Ed Day

Can we prevent drug related deaths by training opioid users to recognise and manage overdoses

BackgroundNaloxone has been evidenced widely as a means of reducing mortality resulting from opiate overdose, yet its distribution to drug users remains limited. However, it is drug users who are most likely to be available to administer naloxone at the scene and who have been shown to be willing and motivated to deliver this intervention. The current study builds on a national training evaluation in England by assessing 6-month outcome data collected primarily in one of the participating centres.MethodsSeventy patients with opioid dependence syndrome were trained in the recognition and management of overdoses in Birmingham (n = 66) and London (n = 4), and followed up six months after receiving naloxone. After successful completion of the training, participants received a supply of 400 micrograms of naloxone (in the form of a preloaded syringe) to take home. The study focused on whether participating users still had their naloxone, whether they retained the information, whether they had witnessed an overdose and whether they had naloxone available and were still willing to use it in the event of overdose.Results & DiscussionThe results were mixed - although the majority of drug users had retained the naloxone prescribed to them, and retention of knowledge was very strong in relation to overdose recognition and intervention, most participants did not carry the naloxone with them consistently and consequently it was generally not available if they witnessed an overdose. The paper discusses the reasons for the reluctance to carry naloxone and potential opportunities for how this might be overcome. Future issues around training and support around peer dissemination are also addressed.ConclusionOur findings confirm that training of drug users constitutes a valuable resource in the management of opiate overdoses and growth of peer interventions that may not otherwise be recognised or addressed. Obstacles have been identified at individual (transportability, stigma) and at a systems level (police involvement, prescription laws). Training individuals does not seem to be sufficient for these programmes to succeed and a coherent implementation model is necessary.

Relating counselor attributes to client engagement in England

Client functioning and treatment engagement were examined in relation to staff attributes and organizational climate across a diverse sample of drug treatment and outreach programs in England. Self-rating assessments were obtained from 1,539 clients and 439 counselors representing 44 programs, and results were interpreted using comparable data from studies of treatment programs in the United States. Client scores on treatment participation and counseling rapport in England were directly related to their higher levels of motivation and psychosocial functioning, as well as to staff ratings of professional attributes and program atmosphere. By linking records from English clients with their counselors in each program, findings also indicate these relationships are rooted in the personal interactions between clients and their counselor. Standardized assessments of treatment structure, process, and performance used across therapeutic settings and national boundaries show there is generalizability in the pattern of clinical dynamics, including the relationships between organizational functioning and quality of services.

Detecting lifetime alcohol problems in individuals referred for liver transplantation for nonalcoholic liver failure

Transplantation for alcoholic liver disease is becoming increasingly common, and with adequate screening, short‐ to medium‐term outcomes are very good. However, while conducting a prospective study of the outcome of liver transplantation in Birmingham, United Kingdom, we observed that a research diagnosis of alcohol abuse or dependence was made in a number of cases in which no reference to alcohol problems had been made by the referring agency. This article explores the characteristics of these “missed” cases and highlights key patient characteristics that might prompt a more detailed assessment of alcohol consumption. Two hundred eight individuals completed the research interview, and 80 (39%) met Diagnostic and Statistical Manual of Mental Disorders IV criteria for a lifetime diagnosis of either alcohol abuse (n = 29) or dependence (n = 51). When the initial referral details were reviewed, the possibility of alcohol problems had not been raised in 10 (12.5%) of these cases. Hepatitis C was the most common primary diagnosis in the missed cases, but there was no difference between diagnosed and missed cases in terms of demographic factors, severity of liver disease, or the number or degree of lifetime problems associated with alcohol. However, members of the missed group were more likely to have drunk alcohol in the past 6 months and in a greater volume and were more likely to have used illicit drugs such as opiates, amphetamines, hallucinogens, and cannabis. These findings point to the need to take an adequate history of lifetime alcohol problems in all patients being considered for liver transplantation. Liver Transpl 14:1609–1613, 2008.

Clinical provision of improvised nasal naloxone without experimental testing and without regulatory approval: imaginative shortcut or dangerous bypass of essential safety procedures?

CONTEXT Take-home naloxone is increasingly provided to prevent heroin overdose deaths. Naloxone 0.4-2.0 mg is licensed for use by injection. Some clinicians supply improvised nasal naloxone kits (outside licensed approval). Is this acceptable? AIMS (1) To consider provision of improvised nasal naloxone in clinical practice and (2) to search for evidence for pharmacokinetics and effectiveness (versus injection). METHODS (1) To document existing nasal naloxone schemes and published evidence of pharmacokinetics (systematic search of the CINAHL, Cochrane, EMBASE and MEDLINE databases and 18 records included in narrative synthesis). (2) To analyse ongoing studies investigating nasal naloxone (WHO International Clinical Trials Registry Platform and US NIH RePORT databases). FINDINGS (1) Multiple studies report overdose reversals following administration of improvised intranasal naloxone. (2) Overdose reversal after nasal naloxone is frequent but may not always occur. (3) Until late 2015, the only commercially available naloxone concentrations were 0.4 mg/ml and 2 mg/2 ml. Nasal medications are typically 0.05-0.25 ml of fluid per nostril. The only published study of pharmacokinetics and bioavailability finds that nasal naloxone has poor bioavailability. QUESTIONS FOR DEBATE: (1) Why are pharmacokinetics and bioavailability data for nasal naloxone not available before incorporation into standard clinical practice? (2) Does nasal naloxone have the potential to become a reliable clinical formulation? (3) What pre-clinical and clinical studies should precede utilization of novel naloxone formulations as standard emergency medications? CONCLUSIONS The addictions treatment field has rushed prematurely into the use of improvised nasal naloxone kits. Evidence of adequate bioavailability and acceptable pharmacokinetic curves are vital preliminary steps, especially when effective approved formulations exist.

Transplantation for alcoholic liver disease: Report of a consensus meeting

A one-day consensus meeting was convened at the Clinical Research Facility in Birmingham on 19 November 2004. The group sought to include representatives from the eight UK and Eire liver transplant units and in the event received 28 delegates from seven units. The purpose of the group was to look at issues regarding the transplantation of patients with alcoholic liver disease (ALD) primarily from a psychosocial and addiction perspective rather than from a physical one. The group hoped to define some of the issues and dilemmas that surround the decision to transplant the ALD patient in an era of donor shortage, paying particular attention to the issue of return to alcohol use post-transplant.

Mobile phone ownership, usage and readiness to use by patients in drug treatment

BACKGROUND Mobile phone based interventions using text-messages and smartphone apps demonstrate promise for enhancing the treatment of substance use disorders. However, there is limited evidence on the availability of mobile phones among people in substance use treatment, as well as usage patterns, contact preferences and willingness to use phone functions such as geo-location for treatment purposes. METHOD A questionnaire was completed by 398 patients enrolled in four UK community drug treatment services. The majority (74%) reported being in treatment for heroin dependence, 9% for alcohol, 4% prescription drugs, 1% amphetamines, 1% club drugs and 1% cannabis. The remaining reported a combination of different drug categories. RESULTS Eighty-three percent of patients reported owning a mobile phone; 57% of phones were smartphones and 72% of clients had a pay-as-you-go contract. Forty-six percent of phone owners changed their number in the previous year. Eighty-six percent were willing to be contacted by their treatment provider via mobile phone, although 46% thought the use of geo-location to be unacceptable. CONCLUSION Mobile phones are widely available among individuals receiving community drug treatment and should be considered as a viable contact method by service providers, particularly text-messaging. However, patients may not have access to sophisticated features such as smartphone apps, and, up to date records of contact numbers must be frequently maintained. Developers need to be sensitive to issues of privacy and invasiveness around geo-location tracking and frequency of contact.

A preliminary evaluation of integrated treatment for co-existing substance use and severe mental health problems: Impact on teams and service users

Aim: This study sought to develop a methodology to measure the integration of substance use treatment within five existing assertive outreach (AO) teams in Birmingham, UK. Changes in the way teams approach and discuss drug and alcohol problems amongst clients with severe mental health problems were anticipated. This was assessed at team meetings, through clinical sessions and case notes. The impact of change in team practice was also measured at the level of service users by assessing psychiatric symptoms, engagement, amount of substance used, and conviction ratings of positive substance-related beliefs. Method: Each team were provided with training and supervision to deliver cognitive behavioural integrated treatment (C-BIT). This aimed to increase awareness of the relationship between psychosis and problem substance use and provide skills to manage these difficulties. Data was collected at intervals over a 36 month period. Results: Staff within teams increased in self reported confidence and skills to deliver C-BIT and these gains were maintained over time. Findings suggest that following training, integration was achieved to a degree and changes in teams practice were observed. Improvements in client engagement and reduction in alcohol intake and positive alcohol-related beliefs were also noted but occurred regardless of team training. Conclusions: Training and supporting AO staff to use an integrated treatment approach is well received and produces lasting changes in confidence and practice. Whether this can go on to impact upon client outcome is yet to be established.

Alcohol and Substance Abuse in Solid-Organ Transplant Recipients

This review focuses on alcohol and substance abuse in the context of solid-organ transplantation. Alcohol and substance abuse are common and may lead to a need for solid-organ transplantation and may also contribute to significant physical and psychologic problems that impact upon the recipient. Damaging levels of alcohol intake can occur in the absence of dependence. Alcohol or substance abuse after transplantation is associated with poor medication compliance and this may increase risk of graft loss. Intravenous drug use is associated with increased risk of infections (especially secondary to opportunistic organisms—bacterial, viral, protozoal, and others—and such infections may be more severe in the immunosuppressed), but there is only anecdotal evidence that such behavior has a worse outcome in transplant recipients. Whereas previous alcohol excess and drug use in kidney recipients are both associated with a small but statistically significantly increased risk of adverse outcomes (hazard ratio, 1.16–1.56), alcohol use within recommended guidelines after transplantation appears safe and possibly beneficial. Robust data are lacking for other organs, but those available suggest that heart transplantation is safe in individuals with a history of alcohol or substance abuse. Health specialists in drug or alcohol addiction should carefully screen all potential transplant candidates for these conditions, and where there is evidence of dependency or abuse, effective psychologic and physical treatment should be offered. Studies have shown that interventions such as psychologic intervention have improved alcohol behavior in the context of liver transplantation. Although there are no comparable studies with other solid-organ recipients, it is reasonable to expect transferable outcomes.

Outpatient versus inpatient opioid detoxification: A randomized controlled trial

Opioid detoxification is not an effective stand-alone treatment for heroin dependence but is nevertheless an essential step in the path to recovery. There has been relatively little previous controlled research on the impact of treatment setting on the likelihood of successful completion of detoxification. In this study, 68 opioid-dependent patients receiving community treatment (predominantly with methadone) and requesting detoxification were randomly assigned to an inpatient versus outpatient setting. Both groups received the same medication (lofexidine), and the primary outcome measure was being opioid-free at detoxification completion. More inpatients (n = 18, 51.4%) than outpatients (n = 12, 36.4%) completed detoxification, but this difference was not statistically significant (χ(2) = 1.56, p = .21). However, the outpatient group received a significantly longer period of medication, and when the length of detoxification was controlled for, the results favored the inpatient setting (Exp(B) = 13.9, 95% confidence interval = 2.6-75.5, p = .002). Only 11 (16%) participants were opioid-free at the 1-month follow-up and 8 at the 6-month follow-up, with no between-group difference. Inpatient and outpatient opioid detoxification settings were not significantly different in completion or follow-up abstinence rates, but aspects of the study design may have favored the outpatient setting. Future studies should test patient characteristics that predict better outcomes in each setting.

Relationship between Drug Treatment Engagement and Criminal Thinking Style among Drug-Using Offenders

There has been considerable debate about the effectiveness of drug treatment in reducing offending and drug use, with limited support for the effectiveness of the UK Drug Intervention Programme to reduce offending through diversion into treatment. The current paper examines drug users diverted into treatment in one UK city to assess their treatment engagement and criminal thinking styles. There is an association between higher criminal thinking and both poorer engagement in treatment and worse client functioning. The key implication is that to address offending-prone behaviour as a determinant of ongoing drug use, it is essential that criminal thinking styles are addressed.