Teodora Groshkova

Supervised injectable heroin or injectable methadone versus optimised oral methadone as treatment for chronic heroin addicts in England after persistent failure in orthodox treatment (RIOTT): a randomised trial

BACKGROUND Some heroin addicts persistently fail to benefit from conventional treatments. We aimed to compare the effectiveness of supervised injectable treatment with medicinal heroin (diamorphine or diacetylmorphine) or supervised injectable methadone versus optimised oral methadone for chronic heroin addiction. METHODS In this multisite, open-label, randomised controlled trial, we enrolled chronic heroin addicts who were receiving conventional oral treatment (>or=6 months), but continued to inject street heroin regularly (>or=50% of days in preceding 3 months). Randomisation by minimisation was used to assign patients to receive supervised injectable methadone, supervised injectable heroin, or optimised oral methadone. Treatment was provided for 26 weeks in three supervised injecting clinics in England. Primary outcome was 50% or more of negative specimens for street heroin on weekly urinalysis during weeks 14-26. Primary analysis was by intention to treat; data were adjusted for centre, regular crack use at baseline, and treatment with optimised oral methadone at baseline. Percentages were calculated with Rubins rules and were then used to estimate numbers of patients in the multiple imputed samples. This study is registered, ISRCTN01338071. FINDINGS Of 301 patients screened, 127 were enrolled and randomly allocated to receive injectable methadone (n=42 patients), injectable heroin (n=43), or oral methadone (n=42); all patients were included in the primary analysis. At 26 weeks, 80% (n=101) patients remained in assigned treatment: 81% (n=34) on injectable methadone, 88% (n=38) on injectable heroin, and 69% (n=29) on oral methadone. Patients on injectable heroin were significantly more likely to have achieved the primary outcome (72% [n=31]) than were those on oral methadone (27% [n=11], OR 7.42, 95% CI 2.69-20.46, p<0.0001; adjusted: 66% [n=28] vs 19% [n=8], 8.17, 2.88-23.16, p<0.0001), with number needed to treat of 2.17 (95% CI 1.60-3.97). For injectable methadone (39% [n=16]; adjusted: 30% [n=14]) versus oral methadone, the difference was not significant (OR 1.74, 95% CI 0.66-4.60, p=0.264; adjusted: 1.79, 0.67-4.82, p=0.249). For injectable heroin versus injectable methadone, a significant difference was recorded (4.26, 1.63-11.14, p=0.003; adjusted: 4.57, 1.71-12.19, p=0.002), but the study was not powered for this comparison. Differences were evident within the first 6 weeks of treatment. INTERPRETATION Treatment with supervised injectable heroin leads to significantly lower use of street heroin than does supervised injectable methadone or optimised oral methadone. UK Government proposals should be rolled out to support the positive response that can be achieved with heroin maintenance treatment for previously unresponsive chronic heroin addicts. FUNDING Community Fund (Big Lottery) Research section, through Action on Addiction.

Drugs and pregnancy—outcomes of women engaged with a specialist perinatal outreach addictions service

Substance misuse during pregnancy may result in harm to both mother and child. The aims of this study were to assess changes in outcomes of women seen by a specialist perinatal addictions outreach service (1989-1991 versus 2002-2005) and compare outcomes to the local hospital maternity population (2004-2005). A cross-sectional audit of health-care records was conducted comparing the outcomes of women in 2002-2005 with earlier data from 1989-1991 and the local maternity population (2004-2005). The service was attended by 126 women, of whom 83% of opioid-dependent women started/continued opioid maintenance treatment. Of 118 babies delivered, there were two stillbirths and one early neonatal death, 20% were premature, 28% were low birth weight, 21% required the Special Care Baby Unit and 21% of babies born to opioid-dependent mothers were treated for neonatal abstinence syndrome (NAS). Fewer babies required treatment for NAS in 2002-2005 compared to 1989-1991 (21% versus 44%). There were higher rates of miscarriage (3% versus <1%), low birth weight (28% versus 9%) and premature babies (20% versus 9%) compared to the local maternity population (2004-2005). Integrated perinatal addictions treatment may deliver benefits; however, engaging women into treatment earlier and reducing substance use before conception remains the objective.

Cost-effectiveness of injectable opioid treatment v. oral methadone for chronic heroin addiction

BACKGROUND Despite evidence of the effectiveness of injectable opioid treatment compared with oral methadone for chronic heroin addiction, the additional cost of injectable treatment is considerable, and cost-effectiveness uncertain. AIMS To compare the cost-effectiveness of supervised injectable heroin and injectable methadone with optimised oral methadone for chronic refractory heroin addiction. METHOD Multisite, open-label, randomised controlled trial. Outcomes were assessed in terms of quality-adjusted life-years (QALYs). Economic perspective included health, social services and criminal justice resources. RESULTS Intervention costs over 26 weeks were significantly higher for injectable heroin (mean £8995 v. £4674 injectable methadone and £2596 oral methadone; P<0.0001). Costs overall were highest for oral methadone (mean £15 805 v. £13 410 injectable methadone and £10 945 injectable heroin; P = n.s.) due to higher costs of criminal activity. In cost-effectiveness analysis, oral methadone was dominated by injectable heroin and injectable methadone (more expensive and less effective). At willingness to pay of £30 000 per QALY, there is a higher probability of injectable methadone being more cost-effective (80%) than injectable heroin. CONCLUSIONS Injectable opioid treatments are more cost-effective than optimised oral methadone for chronic refractory heroin addiction. The choice between supervised injectable heroin and injectable methadone is less clear. There is currently evidence to suggest superior effectiveness of injectable heroin but at a cost that policy makers may find unacceptable. Future research should consider the use of decision analytic techniques to model expected costs and benefits of the treatments over the longer term.

Motivation in substance misuse treatment

This review summarises the different motivational frameworks that are commonly applied to the study of substance misuse and explores the potential of a comprehensive conceptualisation of motivation based on the self-determination theory (SDT). The most prominent conceptualisations of motivation to change amongst substance misusing patients are identified. Defining and measuring the concept of motivation within a sound theoretical framework has been a challenge. The literature lends little support to the conceptualisation of motivation as internal and external types. Promising work employs a dynamic model of motivation, but empirical research based on such a framework is still in its infancy. There is empirical support to the conceptual distinction between motivation and treatment readiness and it appears that such a distinction can be particularly useful to treatment services. Clients’ motivation has significant implications for initiating and sustaining recovery, and future conceptual and methodological improvements are needed that can improve our understanding of how people change addictive behaviours and what can be done better to assist them in their attempts to recover from addiction.

Recovery Group Participation Scale (RGPS): Factor Structure in Alcohol and Heroin Recovery Populations

Recovery group participation is relevant to both clinical and research activity. Its measurement with the Recovery Group Participation Scale (RGPS) is an attempt to have a measurement of participation across a range of recovery groups. The factor structure, among other psychometric properties of the scale, is however, undefined. The present study examined the factor structure of the RGPS in alcohol and drug recovery populations in Birmingham and Glasgow, United Kingdom. Participants from the Birmingham (n = 219) and Glasgow (n = 205) recovery studies who had a completed form of the RGPS formed the basis for the factor structure examination. Principal component analysis extracted one factor, which accounted for 39.3% and 67.4% in the Birmingham and the Glasgow samples, respectively. Overall scores on the RGPS were associated with higher quality-of-life scores and with greater self-esteem and social networks of nonusers in recovery. The key question that remains to be addressed is the evolving role of recovery group participation in prospective studies of growth of recovery capital and sustained recovery.

Well-Being and Recovery Functioning among Substance Users Engaged in Posttreatment Recovery Support Groups

There is a growing literature that seeks to evaluate the role of “recovery capital” in the resolution of substance use disorders. In this study, a structured instrument (the Assessment of Recovery Capital), along with an assessment of social networks among 176 former illicit drug users and drinkers, is measured in three locations in England. There were relationships between recovery capital and vocational activity (training or employment), physical health, psychological health, and overall quality of life, with larger social networks associated with enhanced personal and social recovery capital. The study demonstrates high levels of personal and social well-being—manifesting in engagement in community activities and strong social networks—among persons engaged in recovery support activities that was not linked to time in recovery.

What is recovery? : functioning and recovery stories of self-identified people in recovery in a services user group and their peer networks in Birmingham England

The study was based on a peer snowballing method involving members of a service users group in Birmingham, United Kingdom, who were asked to identify and interview members of their peer networks who had achieved “sustained recovery” of one year. Two hundred and nineteen individuals were recruited who defined themselves as being in recovery, consisting of 132 individuals in medication maintained recovery and 87 in abstinent recovery. Those in maintained recovery were more anxious about using heroin and had lower self-efficacy, worse physical health, poorer quality of life, and more peer group members still using. Being older was associated with greater quality of life (rather than time since last use) supporting a “maturing out” hypothesis.

Comparing the Addiction Careers of Heroin and Alcohol Users and Their Self-Reported Reasons for Achieving Abstinence

This study employs a developmental model (Hser, Longshore, & Anglin, 2007) for mapping alcohol- and drug-using careers, following in the tradition of work done by Blomqvist (1999). Based on a rolling sample of 269 former alcohol and heroin addicts, initially reported by Best, Ghufran, Day, Ray, & Loaring (2007), this article examines differences in trajectories of careers among problem substance users and examines reasons for achieving and maintaining desistance, based on three groups: primary drinkers (n = 98), primary heroin users (n = 104), and those who reported problems with both alcohol and drugs (n = 67).Former heroin users reported more rapid escalation to problematic use but much shorter careers involving daily use than was the case in the alcohol cohort. Alcohol and heroin users also differed in their self-reported reasons for stopping use, with drinkers more likely to report work and social reasons and drug users more likely to report criminal justice factors. In sustaining abstinence, alcohol users were slightly more likely to report partner support, while drug users were more likely to report peer support and were also more likely to emphasize the need to move away from substance-using friends than was the case for former alcohol users. Users of both alcohol and heroin were least likely to cite partner factors in sustaining recovery but were more likely to need to move away from using friends and to cite stable accommodation as crucial in sustaining abstinence. Career factors would appear to vary across substance types, with multiple-substance users having trajectories that share characteristics with the primary users of each substance. Poly-drug use patterns have significant implications for our understanding of addiction careers and desistance patterns.

The Evolution of a UK Evidence Base for Substance Misuse Recovery

This article examines the academic sources and origins of the „recovery movement” in the drugs field in the United Kingdom and considers a series of disparate evidence sources that have been applied and used in this regard. Only two of these originate in traditional addictions materials—treatment outcome and cohort studies—with the remaining studies reviewed coming from a range of other areas. In particular, the sources include a switch in focus from the specialist treatment clinic to the community, and from the therapeutic to the more broadly social. The framework for this approach is explicitly developmental and attends to the published research around crime careers and addiction careers. The final sections of the article review recent UK addiction recovery research and assess where we are and what we currently know—and as a consequence the key gaps and the methodological questions that need to be addressed.

Identifying and Recruiting Recovery Champions: Exploratory Action Research in Barnsley, South Yorkshire

The UK Drug Strategy has embraced the philosophy of recovery as an “individual, person-centered journey” (Her Majestys [HM] Government, 2010, p. 19) and is supported by a local network of recovery champions. The purpose of this article is to examine proactive attempts at establishing such networks based on training and working with a mixture of people in recovery and professionals, supported by a local recovery leader. What is presented in this article is a case study of an initiative attempting to access and link recovery champions. The early stages of the initiative were planned in advance, but the later stages were evolutionary and were based on the decisions of the emerging recovery champions group. The initiative started with a series of workshops to raise awareness about recovery, and from this, to recruit an initial group of candidate champions. Small groups were successfully recruited to participate in subsequent champions workshops, and they have since translated that commitment to a range of actions and directions, which have attempted to generate a visible recovery community and to challenge stereotypes and stigma perceptions. The final section of the article will review the utility of the label of “recovery champion” and will examine the role of such networks in enabling and supporting the emergence of a local culture of recovery.