Drug and Alcohol Dependence

Editorial Board

2012-05-01

Strategies for evaluating the economic value of drugs in alcohol dependence treatment

2012-05-01

Abstract: Background: To assess existing health economic strategies, which are used to evaluate the economic value of drugs to treat alcohol dependence (AD) such as acamprosate, naltrexone and any other pharmaceuticals.Methods: A systematic literature search on AD treatment economic evaluation studies was performed in multiple electronic bibliographic and economic databases.Results: A total of seven studies were found that involved economic evaluations of pharmacotherapy treatment of AD. It was seen that all individual pharmacotherapy treatment programs including acamprosate, naltrexone and combined treatments have resulted in a net benefit or cost savings. However, the examined studies used different methods to estimate the costs, cost savings, and cost effectiveness of the treatments.Conclusions: Pharmacotherapy treatment of AD produced marked economic benefits. However, the number of studies on the economic evaluation of pharmacotherapy for AD treatment is limited. The gaps in these studies have also been identified as necessitating more research.

Piperazine compounds as drugs of abuse

M.D. Arbo, M.L. Bastos, H.F. Carmo — 2012-05-01

Abstract: Synthetic drugs are among the most commonly abused drugs in the world. This abuse is widespread among young people, especially in the dance club and rave scenes. Over the last several years, piperazine derived drugs have appeared, mainly available via the internet, and sold as ecstasy pills or under the names of “Frenzy”, “Bliss”, “Charge”, “Herbal ecstasy”, “A2”, “Legal X” and “Legal E”. Although in the market piperazine designer drugs have the reputation of being safe, several experimental and epidemiological studies indicate risks for humans. Piperazine designer drugs can be divided into two classes, the benzylpiperazines such as N-benzylpiperazine (BZP) and its methylenedioxy analogue 1-(3,4-methylenedioxybenzyl)piperazine (MDBP), and the phenylpiperazines such as 1-(3-chlorophenyl)piperazine (mCPP), 1-(3-trifluoromethylphenyl)piperazine (TFMPP), and 1-(4-methoxyphenyl)piperazine (MeOPP). Toxicokinetic properties, including metabolic pathways, actions and effects in animals and humans, with some hypothesis of mechanism of action, and analytical approaches for the identification of these drugs are summarized in this review.

Intensive intervention for alcohol-dependent smokers in early recovery: A randomized trial

2012-05-01

Abstract: Introduction: The purpose of this study was to investigate the efficacy of an intensive tobacco cessation intervention for alcohol-dependent smokers in early recovery.Methods: A total of 162 alcohol-dependent smokers were randomized to either intensive intervention for smoking cessation or usual care. The intensive intervention consisted of 16 sessions of individual cognitive behavior therapy (CBT) and combination nicotine replacement therapy that lasted 26 weeks. Usual care involved referral to a free-standing smoking cessation program that provided smoking cessation counseling of varying duration and guideline-concordant medications. The primary cessation outcome was verified 7-day point prevalence abstinence (PPA) at 12, 26, 38, and 52 weeks.Results: At 12 and 26 weeks, the verified 7-day point-prevalence quit rate was significantly higher for the intensive intervention group than for the usual care group (both p=0.03). However, the quit rates for the two treatment groups were not significantly different at 38 or 52 weeks. Verified 30-day alcohol abstinence rates were not significantly different for the two treatment groups at any of the follow-up assessments.Conclusions: The intensive smoking cessation intervention yielded a higher short-term smoking quit rate without jeopardizing sobriety. A chronic care model might facilitate maintenance of smoking cessation during the first year of alcohol treatment and perhaps for longer periods of time. It is hoped that studies such as this will inform the development of more effective interventions for concurrent alcohol and tobacco use disorders.

Individual-level syringe coverage among Needle and Syringe Program attendees in Australia

Jenny Iversen, Libby Topp, Handan Wand, Lisa Maher — 2012-05-01

Abstract: Background: Harm associated with injecting drug use is a significant public health issue and a major cause of morbidity and mortality, with global estimates of 3 million injectors infected with HIV and 8 million living with chronic hepatitis C virus (HCV) infection. Estimates of program coverage are widely used in the context of HIV prevention and are critical in determining the effectiveness of interventions such as Needle and Syringe Programs (NSPs).Methods: Data from a national cross-sectional study of NSP attendees in Australia were used to estimate individual-level syringe coverage as a proportion of monthly injections covered by a new syringe. Univariate and multivariate logistic regressions modelled associations between demographics, injecting risk, anti-HIV and HCV prevalence and syringe coverage. The median number of syringes retained per NSP attendee per annum was also estimated.Results: Twenty percent of participants had insufficient new syringes for all injections. Syringe reuse (including reuse of one's own syringe) was independently associated with syringe coverage of <100%. Conversely, procurement of syringes from an NSP was independently associated with syringe coverage ≥100%, with a greater protective effect occurring when NSP utilisation was combined with current engagement in opiate substitution therapy. The median number of syringes retained per participant per annum was 720, equivalent to 2 per day.Conclusions: While Australian NSP attendees report high syringe coverage by international standards, prevention efforts could be scaled up. Syringe reuse was associated with syringe coverage of <100%, suggesting the utility of reuse as a proxy for individual-level syringe coverage.

Illicit use of buprenorphine in a community sample of young adult non-medical users of pharmaceutical opioids

Raminta Daniulaityte, Russel Falck, Robert G. Carlson — 2012-05-01

Abstract: Background: There is growing evidence about illicit use of buprenorphine in the U.S. The study aims to: (1) identify prevalence and predictors of illicit buprenorphine use in a community sample of 396 young adult (18–23 years old) non-medical users of pharmaceutical opioids and (2) describe knowledge, attitudes and behaviors linked to illicit buprenorphine use as reported by a qualitative sub-sample (n=51).Methods: Participants were recruited using respondent-driven sampling. Qualitative interview participants were selected from the larger sample. The sample (n=396) was 54% male and 50% white; 7.8% reported lifetime illicit use of buprenorphine.Results: Logistic regression analysis results indicate that white ethnicity, intranasal inhalation of pharmaceutical opioids, symptoms of opioid dependence, and a greater number of pharmaceutical opioids used in lifetime were statistically significant predictors of illicit buprenorphine use. Qualitative interviews revealed that buprenorphine was more commonly used by more experienced users who were introduced to it by their “junkie friends.” Those who used buprenorphine to self-medicate withdrawal referred to it as a “miracle pill.” When used to get high, reported experiences ranged from “the best high ever” to “puking for days.” Participants reported using buprenorphine/naloxone orally or by intranasal inhalation. Injection of buprenorphine without naloxone was also reported.Conclusion: Our findings suggest that illicit buprenorphine use is gaining ground primarily among whites and those who are more advanced in their drug use careers. Continued monitoring is needed to better understand evolving patterns and trends of illicit buprenorphine use.

How profitable is methamphetamine dealing in Australia?

Wendy Gong, Alison Ritter, David Bright, Chris Doran — 2012-05-01

Abstract: Introduction: The illicit drug trade is the largest in value among global illicit commodities, at some $320 billion US dollars, according to the UN World Drug Report. Endeavours to control such a large illicit market would be enhanced by improved understanding of the economics of the trade. However, due to its illicit nature many aspects of the illicit drug market are largely unknown. This study explored one economic aspect of illicit drug dealing, profitability, with the aim of developing a better picture of the financial gains from illicit drug dealing.Methods: Data were obtained from judges sentencing remarks, key informants from law enforcement, and other published reports which detail the prices paid for methamphetamine in Australia. The financial margins attained from non-crystal methamphetamine dealing in Australia were calculated by examining the best fit for the relationship between prices and quantities: in this case a power law.Results: If it is assumed that a single deal is divided (“cut”) between 4 times and 20 times before selling to the next customer, the mark-ups can range from 24% to 59%. The mark-ups appear low compared with those found in US research, but similar to those found in UK research.Conclusions: To our knowledge, this is the first attempt to analyse profitability of methamphetamine dealing in Australia. The findings of this study will help in understanding the motivations and decisions of drug dealers, and potentially assist drug law enforcement agencies to design better strategies to dismantle supply chain linkages which generate excessive profits.

Pregnancies exposed to methadone, methadone and other illicit substances, and poly-drugs without methadone: A comparison of fetal neurobehaviors and infant outcomes

L.M. Jansson, J.A. Di Pietro, A. Elko, E.L. Williams, L. Milio, M. Velez — 2012-05-01

Abstract: Background: It is suspected that there is a continuum of impairment among prenatally drug-exposed infants, such that opioid and/or poly-drug exposure confers the highest risk for adverse neonatal outcomes than other classes of substances or single substance exposures. Suitable control groups are difficult to identify. This study compared fetal neurobehavioral development and infant outcomes in offspring of three groups of pregnant women in drug treatment. Exposure groups include: Methadone+other illicit substances (MM+Poly) and two groups currently abstinent for poly drug exposures: Methadone only (MM/A) and Non-Methadone (NM/A).Methods: Forty-nine women (19 MM+Poly, 18 MM/A, and 12 NM/A) underwent fetal monitoring at 36 weeks gestation at peak and trough levels of methadone (MM+Poly; MM/A) or at comparable morning and afternoon times (NM/A). Fetal heart rate (FHR), heart rate variability (FHRV) and motor activity (FM) data were collected. Infant measures included birth outcomes and Neonatal Abstinence Syndrome (NAS) assessment.Results: As compared to the NM/A group, cardiac measures were decreased in methadone-exposed fetuses at peak levels. FHR was significantly more suppressed in the MM+Poly group. FM was significantly lower in the MM/A vs. the NM/A group at both peak and trough, indicative of more persistent exposure effects. The MM+Poly group delivered 1 week earlier and required NAS pharmacological treatment twice as often as the MM/A group.Conclusions: Results support the notion that poly-drug exposure may potentiate the effects of methadone on the fetus and infant and highlights the need for intensified treatment for methadone-maintained women who abuse other substances.

Latent classes of heroin and cocaine users predict unique HIV/HCV risk factors

P.T. Harrell, B.E. Mancha, H. Petras, R.C. Trenz, W.W. Latimer — 2012-05-01

Abstract: Background: Patterns of heroin and cocaine use vary and may be associated with unique risk factors for bloodborne infections.Methods: Latent class analysis identified sub-populations of 552 heroin and cocaine users in Baltimore, Maryland. Using latent class regression, these classes were analyzed for associations with demographic characteristics, risky behaviors, Hepatitis C, and HIV.Results: Three classes were found: Crack/Nasal-Heroin users (43.5%), Polysubstance users (34.8%), and Heroin Injectors (21.8%). Compared to Polysubstance users, Crack/Nasal-Heroin users were almost 7 times more likely to identify as Black (OR=6.97, 95% CI=4.35–11.2). Sharing needles was over 2.5 times more likely among Polysubstance users than among Heroin Injectors (OR=2.66, 95% CI=1.49–4.75). Crack/Nasal-Heroin users were 2.5 times more likely than Polysubstance users to exchange drugs for sex (OR=2.50, 95% CI=1.22–5.13). Crack/Nasal-Heroin users were less likely than Heroin Injectors to have Hepatitis C (OR=0.10, 95% CI=0.06–0.18), but no significant differences were found for HIV.Conclusions: Subpopulations of cocaine and heroin users differed in demographic classifications, HIV-risk behaviors, and Hepatitis C infection. All subpopulations included substantial numbers of HIV-positive individuals. Findings provide further evidence that non-injection drug users face significant infectious disease risk.

A preliminary study of the neural effects of behavioral therapy for substance use disorders

2012-05-01

Abstract: Background: The mechanisms by which behavioral therapies for substance use disorders (SUDs) exert their effects and the components of treatment that contribute most to substance use outcome remain unclear. Disruptions to aspects of impulse control and attention have been hypothesized to contribute to the development and maintenance of addiction; moreover, alterations in these processes may underlie responses to treatment.Methods: Individuals participating in a randomized clinical trial evaluating computer-assisted cognitive behavioral therapy (CBT) for substance abuse participated in fMRI Stroop before and after treatment. A non-substance-using comparison group performed the same task under test–retest conditions.Results: The patient group demonstrated decreased Stroop-related BOLD signal in regions including the anterior cingulate, inferior frontal gyrus and midbrain at post-treatment relative to pre-treatment, and displayed a greater decrease in the subthalamic nucleus and surrounding regions compared to healthy controls following test–retest.Conclusions: Behavioral therapies may be associated with reduction in substance use and effects on neural systems involved in cognitive control, impulsivity, motivation and attention.

The Physicians’ Competence in Substance Abuse Test (P-CSAT): A multidimensional educational measurement tool for substance abuse training programs

John M. Harris, Huaping Sun — 2012-05-01

Abstract: Background: Efforts to enhance physician substance abuse (SA) management skills lack tools to assess skills and training effectiveness. We sought to develop an easily administered survey to assess SA fact-based skills and clinical decision-making.Methods: We prepared 60 fact-based items dealing with SA knowledge, attitudes, and behaviors (KAB) and 53 script concordance test (SCT) items assessing SA decision-making. We used expert review and standard psychometric criteria to eliminate discordant or non-contributory survey items. We tested 92 draft items in 117 physicians, including 13 with additional SA training (trained), and 17 recognized SA experts. We assessed final survey internal consistency with Cronbach's alpha and differences in scores between experts, trained physicians, and physicians without SA training (novices) with the Kruskal–Wallis test.Results: Following refinement, the draft survey was reduced to 30 KAB and 33 SCT items. Alpha was 0.901 for the final 63-item survey and 0.887 and 0.797 for the KAB and SCT subscales, respectively. Novices, trained physicians, and experts scored means of 196, 213, and 261 respectively out of 315 possible points on the final survey. The KAB and SCT subscale results showed similar patterns. Score differences for the overall survey and its subscales were highly significant (p<0.001).Conclusions: This survey, which we have named the Physicians’ Competence in Substance Abuse Test (P-CSAT) and placed in the public domain, meets baseline criteria for reliability and validity. Future studies should determine the extent to which the P-CSAT provides consistent results in other practitioner populations and responds to SA educational efforts.

Receipt of opioid agonist treatment in the Veterans Health Administration: Facility and patient factors

Elizabeth M. Oliva, Alex H.S. Harris, Jodie A. Trafton, Adam J. Gordon — 2012-05-01

Abstract: Background: Opioid agonist treatment (OAT)—through licensed clinic settings (C-OAT) using methadone or buprenorphine or office-based settings with buprenorphine (O-OAT)—is an evidence-based treatment for opioid dependence. Because of limited availability of on-site C-OAT (n=28 of 128 facilities) in the Veterans Health Administration (VHA), O-OAT use has been encouraged. This study examined OAT utilization across VHA facilities and the patient and facility factors related to variability in utilization.Method: We examined 12 months of VHA administrative data (fiscal year [FY] 2008, October 2007 through September 2008) for evidence of OAT utilization and substance use disorder program data from an annual VHA survey. Variability in OAT utilization across facilities and patient and facility factors related to OAT utilization were examined using mixed-effects, logistic regression models.Results: Among 128 VHA facilities, 35,240 patients were diagnosed with an opioid use disorder. Of those, 27.3% received OAT: 22.2% received C-OAT and 5.1% received O-OAT with buprenorphine. Substantial facility-level variability in proportions of patients treated with OAT was found, ranging from 0% to 66% with 44% of facilities treating <5%. Significant patient-level predictors of OAT receipt included being male, age ≥56, and without another mental health diagnosis. Significant facility-level predictors included offering any OAT services (C-OAT or O-OAT) and specialty substance abuse treatment services on weekends.Conclusion: In FY2008, prior to the VHA national mandate of access to buprenorphine OAT, substantial variation in the use of OAT existed, partially explained by patient- and facility-level factors. Implementation efforts should focus on increasing access to this evidence-based treatment, especially in facilities at the low end of the distribution.

Overexpression of α3/α5/β4 nicotinic receptor subunits modifies impulsive-like behavior

2012-05-01

Abstract: Recent studies have revealed that sequence variants in genes encoding the α3/α5/β4 nicotinic acetylcholine receptor subunits are associated with nicotine dependence. In this study, we evaluated two specific aspects of executive functioning related to drug addiction (impulsivity and working memory) in transgenic mice over expressing α3/α5/β4 nicotinic receptor subunits. Impulsivity and working memory were evaluated in an operant delayed alternation task, where mice must inhibit responding between 2 and 8s in order to receive food reinforcement. Working memory was also evaluated in a spontaneous alternation task in an open field. Transgenic mice showed less impulsive-like behavior than wild-type controls, and this behavioral phenotype was related to the number of copies of the transgene. Thus, transgenic Line 22 (16–28 copies) showed a more pronounced phenotype than Line 30 (4–5 copies). Overexpression of these subunits in Line 22 reduced spontaneous alternation behavior suggesting deficits in working memory processing in this particular paradigm. These results reveal the involvement of α3/α5/β4 nicotinic receptor subunits in working memory and impulsivity, two behavioral traits directly related to the vulnerability to develop nicotine dependence.

Heart rate turbulence during acute alcohol withdrawal syndrome

2012-05-01

Abstract: Background: Alcohol withdrawal syndrome is associated with an increased incidence of cardiac arrhythmias and sudden cardiac death. Heart rate turbulence (HRT) parameters were applied during withdrawal to estimate cardiac regulation during treatment with clomethiazole.Methods: Twenty-two patients suffering from alcohol withdrawal syndrome were included in the study. Heart rate regulation was obtained by means of Holter ECG analyzing time intervals before medication, and 2 and 6h after medication. Slope and onset of HRT were calculated in addition to heart rate variability (HRV) parameters. Furthermore, we calculated the slope and the onset of ectopic beat-like events.Results: Heart rate variability parameters indicated a minor reduction of vagal modulation during withdrawal syndrome. Especially, the fractal scaling exponent BBI alpha1 (4–16) indicated the autonomic shift. In contrast to HRV parameters, no significant changes were observed in the HRT parameters. Significant correlations were observed between severity of withdrawal, as assessed by the AWS scale, and the fractal scaling exponent BBI alpha2 (16–64), and the onset and the slope of HRT of ectopic beat-like activity.Conclusion: Increased sympathetic modulation during withdrawal and clomethiazole treatment is not associated with changes of heart rate turbulence parameters predictive of cardiac death after myocardial infarction.