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Aims: Ketamine use among young adults in England has increased significantly, with prevalence more than doubling in the past five years. Ketamine use disorder (KUD) is a disorder of regulation arising from repeated or continuous use of ketamine for at least three months. The systemic effects can include urinary, sexual, hepatic and cardiovascular dysfunction, memory impairment and mental illness. Although people who use ketamine constitute a smaller proportion of patients in addictions services compared with opioid or alcohol users, the complexity and morbidity of KUD dictates the need for interdisciplinary collaboration. In 2024, a collaborative effort between a local addiction and urology service was initiated to address KUD and ketamine uropathy (KU). Methods: Both services presented at the local Addictions Continuing Professional Development Day to share knowledge and develop staff understanding on KUD and KU. Meetings were held to evaluate local prevalence of KUD and KU, address barriers to treatment and develop easier referral pathways into both services. Best practice guidance on KU was reviewed and a new interdisciplinary treatment model implemented. Re-strategisation required clinician time and adjustments to clinic schedules. Results: In 2024, nine patients from Urology and 23 patients from the addiction service with ketamine use were seen. Key improvements included the establishment of a direct two-week referral pathway to Urology, development of referral and assessment proformas and initiation of monthly interdisciplinary team meetings. These changes aimed to reduce delays in initiation of treatment and improve co-ordination between services. However, the major challenge faced was a high attrition rate in the clinics. Areas identified as requiring further attention included management of weight loss and constipation, medication for symptomatic relief of ketamine withdrawal and cravings, safe analgesic alternatives, treatment of co-occurring mental illness and trauma, safeguarding and risk considerations and psychological therapeutic options. The embarrassment of urinary incontinence was identified as a barrier to appointment attendance. Conclusion: An interdisciplinary management approach is recommended to optimize patient care. Systemic complications of KUD and co-occurring mental illness should be treated simultaneously. Intensifying the support from Addiction Recovery Coordinators may improve attendance at appointments. Recommendations include more health worker education and staffing, early pain team involvement and provision of harm reduction advice. Peer-informed, ketamine-focused psychosocial programmes and national psychiatry guidelines for KUD are required. Our collaborative model demonstrates a significant step towards improving management of KU and KUD, however its impact on clinical outcomes will need further evaluation.

Background Breaking Free Online (BFO), a computer-assisted therapy (CAT) program for substance use disorders (SUD), has been available across UK treatment services for the past decade and has demonstrated efficacy. The Covid-19 pandemic has contributed to digital and ‘telehealth’ approaches to healthcare delivery becoming more common and accepted, and has in parallel, increased numbers of referrals to SUD services because of the impact pandemic-related stress has had on substance using habits in the general population. Digital and telehealth approaches, such as BFO, have the potential to support the treatment system to meet this increased demand for SUD services. Methods Parallel-group randomized controlled trial of eight-week BFO as an adjunct to standard treatment for SUD, in comparison to standard treatment only, at a National Health Service (NHS) Mental Health Trust in North-West England. Participants will be service users aged 18 years and over with demonstrable SUD for at least 12-months. Interventional and control groups will be compared on multiple measures from baseline to post-treatment assessment at eight-weeks, and then three and six-months follow-up. Primary outcome will be self-reported substance use, with secondary outcomes being standardized assessments of substance dependence, mental health, biopsychosocial functioning and quality of life. Discussion This study will examine whether BFO and telehealth support, when delivered as an adjunct to standard SUD interventions, improves outcomes for services users receiving NHS SUD treatment. Findings from the study will be used to inform both developments to the BFO program and guidance around augmenting the delivery of CAT programs via telehealth. Trial registration registered with ISRCTN on 25th May 2021—registration number: 13694016. Protocol version: 3.0 05th April 2022. Trial status: This trial is currently open to recruitment—estimated to be completed in May 2023.

Background Sublingual tablet buprenorphine (BUP-SL) and oral liquid methadone (MET) are the daily, standard-of-care (SOC) opioid agonist treatment medications for opioid use disorder (OUD). A sizable proportion of the OUD treatment population is not exposed to sufficient treatment to attain the desired clinical benefit. Two promising therapeutic technologies address this deficit: long-acting injectable buprenorphine and personalised psychosocial interventions (PSI). This study will determine (A) the effectiveness and cost-effectiveness — monthly injectable, extended-release (BUP-XR) in a head-to-head comparison with BUP-SL and MET, and (B) the effectiveness of BUP-XR with adjunctive PSI versus BUP-SL and MET with PSI. Safety, retention, craving, substance use, quality-adjusted life years, social functioning, and subjective recovery from OUD will be also evaluated. Methods This is a pragmatic, multi-centre, open-label, parallel-group, superiority RCT, with a qualitative (mixed-methods) evaluation. The study population is adults. The setting is five National Health Service community treatment centres in England and Scotland. At each centre, participants will be randomly allocated (1:1) to BUP-XR or SOC. At the London study co-ordinating centre, there will also be allocation of participants to BUP-XR with PSI or SOC with PSI. With 24 weeks of study treatment, the primary outcome is days of abstinence from non-medical opioids during study weeks 2–24 combined with up to 12 urine drug screen tests for opioids. For 90% power (alpha, 5%; 15% inflation for attrition), 304 participants are needed for the BUP-XR versus SOC comparison. With the same planning parameters, 300 participants are needed for the BUP-XR and PSI versus SOC and PSI comparison. Statistical and health economic analysis plans will be published before data-lock on the Open Science Framework. Findings will be reported in accordance with the Consolidated Standards of Reporting Trials and Consolidated Health Economic Evaluation Reporting Standards. Discussion This pragmatic randomised controlled trial is the first evaluation of injectable BUP-XR versus the SOC medications BUP-SL and MET, with personalised PSI. If there is evidence for the superiority of BUP-XR over SOC medication, study findings will have substantial implications for OUD clinical practice and treatment policy in the UK and elsewhere. Trial registration EU Clinical Trials register 2018-004460-63.