Einat Peles

One-Year and Cumulative Retention as Predictors of Success in Methadone Maintenance Treatment: A Comparison of Two Clinics in the United States and Israel

ABSTRACT Outcome predictors between two methadone maintenance treatment clinics in Tel-Aviv, Israel, and Las Vegas, Nevada, were determined by comparing patients characteristics. All patients admitted to the two clinics (302 from Las Vegas and 492 from Tel-Aviv) were studied with respect to variables at admission and follow-up. Las Vegas patients were older, contained more females, had more hepatitis C positive markers, and more urine analyses that were positive for cocaine, amphetamines, and tetrahydrocannabinol (THC) on admission than the Tel-Aviv patients. After 1 year, Tel-Aviv patients had higher retention (73.6% vs. 61.6%) and similar opiate abstinence (65.8% vs. 64.9%) compared to Las Vegas patients. Predictors for cumulative retention (Cox regression) for both clinics were higher methadone dosages greater than or equal to 100 mg/day (Tel-Aviv OR [odds ratio] = 2.1, 95% confidence interval [CI] = 1.6–2.9; Las Vegas OR = 1.8, 95% CI = 1.3–2.5). Also, in Tel-Aviv, predictors were no opiate use after 1 year (OR = 1.7, 95% CI = 1.4–2.2) and no benzodiazepine after 1 year, and in Las Vegas no cocaine and no amphetamines after 1 year and age less than or equal to 30 years. The two major predictors in the two clinics were successful in both outcomes: 1 year retention and opiate abstinence.

Documented poor sleep among methadone-maintained patients is associated with chronic pain and benzodiazepine abuse, but not with methadone dose

UNLABELLEDnFollowing the findings of perceived poor sleep and of chronic pain among former heroin addicts, current methadone maintenance treatment (MMT) patients, and its possible relation to methadone dose, we studied these patients objective sleep parameters. Former heroin addicts maintained on Low (n=19, <80 mg/d) or High (n=25, >150 mg/d) methadone doses, underwent one-night polysomnography (PSG). Patients filled Pittsburgh Sleep Quality Index (PSQI) and chronic pain questionnaires, and current drug abuse was assessed by urine tests.nnnRESULTSnOf the 44 patients, 18 (40.9%) had chronic pain, while 24 (54.5%) abused BDZ. High vs. Low methadone dose groups had more years of opiate abuse and lower % of NREM (non rapid eye movement) deep sleep (stages 3-4) with no other differences between groups. Years of opiate abuse and NREM stages 3-4 inversely correlated (R=-0.34, p=0.03). Chronic vs. non-chronic pain patients had lower sleep efficiency and sleep time, and higher wake stage. BDZ abusers vs. no-BDZ abusers had shorter % of NREM stages 3-4, shorter REM % and longer % of NREM light sleep (stage 2). Perceived sleep (as assessed by the PSQI) was worse among the chronic pain group and among the BDZ abusers.nnnCONCLUSIONSnPatients with chronic pain or BDZ abuse presented both perceived and objective poorer sleep, regardless of methadone dosage. Sleep evaluation and treatment should address these two prevalent conditions in order to improve MMT patients quality of sleep (and of life) and overall treatment outcome.

The Differential Effect of Methadone Dose and of Chronic Pain on Pain Perception of Former Heroin Addicts Receiving Methadone Maintenance Treatment

UNLABELLEDnThe reports on pain perception among former heroin addicts receiving methadone maintenance treatment (MMT) vary with regard to pain and intolerance threshold, and perception of suprathreshold stimuli has not been previously evaluated. Our aim was to systematically assess perception of threshold and suprathreshold noxious and innocuous stimuli with special attention to the effect of MMT dose and the presence of chronic pain. Noxious and innocuous, thermal and mechanical thresholds and ratings of suprathreshold heat-pain stimuli were measured among 31 MMT subjects receiving high and low MMT dose, with and without chronic pain, and in 17 healthy controls. The characteristics of chronic pain were also evaluated. MMT dose and chronic pain differentially affected pain perception. Whereas MMT dose did not affect thresholds, chronic pain MMT subjects exhibited increased pain threshold and pain-free MMT subjects exhibited decreased pain threshold compared with controls. MMT in general was associated with decreased perception of suprathreshold pain; however, MMT subjects with chronic pain exhibited increased suprathreshold pain ratings. It appears that subjects receiving MMT are hyperalgesic but that chronic pain in these subjects interferes with threshold measurements, inducing an apparent hypoalgesia. On the other hand, chronic pain reduces the analgesic effect of methadone seen in pain-free MMT subjects, amplifying suprathreshold pain perception. Factors such as chronic pain and MMT dose should be taken into account in future studies on pain perception in this population.nnnPERSPECTIVEnWe show that the presence of chronic pain and methadone dose significantly affects perception of pain in former heroin addicts receiving MMT. Studying the alteration in pain perception in these subjects may contribute to understanding the high rates of chronic pain among them and may promote better treatment.

Correlation Between High Methadone Doses and Methadone Serum Levels in Methadone Maintenance Treatment (MMT) Patients

Abstract Aims: To evaluate the relation between high methadone doses and methadone serum levels in MMT patients. Design:One hundred fifty-one steady methadone-dose patients were evaluated for methadone serum levels using GCMS. Urine samples during the month prior to the study-day were analyzed and defined as positive if any sample was positive for any drug. Findings:Methadone dose correlated with methadone serum levels (Pearson R = 0.36, p < 0.0005). In 53 patients with no drug abuse, correlation was stronger (R = 0.53, p < 0.0005) than in 98 patients with any drug abuse (R = 0.25, p = 0.01). Conclusions:We extended the well-established correlation between methadone doses and serum levels in patients receiving low or moderate (60 to 120 mg/day) to high methadone doses (up to 290 mg/day)

Sense of coherence as a stable predictor for methadone maintenance treatment (MMT) outcome.

Abstract We studied stability of sense of coherence (SOC) over time and in relation to the outcomes of former heroin addicts in MMT. Between September of 2003 and April of 2006, all 90 newly admitted patients to a MMT clinic in Tel Aviv were studied and followed up for one year. A SOC (inner resources) questionnaire was done at baseline and after one year. Use of opiates, cocaine, benzodiazepines, cannabis and amphetamines in the 13 months after admission was recorded, and defined as positive if at least one urine test for any drug was positive. After one year, 77 (85.6%) stayed in treatment. SOC scores were similar at baseline and after one year, but were lower among 42 patients who still abused any drugs (118.8+27.4), compared with the 35 patients who did not (128.5+26.5, Repeated measures, Groups p = 0.003, Time effect p = 0.5, Time*Group p = 0.003). Cumulative retention revealed that 30 patients with SOC scores greater than 130 had longer retention (3.5 years, 95% CI 3.2–3.9) as compared with 60 patients with SOC scores of 130 or less (2.9 years, 95%CI 2.5–3.3). SOC is a stable parameter that can serve as a predictor for success in MMT, both as retention in treatment and drug abstinence.

Pathological Gambling and Obsessive Compulsive Disorder Among Methadone Maintenance Treatment Patients

ABSTRACT The aims of this study was to assess the prevalence of lifetime pathological gambling (pathological gambling) and current obsessive compulsive disorder among former heroin addicts currently in methadone maintenance treatment. A cross-sectional study of 154 patients from a methadone maintenance treatment clinic affiliated of a tertiary-referral medical center was conducted. The South Oaks Gambling Screen and Yale-Brown Obsessive Compulsive Scale were used for measurement purposes. Lifetime pathological gambling was found in 45 (29.2%) patients (current pathological gambling was found in 10 [6.5%] patients). Clinical obsessive compulsive disorder (defined if scored as moderate to extreme) was found in 51.1% of patients in the pathological gambling groups and 39.4% of patients in the non-pathological gambling group, with higher obsessive scores in the pathological gambling group versus the non-pathological gambling group. Logistic regression (multivariate analyses) found pathological gambling in more males (odds ratio = 3.6, 95% confidence interval = 1.5–8.8), a high obsessive score (odds ratio = 1.07, 95% confidence interval = 0.1–1.1), and older age on admission (40 years and older) (odds ratio = 2.4, 95% confidence interval = 1.1–5.0). Because only 10 (6.5%) patients were still currently gambling, more urgent intervention should be considered to the unexpected high rate of clinical obsessive-compulsive disorder (42.9%) in the sample, possibly because the clinic studied is of a higher severity than that accepted to the methadone maintenance treatment clinics in the community.

Risk factors for weight gain during methadone maintenance treatment

ABSTRACT Background: Weight gain was reported during methadone maintenance treatment (MMT). However, its relation to eating habits and specific risk factors, including methadone dose or serum level, was limited. The aims of this study were to characterize risk factors for weight gain and to study current eating habits, food preferences, and nutrition knowledge. Methods: Patients with available measures of weight and height (body mass index [BMI]) at admission to MMT and at follow-up, when methadone serum levels were determined (after 1 year or when stabilized) (N = 114), were studied (using the Addiction Severity Index [ASI], drugs in urine, methadone doses, and serum levels). In addition, 109 current patients with available earlier (5.8 ± 2.6 years earlier) BMI completed eating behavior rating and nutrition knowledge questionnaires, and their current and earlier BMI were compared. Results: The BMI of 114 newly admitted patients increased from 22.5 ± 3.8 to 24.4 ± 4.3 (P < .0005). Once stabilized on methadone, BMI increased further (24.3 ± 4.5 to 25.6 ± 5.0; P < .0005; n = 74), with no change in methadone doses (125.6 ± 32.5 to 128.0 ± 34.1; F = 1.4, P = .2) or serum levels (495.6 ± 263.7 to 539.8 ± 306.2; F = 1.3, P = .2). Repeated-measures analyses revealed that BMI elevation was higher among 45 hepatitis C virus seronegative and 46 non–benzodiazepine-abusing on-admission patients. Those who scored lower on knowledge about healthy diet and showed a higher sweet-foods preference had a higher BMI. Conclusion: BMI increased over time, but independent of methadone dosage and blood levels. As expected, worse diet habits and a desire for sweet foods are related to higher BMI. Paradoxically, healthier status (i.e., hepatitis C seronegative, no benzodiazepine abuse) at admission is predictive of greater weight gain during MMT. Education about nutrition habits is recommended.

Pathological Gambling in Methadone Maintenance Clinics Where Gambling Is Legal Versus Illegal

Lifetime potential and probable pathological gambling (PG) were assessed using the South Oaks Gambling Screen (SOGS) questionnaire. The prevalence between patients in methadone maintenance treatment (MMT) in Tel Aviv (Israel, gambling is illegal) and MMT patients in Las Vegas (NV, USA, gambling is legal) was compared. Urine toxicology and substance use was assessed as well. PG at MMT admission was higher in Tel Aviv (48/178, 27%) than in Las Vegas (19/113, 16.8%; p = .05). In Tel Aviv gambling mostly preceded opiate abuse (58.3%), while it followed opiate abuse in Las Vegas (66.7%, p < .001). Only 20.8% in Tel Aviv and 21.1% in Las Vegas were currently gambling. Multivariate analyses found older age on admission to MMT odds ratio (OR) = 1.05 (95% confidence interval [CI] 1.01-1.08), being male OR = 2.6 (95% CI 1.3-5.3) and being from the Tel Aviv MMT clinic OR = 2.5 (95% CI 1.3-4.9) to characterize PG. Detection of any drug in MMT admission urine specimens was unrelated to PG. Older age on admission to MMT, and male gender characterized PG in different MMT clinics, independent of the legal status of gambling. Low current PG rates for patients in both MMT clinics suggest that legality may not be relevant.

Characteristics and Outcome of Minority Group Patients in Methadone Maintenance Treatment

Abstract Minority status is associated with mental and physical morbidity, substance dependence, and poor outcomes. To compare characteristics and treatment outcomes between patients from two minority groups in Israel (Christians and Muslims) and patients from the majority population (Jews) in methadone maintenance treatment (MMT), we prospectively studied all patients admitted to our clinic between 1993 and 2012 and followed up until 2013; 655 Jews, 67 Christians, and 37 Muslims. Christian patients differed from Jews and Muslims by younger age at admission to MMT, greater prevalence of drug injectors, and a higher proportion of Hepatitis-C and HIV sera positive. Muslims had comparatively less education and a lower proportion of females. The three groups had similar rates of one-year retention (75.9%) and opiate abstinence (68.1%). They also did not differ in long-term retention (up to 20 years): Muslims 5.5 years (95%CI 3.6-7.4), Christians 7.5 years (95%CI 6-9.1), and Jews 7.6 years (95%CI 7-8.2, p = .3). The Hepatitis-C incidence, however, was higher among the 21 admitted Hepatitis-C seronegative minorities (5.0/100 person years) than the 207 Hepatitis-C seronegative non-minority patients (1.7/100 person years, p=0.03). All groups had good treatment outcomes, except for Hepatitis-C seroconversion, which necessitates a specific preventive intervention among the minority groups.

Characterization of Former Heroin Addict Patients With Hepatitis C Virus Antibodies in a Methadone Maintenance Treatment (MMT) Clinic in Israel

Aims: To compare characteristics, retention in treatment and cessation of drug abuse of 249 positive hepatitis C (HCV+) with 188 negative hepatitis C (HCV−) antibody patients. Methods: Data on Hepatitis C, Hepatitis B and HIV results, urine-proven drug use, and modified ASI of all patients admitted to the Adelson MMT clinic between June/1993–Dec/2002 were prospectively collected. Results: HCV+ patients manifested more ever injecting drug use, immigrants, positive HIV antibody, hepatitis B antigen, years of opiate addiction pre-MMT and benzodiazepines misuse after one year in MMT than HCV− patients, with similar 1-year retention and proportion of opiate use cessation. Conclusions: Although characteristics of HCV+ and HCV− differed, they manifested similar outcomes: treatment retention and proportion of opiate use cessation.