The partial opiate-receptor agonist buprenorphine has been suggested for treatment of heroin dependence, but there are few long-term and placebo-controlled studies of its effectiveness. We aimed to assess the 1-year efficacy of buprenorphine in combination with intensive psychosocial therapy for treatment of heroin dependence.
40 individuals aged older than 20 years, who met DSM-IV criteria for opiate dependence for at least 1 year, but did not fulfil Swedish legal criteria for methadone maintenance treatment were randomly allocated either to daily buprenorphine (fixed dose 16 mg sublingually for 12 months; supervised daily administration for a least 6 months, possible take-home doses thereafter) or a tapered 6 day regimen of buprenorphine, thereafter followed by placebo. All patients participated in cognitive-behavioural group therapy to prevent relapse, received weekly individual counselling sessions, and submitted thrice weekly supervised urine samples for analysis to detect illicit drug use. Our primary endpoint was 1-year retention in treatment and analysis was by intention to treat.
1-year retention in treatment was 75% and 0% in the buprenorphine and placebo groups, respectively (p=0.0001; risk ratio 58.7 [95% CI 7.4-467.4]). Urine screens were about 75% negative for illicit opiates, central stimulants, cannabinoids, and benzodiazepines in the patients remaining in treatment.
The combination of buprenorphine and intensive psychosocial treatment is safe and highly efficacious, and should be added to the treatment options available for individuals who are dependent on heroin.
Comment In: Lancet. 2003 May 31;361(9372):1907; author reply 1907-812788596
Comment In: Lancet. 2003 Feb 22;361(9358):634-512606172
Comment In: Lancet. 2003 May 31;361(9372):1906-7; author reply 1907-812788595
BACKGROUND AND OBJECTIVES: The Beck Depression Inventory (BDI) is a widely used measure of depression severity in both research and clinical contexts. This study aimed at assessing its stability and associations with ongoing drug use in a sample of patients in opiate agonist maintenance treatment who were not abstinent from illicit drugs. DESIGN AND METHOD: The study was a prospective, naturalistic study. Subjects in enhanced or standard psychosocial services along with opiate agonist maintenance treatment were administered the BDI and the European Addiction Severity Index (EuropASI) twice by research technicians, approximately 2 weeks after intake and at 18 months follow-up. FINDINGS: There were rather small mean changes from intake to follow-up in the BDI, and mean-level stability in subjects was rather high as evidenced by a high intra-class correlation between intake score and follow-up score. The stability of the BDI was reduced at high levels of drug use severity at intake, and BDI was a moderate predictor of drug use severity at follow-up. CONCLUSIONS: The BDI measures a construct that is both stable and of predictive validity in a sample of non-abstinent opiate agonist maintenance patients, although very severe drug use at baseline appeared to reduce the stability of the BDI.
Opioid maintained patients report high levels of anxiety, but the use of benzodiazepines among these patients has been associated with negative outcomes such as increased risk of overdose and death and poorer retention in programmes. Previous research has used interview or urine analysis to assess benzodiazepine use. In this study a prescription database was applied.
The Norwegian Prescription Database covers all prescriptions for the entire population from 1 January 2004. Benzodiazepine prescriptions to patients receiving methadone (N=1364) or buprenorphine (N=805) in 2004 and 2005 were studied. Type and amount of drugs received were investigated.
Overall 40% of the patients received at least one prescription for a benzodiazepine drug. Oxazepam was the most frequently prescribed drug. Female patients, methadone-maintained patients and patients in the liberal programmes received a prescription more often. Prescribed doses were high and highest in the liberal programmes. Older patients received more hypnotics. Dose of maintenance drug was positively related to amount of anxiolytics prescribed.
This study showed that more benzodiazepines were prescribed to opioid maintenance treatment patients than previously shown by investigations using interview or urine analysis. The doses prescribed were generally high. In light of the negative outcomes following benzodiazepine use in these patients, Norwegian doctors need to review their prescription practices.
A seven-year follow-up of heroin dependent patients treated in a buprenorphine-maintenance program combining contracted work/education and low tolerance for non-prescribed drug use. Gender-specific differences in outcome were analysed.
A consecutively admitted cohort of 135 men and 35 women, with eight years of heroin abuse/dependence on average was admitted to enhanced buprenorphine maintenance treatment. Standardized interviews, diagnostic assessments of psychiatric disorders and psychosocial conditions were conducted at admission and at follow-ups. Outcome associated with gender was reported for abstinence, retention, psychiatric symptoms, employment and criminal convictions.
148 patients started treatment. After seven years, 94/148 patients (64%) were retained in the program, employed and abstinent from drugs and alcohol. Women had more continuous abstinence, retention and employment than men (76% versus 60%). After one year patients with a high-risk consumption of alcohol were no longer heavy consumers of alcohol and remained so throughout the study (p?
Cites: Drug Alcohol Depend. 1997 Apr 14;45(1-2):93-1049179511
The number of opioid-related deaths in Ontario is rising, and remote First Nations communities face unique challenges in providing treatment for opioid use disorder. Geographic barriers and resource shortages limit access to opioid agonist therapy, such as buprenorphine or methadone. However, attempts to rapidly expand access have the potential to overlook community consultation. Our experience in Moose Factory, Ontario, offers insight into the ethical questions and challenges that can arise when implementing opioid agonist therapy in Northern Ontario and provides an example of how a community working group can strengthen relationships and create a culturally relevant program. We call on medical regulators and the provincial and federal governments to invest in community-based opioid dependence treatment programs that incorporate cultural and land-based healing strategies and draw on First Nations teachings.
To investigate convictions for driving under the influence (DUI) before, during and after opioid maintenance treatment (OMT) and to examine factors associated with convictions for DUI during treatment.
Treatment data on all patients who started OMT in Norway between 1997 and 2003 (n?=?3221) were cross-linked with national criminal records using unique person identifiers. Patients were followed over a 9-year period, before, during and in periods out of opioid maintenance treatment.
Data were formal charges leading to convictions recorded during four different time-periods: 3 years prior to application, waiting-list, in-treatment and in periods out of treatment.
During OMT, convictions for DUI were reduced by almost 40% compared with pre-application levels. The conviction rate for DUI for males in the pre-application period was 9.59 per 100 person-years (PY) and for females, 3.44 per 100 PY. During OMT, rates of DUI convictions were reduced to 5.97 per 100 PY among men and to 1.09 per 100 PY among women. However, when estimating the effect of OMT on convictions for DUI, the interaction between gender and exposure to OMT was not statistically significant. Patients who remained in continuous treatment had fewer convictions for DUI during treatment compared with patients in discontinuous treatment. Compared with patients having no road traffic convictions during the pre-application period, patients with two or more pre-application convictions for DUI had higher odds [odds ratio (OR)?=?3.69 (2.30-5.93)] for further convictions for DUI during OMT.
In Norway, patients receiving opioid maintenance treatment (OMT) have reduced convictions for driving under the influence (DUI) compared with their pre-treatment levels. Being male and having a previous history of several convictions for DUI were found to be important risk factors for convictions for DUI during OMT.
To investigate the effectiveness of buprenorphine maintenance treatment (BMT) among opioid dependents who are mainly misusing buprenorphine intravenously.
The study was a prospective naturalistic follow-up with a non-randomized control group. In Finland, 30 opioid dependents reporting previous misuse of buprenorphine and participating in the outpatient BMT and 30 matched controls participating in a syringe exchange program (SEP) were followed. Based on the evidence for the superiority of maintenance treatment, randomization was not done. The effectiveness was evaluated by retention rate, European Addiction Severity Index (EuropASI) interviews, Beck Depression Inventory (BDI), visual analogue scale for quality of life (VAS) during the 2-year follow-up and mortality rates during the 3-year follow-up. Because of drop-outs in the SEP group, only the BMT group was interviewed at 24 months.
At 3 months, the retention rate of the BMT group was 100% and of the SEP group 47%. At 12 months, the corresponding percentages were 83% and 37%. The total EuropASI composite score improved significantly only in the BMT group. In the BMT group, the BDI total score and VAS scales for quality of life improved significantly more than they did in the SEP group. During 3-year follow-up, four patients in the SEP died and none in the BMT.
BMT appears to be an effective treatment for opioid dependents using mainly buprenorphine intravenously. On the other hand, bare SEP appears to result in high drop-out, not significant improvements and deaths.