AT Forum NEWS NOTES & UPDATES #113

September – October 2007

Compiled & Edited by Sue Emerson - Publisher

Prior Edition: July-August 2007

List of all News/Updates

Contents

Research Roundup

Miscellaneous
Intravenous and Intranasal Heroin-Dependent Methadone Treatment-Seekers Responses to Treatment
Leading Causes of Premature Death in Heroin Users
Methadone at Therapeutic Levels Linked to SCD
Who Receives and Remains in Office-Based Buprenorphine Treatment?
NDRI New Center for Technology and Health Research Launched

Hepatitis C/HIV/AIDS
Antiretroviral Medication Affects Dose of Methadone
Increased HIV Risk Associated with Criminal Justice Involvement among Men on Methadone
One-fourth Of HIV Patients Believe Their Doctors Stigmatize Them

Government News and Reports
SAMHSA Releases 2006 Survey on Drug Use and Health
NIDA US Geographic Drug Abuse Patterns and Trends Report Released
Centers for Disease Control and Prevention (CDC) Publishes Fact Sheet on HIV/AIDS Among Hispanics/Latinos
The 2007 NIDA Drug Abuse and Risky Behaviors: The Evolving Dynamics of HIV/AIDS Meeting Presentations Available for Download
Sign Up for SAMHSA's eNetwork

Journal Update
Heroin Addiction and Related Clinical Problems – September 2007 Now Available

 
Research Roundup

Miscellaneous

Intravenous and Intranasal Heroin-Dependent Methadone Treatment-Seekers Responses to Treatment

This study compared the characteristics of intravenous (i.v.) and intranasal (i.n.) heroin users seeking methadone treatment, and their response to treatment.

• A total of 319 heroin-dependent adults participated in the study at a methadone clinic in Baltimore City, MD. Participants were randomly assigned to receive interim methadone treatment or to a waiting list. Participants were divided into two groups based on their route of heroin ingestion: i.v. or i.n.
• Interim methadone treatment consisted of providing an adequate and stable dose of methadone, but no psychosocial services, to heroin-dependent adults for up to 120 days while they awaited an opening for comprehensive methadone treatment.
• Findings: At baseline, over 60% of participants were i.n. users and had been for an average of over 12 years; i.v. users, compared to i.n. users, were more likely to have ever used cocaine, to have used cocaine in the past 30 days, to have more medical complications and to report more income generated from criminal behavior. Both i.v. and i.n. users reduced their self-reported days of heroin use, cocaine use and days of criminal activity in response to interim methadone treatment.
• Author conclusions: Despite differences in baseline characteristics, i.n. and i.v. heroin-dependent individuals did not differ in their response to interim methadone treatment.

Source: Highfield DA, Schwartz RP, Jaffe JH, O'grady KE.Intravenous and intranasal heroin-dependent treatment-seekers: characteristics and treatment outcome.Addiction 2007 Sep 3 [Epub ahead of print]

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Leading Causes of Premature Death in Heroin Users

Many studies on mortality in heroin users report traditional mortality data, which does not account for age at death. To examine causes of premature death and years of potential life lost (YPLL) among heroin users, researchers assessed 581 ethnically diverse men who had been admitted to a compulsory drug treatment program in California for heroin-dependent criminal offenders. Subjects were evaluated every 10 years over 33 years.

• During follow-up, 282 subjects (49%) died. Mean age was 25 years at study entry and 47 years at death. On average, YPLL before age 65 was 18 years per person.
• The leading causes of death were heroin overdose (17% of deaths), chronic liver disease (15%), cardiovascular disease (12%), cancer (11%), accidents (8%), and homicide (7%).
• The leading causes of YPLL were heroin overdose (22% of all YPLL), chronic liver disease (14%), accidents (10%), cardiovascular disease (9%), homicide (9%), and cancer (5%).
• YPLL for each cause of death examined was significantly and substantially higher among subjects in this study than among the U.S. population (e.g., 43 YPLL versus 12 YPLL from unintentional injuries, including overdoses and accidents).

Comments: This study’s strength is its consideration of premature mortality among heroin users. The results revealed disparities between leading causes of death and YPLL among heroin users and extremely large discrepancies in YPLL between heroin users and the U.S. population. One conclusion from this study is that inadequate drug treatment capacity may be partly responsible for the higher number of premature deaths among persons with opioid dependence.

Published by: Alcohol, Other Drugs, and Health: Current Evidence

Boston University School of Medicine/ Boston Medical Center

July/August 2007 issue. Article accessed 9/12/07

Julia H. Arnsten, MD, MPH

Original Source : Smyth B, Hoffman V, Fan J, et al.Years of potential life lost among heroin addicts 33 years after treatment.Prev Med2007;44(4):369–374

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Methadone at Therapeutic Levels Linked to SCD

DENVER — As reported by Bruce Jancin of Family Practice News, “Methadone in therapeutic doses appears to be associated with increased risk of sudden cardiac death, Dr. Carmen Socoteanu reported at the annual meeting of the Heart Rhythm Society”.

“This observation from a prospective case-control study has important public health implications in light of how widely the drug is prescribed for chronic pain control and opioid addiction,” added Dr. Socoteanu of Oregon Health and Science University, Portland.

Dr. Socoteanu reported on 22 consecutive cases of sudden cardiac death (SCD) featuring therapeutic blood levels of methadone. The cases were evaluated by the state medical examiner with detailed autopsies as part of the ongoing Oregon Sudden Unexplained Death Study sponsored by the Centers for Disease Control and Prevention.

Dr. John P. DiMarco commented that he would take home a key lesson from the study: “a reminder that noncardiac drugs can cause arrhythmias and cardiac death. When physicians think about proarrhythmic drugs, they tend to focus on antiarrhythmic agents and other cardiac medications. That's particularly true of cardiologists. But methadone is an IKr potassium channel blocker that prolongs the QT interval and can cause torsades de pointes,” noted Dr. DiMarco, professor of medicine and director of the electrophysiology service at the University of Virginia, Charlottesville.
<Click here to view the one page PDF file…>

Source: Jancin B.Methadone at Therapeutic Levels Linked to SCD.Fam Pract New2007Jul37(13):11

Note: AT Forum continues to recognize the importance of cardiac concerns in MMT <click here…> to access the reports.

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Who Receives and Remains in Office-Based Buprenorphine Treatment?

Researchers analyzed data from a medical record review of 86 patients receiving office-based buprenorphine treatment from 6 physicians in New York City.

• One-half of patients were misusing a prescription opioid at intake, 35% were using heroin, and 9% were using both. The remaining subjects were either transferring from other treatment, had cravings, or had fear of relapse.
• Almost 50% reported misusing non-opioid drugs (e.g., cocaine, marijuana) at intake.
• Sixty-three percent of patients received prescriptions for at least 1 psychiatric medication during buprenorphine treatment.
• The median time in treatment was 8 months (range <1 to 30 months).
• According to the last entry in the medical record, 24% were misusing any substance and 8% were misusing opioids. Fifty-eight percent were still receiving buprenorphine (52% from the index physician).
• Factors associated with retention in buprenorphine treatment with the index physician included full-time employment or other forms of support, stable housing, and prescription opioid (versus heroin) misuse at intake. Psychiatric disorders or substance misuse during treatment did not affect retention.

Comments: This is one of a growing number of descriptive studies of unselected patients receiving office-based buprenorphine treatment. It demonstrates that successful buprenorphine treatment can be achieved in office-based settings. To ensure successful treatment in these patients who often have psychiatric comorbidity, strong referral networks and access to consultation for complex cases are desirable.

Published by: Alcohol, Other Drugs, and Health: Current Evidence

Boston University School of Medicine/ Boston Medical Center

July/August 2007 issue. Article accessed 9/12/07

Julia H. Arnsten, MD, MPH

Original Source: Magura S, Lee SJ, Salsitz EA, et al.Outcomes of buprenorphine maintenance in office-based practice.J Addict Dis.2007;26(2):13–23.

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NDRI New Center for Technology and Health Research Launched

On August 31, 2007, National Development and Research Institutes, Inc. (NDRI) announced it has launched a new research center, the Center for Technology and Health (CTH). This interdisciplinary research and development group will focus on the systematic application of technologies to the health sciences and health care, with a special emphasis on substance use disorders.

Current CTH projects in progress include:

• Computer Delivery of Effective Psychosocial Interventions in Methadone Treatment
• Computer-Assisted HIV Prevention for Young Drug Users

To find out additional information about these projects <click here… >

Source: National Development and Research Institutes, Inc. (NDRI) August 31, 2007.

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Hepatitis C/HIV/AIDS

Antiretroviral Medication Affects Dose of Methadone

Pharmacokinetic interactions between antiretrovirals and methadone can potentially affect levels of either medication and lead to over- and/or underdosing. These researchers evaluated the average change in methadone dose that occurred with co-administration of nevirapine, efavirenz, ritonavir-boosted lopinavir, or atazanavir in 120 patients in a directly observed therapy program. All patients also had Hepatitis C.

• For patients on nevirapine, the median change in methadone dose in the 3 months after baseline (HAART* initiation) was 20 mg/d, with 32 (86%) of 37 patients requiring daily dose increases.
• For patients on efavirenz, the median change in methadone dose from baseline was 7.5 mg/d with 11 (61%) of 18 patients requiring daily increases.
• For patients on ritonavir-boosted lopinavir or atazanavir, the median change from baseline was 0 for both.
• The HIV virus was suppressed to fewer than 400 copies/mL in 67%–76% of patients, with no difference based on antiretroviral regimen.

Comments: Clinicians providing either methadone or antiretrovirals to patients should be mindful of the potential interactions between these medications. Interactions can alter methadone levels, which can lead to sedation (from increased levels) or withdrawal (from decreased levels). Depending on the specific case, the dose of methadone will need to be increased, decreased, or maintained. Notably, there were significant variations in methadone dose requirements between individual patients. These data support close clinical observation of and medication adjustment in patients receiving methadone and HAART.

*Highly active antiretroviral therapy (HAART)

Published by: Alcohol, Other Drugs, and Health: Current Evidence

Boston University School of Medicine/ Boston Medical Center

July/August 2007 issue. Article accessed 9/12/07

David A. Fiellin, MD

Original Source: Tossonian HK, Raffa JD, Grebely J, et al.Methadone dosing strategies in HIV-infected injection drug users enrolled in a directly observed therapy program.J Acquir Immune Defic Syndr.2007;45(3):324–327.

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Increased HIV Risk Associated with Criminal Justice Involvement among Men on Methadone

This paper examined the relationship between HIV risk and criminal justice involvement among a random sample of 356 men enrolled in methadone maintenance treatment programs in New York City. Analyses were performed to estimate the associations between measures of criminal justice involvement and participant HIV risk, controlling for socio-demographic variables.

Findings:

• A lifetime history of incarceration was significantly associated with being HIV positive.
• Recent arrest was associated with unprotected vaginal sex and having multiple female sexual partners.
• Sex trading was associated with both arrest and incarceration, and the strongest association was found between selling sex and recent incarceration
• Results suggest that recent criminal justice involvement among men with substance abuse histories is associated with increased HIV risk behaviors.

Authors Conclusions: Findings underscore the need for targeted HIV prevention efforts for men on methadone with a recent history of arrest or incarceration

Source: Epperson M, El-Bassel N, Gilbert L, Orellana ER, Chang M.AIDS Behav.2007 Aug 18 [Epub ahead of print]

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One-fourth Of HIV Patients Believe Their Doctors Stigmatize Them
August 31, 2007 - University of California – Los Angeles

“Even the perception that physicians are stigmatizing patients for carrying the virus that causes AIDS can discourage these individuals from seeking proper medical care, “according to a new UCLA study.

The study results were based on surveys of 223 HIV-positive individuals in Los Angeles County, with initial baseline interviews taking place between May 2004 and June 2005 and follow-up interviews conducted six months later, from November 2004 to December 2005.

Findings:

• The researchers found that at baseline 26 percent of the patients reported at least one of the four types of perceived stigma from a health care provider, and 19 percent reported the same at follow-up. Also, 58 percent claimed low access to care on at least one of the six relevant questions at baseline, as did 57 percent at follow-up.
• "Most importantly, we found that those who perceived stigma from a health care provider had more than twice the odds of reporting low access to care, even after examining the effect prospectively and adjusting for a host of sociodemographic and clinical characteristics," the researchers said.
• Researchers noted the significance that perceived stigma "could greatly affect [patients'] use of needed medical services, including antiretroviral therapy. Because of this, patients may seek medical care only when their illness has progressed to a more severe stage, leading to more intensive medical interventions, hospitalization and earlier death.”

Source: Kinsler JJ, Wong MD, Sayles JN, Davis C, Cunningham WE.AIDS Patient Care and STDs. 2007,21(8):584-592.doi:10.1089/apc.2006.0202.

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Government News and Reports

SAMHSA Releases 2006 Survey on Drug Use and Health

The National Survey on Drug Use and Health is an annual survey of approximately 67,500 people. The survey provides statistical breakdowns for many types of substances including marijuana, prescription drugs, cocaine, methamphetamines, and heroin.

The 2006 survey reveals that an estimated 22.6 million persons (9.2 percent of the population ages 12 and older) may have had either substance abuse or dependency problems in the past year. Of these, 3.2 million were dependent on or abused both alcohol and illicit drugs; 3.8 million were dependent on or abused illicit drugs but not alcohol; and 15.6 million were dependent on or abused alcohol but not illicit drugs.

Findings on illicit drug use treatment and treatment needed include:

• In 2006, the number of persons aged 12 or older needing treatment for an illicit drug use problem was 7.8 million (3.2 percent of the total population). Of these, 1.6 million (0.6 percent of the total population and only 20.3 percent of the persons who needed treatment) received treatment at a specialty facility for an illicit drug use problem in the past year. These estimates are similar to 2002-2005.
• Of the 6.2 million people who needed but did not receive specialty treatment for illicit drug use in 2006, 496,000 (8.0 percent) reported that they perceived a need for treatment for their illicit drug use problem.
• Among people who needed but did not receive illicit drug use treatment and felt they needed treatment (based on 2004-2006 combined data), the six most often reported reasons for not receiving treatment were (a) no health coverage and could not afford cost (35.1 percent), (b) not ready to stop using (31.8 percent), (c) not knowing where to go for treatment (14.7 percent), (d) concern that getting treatment might cause neighbors/community to have negative opinion (13.5 percent), (e) possible negative effect on job (12.8 percent), and (f) being able to handle the problem without treatment (12.4 percent).

To access the 282 page survey <click here…>

Source: SAMHSA, September 6, 2007

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NIDA US Geographic Drug Abuse Patterns and Trends Report Released
Cesar Fax – August 30, 2007

For the past 30 years, NIDA’s Community Epidemiology Work Group (CEWG) has served as a national drug abuse surveillance system. Comprised of a network of epidemiologists and researchers from 22 geographically dispersed areas of the nation, the CEWG meets twice a year to share qualitative and quantitative information on current and emerging drug abuse patterns and trends.

Following are highlights from the recently released report on the proceedings of the 61 st meeting, held this past January:

• Heroin abuse indicators were stable or mixed at high levels in 5 CEWG areas (Baltimore, Boston, Detroit, Los Angeles, and New York City) and at low levels in 10 CEWG areas. While 2 CEWG areas (Chicago and New Mexico) reported increases in abuse indicators, five areas (Atlanta, Denver, Philadelphia, St. Louis, and San Francisco) reported decreases in heroin abuse indicators.
• Hydrocodone and oxycodone continue to be the most widely abused other opiates in many CEWG areas. For example, in Atlanta, “multiple abuse indicators show that hydrocodone is the most commonly abused narcotic analgesic . . . , followed by oxycodone”. Indicators of the abuse of fentanyl continued to increase in 5 CEWG areas. Nine CEWG areas reported deaths involving methadone. In Maine, “methadone has caused more deaths than any other drug (38 percent of the drug deaths in 2005).”

To access the 108 page report <click here… >

Source: National Institute on Drug Abuse NIH Publication No. 07-6200 Printed August 2007

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Centers for Disease Control and Prevention (CDC) Publishes Fact Sheet on HIV/AIDS Among Hispanics/Latinos

The HIV/AIDS epidemic is a serious threat to the Hispanic/Latino community. In addition to being a population seriously affected by HIV, Hispanics/Latinos continue to face challenges in accessing health care, prevention services, and HIV treatment. In 2004, HIV/AIDS was the fourth leading cause of death among Hispanic/Latino men and women aged 35 to 44.

This 8-page report reviews:

• 2005 statistics on HIV/AIDS by race/ethnicity and transmission categories for Hispanic/Latino adults and adolescents living with HIV/AIDS.
• Risk factors and barriers to prevention including: substance use, sexually transmitted diseases, cultural beliefs, and socioeconomic issues.

To view the 8-page PDF file. <click here… >

Source: Centers for Disease Control and Prevention (CDC) August 2007

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The 2007 NIDA Drug Abuse and Risky Behaviors: The Evolving Dynamics of HIV/AIDS Meeting Presentations Available for Download

The 2007 Drug Abuse and Risky Behaviors: The Evolving Dynamics of HIV/AIDS meeting (May 8-9, 2007) responded to deep concern about the continuing spread of HIV/AIDS in the United States and abroad and invited the scientific community to engage in a dialog to further our understanding of the problem and how it is changing. It provided a timely forum to explore our growing knowledge of the behavioral and social factors that affect HIV infection rates among various populations, including the multiple influences of drug abuse and addiction on HIV risk. It underscored how research could inform public health policy and identified emerging opportunities to address this evolving pandemic.

Sponsored by NIDA in collaboration with multiple NIH Institutes and the Centers for Disease Control and Prevention, this meeting highlighted the drug abuse-HIV link. Speakers addressed a variety of related topics, including how drugs of abuse alter brain function and impair decision making, how substance abuse affects HIV/AIDS risk in diverse demographics, how and to what extent substance abuse influences sexual risk behaviors, and how testing and counseling can be incorporated as key components of HIV prevention strategies for different drug-abusing populations.

The following four presentations from the meeting are available for download in PDF or PowerPoint formats at the NIDA website <click here… >

• HIV/AIDS in 2007: A Brief Overview
• NIH AIDS Research Priorities
• Drug Abuse Treatment in HIV Prevention and Care: Past Successes and Future Challenges
• The Role of Drug Abuse in the Evolving HIV Epidemic

Source: NIDA – August 14, 2007

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Sign Up for SAMHSA's eNetwork

SAMHSA recently launched a new “eNetwork”—an electronic service that provides announcements of the latest information about grants, publications, campaigns, programs, statistics, and data reports.
To join the eNetwork <click here… >

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Journal Update

Heroin Addiction and Related Clinical Problems. 2007(September), Vol. 9, No. 3

The September 2007 issue of Heroin Addiction and Related Clinical Problems which is the official journal of Europad in now available online. Articles include:

• Addiction Treatment: When Will Medical Principles Matter?
• New Approaches in the Treatment of Opioid Dependency during Pregnancy
• Clinical Features of Heroin Dependence Onset in Young Women
• Supporting GP’s in Improving Substitute Prescribing for Opiate Users in the UK
• Mortality Among Opiate Abusers in Stockholm: A Longitudinal Study
• Methadone Treatment in an Italian Criminal Mental Hospital

<Click here…> to download the 60 page PDF file.

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