurse, every 6 months. (text taken from: http://www.bccsu.ca/access/ and http://www.bccsu.ca/vidus/)
What did the study find?
48% said they had stopped methadone treatment. Those who were homeless, or injected heroin daily, were more likely to stop methadone treatment. Those who also received other addiction treatment, received doses of at least 60 ml of methadone, or had Hepatitis C, were less likely to stop methadone treatment.
Heavy alcohol use was not linked to treatment discontinuation.
Why is continuous methadone treatment useful?
People who enroll in methadone treatment may continue to use illicit drugs and alcohol. There is a need to understand how to manage continuous drug use while receiving methadone treatment. Receiving therapeutic doses of methadone and also additional addiction treatment may reduce treatment interruption.
Study: Klimas, J., Nosova, E., Socías, E., Nolan, S., Brar, R., Hayashi, K., Milloy, M., Kerr, T., Wood, E. (2018) Factors associated with discontinuation of methadone maintenance therapy (MMT) among persons who also use alcohol in Vancouver, Canada. Drug and Alcohol Dependence, May 1, Volume 186, Pages 182–186
Read about other similar research here.
Youth opioid addiction, and related harms continue to rise in North America. With an increasing number of opioid overdoses, there remain significant barriers to care for youth with addiction. The time for evidence-based treatment of youth opioid addiction is now.
Based on the extensive literature on treatment of opioid use disorder among adults, medicated-assisted treatment is likely to be an important or even essential component of treatment of opioid use disorder for most youth. This post summarises a recent article in the American Journal of Drug and Alcohol Abuse, where we outline the current dilemmas and questions regarding the use of medication-assisted treatment for youth opioid addiction and propose some potential solutions based on the current evidence.
The prevalence of risky opioid use, opioid use disorder, and related harms continue to rise among youth in North America (age 15–25). These growing harms point to an urgent need to expand and scale-up early access to evidence-based treatments for youth opioid addiction. Treatment of youth opioid addiction may be different than treatment of adults because neurodevelopment of brain regions, associated with motivation and impulsivity, happens mainly during adolescence and young adulthood.
Strategies that reduce barriers to treatment commonly experienced by youth and that address clinical care dilemmas when treating youth opioid addiction are urgently needed.
Medications for youth opioid addiction
The American Academy of Paediatrics recently supported buprenorphine/naloxone and methadone for youth opioid addiction. Although research has shown their effectiveness in adults, only a few studies did so among youth.
Based on the strong evidence in the adults and available evidence to date among youth, first-line OAT for youth should be buprenorphine/naloxone, with methadone as an alternative treatment option when buprenorphine/naloxone cannot be used.
Minimum age requirement needs re-evaluation
The literature still disagrees regarding the minimal age requirement to prescribe OAT. For instance, buprenorphine/naloxone is currently approved for opioid addiction at age 16 in the United States and at age 18 in Canada. But the U.S. youth has to fail addiction treatment twice before they can be prescribed methadone under the age of 18. Also, treatment with medications has been prescribed to 10 times more adults than youth although it’s the first line of treatment in many guidelines. This underscores the urgent need to improve medication-assisted treatment access for youth. We still need safety data regarding use of OAT among youth. But the pros are likely to outweigh the cons given the lethality and multiple harms associated with opioid addiction.
Longer tapers are more effective than shorter tapers
How long should be the successful tapers and how to do them effectively? These questions are still unanswered by scientific literature. Studies to date have shown that longer tapers are more effective to reduce opioid use and prevent relapse For this reason, our provincial guidelines in British Columbia, Canada, recommend that tapers for adults, if undertaken, “occur over a minimum 52 weeks duration and with close monitoring during and after the taper given overdose risk is increased.”
Naltrexone injectable versus implantable
Opioid antagonists, such as Naltrexone, have not been evaluated widely among youth. Oral Naltrexone has many problems, such as low compliance, increased risk for relapse and overdose. The researchers should compare methadone or buprenorphine/naloxone with extended-release injectable or implantable naltrexone in youth. This information will help clinicians select the best treatment for youth opioid addiction.
Psychosocial interventions: retention on OAT remains a challenge
Psychosocial interventions are common for treating youth opioid addiction, but are done in a way that is not supported by science. For example, they consist of short-term detox with a referral to individual or group therapy in rehab or outpatient settings. Youth drop out from such treatment frequently. But retention on OAT remains a challenge. For example, one study found that only “56% of youth aged 18–25 years were retained on buprenorphine at 6 months, compared with a 78% of people aged 26 years or more.” OAT seems more efficacious in retaining youth in treatment. Psychosocial intervention is better done in combination with pharmacologic treatment. We need more trials involving youth.
The Prescription Opioid Addiction Treatment Study – POATS
The Prescription Opioid Addiction Treatment Study (POATS) showed that tapering off buprenorphine/naloxone (even after 12 weeks of treatment), was associated with a 90% relapse rate. Ongoing counselling did not make a difference. Based on the adult POATs study, it seems that keeping people on buprenorphine/naloxone is better than tapering them without supports. Psychosocial interventions may help people receiving OAT. Many studies found contingency management helpful. Researchers should do more studies on contigency management.
When in doubt, do not taper
Based on the above, we need more research to better understand optimal treatment approaches for OPIOID ADDICTION in youth. Based on the current evidence, buprenorphine/naloxone appears to be a safe and efficacious option for youth and we propose this should be first-line treatment for OPIOID ADDICTION. More studies comparing OAT and extended-release naltrexone are needed in this population. When treatment is initiated, longer duration (>52 weeks) of OAT is recommended. Decision to taper should be governed by the principle “when in doubt, do not taper” while taking into account the potential risks of relapse and overdose as well as access to chronic relapse prevention care; close monitoring is essential during and after the taper completion. We suggest psychosocial interventions be routinely offered in combination with OAT. Lastly, given the efficacy of OAT, we recommend these medications be provided based on the risk and benefit assessment of each case, regardless of age.
Cited study: Derek C. Chang, Jan Klimas, Evan Wood & Nadia Fairbairn. (In Press) Medication-assisted treatment for youth with opioid use disorder: Current dilemmas and remaining questions. The American Journal of Drug and Alcohol Abuse Vol. 0 , Iss. 0,0
Why clinician-scientist matters
Source: Klimas, J., McNeil, R., Small, W., Cullen, W. Clinician-Scientist Training in Addiction Medicine: A Novel Programme in a Canadian Setting. Academic Medicine 92(10):1367, October 2017.
Addiction training is feasible and acceptable for doctors and junior physicians; however, important barriers persist. We need to learn more about the experience of addiction physicians in the fellowship training programs. Here are the 6 ways to help improve the training.
6 ways to better training
Recently, new programmes have emerged to train the comprehensive addiction medicine professionals internationally and one of them is in Vancouver, Canada. We interviewed 26 persons who completed this training programme. They were psychiatrists, internal medicine and family medicine physicians, faculty, mentors, medical students and residents. All received both addiction medicine and research training. We found six barriers and enablers of training implementation: (1) organisations, (2) structures, (3) teachers, (4) learners, (5) patients and (6) community. Human resources, a variety of rotations, peer support and mentoring fostered implementation of addiction training. Money, time as well as space limitations hindered implementation.
Why training clinicians in addictions
Addiction care is usually provided by unskilled lay-persons in most countries and thus the resulting care inadequate. Effective treatments are overlooked and millions of people suffer despite recent discovery of new treatments for substance use disorders. In rare instances when addiction care is provided by medical professionals, they are not adequately trained in caring for people with substance use disorders; therefore, feel unprepared to provide such care. Physician scientists are the bridge between science and practice. Despite large evidence-base upon which to base clinical practice, most health systems have not combined training of healthcare providers in addiction medicine and research.
Klimas, J., Small, W., Ahamad, K., Mead, A., Rieb, L., Cullen, W., Wood, E., McNeil, R. (2017) Barriers and Facilitators to Implementing Addiction Medicine Fellowships: A Qualitative Study with Fellows, Medical Students, Residents and Preceptors. Addiction Science & Clinical Practice, 12:21
Traditionally, nursing and physician education have been separated through separate programmes despite working closely together in real-world practice.
Our Perspective in the Journal of Addiction Nursing, we argue that addiction training for nurses is as important as training physicians to heal the growing divide between recent discoveries in addiction science and the inadequate care delivered to people with substance use disorders, mostly by unskilled lay personnel.
Interdisciplinary education between physicians, nurses and other allied health providers can promote collaboration and improve decision-making to optimize approaches to patient care.
Why nursing education in addiction medicine matters
Nurses play an essential role in assessing and treating the full range of substance use disorders. Unfortunately, there is a systemic lack of curricula and comprehensive training programmes for nurses to learn and practice evidence-based addiction care. This lack has negative impact on nurses’ knowledge and skills, and, as a result, millions of people have suffered. Addiction science has increasingly identified a range of evidence-based approaches to treat substance-use disorders, particularly through early identification and treatment. However, most treatments are not used enough and well. Better nursing education can improve accurate use of evidence-based treatments.
To this end, a promising initiative has recently been launched at the University of British Columbia (UBC) and St. Paul’s hospital, i.e., an Addiction Nursing Fellowship. The fellowship provides 12 months of specialised training for nurses. In addition, they obtain research training through intensive mentorship. They can publish research manuscripts, visit academic half-days, journal clubs and conferences. They receive media training, learn to influence public policy, advocate for patients, and lead academic research projects.
Thus, while addiction medicine fellowships for physicians exist in many settings and play an important role in bridging the gap between science and practice in clinical care, the impact of these fellowships may be increased by training nurses and other allied health professionals alongside physicians. Nurses have huge potential of nurses to improve access to care and quality of life for people with substance use disorders. That’s why we need more nurse-specific fellowships, better undergraduate curricula in addiction nursing, and interdisciplinary training opportunities.
Source: Voon, P., Johnson, C., Small, W., Klimas, J. (2017) Nursing Fellowship in Addiction Medicine: A Novel Programme in a Canadian setting. Journal of Addiction Nursing 28(3):148-149, July/September 2017.