New Report Sheds Light on Global Epidemiology of Stimulant-Use Disorders

A brand new study by researchers at the Australia National Health and Medical Research Council estimates the global burden of disease due to cocaine and amphetamine. Based on large systematic reviews of epidemiological data, disease models and global prevalence estimates, the authors present comorbidity-adjusted years of life lost to disability (YDL), years of life lost (YLL) and disability-adjusted life years (DALY) estimates. The authors note that their estimates include only the disease burdens attributable directly to amphetamine- and cocaine-use disorders, leaving out the likely considerable HIV- and HCV-attributable costs and burden.

via ScienceDirect:

Abstract

Aims

To estimate the global prevalence of cocaine and amphetamine dependence and the burden of disease attributable to these disorders.

Methods

An epidemiological model was developed using DisMod-MR, a Bayesian meta-regression tool, using epidemiological data (prevalence, incidence, remission and mortality) sourced from a multi-stage systematic review of data. Age, sex and region-specific prevalence was estimated for and multiplied by comorbidity-adjusted disability weightings to estimate years of life lost to disability (YLDs) from these disorders. Years of life lost (YLL) were estimated from cross-national vital registry data. Disability-adjusted life years DALYs) were estimated by summing YLDs and YLLs in 21 regions, by sex and age, in 1990 and 2010.

Results

In 2010, there were an estimated 24.1 million psychostimulant dependent people: 6.9 million cocaine and 17.2 million amphetamines, equating to a point prevalence of 0.10% (0.09-0.11%) for cocaine, and 0.25% (0.22-0.28%) for amphetamines. There were 37.6 amphetamine dependence DALYs (21.3-59.3) per 100,000 population in 2010 and 15.9 per 100,000 (9.3-25.0) cocaine dependence DALYs. There were clear differences between amphetamines and cocaine in the geographic distribution of crude DALYs. Over half of amphetamine dependence DALYs was in Asian regions (52%), whereas almost half of cocaine dependence DALYs was in the Americas (44%, with 23% in North America High Income).

Conclusion

Dependence upon psychostimulants is a substantial contributor to global disease burden; the contribution of cocaine and amphetamines to this burden varies dramatically by geographic region. There is a need to scale up evidence-based interventions to reduce this burden.

Figure 1 compares the DALYs of amphetamines and cocaine between genders:

Fig. 2 shows the distribution of "crude estimated DALYs" due to either substance:

And Fig. 3 shows "Country-level DALYs per 100,000 population due to amphetamine dependence, age-standardized, for persons in 2010":

Source:
http://www.sciencedirect.com/science/article/pii/S0376871614000234

Do Adverse Childhood Experiences Make Amphetamine More Pleasurable?

In a fascinating new study, researchers from the University of Maryland and Johns Hopkins University observed the way amphetamine affects the brain, comparing subjects who reported adverse childhood experiences (ACE) with those who did not. They found significant differences between groups in the way the drug impacted the dopamine (DA) neurotransmitter in the ventral striatal (VS) region of the brain, finding a significant positive correlation between early childhood trauma and VS DA release.

The results, published online in the journal, Psychopharmacology, suggest that adverse childhood experiences may enhance vulnerability to amphetamine-use disorders later in life by changing the way the brain transmits dopamine. Interestingly, a positive association between childhood trauma and amphetamine-induced pleasure was suggested for men, but vice versa for women.

Here's the abstract via SpringerLink, and an interesting image from the article:

Abstract

Rationale

Childhood exposure to severe or chronic trauma is an important risk factor for the later development of adult mental health problems, such as substance abuse. Even in nonclinical samples of healthy adults, persons with a history of significant childhood adversity seem to experience greater psychological distress than those without this history. Evidence from rodent studies suggests that early life stress may impair dopamine function in ways that increase risks for drug abuse. However, the degree to which these findings translate to other species remains unclear.

Objectives

This study was conducted to examine associations between childhood adversity and dopamine and subjective responses to amphetamine in humans.

Methods

Following intake assessment, 28 healthy male and female adults, aged 18–29 years, underwent two consecutive 90-min positron emission tomography studies with high specific activity [11C]raclopride. The first scan was preceded by intravenous saline; the second by amphetamine (AMPH 0.3 mg/kg).

Results

Consistent with prior literature, findings showed positive associations between childhood trauma and current levels of perceived stress. Moreover, greater number of traumatic events and higher levels of perceived stress were each associated with higher ventral striatal dopamine responses to AMPH. Findings of mediation analyses further showed that a portion of the relationship between childhood trauma and dopamine release may be mediated by perceived stress.

Conclusions

Overall, results are consistent with preclinical findings suggesting that early trauma may lead to enhanced sensitivity to psychostimulants and that this mechanism may underlie increased vulnerability for drug abuse.

http://link.springer.com/article/10.1007%2Fs00213-013-3407-z

Study: Burden of Disease Associated with Alcohol-use Disorders Higher Than Previously Thought

In a paper published online last week in the journal, Alcoholism: Clinical and Experimental Research, a group of international researchers have brought fresh eyes to a familiar data set: the NIAAA's NESARC. Whereas past studies have estimated the alcohol-attributable global burden of disease, or rates of alcohol-attributable deaths and years of life lost, no study has focused specifically on the burden of disease in the United States associated with alcohol-use disorders (AUD). This is important, the authors note, because alcohol-use disorders (including "abuse" and "dependence" from DSM or "the harmful use of alcohol" from ICD) "were identified as the largest disease category contributing to the alcohol-attributable global burden of disease for the year 2004, making up approximately one-third of this burden." By using US-specific data, including population and death statistics as well as Waves 1 and 2 of the NESARC, the authors were able to estimate the burden of disease from AUD in the US in 2005.


Results

"In the United States in 2005, 65,000 deaths, 1,152,000 years of life lost due to premature mortality (YLL), 2,443,000 years of life lost due to disability (YLD), and 3,595,000 disability-adjusted life years (DALYs) lost were associated with AUD. For individuals 18 years of age and older, AUD were associated with 3% of all deaths (5% for men and 1% for women), and 5% of all YLL (7% for men and 2% for women). The majority of the burden of disease associated with AUD stemmed from YLD, which accounted for 68% of DALYs associated with AUD (66% for men and 74% for women). The youngest age group had the largest proportion of DALYs associated with AUD stemming from YLD."

Some figures from the article:

Prevalence of alcohol use disorders by category, sex, and age in 2005. 

And:

Proportion of all deaths associated with alcohol use disorders in 2005, by sex and age


You can read the abstract of the paper by Rehm, et al. here:

http://onlinelibrary.wiley.com/doi/10.1111/acer.12331/abstract

Would love to hear readers reactions to these numbers. 

Study: Sex-Dependent Differences in Subjective Cannabis Effects (Do Women Enjoy Pot More Than Men?)

A new article by researchers at the New York State Psychiatric Institute and Department of Psychiatry at Columbia University explores the differences in the way men and women report their subjective experiences of the effects of cannabis. The authors reviewed data from four separate outpatient studies evaluating a range of cannabis-induced effects. In the final analysis, the subjects (35 men and 35 women) were all daily or near-daily cannabis users and their responses to standardized measures of mood, physical symptoms, and cannabis-related drug effects were recorded over time, beginning immediately after consumption.

It turns out, women were significantly more likely to report more feelings associated with enjoyment (and abuse liability) than men were:

According to the authors: "The results from this study demonstrate that when cannabis smokers are matched for use, ratings of cannabis’ subjective effects that are associated with abuse liability are higher in women compared to men. Although men and women significantly differed in body weight, sex differences were not observed for all subjective effects, including ratings of cannabis intoxication. "

In addition, cannabis use is more prevalent among men than women in the US (51.4% vs 37.4%, resp.). "Yet among cannabis smokers, women have a faster trajectory to cannabis-use disorders, which the current findings might in part explain." The authors call for more research to further explain the clinical significance of sex differences in the effects of cannabis and cannabis-use disorders.

The article by Cooper & Haney can be viewed here:

http://www.drugandalcoholdependence.com/article/S0376-8716%2813%2900529-2/abstract

Illicit Online Retailers Expand In Response to Silk Road Closure

In an editorial published last week in the journal, Addiction, researchers from the University of New South Wales, Australia, sought to quantify the movement of illicit online drug retailers to alternative marketplaces on the so-called "dark web". On October 3, 2013, the FBI shut down the Silk Road, the largest of these marketplaces for illicit substances, and often referred to in mainstream media as the eBay of illegal drugs. Since then, consumers and sellers have simply moved to other sites, which themselves have seen an explosion in the number active retailers since October 3rd.

Two sites in particular have seen dramatic increases: "Black Market Reloaded" has experienced a two-fold increase in active retailers, and "Sheep Marketplace" a five-fold increase. A new version of the Silk Road, "Silk Road 2.0", opened in November and had 92 vendors by their second day of operation.

Here's the graph from the editorial:

Via:
http://onlinelibrary.wiley.com/doi/10.1111/add.12422/full

Study: Hallucinogen Use Predicts Reduced Criminal Justice Recidivism

In a potentially fascinating article, published in this month's Journal of Psychopharmacology, researchers identified a correlation between naturalistic hallucinogen use and reduced recidivism among substance-involved offenders under community corrections supervision. The sample is very large (n=25,622) and it appears the relationship remains after controlling for "an array of potential confounding factors." Given the report last year that lifetime psychedelic use was not associated with current mental health problems in an adult population, this study's implications could be especially interesting.

Unfortunately, my institution doesn't allow me access to this journal - if there are any readers who can access the full article, please let me know.

(Comment after the fact: Keep in mind that this shows a correlation and that correlation does not establish directionality. That it, it's at least equally plausible that people with a diagnosis of psychedelic use disorder (a tiny fraction of the population) are different in ways that statistical controls cannot compensate for, and are therefore less like to reoffend. This makes sense in that psychedelic drug use is minimally addictive, if at all, and craving and urges are not typical in this group. It seems highly implausible to me that hallucinogen use had a beneficial effect. The authors should never have been allowed to make that claim, a fault of the editor. In addition, use of LSD or psilocybin has never been associate with increased incidence of mental disorders, in contrast to MDMA or synthetic cannabinoids.)

Here's the abstract via SagePub:

Abstract

Hallucinogen-based interventions may benefit substance use populations, but contemporary data informing the impact of hallucinogens on addictive behavior are scarce. Given that many individuals in the criminal justice system engage in problematic patterns of substance use, hallucinogen treatments also may benefit criminal justice populations. However, the relationship between hallucinogen use and criminal recidivism is unknown. In this longitudinal study, we examined the relationship between naturalistic hallucinogen use and recidivism among individuals under community corrections supervision with a history of substance involvement (n=25,622). We found that hallucinogen use predicted a reduced likelihood of supervision failure (e.g. noncompliance with legal requirements including alcohol and other drug use) while controlling for an array of potential confounding factors (odds ratio (OR)=0.60 (0.46, 0.79)). Our results suggest that hallucinogens may promote alcohol and other drug abstinence and prosocial behavior in a population with high rates of recidivism.

Sources:
http://jop.sagepub.com/content/28/1/62.abstract
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0063972

Update:
Thanks to Paul and Jason for sending the full piece. 
Treatment Accountability for Safer Communities (TASC)provided the authors access to de-identified records on 25,622 felony-charged individuals on community corrections supervision from  between 2002-2007. "Any hallucinogen use" was not a descriptor in the data, so they were confined to hallucinogen-use disorder, abuse or dependence, assuming that case workers would likely interpret any use as disordered. Interestingly, 73.6% of folks with a hallucinogen-use disorder in the sample were white/Caucasian. And, according to the researchers, hallucinogen-use disorder was the third strongest predictor of recidivism rates, behind cocaine- and cannabis-use disorder, respectively, which most strongly (but positively) predicted recidivism.The authors call for RCTs to explore hallucinogen-based therapies in the criminal justice population.

Vermont Governor Devotes Entire State of the State Address to Drug Addiction

From yesterday's NY Times:

In Annual Speech, Vermont Governor Shifts Focus to Drug Abuse

In a sign of how drastic the epidemic of drug addiction here has become, Gov. Peter Shumlin on Wednesday devoted his entire State of the State Message to what he said was “a full-blown heroin crisis” gripping Vermont.

“In every corner of our state, heroin and opiate drug addiction threatens us,” he said. He said he wanted to reframe the public debate to encourage officials to respond to addiction as a chronic disease, with treatment and support, rather than with only punishment and incarceration.

“The time has come for us to stop quietly averting our eyes from the growing heroin addiction in our front yards,” Governor Shumlin said, “while we fear and fight treatment facilities in our backyards.”

...

Read the rest of the story here: 

http://www.nytimes.com/2014/01/09/us/in-annual-speech-vermont-governor-shifts-focus-to-drug-abuse.html

Wacky Progressives and Scientific Illiteracy

In a disturbing article in the New York Times, Amy Harmon chronicles the tale of a brave county councilman on the island of Kona, Hawaii, who refused to be steamrolled by those who categorically believe that genetically modified organisms (GMOs) are dangerous and should be banned across the board. He actually took the time to look into the scientific research, to consult with scientists who know about this, and he attempted to draw a reasonable conclusion. He is faced, however, with a group of true believers, who keep repeating obscure claims based on long-discredited "research." They shout down their opponents and make outlandish claims that have no scientific basis or rationale. They demonize their opponents, and constantly shift the arguments when faced with scientific facts. Most disturbing of all was the refusal of his fellow council members to even allow scientists to testify, instead giving the floor repeatedly to unqualified zealots who continued to make broad, unsupportable statements. 

It turns out, then, that it's not only climate-change deniers and birthers who maintain passionately held beliefs that have no scientific basis. Worse, it shows how repeating false claims becomes a sort of echo chamber for those with similar beliefs. Finally it shows that such behavior is not limited to Tea Party fanatics or religious zealots, but applies equally to so-called progressives on the left side of the political spectrum. I write about this because it applies as well to too much in the fields of psychotherapy, behavior change and addiction treatment.

We tolerate too much of this type of thinking in our field. How many treatment centers offer "holistic" therapies such as yoga, energy field work, Reiki, or massage, or worse, "nutritional treatment" that is not only unsupported, but may well be harmful? Why are state agencies still allowing such centers to obtain licensure? Why are people paying for brain scans or quantitative EEGs or neurofeedback? And, of course, why do so many people cling to the fiction that 90x90 is effective for most people, or that 12-step approaches are 100% effective if you follow directions? (What treatments for human maladies, short of penicillin for strep throat, can claim 100% effectiveness?)

I'm not arguing that an absence of evidence of effectiveness is evidence of ineffectiveness. There is lots we all do that hasn't been studied well, simply because it is impossible to conduct a large randomized controlled trial on every possible therapy. However, in addiction treatment we have a very large and very strong evidence base from which to draw. It's actually far better than in many other areas of health care. In order to include an approach in a licensed program, at the least, we should require 1) a scientifically plausible rationale for a treatment, 2) that unsupported treatments should not be likely to cause significant harm or cost a significant amount of money, 3) that there is not significant evidence that the approach is not effective, and 4) that there is not a well-supported approach already available.

I'm also not suggesting that yoga, meditation, Reiki, energy field work, reflexology, acupuncture, massage, etc., may not be experienced as beneficial to some people. I recently underwent Rolfing, for example, which I found to be very helpful (if painful). But I didn't expect my health insurance to pay for it, and I reject any large claims concerning what it and similar approaches might accomplish. Such approaches might be made available to clients (at their own expense), but not as presented as a scientifically based health practice.

I have been surprised at how trendy the psychotherapy community is in general, not just in addiction treatment. One current example is the spread of dialectical behavior therapy (DBT) beyond its proven focus on borderline personality disorder. It seems that it's being applied to anyone and for every condition short of psychosis. Another trend is "trauma informed therapy" using eye-movement desensitization and reprocessing therapy (EMDR), DBT, prolonged exposure, or mindfulness. All of a sudden, everyone has "trauma" for which these are appropriate treatments, even though many do not meet criteria for post-traumatic stress disorder (PTSD.) What was psychoanalysis if not focused on trauma? For that matter, "mindfulness" is another trendy approach, with practitioners charging for something the Buddha gave away 2600 years ago and which can be had for free at your local Buddhist meditation center.

At the same time, I seldom encounter high quality cognitive-behavior therapy (CBT) being applied to co-existing anxiety or depressive disorders, in spite of a mountain of evidence supporting their effectiveness. And too many in our field still believe that "I don't believe in it" is an adequate reason to not support anti-relapse medications that also have a strong evidence base. When we have such well-supported therapies, why aren't we using them? Why are we instead embracing half-baked ideas and approaches? Why do we tolerate so much scientific ignorance? Why do we tolerate lack of informed consent, where clients are not given information about what the evidence supports and what it does not, but instead receive biased and incorrect information that deprives them of the opportunity to make an informed decision?

Study: Looking for the uninsured in Massachusetts? Check opioid dependent persons seeking detoxification

An interesting study from Drug and Alcohol Dependence cites the rate of uninsurance at a large Massachusetts detox program as 23% in the 2013 sample they observed (five years after the insurance mandate). That's nearly five times higher than the state average of 4.8%. The authors highlight correlates of being uninsured (table below), which include being young and being male (expected), but also having a higher level of education (unexpected). Finally, more than half of the uninsured participants in the study had been so for more than one year, highlighting the ongoing need for outreach and education about public programs.

Here is the abstract via ScienceDirect:

Abstract

Background

We examined the rate of uninsurance among persons seeking detoxification at a large drug treatment program in Massachusetts in 2013, five years after insurance mandates.

Methods

We interviewed three hundred and forty opioid dependent persons admitted for inpatient detoxification in Fall River, Massachusetts. Potential predictors of self-reported insurance status included age, gender, ethnicity, employment, homelessness, years of education, current legal status, and self-perceived health status.

Results

Participants mean age was 32 years, 71% were male, and 87% were non-Hispanic Caucasian. Twenty-three percent were uninsured. In the multivariate model, the odds of being uninsured was positively associated with years of education (OR = 1.22, 95%CI 1.03; 1.46, p < .05), higher among males than females (OR = 2.63, 95%CI 1.33; 5.20, p < .01), and inversely associated with age (OR = 0.94, 95%CI 0.90; 0.98, p < .01).

Conclusion

Opioid dependent persons recruited from a detoxification program in Massachusetts are uninsured at rates far above the state average. With the arrival of the Affordable Care Act, drug treatment programs in Massachusetts and nationally will be important sites to target to expand health coverage.

And here's a table from the report:

Correlates of Being Uninsured (n = 340).

Correlate	Unadjusted OR (95%CI)	Adjusted OR (95%CI)
Age	0.95** (0.91; 0.98)	0.94** (0.90; 0.98)
Gender (Male)	1.98* (1.07; 3.69)	2.63** (1.33; 5.20)
Non-Hispanic Caucasian (Yes)	2.48 (0.94; 6.54)	2.30 (0.83; 6.41)
Homeless (Yes)	0.38 (0.11; 1.29)	0.33 (0.09; 1.21)
Employed Part- or Full-Time (Yes)	1.09 (0.49; 2.42)	0.77 (0.32; 1.89)
Education (Years)	1.16* (1.01; 1.33)	1.22* (1.03; 1.46)
Pending criminal charges (Yes)	1.03 (0.58; 1.82)	0.92 (0.51; 1.65)
Perceived Health	0.71* (0.54; 0.93)	0.78 (0.58; 1.05)

* p < .05, **p < .01

http://www.sciencedirect.com/science/article/pii/S0376871613005322

Are Financial Incentives the Answer to SBIRT Implementation?

Researchers from Imperial College London may have found a way to increase alcohol screening and brief intervention in a primary care setting: financial incentives. The results, published online Dec. 26 in the Journal of Public Health, show that offering a points-based incentive for successful screening, brief intervention and referral to specialists significantly increased the number of patients who were screened. As a result, the authors say, more patients with risky alcohol intake were identified and offered care, reducing hazardous and harmful drinking in some.

While the evidence for SBIRT is abundant and well-known, there have been considerable problems in promoting widespread implementation - especially in primary care. Financial incentives could be one effective means of changing this. (Granted, a large-scale effort by the federal government or the insurance companies would likely be required to provide funding. In this study, data was collected from 2008-2011, until the UK's Quality and Outcomes Framework funding was withdrawn.)

Abstract

Introduction Alcohol screening and brief intervention (ASBI) is effective but underprovided in primary care. Financial incentives may help address this. This study assesses the impact of a local pay-for-performance programme on delivery of ASBI in UK primary care.

Methods Longitudinal study using data from 30 general practices in north-west London from 2008 to 2011 with logistic regression to examine disparities in ASBI delivery.

Results Of 211 834 registered patients, 45 040 were targeted by the incentive (cardiovascular conditions or high risk; mental health conditions), of whom 65.7% were screened (up from a baseline of 4.8%, P< 0.001), compared with 14.7% of non-targeted patients (P < 0.001). Screening rates were lower after adjustment in younger patients, White patients, less deprived areas and in patients with mental health conditions (P < 0.05). Of those screened, 11.5% were positive and 88.6% received BI. Men and White patients were significantly more likely to screen positive. Women and younger patients were less likely to receive BI. 30.1% of patients re-screened were now negative. However, patients with mental health conditions were less likely to re-screen negative than those with cardiovascular conditions.

Conclusion Financial incentives appear to be effective in increasing delivery of ASBI in primary care and may reduce hazardous and harmful drinking in some patients. The findings support universal rather than targeted screening.

Source: http://intljpubhealth.oxfordjournals.org/content/early/2013/12/26/pubmed.fdt121.abstract

Cochrane Releases New Reviews on MAT

The highly-respected Cochrane Library, known for its meticulous reviews of the current state of medical knowledge, has updated and released two reviews on medication-assisted treatment recently. The first, "Maintenance agonist treatments for opiate-dependent women", aims to " assess the effectiveness of any maintenance treatment alone or in combination with psychosocial intervention compared to no intervention, other pharmacological intervention or psychosocial interventions for child health status, neonatal mortality, retaining pregnant women in treatment and reducing the use of substances." The second, "Pharmacological interventions for drug-using offenders" aims to " assess the effectiveness of pharmacological interventions for drug-using offenders in reducing criminal activity and/or drug use." In both cases, the authors note the effectiveness of opioid medications in assisting patients to achieve desired outcomes (although the effect on criminal activity in the second study was significant, but less pronounced). However, they cautioned against generalizing the findings as the body of evidence of both topics is still too small.

Here are the abstracts, via Wiley:

Maintenance agonist treatments for opiate-dependent pregnant women

Abstract

Background

The prevalence of opiate use among pregnant women can range from 1% to 2% to as high as 21%. Heroin crosses the placenta and pregnant, opiate-dependent women experience a six-fold increase in maternal obstetric complications such as low birth weight, toxaemia, third trimester bleeding, malpresentation, puerperal morbidity, fetal distress and meconium aspiration. Neonatal complications include narcotic withdrawal, postnatal growth deficiency, microcephaly, neuro-behavioural problems, increased neonatal mortality and a 74-fold increase in sudden infant death syndrome.

Objectives

To assess the effectiveness of any maintenance treatment alone or in combination with psychosocial intervention compared to no intervention, other pharmacological intervention or psychosocial interventions for child health status, neonatal mortality, retaining pregnant women in treatment and reducing the use of substances.

Search methods

We searched the Cochrane Drugs and Alcohol Group Trials Register (September 2013), PubMed (1966 to September 2013), CINAHL (1982 to September 2013), reference lists of relevant papers, sources of ongoing trials, conference proceedings and national focal points for drug research. We contacted authors of included studies and experts in the field.

Selection criteria

Randomised controlled trials assessing the efficacy of any maintenance pharmacological treatment for opiate-dependent pregnant women.

Data collection and analysis

We used the standard methodological procedures expected by The Cochrane Collaboration.

Main results

We found four trials with 271 pregnant women. Three compared methadone with buprenorphine and one methadone with oral slow-release morphine. Three out of four studies had adequate allocation concealment and were double-blind. The major flaw in the included studies was attrition bias: three out of four had a high drop-out rate (30% to 40%) and this was unbalanced between groups.

Methadone versus buprenorphine: the drop-out rate from treatment was lower in the methadone group (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.41 to 1.01, three studies, 223 participants). There was no statistically significant difference in the use of primary substance between methadone and buprenorphine (RR 1.81, 95% CI 0.70 to 4.69, two studies, 151 participants). For both, we judged the quality of evidence as low. Birth weight was higher in the buprenorphine group in the two trials that could be pooled (mean difference (MD) -365.45 g (95% CI -673.84 to -57.07), two studies, 150 participants). The third study reported that there was no statistically significant difference. For APGAR score neither of the studies which compared methadone with buprenorphine found a significant difference. For both, we judged the quality of evidence as low. Many measures were used in the studies to assess neonatal abstinence syndrome. The number of newborns treated for neonatal abstinence syndrome, which is the most critical outcome, did not differ significantly between groups. We judged the quality of evidence as very low.

Methadone versus slow-release morphine: there was no drop-out in either treatment group. Oral slow-release morphine seemed superior to methadone for abstinence from heroin use during pregnancy (RR 2.40, 95% CI 1.00 to 5.77, one study, 48 participants). We judged the quality of evidence as moderate.

Only one study which compared methadone with buprenorphine reported side effects. For the mother there was no statistically significant difference; for the newborns in the buprenorphine group there were significantly fewer serious side effects.

In the comparison between methadone and slow-release morphine no side effects were reported for the mother, whereas one child in the methadone group had central apnoea and one child in the morphine group had obstructive apnoea.

Authors' conclusions

We did not find sufficient significant differences between methadone and buprenorphine or slow-release morphine to allow us to conclude that one treatment is superior to another for all relevant outcomes. While methadone seems superior in terms of retaining patients in treatment, buprenorphine seems to lead to less severe neonatal abstinence syndrome. Additionally, even though a multi-centre, international trial with 175 pregnant women has recently been completed and its results published and included in this review, the body of evidence is still too small to draw firm conclusions about the equivalence of the treatments compared. There is still a need for randomised controlled trials of adequate sample size comparing different maintenance treatments.

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006318.pub3/abstract

 

Pharmacological interventions for drug-using offenders

Abstract

Background

The review represents one in a family of four reviews focusing on a range of different interventions for drug-using offenders. This specific review considers pharmacological interventions aimed at reducing drug use and/or criminal activity for illicit drug-using offenders.

Objectives

To assess the effectiveness of pharmacological interventions for drug-using offenders in reducing criminal activity and/or drug use.

Search methods

Fourteen electronic bibliographic databases (searched between 2004 and 21 March 2013) and five additional Web resources (searched between 2004 and 11 November 2011) were searched. Experts in the field were contacted for further information.

Selection criteria

Randomised controlled trials assessing the efficacy of any pharmacological interventions for reducing, eliminating or preventing relapse in drug-using offenders were included. Data on the cost and cost-effectiveness of interventions were reported.

Data collection and analysis

We used standard methodological procedures as expected by The Cochrane Collaboration.

Main results

A total of 76 trials across the four reviews were identified. After a process of prescreening had been completed, 17 trials were judged to meet the inclusion criteria for this specific review (six of the 17 trials are awaiting classification for the review). The remaining 11 trials contained a total of 2,678 participants. Nine of the eleven studies used samples with a majority of men. The interventions (buprenorphine, methadone and naltrexone) were compared to non pharmacological treatments (e.g., counselling) and other pharmacological drugs. The methodological trial quality was poorly described, and most studies were rated as 'unclear' by the reviewers. The biggest threats to risk of bias were generated through blinding (performance and detection bias) and incomplete outcome data (attrition bias). When combined, the results suggest that pharmacological interventions do significantly reduce subsequent drug use using biological measures, (three studies, 300 participants, RR 0.71 (95% CI 0.52 to 0.97)), self report dichotomous data (three studies, 317 participants, RR 0.42, (95% CI 0.22 to 0.81)) and continuous measures (one study, MD -59.66 (95% CI -120.60 to 1.28)) . In the subgroups analysis for community setting, (two studies, 99 participants: RR 0.62 (95% CI 0.35 to 1.09)) and for secure establishment setting, (one study, 201 participants: RR 0.76 (95% CI 0.52 to 1.10)), the results are no longer statistically significant. Criminal activity was significantly reduced favouring the dichotomous measures of re arrest, (one study, 62 participants, RR 0.60 (95% CI 0.32 to 1.14)), re-incarceration, (three studies, 142 participants, RR 0.33 (95% CI 0.19 to 0.56)) and continuous measures (one study, 51 participants, MD -74.21 (95% CI -133.53 to -14.89)). Findings on the effects of individual pharmacological interventions on drug use and criminal activity show mixed results. Buprenorphine in comparison to a non pharmacological treatment seemed to favour buprenorphine but not significantly with self report drug use, (one study, 36 participants, RR 0.58 (95% CI 0.25 to 1.35)). Methadone and cognitive behavioural skills in comparison to standard psychiatric services, did show a significant reduction for self report dichotomous drug use (one study, 253 participants, RR 0.43 (95% CI 0.33 to 0.56)) but not for self report continuous data (one study 51 participants) MD -0.52 (95% CI -1.09 to 0.05)), or re incarceration RR 1.23 (95% CI 0.53 to 2.87)). Naltrexone was favoured significantly over routine parole and probation for re incarceration (two studies 114 participants, RR 0.36 (95% CI 0.19 to 0.69)) but no data was available on drug use. Finally, we compared each pharmacological treatment to another. In each case we compared methadone to: buprenorphine, diamorphine and naltrexone. No significant differences were displayed for either treatment for self report dichotomous drug use (one study, 193 participants RR 1.23 (95% CI 0.86 to 1.76)), continuous measures of drug use MD 0.70 (95% CI -5.33 to 6.73) or criminal activity RR 1.25 (95% CI 0.83 to 1.88)) between methadone and buprenorphine. Similiar results were found for comparisons with Diamorphine with no significant differences between the drugs for self report dichotomous drug use for arrest (one study, 825 participants RR 1.25 (95% CI 1.03-1.51)) or Naltrexone for dichotomous measures of re incarceration (one study, 44 participants, RR 1.10 (95% CI 0.37 to 3.26)), and continuous outcome measure of crime MD -0.50 (95% CI -8.04 to 7.04)) or self report drug use MD 4.60 (95% CI -3.54 to 12.74)).

Authors' conclusions

Pharmacological interventions for drug-using offenders do appear to reduce overall subsequent drug use and criminal activity (but to a lesser extent). No statistically significant differences were displayed by treatment setting. Individual differences are displayed between the three pharmacological interventions (buprenorphine, methadone and naltrexone) when compared to a non pharmacological intervention, but not when compared to each other. Caution should be taken when interpreting these findings, as the conclusions are based on a small number of trials, and generalisation of these study findings should be limited mainly to male adult offenders. Additionally, many studies were rated at high risk of bias because trial information was inadequately described.

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010862/abstract