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Drug and Alcohol Review 2016:35(1);70-75

Abstract

Introduction and Aims Codeine dependence is an emerging public health concern, yet no studies have specifically examined the treatment of codeine dependence. Given the lower potency of codeine it cannot be assumed that buprenorphine dose requirements for heroin dependence will generalise to codeine. This is the first study to examine buprenorphine treatment for codeine dependence. Design and Methods Retrospective case series of 19 codeine-dependent treatment entrants who received sublingual buprenorphine maintenance treatment through six specialist inpatient and outpatient treatment centres. Baseline codeine doses and buprenorphine dose at days 7 and 28 were collected, in addition to details on general demographics, pain and mental health, substance use and outcomes after 28 days of buprenorphine treatment. Results A significant linear relationship was found between initial codeine dose and dose of buprenorphine given at days 7 and 28 for the codeine dose range of 50–960 mg day⁻¹ (mean: 564 mg; 95% confidence interval 431–696 mg). Median buprenorphine dose was 12.0 mg (interquartile range 9.5 mg, range 4–32 mg) at day 7 and 16.0 mg (interquartile range 13.5 mg, range 4–32 mg) at day 28. Buprenorphine doses received were markedly higher than estimated codeine doses based on standard dose conversion tables. Discussion and Conclusions With increasing presentations relating to codeine dependence, these findings provide important guidance to clinicians. Buprenorphine doses were consistently higher than doses estimated based on the dose of codeine consumed, and were comparable with doses used in the treatment of dependence with heroin and more potent prescription opioids.

Keywords: codeine dependence; buprenorphine maintenance; induction; opioid analgesic

50. Buprenorphine Maintenance Treatment of Opiate Dependence: Correlations Between Prescriber Beliefs and Practices

Kai MacDonald, Kristy Lamb, Michael L. Thomas & Wendy Khentigan
Substance Use and Misuse 2016:51(1);85-90
Abstract

Background Despite the existence of evidence-based guidelines, different prescriber practices around buprenorphine maintenance treatment (BMT) of opiate dependence exist. Moreover, certain prescriber beliefs may influence their practice patterns. Objective To understand community BMT practice patterns and discern their relationship to practitioner beliefs. Method: Survey of 30 local BMT prescribers about aspects of BMT, and analysis of correlations between practices and practitioner beliefs. Results Practitioners generally followed standard treatment guidelines, though the most-common maintenances dosages of BMT (4–12 mg) were lower than recommended by some studies. Endorsement of belief in a “spiritual basis” of addiction correlated with lower average BMT doses and less frequent endorsement of the belief that BMT-treated patients are “in recovery.” Conclusions/Importance These data suggest that relatively standardized, longer-term BMT of opiate dependence is accepted among the majority of surveyed prescribers, and certain provider beliefs about addiction may influence prescribing habits and attitudes. Future studies should: (1) assess these findings in larger samples; (2) examine how prescriber beliefs about addiction and BMT compare with those of other addiction treatment providers; and (3) ascertain whether individual prescriber beliefs influence patient outcomes.

Keywords: Opiate dependence; buprenorphine; psychopharmacology; stigma

51. Potential cost-effectiveness of supervised injection facilities in Toronto and Ottawa, Canada

Eva A. Enns, Gregory S. Zaric, Carol J. Strike, Jennifer A. Jairam, Gillian Kolla and Ahmed M. Bayoumi

Addiction 2016:111(3);475-489

Abstract

Background and Aims Supervised injection facilities (legally sanctioned spaces for supervised consumption of illicitly obtained drugs) are controversial public health interventions. We determined the optimal number of facilities in two Canadian cities using health economic methods. Design Dynamic compartmental model of HIV and hepatitis C transmission through sexual contact and sharing of drug use equipment. Setting Toronto and Ottawa, Canada. Participants Simulated population of each city. Interventions Zero to five supervised injection facilities. Measurements Direct health-care costs and quality-adjusted life-years (QALYs) over 20 years, discounted at 5% per year; incremental cost-effectiveness ratios. Findings In Toronto, one facility cost $4.1 million and resulted in a gain of 385 QALYs over 20 years, for an incremental cost-effectiveness ratio (ICER) of $10 763 per QALY [95% credible interval (95CrI): cost-saving to $278 311]. Establishing one facility in Ottawa had an ICER of $6127 per QALY (95CrI: cost-saving to $179 272). At a $50 000 per QALY threshold, three facilities would be cost-effective in Toronto and two in Ottawa. The probability that establishing three, four, or five facilities in Toronto was cost-effective was 17, 21, and 41%, respectively. Establishing one, two, or three facilities in Ottawa was cost-effective with 13, 35, and 41% probability, respectively. Establishing no facility was unlikely to be the most cost-effective option (14% in Toronto and 10% in Ottawa). In both cities, results were robust if the reduction in needle-sharing among clients of the facilities was at least 50% and fixed operating costs were less than $2.0 million.

Conclusions Using a $50 000 per quality-adjusted life-years threshold for cost-effectiveness, it is likely to be cost-effective to establish at least three legally sanctioned spaces for supervised injection of illicitly obtained drugs in Toronto, Canada and two in Ottawa, Canada.

Keywords: Harm reduction; HCV; HIV/AIDS; injection drug use; mathematical modeling; supervised injection facility

52. Development of a brief tool for monitoring aberrant behaviours among patients receiving long-term opioid therapy: The Opioid-Related Behaviours In Treatment (ORBIT) scale

Briony Larance, Raimondo Bruno, Nicholas Lintzeris, Louisa Degenhardt, Emma Black, Amanda Brown, Suzanne Nielsen, Adrian Dunlop, Rohan Holland, Milton Cohen, Richard P. Mattick

Drug and Alcohol Dependence 2016:159;42-52
Abstract

Background Early identification of problems is essential in minimising the unintended consequences of opioid therapy. This study aimed to develop a brief scale that identifies and quantifies recent aberrant behaviour among diverse patient populations receiving long-term opioid treatment. Method 40 scale items were generated via literature review and expert panel (N = 19) and tested in surveys of: (i) N = 41 key experts, and (ii) N = 426 patients prescribed opioids >3 months (222 pain patients and 204 opioid substitution therapy (OST) patients). We employed item and scale psychometrics (exploratory factor analyses, confirmatory factor analyses and item-response theory statistics) to refine items to a brief scale. Results Following removal of problematic items (poor retest-reliability or wording, semantic redundancy, differential item functioning, collinearity or rarity) iterative factor analytic procedures identified a 10-item unifactorial scale with good model fit in the total sample (N = 426; CFI = 0.981, TLI = 0.975, RMSEA = 0.057), and among pain (CFI = 0.969, TLI = 0.960, RMSEA = 0.062) and OST subgroups (CFI = 0.989, TFI = 0.986, RMSEA = 0.051). The 10 items provided good discrimination between groups, demonstrated acceptable test–retest reliability (ICC 0.80, 95% CI 0.60–0.89; Cronbach's alpha = 0.89), were moderately correlated with related constructs, including opioid dependence (SDS), depression and stress (DASS subscales) and Social Relationships and Environment domains of the WHO-QoL, and had strong face validity among advising clinicians. Conclusions The Opioid-Related Behaviours In Treatment (ORBIT) scale is brief, reliable and validated for use in diverse patient groups receiving opioids. The ORBIT has potential applications as a checklist to prompt clinical discussions and as a tool to quantify aberrant behaviour and assess change over time.

Keywords: Chronic pain; Opioid analgesics; Opioid substitution therapy; Addiction; Medication non-adherence

53. Comparison of methods to assess psychiatric medication adherence in methadone-maintained patients with co-occurring psychiatric disorder

Kelly E. Dunn, Van L. King, Robert K. Brooner

Drug and Alcohol Dependence 2016:160;212-217
Abstract

Background Adherence with psychiatric medication is a critical issue that has serious individual and public health implications. This is a secondary analysis of a large-scale clinical treatment trial of co-occurring substance use and psychiatric disorder. Method Participants (n = 153) who received a clinically-indicated psychiatric medication ≥30 days during the 12-month study and provided corresponding data from Medication Event Monitoring System (MEMS) and Morisky Medication Taking Adherence Scale (MMAS) self-report adherence ratings were included in the analyses. Accuracy in MEMS caps openings was customized to each participant’s unique required dosing schedule. Results Consistent with expectations, MEMS-based adherence declined slowly over time, though MMAS scores of forgetting medication remained high and did not change over the 12-month study. MEMS caps openings were not significantly impacted by any baseline or treatment level variables, whereas MMAS scores were significantly associated with younger age and presence of an Axis I disorder and antisocial personality disorder, or any cluster B diagnoses.

Conclusions Results suggest that MEMS caps may be a more objective method for monitoring adherence in patients with co-occurring substance use and psychiatric disorder relative to the MMAS self-report. Participants in this study were able to successfully use the MEMS caps for a 12-month period with <1% lost or broken caps, suggesting this comorbid population is able to use the MEMS successfully. Ultimately, these data suggest that an objective method for monitoring adherence in this treatment population yield more accurate outcomes relative to self-report.

Keywords: MEMS; Medication adherence; Co-occurring; Opioid use disorder; Psychiatric disorder


OVERDOSE AND DRUG RELATED DEATHS
54. Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England

Matthias Pierce, Sheila M. Bird, Matthew Hickman, John Marsden, Graham Dunn, Andrew Jones and Tim Millar