Correct dose keeps treatment going, study finds

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dose

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.

20 per cent heroin eligible, study finds

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medical heroin

This study looked at how many, and what types of people who inject drugs (PWID), in the AIDS Care Cohort to evaluate Exposure to Survival Services Study (ACCESS), would be eligible for medical heroin in Vancouver, Canada.

Medical heroin could possibly help people who have treatment resistant opioid use disorder and who live with HIV/AIDS.

How was the study done?

We looked at how many, and what types of PWID in the ACCESS Study would be eligible for medical heroin. Participants had to meet eligibility criteria from clinical trials of medical heroin.

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. ACCESS 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/)

What did the study find?

478 participants said they injected opioids. 20% met the eligibility criteria for treatment with medical heroin. Those who were homeless, or were involved in the local illicit drug trade, were more likely to be eligible for medical heroin.

20% met the eligibility criteria for treatment with medical heroin and also said they were homeless and dealt drugs.

Why is the medical heroin useful?

Untreated opioid use disorder among people who live with HIV/AIDS can lead to illnesses, overdose, or death. Medical heroin can play an important role in helping people who have treatment resistant opioid use disorders and who live with HIV/AIDS.

Reference: Klimas, J., Dong, H., Fairbairn, N., Socías, E., Barrios, R., Wood, E., Kerr, T., Montaner, J., Milloy, M. (2018) Eligibility for heroin-assisted treatment (HAT) among people who inject opioids and are living with HIV in a Canadian setting. Addiction Science& Clinical Practice. In Press (https://ascpjournal.biomedcentral.com/track/pdf/10.1186/s13722-017-0104-y?site=ascpjournal.biomedcentral.com)

War on drugs, war on wolves

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Wolves in cage

Have you ever heard of compound 1080? No? I’m not surprised. Illegal in most countries, this poison (sodium monofluoroacetate) is used to kill wolves in Canada. Read more about a recent visit to the Northern Lights wolf centre near Golden, BC, that opened my eyes to the cruel practices of money and politics – the usual suspects from the war on drugs.

Caribou’s population in Western Canada is dwindling. Some Canadian provinces, like Alberta and British Columbia, have put in place aggressive measures to save Caribou.

wildlife logo wolves
photocredit: northernlightswildlife.com

Wolves are Caribou’s natural predators. To kill them seems logical in the fight for the Caribou’s survival. But only if we forget that Wolves are keystone species. “A keystone in anarch’s crown secures the other stones in place. Keystone species play the samerole in many ecological communities by maintaining the structure and integrityof the community.” This means that their killing will kick-start a chain reaction, leading to extinction not only of Caribou, but also other species and desolation of the land. The Yellowstone example is a worthwhile lesson: when the park eradicated the thriving predators, the antelopes overcrowded and nearly destroyed the grasslands. Predators have been reintroduced successfully.

“The recovery of the gray wolf after its eradication from Yellowstone National Park, almost ninety years ago, demonstrates how crucial keystone species are to the long-term sustainability of the ecosystems they inhabit.”

Drugs have predictable effects on people – the higher the dose, the more toxic they are. This is different from the addictive potential. Even the most dangerous of drugs – like heroin or cocaine – are used by millions of people relatively without problems and without addiction. Nobody becomes addicted after one dose. This means that we have been lied to about drugs and their effects.

Meanwhile, Canadian’s officials keep laying poisoned baits that will be eaten not only by the wolves, but by all other carnivore, such as, foxes, ravens, etc. The 24-hour delay of the poison kills not only the alpha-female, but her cubs too. When she comes back from the hunt, feeds them the food from her stomach, all of them will die. Seems effective. How come that this strategy won’t save the Caribou?

drug policy
photocredit: drugpolicy.org

Our strategy to solve the drug problem has been based on the lies about drugs’ effects. The war on drugs was declared as the most powerful strategy to eliminate them. Research has shown that it doesn’t work. Instead, wrong people are put to jail when the drug laws are enforced selectively. What’s needed is often viewed as bad by the general public. Clean needles, safe injecting rooms and prescribed heroin are seen as helpful to maintaining harmful behaviour of people with addiction. The opposite is truth. They save lives. Because it’s the public opinion, and not the science, that wins elections, politicians will selectively use to please the public and ignore the science in solving the drug problem. Too bad for people who use drugs, but who cares about them anyway?

Not only are wolves the keystone species, they also are not the reason for Caribou’s sudden decline. Who’s to blame? Firstly, it’s the oil and fracking industry. By taking the land where the old-growth forest hosts Caribou, the industry is pushing them out of their natural habitat. Secondly, Caribou thrives in old-growth forest only. It takes 80-100 years for the forest to grow back again. Finally, they’ll die before they could return back.

Most likely, the Caribou will disappear from Canadian’s landscape. People will say that they were destined to die. We have done everything we could. We even killed the wolves. Similarly, many people who use illicit drugs will die or go to prison. People will say that they lacked motivation or were beyond help. We have done everything we could to help them. We banned the drugs and enforced the law.

The bottom line: end war on wolves

 

“We need wolves to have a future; we need the to have water, air and biodiversity.” But they need your help and your voice. Vote! Contact the politicians and ask them about environmental issues. Likewise, people will continue to use drugs in future. We need an open and science-informed discussion about drugs.

Inspired about parallels between animal and addiction research? Read my blog about killer whales and researchers here.

Disclaimer: the organisations and individuals named in this article have not seen or reviewed this article. The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any agency mentioned.

Training medical students in addiction medicine can help in the opioid crisis

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Naloxone

Better medical education is one solution to the opioid overdose crisis, but our new study suggests that few students have direct experience of overdose management although many have been exposed to patients using opioids.

Every year, more people die in Ireland due to opioid overdoses than in car accidents. Over 200 overdose deaths occur annually in Ireland. Naloxone is an effective treatment; lay people can use it. We surveyed 243 undergraduate medical students doing their final professional completion module before graduating from University College Dublin. This survey showed that medical students commonly encounter patients with opioid use disorders and want more naloxone training in the medical school.

Overdose prevention and management, including naloxone provision, should be a priority for health education.

A total of 197 (82.1%) completed the survey. Just under half were male, and most were aged under 25 (63.3%) and of Irish nationality (76.7%). The students felt moderately prepared to recognise opioid use disorder, but felt less prepared to manage other aspects of opioid use disorder care. Most had taken a history from a patient with an opioid use disorder (82.8%), and a third had witnessed at least one opioid overdose. Although 10.3% had seen naloxone administered, most had never administered naloxone themselves (98.5%). Half supported wider naloxone availability; this was lower than support rates among GPs (63.6%) and GP trainees (66.1%).

Over half of the medical students supported wider naloxone availability and its lay distribution to address the growing overdose problem in Ireland.

Most students had taken a history from a patient with an opioid use disorder and a third had witnessed at least one opioid overdose.

Few students had direct experience of overdose management although many met patients using opioids.

High level of student exposure to patients using opiates suggests we have an opportunity to increase addiction content in medical curricula.

Educate students

Medical school offers limited addiction medicine education. Medical graduates may not be adequately prepared to diagnose and manage opioid use disorders and emergency drug overdoses.

Tobin, H., Klimas, J., Barry, T., Egan, M., Bury, G. (2017, In Press) Opiate Use Disorders and Overdose: Medical Students’ Experiences, Satisfaction with Learning and Attitudes toward Community Naloxone Provision. Addictive Behaviors.

Resolving youth opioid addiction needs evidence-based care

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youth opioid addiction

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