Laura Brandt

Substance Abuse/Dependence Treatment: A European Perspective

During the past decade, substantial progress has been made in the field of addiction medicine in Europe, particularly regarding the development of new treatment interventions, resulting in a wide range of therapeutic options for patients with substance use disorders. However, not all interventions are evidence based. Patients with cannabis and cocaine/amphetamine use disorders and special patient populations especially lack evidence-based treatment recommendations. Many patients undergo treatment that has not been scientifically evaluated for quality and efficacy. Moreover, there are large disparities regarding availability and treatment access across Europe, with the new member states of the European Union (EU) reporting long waiting lists and low treatment coverage. Even in Austria, which ranks among the countries with relatively high treatment coverage and good diversification of treatment in opioid maintenance therapy due to the availability of methadone, buprenorphine, and slow-release oral morphine (SROM), a considerable population of untreated or inadequately treated patients exists. Treatment for substance use disorders in Europe still has scope for improvement in terms of treatment availability and access, which is ideally provided by further development and implementation of evidence-based interventions.

Opioid Maintenance Treatment - A Call for a Joint European Quality Care Approach

Aims: The aim of this exploratory analysis of European Quality Audit of Opioid Treatment data was to identify areas of improvement for current opioid maintenance treatment (OMT) approaches. Methods: Factors facilitating treatment entry, retention and refusal were compared between 8 European countries and between OMT patient (OMT-P) and active opioid user (AOU) sample groups. Both groups were divided into those who had never had OMT before (un-experienced OMT-P (n = 573) and AOU (n = 360)) and those who had been maintained at least once prior to this investigation (experienced OMT-P (n = 746) and AOU (n = 377)). Results: The European comparison showed that motives for starting OMT vary distinctly between countries (p ≤ 0.001). Transnationally, experienced AOU reported concerns about their ability to follow treatment rules and negative treatment experiences as decisive reasons for staying out of OMT. Greater flexibility, less pressure to reduce their treatment dose and greater treatment structure were ranked significantly higher by experienced compared to un-experienced OMT-P as factors that might facilitate treatment retention (p ≤ 0.05). Conclusion: Increasing awareness of potential shortcomings of OMT delivery systems is crucial to optimally match treatment approaches to patient needs and also to reduce the considerable economic burden of addiction to society.

Adult ADHD Is Associated With Gambling Severity and Psychiatric Comorbidity Among Treatment-Seeking Problem Gamblers:

Objective: The aim of this study is as follows: (a) exploring retrospective childhood and adult ADHD symptomatology in treatment-seeking gamblers, (b) providing detailed characteristics of the association between pathological gambling (PG) and ADHD, and (c) identifying risk factors for a history of ADHD. Method: Eighty problem gamblers (20% female) were examined using a standardized interview (PG: Diagnostic and Statistical Manual of Mental Disorders [4th ed.; DSM-IV] criteria, Gambling Attitudes and Beliefs Survey; ADHD: Wender Utah Rating Scale–deutsche Kurzform, Adult ADHD Self-Report Scale; comorbidities: Mini International Neuropsychiatric Interview). Results: Forty-three percentage of patients screened positive for childhood ADHD, and in 11%, ADHD persisted in adulthood. Patients with adult ADHD had more severe gambling problems (p = .009, d = 1.03) and a higher number of psychiatric comorbidities (p < .001, d = 1.62) compared with those without ADHD. Substance abuse/dependence constituted a predictor for having a history of ADHD (odds ratio [OR] = 4.07, p = .025). Conclusion: ADHD–PG comorbidity is linked to factors that worsen the prognosis. Thus, screening for ADHD and verifying persistence in adulthood should be an integral component in the interdisciplinary treatment of problem/pathological gamblers.

Neonatal abstinence syndrome: where are we, and where do we go from here?

Purpose of review Over the last 15 years the prevalence of neonatal abstinence syndrome (NAS) increased almost five-fold. A considerable diversity seems to prevail in the management of NAS. This review provides an overview of factors affecting the expression and course of NAS, and recent developments in NAS assessment and treatment. Recent findings Apart from different pharmacological and nonpharmacological treatment modalities, maturity of the infant and genetic variations likely are (co)responsible for interpatient variability in NAS severity, despite similar maternal exposure. Recent efforts concerning the further development of NAS severity scoring systems focus on the development of brief screening measures; in addition, pupil diameter and skin conductance have been proposed as complements to observer-rated scales. The decrease in incidence of NAS begins in the appropriate management of medication assisted treatment of the mother. Summary Mitigating the negative outcomes for infants affected by NAS, their mothers and the healthcare system implies, first and foremost, developing and implementing an organized protocol for the management of NAS, and the homogenous use of a standardized scoring system utilizing interobserver reliability and a guide for medication initiation, maintenance, and weaning which is consistent with traditional methods of treatment for neonates.

Management of Substance Abuse in Pregnancy: Maternal and Neonatal Aspects

In Europe, the USA and Australia the prevalence of smoking during pregnancy ranges between 10 and 27 %. Drinking alcohol is reported by 8.5–19.5 % of pregnant women, with a potentially significant number of unreported cases. Additionally, there are as many as 60,000–100,000 pregnant women using illicit drugs per year, with a high percentage of poly-drug users. Substance-dependent women have a high incidence of co-morbid psychiatric disorders, with DSM-IV axis I affective and post-traumatic stress as well as axis II personality disorders being the most frequent co-morbidities. Due to serious consequences of licit and illicit substance use during pregnancy as well as undetected/untreated psychiatric co-morbidities, the primary focus must be on adequate diagnostic assessment. Treatment, tailored individually to the kind of substance dependence and under consideration of evidence-based treatment options available as early as possible during pregnancy, leads to better pregnancy outcomes and fewer birth complications. Neonates born to mothers who are chronic illicit drug users or provided maternal medication-assisted treatment frequently develop a Neonatal Abstinence Syndrome (NAS). Pharmacological NAS treatment should be provided based on principles of accurate assessment and diagnosis, with non-pharmacological measures such as rooming-in being vital supportive interventions. The economic burden of substance dependence during pregnancy and related follow-up costs are significant. To lower societal costs and increase the quality of life of both mothers and children, international treatment standards, building on previous recommendations, must be established and implemented.

Hepatitis C infection and psychiatric burden in two imprisoned cohorts: young offenders and opioid-maintained prisoners

Prisoners constitute a considerable gap in the hepatitis C virus (HCV) tested population. The present study examined HCV prevalence in imprisoned opioid-maintained patients (OMT-P) and adolescents and young adults (AYA, 14-26 years). In addition, HCV testing and treatment provision, knowledge of HCV status and psychiatric comorbidity were assessed. Data collection took place in six Austrian prisons. Participants were N = 133 for OMT-P (78% male, mean age 35.7 years) and N = 71 for AYA (100% male, mean age 19.8 years). Analysis of HCV serology was conducted. Psychiatric comorbidity and addiction severity were assessed applying standardized questionnaires and interviews. Antibodies were detected in 74.4% of OMT-P, and in 45.0% HCV infection was confirmed. Only one AYA was infected with HCV. None of the participants was receiving treatment for HCV. Eleven percent of OMT-P (50.7% of AYA) did not know their HCV status, and 14.3% of OMT-P (36.6% of AYA) had not been tested in prison. Among OMT-P, lifetime IDU [OR = 330.33, CI = 25.91-4433.20] and age at first IDU [OR = 0.90, CI = 0.82-0.98] significantly predicted HCV status. In both samples, a high prevalence of affective disorders was observed. Despite the high prevalence of HCV among opioid-dependent detainees, the unique opportunities for comprehensive testing and treatment of HCV are substantially underutilized. This is in stark contrast to the UN Basic Principles for the Treatment of Prisoners.

Monitoring neonatal abstinence syndrome in buprenorphine-exposed in vitro fertilization twins: A case study.

ABSTRACT Background: Prior studies have reported on the pregnancies and outcomes of in vitro fertilization (IVF) in special subpopulations; however, there is a lack of studies on opioid-exposed IVF-conceived neonates. Case Presentation: A young adult IVF-pregnant woman was maintained on buprenorphine throughout pregnancy and received follow-up from the addiction clinic from estimated gestational week 32. She delivered healthy dichorionic twins via cesarean section at 38 weeks gestational age (buprenorphine dose at time of delivery: 16 mg). All maternal supervised urinalysis taken as of gestational week 32 were negative for concomitant substances (prior to treatment initiation at the addiction clinic, only self-reports of abstinence from concomitant substances were available). Both healthy children (male birth weight: 3140 g, female birth weight: 2650 g) developed an unusual course of neonatal abstinence syndrome (NAS) requiring extensive treatment (total morphine dose male: 22 mg, and female: 26.75 mg; length of treatment: 33 and 34 days, respectively; duration of hospitalization: 40 days). Discussion: The highly severe and long-lasting NAS in both neonates represents a very unusual course following an uneventful pregnancy, and influencing iatrogenic factors cannot be ruled out. Given the multiple variables influencing infant outcomes, this highlights the importance of high-quality, evidence-based standard operating procedures, which (1) are initiated as early as possible during pregnancy to minimize risk factors for adverse infant outcomes, such as concomitant substance use during pregnancy; (2) support the substance-dependent woman throughout the postpartum period, especially in cases of multiple and/or IVF-conceived pregnancies, where additional challenges may arise; and (3) consider the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

Tobacco Cessation: A Guide for Clinicians

Smoking behavior is a complex phenomenon that entails innumerable variables. Successful treatment interventions must be based on a comprehensive diagnosis and must consider the whole spectrum of factors influencing smoking behavior and nicotine dependence.

Limitations to Participation in Opioid Maintenance Treatment in Europe

Objective Our aim was to identify areas of improvement for current Opioid Maintenance Treatment (OMT) approaches, by analysing European Quality Audit of Opioid Treatment (EQUATOR) data from 8 European countries (Austria, Denmark, France, Germany, Norway, Portugal, Sweden, UK). Method A standardised face-to-face survey was administered to OMT patients (OMT-P) and active opioid user (AOU). Reasons for entering and staying out of OMT, rules pertaining to OMT, and factors facilitating OMT retention were compared between countries, and between OMT-P and AOU groups. Both groups were divided into those who never had OMT before [un-experienced OMT-P (n=573) and AOU (n=360)] and those who had been maintained at least once [experienced OMT-P (n=746) and AOU (n=377)]. Results Motives for starting OMT vary distinctly between countries (p≤0.001). Transnationally, experienced AOU reported concerns about their ability to follow treatment rules and negative treatment experiences as decisive reasons for staying out of OMT . Greater flexibility, less pressure to reduce their treatment dose and greater treatment structure were ranked significantly higher by experienced compared to un-experienced OMT-P as factors that might facilitate treatment retention (p≤0.05). Conclusion The major strength of this investigation was the homogenous methodology applied in all countries, which enabled new insights in variations between treatment systems and their impact on patient outcome. Treatment systems need to aim an optimal balance between flexibility and structure. Standardised approaches that still permit tailoring treatment to individual patient needs are crucial to yield maximum benefit for patients, and reduce the considerable societal economic burden of addiction.

Health-related and legal interventions: A comparison of allegedly delinquent and convicted opioid addicts in Austria

In Austria, judges can offer quasi-compulsory treatment options (in- and outpatient settings) as an alternative to imprisonment for drug-related delinquencies. A standard assessment of medical, psychological and legal data on the implementation of health-related and legal interventions in Austria was applied in 96 opioid-dependent individuals (10.4% female) undergoing quasi-compulsory treatment, receiving health-related measures. Additional data from the official prison registry were collected (data of 228 imprisoned individuals sentenced for drug-related crimes; 14.5% female) to gain comparable information to in- and outpatient health-related measure groups. Health-related measures were offered significantly more often to individuals charged with solely narcotics possession and/or trade, whereas imprisonment was filed significantly more often when concomitant property or violent crimes were committed in addition to drug possession/dealing (p < 0.001). Both cohorts had high prevalences of previous convictions (health-related measure 84.4%, prison 93.9%). The majority of patients in health-related measures suffered at the time of investigation from severe depression (62.5%), anxiety disorders (58.3%) and had a high loading of suicidal ideation (45.8%). Women showed a higher prevalence of affective disorders (p = 0.042), with higher administration rates of psychopharmacological medication (p = 0.045), whereas male offenders scored significantly higher in violent behaviour (p = 0.004). Inpatients showed a significantly higher burden of comorbid disorders compared to outpatients and reported a higher need for psychiatric treatment and legal counselling (all p < 0.001). The inpatient sample had a longer duration of opioid use (p = 0.024), a higher lifetime prevalence of intravenous drug use (p < 0.001) and a higher rate of hepatitis C infections (p = 0.012). Results confirm that imprisonment is sentenced to a vast extent for severe crimes, and health-related measure is well accepted among judges. However, based on patients’ high loading of previous convictions and alarmingly high burden of comorbidities, quality improvement and assurance in health-related measure are required when patients have their first contact with the criminal justice system. Continuous focus on applying diversion procedures is also required to reduce societal costs.