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The life of the heroin user : typical beginnings, trajectories and outcomes
\"Heroin is a worldwide scourge and a seemingly intractable one. The Life of the Heroin User: Typical Beginnings, Trajectories and Outcomes is the first book to apply a biographical approach to the lifecycle of the heroin user from birth until death. Chapters address each stage of the user's life, including childhood, routes to use, the development of dependence, problems arising from addiction, death and options for treatment and prevention. Drawing on over two decades of experience in the field of opium research, Shane Darke examines major theoretical approaches to the development of opiate dependence and the efficacy of treatment options for opiate dependence. Key points are presented at the end of each chapter. The most detailed review available of what is likely to happen to the dependent heroin user, this is an important book for clinicians, researchers and students in the fields of drug and alcohol studies and public health\"-- Provided by publisher.
Book
Abuse Liability of Prescription Opioids Compared to Heroin in Morphine-Maintained Heroin Abusers
Abuse of prescription opioid medications has increased dramatically in the United States during the past decade, as indicated by a variety of epidemiological sources. However, few studies have systematically examined the relative reinforcing effects of commonly abused opioid medications. The current double-blind, placebo-controlled in-patient study was designed to compare the effects of intravenously delivered fentanyl (0, 0.0625, 0.125, 0.187, and 0.250 mg/70 kg), oxycodone (0, 6.25, 12.5, 25, and 50 mg/70 kg), morphine (0, 6.25, 12.5, 25, and 50 mg/70 kg), buprenorphine (0, 0.125, 0.5, 2, and 8 mg/70 kg), and heroin (0, 3.125, 6.25, 12.5, and 25 mg/70 kg) in morphine-maintained heroin abusers (
N
=8 completers maintained on 120 mg per day oral morphine in divided doses (30 mg q.i.d.)). All of the participants received all of the drugs tested; drugs and doses were administered in non-systematic order. All of the drugs produced statistically significant, dose-related increases in positive subjective ratings, such as ‘I feel a good drug effect’ and ‘I like the drug.’ In general, the order of potency in producing these effects, from most to least potent, was fentanyl>buprenorphine⩾heroin >morphine=oxycodone. In contrast, buprenorphine was the only drug that produced statistically significant increases in ratings of ‘I feel a bad drug effect’ and it was the only drug that was not self-administered above placebo levels at any dose tested. These data suggest that the abuse liability of buprenorphine in heroin-dependent individuals may be low, despite the fact that it produces increases in positive subjective ratings. The abuse liabilities of fentanyl, morphine, oxycodone, and heroin, however, appear to be similar under these experimental conditions.
Journal Article
Substance Use in Older Adults
By 2050, 85.7 million people in the United States are projected to be 65 or older. Older adults are especially prone to the effects of substances, and a 2021 survey showed that 4 million older adults were dealing with a substance use disorder. As the country's population ages, clinicians will inevitably have to care for a greater number of older adults with substance use disorders, but the literature on the topic—and the evidence base for treatment—is limited.
In Substance Use in Older Adults, more than 20 contributors translate their real-world experience in geriatric psychiatry into an accessible, evidence-based guide to screening for and assessing substance use in older adults. Early chapters discuss not only etiology and epidemiology but also comorbidities and management and subsequent sections address the problematic use of specific substances, including
• Alcohol• Tobacco• Opioids• Sedatives• Stimulants• Cannabinoids
Readers will find guidance on safe prescribing practices for older patients, as well as an examination of the cultural and ethical issues that may arise when working with this patient population.
Rife with case examples that illustrate key points in clinical practice, Substance Use in Older Adults also features numerous tables that can be referenced time and again with information on comorbidities, screening frameworks, and interventions for specific substances; stigma-reducing language; the pharmacological implications of physiological changes in older adults; and more.
Clinicians from psychiatric professionals to primary care providers will benefit from exhaustive listings of additional resources. This guide also includes resources for patients, families, and caregivers that will help to strengthen the partnership between clinician and patient.
eBook
1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial
The partial opiate-receptor agonist buprenorphine has been suggested for treatment of heroin dependence, but there are few long-term and placebo-controlled studies of its effectiveness. We aimed to assess the 1-year efficacy of buprenorphine in combination with intensive psychosocial therapy for treatment of heroin dependence.
40 individuals aged older than 20 years, who met DSM-IV criteria for opiate dependence for at least 1 year, but did not fulfil Swedish legal criteria for methadone maintenance treatment were randomly allocated either to daily buprenorphine (fixed dose 16 mg sublingually for 12 months; supervised daily administration for a least 6 months, possible take-home doses thereafter) or a tapered 6 day regimen of buprenorphine, thereafter followed by placebo. All patients participated in cognitive-behavioural group therapy to prevent relapse, received weekly individual counselling sessions, and submitted thrice weekly supervised urine samples for analysis to detect illicit drug use. Our primary endpoint was 1-year retention in treatment and analysis was by intention to treat.
1-year retention in treatment was 75% and 0% in the buprenorphine and placebo groups, respectively (p=0·0001; risk ratio 58·7 [95% CI 7·4–467·4]). Urine screens were about 75% negative for illicit opiates, central stimulants, cannabinoids, and benzodiazepines in the patients remaining in treatment.
The combination of buprenorphine and intensive psychosocial treatment is safe and highly efficacious, and should be added to the treatment options available for individuals who are dependent on heroin.
Journal Article
Diacetylmorphine versus Methadone for the Treatment of Opioid Addiction
In this 12-month randomized trial involving 251 long-term heroin users, injectable diacetylmorphine (the active ingredient in heroin) was more effective than oral methadone in achieving retention in treatment for addiction and in reducing illicit-drug use and other illegal activity. As compared with methadone, injectable diacetylmorphine was associated with more serious adverse events, including seizures and drug overdoses.
In long-term heroin users, injectable diacetylmorphine (the active ingredient in heroin) was more effective than oral methadone in achieving retention in treatment for addiction and in reducing illicit-drug use and other illegal activity.
Opioid dependence, most commonly manifested as heroin dependence, is a chronic relapsing condition
1
that is estimated to affect more than 1 million persons in North America.
2
,
3
The risks of opioid dependence include fatal overdoses, infections (including endocarditis, human immunodeficiency virus infection, and hepatitis C virus infection), social disintegration, violence, and crime. The associated burdens on communities include medical, public health, and criminal-justice costs as well as public disorder and crimes against property.
Methadone, the standard opioid-substitution treatment, has been shown to reduce major risks associated with untreated opioid dependence in patients who are willing to undergo and are successfully . . .
Journal Article
Use of contingency management incentives to improve completion of hepatitis B vaccination in people undergoing treatment for heroin dependence: a cluster randomised trial
Poor adherence to treatment diminishes its individual and public health benefit. Financial incentives, provided on the condition of treatment attendance, could address this problem. Injecting drug users are a high-risk group for hepatitis B virus (HBV) infection and transmission, but adherence to vaccination programmes is poor. We aimed to assess whether contingency management delivered in routine clinical practice increased the completion of HBV vaccination in individuals receiving opioid substitution therapy.
In our cluster randomised controlled trial, we enrolled participants at 12 National Health Service drug treatment services in the UK that provided opioid substitution therapy and nurse-led HBV vaccination with a super-accelerated schedule (vaccination days 0, 7, and 21). Clusters were randomly allocated 1:1:1 to provide vaccination without incentive (treatment as usual), with fixed value contingency management (three £10 vouchers), or escalating value contingency management (£5, £10, and £15 vouchers). Both contingency management schedules rewarded on-time attendance at appointments. The primary outcome was completion of clinically appropriate HBV vaccination within 28 days. We also did sensitivity analyses that examined vaccination completion with full adherence to appointment times and within a 3 month window. The trial is registered with Current Controlled Trials, number ISRCTN72794493.
Between March 16, 2011, and April 26, 2012, we enrolled 210 eligible participants. Compared with six (9%) of 67 participants treated as usual, 35 (45%) of 78 participants in the fixed value contingency management group met the primary outcome measure (odds ratio 12·1, 95% CI 3·7–39·9; p<0·0001), as did 32 (49%) of 65 participants in the escalating value contingency management group (14·0, 4·2–46·2; p<0·0001). These differences remained significant with sensitivity analyses.
Modest financial incentives delivered in routine clinical practice significantly improve adherence to, and completion of, HBV vaccination programmes in patients receiving opioid substitution therapy. Achievement of this improvement in routine clinical practice should now prompt actual implementation. Drug treatment providers should employ contingency management to promote adherence to vaccination programmes. The effectiveness of routine use of contingency management to achieve long-term behaviour change remains unknown.
National Institute for Health Research (RP-PG-0707-10149).
Journal Article
Frequency dependence of pollinator visitation rates suggests that pollination niches can allow plant species coexistence
1. How do many species coexist within a trophic level? Resource niches are the classical answer, but in plants which share a small set of abiotic resources, the possibilities for resource partitioning are limited. One possible explanation is that plant species have different pollination niches, with each species specialized to a subset of the available animal species. If this pollinator partitioning results in negative frequency dependence such that each plant species' reproduction is reduced when it becomes abundant, pollination niches could maintain plant diversity, provided that the strength of negative frequency dependence is sufficient to overcome fitness inequalities between species. 2. We tested this idea by quantifying the effect of species relative abundance on pollinator visitation rate in a 7,000 m² plot of South African Fynbos vegetation. In addition, we quantified the effect of intraspecific abundance variation at a smaller spatial scale (9 m² plots), documented species' pollination niches, and tested the importance of pollinators for seed set in a subset of the plant species. 3. We found that visitation rate indeed declined sharply across the 33 plant species with increasing abundance, but visitation rate was also somewhat depressed in very rare species such that the resulting relationship between visitation rate and relative abundance was hump-shaped. Pollinator niche partitioning among plant species was evident, but less pronounced than in many other studies. Visitation rate was slightly higher in more generalized species, suggesting that they have access to a larger pollination resource. At the intraspecific level and smaller spatial scale, results were less clear and varied among species. Pollinators enhanced seed set in most species. 4. Synthesis. The results imply that, above an abundance threshold, intraspecific competition for pollination could limit the reproduction of common species, thus promoting plant species coexistence. However, the rarest plant species could become extinct due to pollen limitation, that is, an Allee effect. In addition, interactions with pollinators may introduce frequency-independent fitness differences between plant species, thereby increasing the strength of negative frequency dependence required for stable coexistence. These findings shed new light on the role of the pollination niche in plant coexistence.
Journal Article