Gwenaelle Maradan

Suicidal risk among patients enrolled in methadone maintenance treatment: HCV status and implications for suicide prevention (ANRS Methaville).

BACKGROUND Suicide is a critical issue among opioid users. The aim of this study was to assess the relationship between HCV status and suicidal risk in patients receiving methadone treatment. METHODS We used data from Methaville, a multicenter, pragmatic randomized trial designed to evaluate the feasibility of methadone induction in primary care compared with induction in specialized centers. Suicidal risk was assessed at enrollment and after one year of methadone treatment using the suicidality module in the MINI International Neuropsychiatric Interview. Socio-demographic characteristics, drug and alcohol consumption, behavioral and personality factors, history of drug use and health indicators were also assessed. RESULTS A total of 195 individuals were enrolled from January 2009 to December 2010. Suicidal risk assessment was available at month 0 (M0) and M12 for 159 (72%) and 118 (73%) individuals, respectively. Forty-four (28%) were at risk of suicide at M0 and 17 (14%) at M12 (p=0.004). One patient attempted suicide by overdose during the one-year follow-up. The following three factors were associated with suicidal risk: hepatitis C virus (HCV) positive status (OR [95%CI]=17.25 [1.14-161.07]; p=0.04), receiving food assistance (OR [95%CI]=0.05 [0.00-1.05]; p=0.05) and a higher number of health problems (OR [95%CI]=1.24 [1.08-1.44]; p=0.003). CONCLUSIONS Special attention should be given to HCV-positive patients through suicidal risk prevention strategies and routine suicide assessment as part of a comprehensive approach to prevention and care for opioid users. Our results represent a new and powerful argument for the expansion of access to HCV treatment to drug users with chronic infection.

Variations in Cannabis Use Level and Correlates in Opiate-Users on Methadone Maintenance Treatment: A French Prospective Study

INTRODUCTION Concurrent cannabis use is very frequent among opioid users on methadone maintenance treatment (MMT), which could reflect a coping strategy during MMT. The aims of this study were to describe variations in cannabis use and to explore whether MMT could modify the patterns of cannabis use correlates. METHODS The sample included 188 opioid-dependent individuals who initiated MMT and were prospectively followed for 12 months. Cannabis use was monitored at enrollment and at months 3, 6 and 12. The relationships between cannabis use level (non-daily use and daily use vs. no use in the previous month) and its determinants (socioeconomic factors, substance use characteristics and mental health) were explored using mixed multinomial logistic regressions. RESULTS No significant variation trend in cannabis use levels was observed during the follow-up period among the 188 subjects analyzed (p=0.85). After adjustment for socio-demographic factors, opioid use was associated with both non-daily (OR=3.11, p=0.01) and daily cannabis use (OR=2.58, p=0.04). Moreover the number of health problems reported was associated with daily cannabis use (OR=1.12 per 1-problem increase, p=0.004). The factors associated with cannabis use appeared similar before and after starting treatment (no significant interaction observed between MMT and any factor). CONCLUSIONS Cannabis use during MMT more likely reflects pre-existing common liability to substance use or self-medication practices towards health problems than a behavior aimed at managing problems with MMT. With recent research suggesting an interaction between cannabinoid and opioid systems, the benefit of cannabis-based pharmacotherapies during MMT should be further explored in addiction research.

Treatment interruption in HIV-positive patients followed up in Cameroon's antiretroviral treatment programme: individual and health care supply-related factors (ANRS-12288 EVOLCam survey)

Decreasing international financial resources for HIV and increasing numbers of antiretroviral treatment (ART)‐treated patients may jeopardise treatment continuity in low‐income settings. Using data from the EVOLCam ANRS‐12288 survey, this study aimed to document the prevalence of unplanned treatment interruption for more than 2 consecutive days (TI>2d) and investigate the associated individual and health care supply‐related factors within the Cameroonian ART programme.

Pain in methadone patients: Time to address undertreatment and suicide risk (ANRS-Methaville trial)

Background Pain in opioid-dependent patients is common but data measuring the course of pain (and its correlates) using validated scales in patients initiating methadone treatment are sparse. We aimed to assess pain and its interference in daily life, associated correlates, and undertreatment before and during methadone treatment. Methods This is a secondary analysis using longitudinal data of a randomized trial comparing two methadone initiation models. We assessed the effect of methadone initiation and other correlates on pain intensity and interference (using the Brief Pain Inventory) at months 0, 6 and 12 using a mixed multinomial logistic regression model. Results The study group comprised 168 patients who had data for either pain intensity or interference for at least one visit. Moderate to severe pain was reported in 12.9% of patients at M0, 5.4% at M6 and 7.3% at M12. Substantial interference with daily functioning was reported in 36.0% at M0, 14.5% at M6 and 17.1% at M12. Of the 98 visits where patients reported moderate to severe pain or substantial interference, 55.1% reported no treatment for pain relief, non-opioid analgesics were reported by 34.7%, opioid analgesics by 3.1% and both opioid and non-opioid analgesics by 7.1%. Methadone was associated with decreased pain intensity at 6 months (OR = 0.29, p = 0.04) and 12 months (OR = 0.30, p = 0.05) of follow-up and tended to be associated with substantial pain interference. Suicide risk was associated with both pain intensity and pain interference. Conclusions Methadone in opioid-dependent patients can reduce pain. However, undertreatment of pain in methadone patients remains a major clinical concern. Patients with pain are at higher risk of suicide. Adequate screening and management of pain in this population is a priority and needs to be integrated into routine comprehensive care.

Decrease in self-reported offences and incarceration rates during methadone treatment: A comparison between patients switching from buprenorphine to methadone and maintenance treatment incident users (ANRS-Methaville trial)

BACKGROUND Patients receiving buprenorphine who are poor responders can continue to commit drug-related offences. Switching them from buprenorphine to methadone may result in reduced criminal behaviour. We compared self-reported offences and incarceration before and after starting methadone treatment of patients switching from buprenorphine (PSB) and maintenance treatment incident users (MIU). METHODS Data on offences, incarceration and other information, were obtained via a telephone interview. Mixed models were used to assess the impact of methadone initiation and being PSB or MIU on (1) the number of days when offences were committed (drug sale, drug purchase, other offences) and (2) experiencing incarceration during the previous 6 months. RESULTS Among the 176 patients with at least one assessment for self-reported offences, 51.7% were PSB. Receiving methadone was significantly associated with a reduction in the number of days when drug sale or drug purchase offences were committed, but not other offences. PSB and MIU groups were different only for drug purchase, as PSB were more likely to have a higher number of days of drug purchase from month 3 onwards. A reduction of 77% in the likelihood of experiencing incarceration was observed and this was comparable in PSB and MIU. CONCLUSION Switching non-responding buprenorphine patients to methadone can result in a major reduction in offences and incarceration rates. Increasing access to methadone, using more flexible models of care is urgent for clinical and public health reasons.

Larger is not necessarily better! Impact of HIV care unit characteristics on virological success: results from the French national representative ANRS-VESPA2 study.

OBJECTIVES To determine the impact of hospital caseload size on HIV virological success when taking into account individual patient characteristics. METHODS Data from the ANRS-VESPA2 survey representative of people living with HIV in France was used. Analyses were carried out on the 2612 (86.4% out of 3022) individuals receiving antiretroviral (ARV) treatment for at least one year. Outcomes correspond to two definitions of virological success (VS1 and VS2 respectively) and were analyzed under a multi-level modeling framework with a special focus on the effect of the caseload size on VS. RESULTS Structures with caseloads <1700 patients were more likely to have increased the proportion of patients achieving virological success (59% and 81% for VS1 and VS2, respectively) than structures whose caseloads numbered ≥1700 patients. Our results highlight that patients in the 11 largest care units in the sample were exposed to a context where their VS was potentially compromised by care unit characteristics, independently of both their individual characteristics and their own HIV treatment adherence behavior. CONCLUSIONS Our results suggest that - at least in the case of HIV care - in France large care units are not necessarily better. This result serves as an evidence-based warning to public authorities to ensure that health outcomes are guaranteed in an era when the French hospital sector is being substantially restructured.

Interest in HIV pre-exposure prophylaxis in men who have sex with men in West Africa (CohMSM ANRS 12324 - Expertise France)

To explore the interest in taking PrEP among Western African men who have sex with men (MSM).

Posttraumatic Stress Disorder as a Significant Correlate of Voluntary Antiretroviral Treatment Interruption in Adult HIV-Infected Patients Followed up in French Hospitals: Data From the ANRS-VESPA2 National Survey

OBJECTIVE Although antiretroviral treatment (ART) no longer requires 100% adherence, voluntary treatment interruption (VTI) still may have a negative impact on virologic success. Previous studies have shown that posttraumatic stress disorder (PTSD) is more prevalent in HIV-infected patients than in the general population. However, no study has yet investigated the relationship between PTSD and VTI. We analyzed this relationship using data from a French national survey representative of HIV-infected adults followed up in hospitals. METHODS A total of 3,022 HIV-infected adults participated in the ANRS-VESPA2 survey (April 2011-January 2012) and answered a face-to-face questionnaire that included the Composite International Diagnostic Interview Short-Form to diagnose PTSD and assess sociobehavioral variables such as VTI. Multivariable logistic regression models were used to study the relationship between PTSD and VTI. RESULTS Among the 2,768 ART-treated participants with available data for both PTSD screening and ART interruption (study sample), prevalence of PTSD was 13.3%, and 7.2% of individuals reported VTI during the previous month. After adjustment for being a female Sub-Saharan African immigrant and reporting harmful alcohol consumption (Alcohol Use Disorders Identification Test score ≥ 8), lifetime PTSD was found to be independently associated with VTI (adjusted odds ratio [95% CI] = 1.64 [1.07-2.53], P = .025). CONCLUSIONS PTSD is highly prevalent in HIV-infected patients followed up in French hospitals and is a significant predictor of VTI. PTSD is a psychiatric disorder that is still underdiagnosed and undertreated in many countries despite its negative consequences on health behaviors. As there is evidence of effective treatment for PTSD, HIV care providers need to be trained in screening for this disorder.

Access to care for people with alcohol use disorder in France: a mixed-method cross-sectional study protocol (ASIA)

Introduction Alcohol use disorder (AUD) is a major public health concern worldwide. In France, only 10% of people with AUD (PWAUD) receive medical care. General practitioners (GP) are one of the main entry points for AUD care. The present ongoing study, entitled ASIA (Access to Care and Indifference toward Alcohol, Accès aux Soins et Indifference à l’Alcool in French), aims to improve knowledge about factors associated with access to care for AUD by exploring related GP and PWAUD practices, experiences and perceptions. Methods and analysis The ASIA project is an ongoing cross-sectional multisite study based on a complementary mixed-method approach (quantitative and qualitative) using a convergent parallel design. The double-perspective design of the study will enable us to collect and compare data regarding both PWAUD and GP points of view. For the PWAUD quantitative study, 260 PWAUD will be interviewed using a telephone-based questionnaire. For the qualitative study, 36 PWAUD have already been interviewed. The GP quantitative study will include 100 GP in a 15 min survey. Fifteen GP have already participated in semistructured interviews for the qualitative study. Logistic regression will be used to identify predictors for access to care. With respect to data analyses, qualitative interviews will be analysed using semantic analysis while quantitative logistic regression will be used for quantitative interviews. Ethics and dissemination This study was approved by the CNIL (French National Commission on Informatics and Liberties) (approval reference number: C16-10, date of approval: 17 July 2017), the CCTIRS (Advisory Committee on Information Processing in Material Research in the Field of Health) and the CEEI (Evaluation and Ethics Committee) (approval reference number: 16–312, date of approval: 8 July 2016) of INSERM (French National Institute of Health and Medical Research). Results from ASIA will be disseminated in peer-reviewed publications, conference presentations, reports and in a PhD thesis.