Dissertations / Theses on the topic 'Opioid substitution treatment program'

Aim: This study’s aim was to improve our understanding of the dietary behaviours of people receiving opioid substitution treatment (OST) in the UK. Setting: The study focuses on people receiving prescribing interventions for OST from pharmacies in Oxfordshire, England. Methods: Dietary behaviours were assessed using a longitudinal convergent parallel mixed methods research design. Quantitative methods included a socio-demographic and drug use questionnaire, SF-36 health related quality of life questionnaire, 24-hour dietary recall interview, and anthropometry measures. Qualitative semi-structured face-to-face interviews were conducted to understand how individuals’ experiences with food and diet influence their dietary behaviours. Follow-ups were conducted four months after baseline data collection. The same quantitative and qualitative research tools were applied at the second stage of the study. Results: Mean (SD) Body Mass Index for males (n=15) and females (n=10) exceeded the normal range [25.2 (5.9) kg/m2 and 33.3 (8.6) kg/m2, respectively] at baseline. Males decreased to the normal range at follow-up [mean (SD) = 24.1 (± 6.2) kg/m2]. Females increased to Obesity Class II at follow-up [mean (SD) = 35.1 (± 8.0) kg/m2]. Non-starch polysaccharide intakes were significantly lower than the Reference Nutrient Intake (RNI). Iron intakes among females were significantly below the RNI. Saturated fat intake and sodium intake exceeded the RNI. Eleven (44%) participants had multiple health conditions. Food consumption was influenced by factors such as childhood eating, mental health issues, digestive issues, limited financial resources, drug use and accommodation. Conclusions: People receiving OST in the UK may be at risk of development of non-communicable diseases (NCDs). Dietary and nutritional recommendations may benefit this population. Recommendations must accommodate for specialised needs. Further research is required in the UK to understand aspects such as multi-morbidity rates, rates of overweight and obesity, food acquisition, food preparation skills and food expenditures.

BACKGROUND: Misuse of drugs is a public health problem which can lead to poor health outcomes. Drug use during pregnancy could potentially harm the unborn baby. Pregnancy usually triggers women to visit their general practitioner (GP) which may provide an opportunity for drug use to be raised and recorded. To date, there are no UK studies with large sample sizes to estimate the burden of drug use during pregnancy. Therefore, my aim was to describe and understand drug use and opioid substitution treatment in and around pregnancy using electronic health records. METHODS: Using a mixed methods design, I firstly, utilized The Health Improvement Network (THIN) to estimate GP recording rates of individuals who use drugs and/or are prescribed opioid substitution treatment in the general population, of women in and around pregnancy and infants with neonatal abstinence syndrome (NAS). Next, I compared rates with national surveys and hospital birth data. Finally, I conducted qualitative interviews to gain GPs’ perspectives regarding their decisions about recording drug-use. RESULTS: GP recording trends for the general population were in keeping with national surveys, but with lower rates. Recording was relatively low in and around pregnancy. GP recording of NAS was similar to hospital data, however rates were lower. Finally, qualitative interview analysis identified that influences on recording drug use were complex and related to pressures at the individual as well as organisational (general practices, Clinical Commissioning Groups) and governmental levels in the shape of government policies. CONCLUSIONS: In conclusion, evidence from the thesis supports the use of THIN as a suitable tool for monitoring trends but not rates of problem drug use in the general population. Electronic primary health records could potentially be used to monitor the impact of problematic drug use in and around pregnancy. The thesis also supports utilising THIN for researching drug use and opioid substitution treatment in the general population.

This thesis explores the physical activity (PA) practices and experiences of a group of drug users receiving opioid substitution treatment (OST). Opioid Substitution treatment is the most widely used form of treatment for individuals with opioid dependence. Existing research in this group (and drug users in general) has tended to focus on harmful behaviours, as opposed to their everyday lives. Additionally, a recent shift in UK drugs policy has places an increased emphasis on the wider aspects of recovery from drug use, including the improvement of health, well-being and re- integration into society. Despite the numerous benefits associated with PA, little research has explored PA among individuals receiving OST. The use of a social-ecological approach to guide and understand the research findings was utilized, with both quantitative and qualitative data collected. Self- reported quantitative data was first collected on demographic information, PA participation, perceived benefits and barriers to PA and health-related quality of life from 100 participants. Objective PA data was also collected from a smaller sub- sample of participants through the use of pedometers. Secondly, semi-structured interviews were conducted with 30 participants, to gain further understanding of PA in this group, with the qualitative data analyzed using the Framework approach. Both quantitative and qualitative findings indicate that much of this population is physically active, largely through walking as a form of active transport, with participant in structured sport and exercise occurring less frequently. However, nearly all participants reported previous participation in structured PA prior to drug use and an a desire to resume participation. The benefits of PA participation were unanimously recognized, with perceived barriers to participation highlighted at multiple levels of influence in line with the social-ecological approach used to theoretically underpin the study. While many individuals receiving OST appear to be physically active through unstructured PA, increased participation in structured PA is often desired, yet prohibited through the presence of multiple barriers, some similar to the general population and others specific to this group. Participation in structured PA may yield additional benefits beyond those gained from unstructured activity, contributing to the wider aspects of individuals’ recovery from opioid dependence in line with current UK policy. However, strategies to increase participation may need to consider the multiple needs of this group in addressing barriers to participation.

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Opioid overdoses are increasing and several efforts are being made to reduce this problem. One potential solution is overdose education and naloxone distribution. Project ASSERT began distributing naloxone in conjunction with its overdose education program in 2009. Project ASSERT’s overdose education and naloxone distribution program trained opioid users in recognition, risk factors, and response to overdoses, as well as how to use nasal naloxone kits. Opioid users that had received overdose education only were compared with those that received overdose education and naloxone kits. The goal was to determine if there were any differences in occurrence of nonfatal overdoses, overdose response, illicit opioid use, and opioid agonist treatment. This retrospective study involved phone-surveying patients from a hospital billing list. It was obtained through Project ASSERT and contained the names of patients that had received overdose education only or overdose education and naloxone distribution from January 2011 to February 2012. Questions were asked about the respondents’ naloxone kits, overdose history since their Project ASSERT visit, response to the last witnessed overdose, 30-day substance use, and overdose risk knowledge. Chi-square tests were used to compare the groups. 51 out of 415 eligible were successfully surveyed from March 2012 to October 2012. The surveys occurred on average 11.8 months after their Project ASSERT visit. 73% (37) had naloxone kits and most kept them where they lived (12). There were 9 successful overdose reversals reported. 76% (39) of the respondents did not overdose in the intervening period. There was no statistical difference between the two groups in overdose occurrence, 19% trained with naloxone versus 29% trained without naloxone (p=0.45). 16 out of 19 (84%) of the naloxone group properly responded to an overdose, whereas 3 out of 8 (38%) of those trained without naloxone properly responded (p=.03). There was no statistical difference in illicit opioid use (p=1.0) and opioid agonist treatment (p=.53), 36% of the group trained with naloxone versus 35% of the group trained without naloxone, and 49% of those trained with naloxone versus 36% of those trained without naloxone, respectively. In studying the association between overdose education only and overdose education and naloxone distribution, it was found that there is not an increase in overdose and illicit opioid use. There also is no reduction in seeking for opioid agonist treatment. However, it was found that having naloxone kits does increase proper response to overdose. This is a promising result that could have an impact in reducing opioid overdose deaths.
2031-01-01

Using thematic analysis, this qualitative study investigates desistance from illicit drug use from the perspective of patients within opioid substitution treatment (OST). Wikström's theoretical framework was used to explain this process. From semi-structured reflective interviews with 12 patients admitted to an OST clinic in Sundsvall, three main themes were identified as relevant to the research aim. These main themes were labelled as follows: Motives for desistance, Perspectives on OST and Recipe for successful desistance. The findings were similar to those of previous research. The participants expressed criticism on specific regulations within OST, but were positive to the treatment in general. They felt a lack of emotional support from OST, but still reported an improvement in mental well being. While varied views on diversion of OST medication were expressed, a majority believe dillicitly used opioids to originate from sources other than OST. In conclusion, the participants viewed OST as an essential method for desistance from illicit drug use. Having a sincere will to desist and perceiving the past illicit opioid use as problematic were also deemed necessary for the treatment to be successful.

2017-06-01

Background: In many countries, buprenorphine and methadone are licensed for the maintenance treatment (MT) of opioid dependence. Despite many short-term studies, little is known about the long-term (12-month) effects of these treatments in different settings, i.e. primary care-based (PMC) and specialized substitution centers (SSCs). Objectives: To describe over a period of 12 months: (1) mortality, retention and abstinence rates; (2) changes in concomitant drug use, somatic and mental health; and (3) to explore differences between different types of provider settings. Methods: 12-Month prospective-longitudinal naturalistic study with four waves of assessment in a prevalence sample of N= 2694 maintenance patients, recruited from a nationally representative sample of N= 223 substitution physicians. Results: The 12-month retention rate was 75%; the mortality rate 1.1%. 4.1% of patients became “abstinent” during follow-up. 7% were referred to drug-free addiction treatment. Concomitant drug use decreased and somatic health status improved. No significant improvements were observed for mental health and quality of life. When controlling for initial severity, small PMC settings revealed better retention, abstinence and concomitant drug use rates. Conclusion: The study underlines the overall 12-month effectiveness of various forms of agonist MT. Findings reveal relatively high retention rates, low mortality rates, and improvements in most 12-month outcome domains, except for mental health and quality of life. PMC settings appear to be a good additional option to improve access to MTs.

Background: In many countries, buprenorphine and methadone are licensed for the maintenance treatment (MT) of opioid dependence. Despite many short-term studies, little is known about the long-term (12-month) effects of these treatments in different settings, i.e. primary care-based (PMC) and specialized substitution centers (SSCs). Objectives: To describe over a period of 12 months: (1) mortality, retention and abstinence rates; (2) changes in concomitant drug use, somatic and mental health; and (3) to explore differences between different types of provider settings. Methods: 12-Month prospective-longitudinal naturalistic study with four waves of assessment in a prevalence sample of N= 2694 maintenance patients, recruited from a nationally representative sample of N= 223 substitution physicians. Results: The 12-month retention rate was 75%; the mortality rate 1.1%. 4.1% of patients became “abstinent” during follow-up. 7% were referred to drug-free addiction treatment. Concomitant drug use decreased and somatic health status improved. No significant improvements were observed for mental health and quality of life. When controlling for initial severity, small PMC settings revealed better retention, abstinence and concomitant drug use rates. Conclusion: The study underlines the overall 12-month effectiveness of various forms of agonist MT. Findings reveal relatively high retention rates, low mortality rates, and improvements in most 12-month outcome domains, except for mental health and quality of life. PMC settings appear to be a good additional option to improve access to MTs.

Background Heroin dependence is associated with increased risk of the transmission of blood-borne viral (BBV) infections such as HIV, as a result of unsafe injecting practices. Opioid Substitution Treatment (OST) Programmes including Methadone Maintenance Treatment (MMT) programmes are a recommended way of addressing heroin dependence with the dual aims of reducing both heroin use and associated harms. However, OST programmes, particularly in prison settings, are often unavailable, in spite of large numbers of prisoners with heroin dependence and the high risk of HIV transmission in the prison setting. Little is currently known about the delivery of OST programmes within prison settings. A systematic literature review conducted within this study revealed that there are only a small number of studies from middle and lower-income countries and the perspectives of the range of stakeholders are often underrepresented. Aim and setting of this study This aim of this study was to understand the role of Methadone Maintenance Treatment (MMT) programmes within the context of HIV prevention programmes and to identify barriers and facilitators that influence the implementation, routine delivery and sustainability of methadone programmes in Indonesian prisons. Study design Three prison settings were selected as part of a qualitative case study. These comprised: a narcotics prison that provided methadone, a general prison that provided methadone, and a general prison, where there was no methadone programme. This allowed the exploration of multiple perspectives of prisoners and the diverse range of staff involved in the implementation of programmes. Interview and observational data were supplemented by data from medical case notes. Qualitative data underwent thematic analysis, with the help of framework analysis for data management. Principal findings This study found that there were many misconceptions about methadone programmes. HIV infection was not recognised as a problem and prison staff, healthcare staff and prisoners alike lacked understanding of the roles of methadone programmes. Prisoners participating in programmes were often stigmatised, while many prisoners believed methadone withdrawal was dangerous and could lead to death. These factors all contributed to low level participation, observed in both prisons with methadone programmes. Lack of confidentiality and associated stigmatisation as well as inappropriate assessment criteria also contributed to this, as did a lack of support systems. A reduction in international funding and a shift in national drug policy priorities away from the provision of methadone to drug-free Therapeutic Community (TC) programmes, together with a failure to embed methadone programmes within the daily prison routine currently pose challenges to effective implementation, delivery and programme sustainability. Conclusion Educating policy makers and practitioners could improve understanding of the roles of methadone programmes and increase support for programme delivery within prisons. It is therefore recommended that Indonesian government and prison policy focuses on ensuring effective delivery and sustainability of methadone programmes for people with heroin dependence in the prison setting.

Background: To assess the long-term course of the feasibility and safety of orally administered heroin [diacetylmorphine (DAM)] tablets in substitution treatment of severely addicted opioid users. Design: Open-label, prospective cohort study with 2 non-randomly assigned treatment arms: DAM tablets only (n = 128) or DAM tablets combined with injected DAM and/or other opioids (n = 237). The average duration of the observation period was 62 months. Study endpoints were the time to discharge from treatment and the number of serious adverse events. Results: Both patient groups had a higher than 70% retention rate after the first 48 months of treatment, with similar long-term retention rates (after 8 years both groups had retention over 50%). The physician-verified rate of serious adverse events was 0.01 events per application year among the exclusively oral substitution group (intention-to-treat analysis) during the last year of observation, and 0.005 events per application year in the other group. Conclusions: Because of their feasibility and safety over years, DAM tablets may be a valuable long-term therapeutic alternative
Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich

Background: To assess the long-term course of the feasibility and safety of orally administered heroin [diacetylmorphine (DAM)] tablets in substitution treatment of severely addicted opioid users. Design: Open-label, prospective cohort study with 2 non-randomly assigned treatment arms: DAM tablets only (n = 128) or DAM tablets combined with injected DAM and/or other opioids (n = 237). The average duration of the observation period was 62 months. Study endpoints were the time to discharge from treatment and the number of serious adverse events. Results: Both patient groups had a higher than 70% retention rate after the first 48 months of treatment, with similar long-term retention rates (after 8 years both groups had retention over 50%). The physician-verified rate of serious adverse events was 0.01 events per application year among the exclusively oral substitution group (intention-to-treat analysis) during the last year of observation, and 0.005 events per application year in the other group. Conclusions: Because of their feasibility and safety over years, DAM tablets may be a valuable long-term therapeutic alternative.
Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

In the mid 1990's the UK government began to focus on problem heroin use mainly as a drug related crime issue, and so attracting and retaining clients became a treatment priority. The concept of flexible prescribing, matching individual clients to treatment programmes appropriate to their drug using history and circumstances, began to gain support amongst politicians and clinicians. As part of this shift in emphasis, prescribing heroin to heroin addicts re-emerged as a treatment option. Injectable (and smokable) diamorphine (pharmaceutical heroin) began to be prescribed in a small number of drug dependency units under the direction of local psychiatrists, including two in North West England. One hundred and thirty three registered drug users were interviewed between August 1995 and February 1997 using a structured questionnaire. Three key areas and their association with heroin substitution prescribing were addressed; levels of criminal activity, levels of illicit drug use, and a range of client held perceptions and attributions regarding coping/quality of life. The mean age of the sample was 30 years, and 75% were male. 61% had used illicit heroin in the past month, spending on average £638, on a habit of 4g per week. Clients were subdivided on a number of variables and comparisons were made between groups according to (IV) prescription type (which drug), and form (injectable/smokable/oral mixture). Significant differences were found across each of three key variables, including differing levels of illicit drug use according to prescription form, and differing levels of specific criminal activity according to prescription type. Significant effects included; Clients on prescriptions which included ampoules were significantly more likely to report being able to cope with life, and spent significantly less time on drug taking activities, than those clients receiving other prescriptions. Clients on prescriptions which included `reefers' (smokable) reported significantly less shop lifting than clients receiving other prescriptions. It was concluded that the available empirical evidence regarding heroin prescribing is limited, and although some clinicians are yet to be convinced, it seems heroin does have its merits as a viable treatment option. Issues of cost and possible dispersion remain, and are discussed in relation to the continuing development of substitution treatment policy in the UK.

Studien syftar till att undersöka hur det går till att sluta använda heroin utan att byta till användning av andra opioidpreparat och utan att erhålla substitutionsbehandling med opioidpreparaten metadon eller buprenorfin. Forskningsgenomgången visar att det är möjligt att sluta med heroin utan substitutionsbehandling, men att det är svårt att leda i bevis att vissa specifika behandlingsmetoder skapar detta resultat. Det empiriska materialet består av djupintervjuer med tio personer som delar erfarenheten av att ha varit heroinberoende och av att ha slutat använda heroin utan att erhålla substitutionsbehandling. Som teoretisk utgångspunkt används en syntes av flera sociologiska och socialpsykologiska teorier och analysbegrepp som syftar till att förklara relationen mellan mänskliga betenden och de sociala sammanhang som människan ingår i och relaterar till. Studien visar att en framgångsrik återhämtning från heroinberoende innebär en sekundär socialisering in i sociala gemenskaper organiserade kring andra företeelser än heroinanvändning, vilket möjliggör för den före detta heroinanvändaren att avhålla sig från heroin- och annan opioidanvändning. Studien visar även att en viktig komponent i återhämtningen är att, framförallt under den första tiden i återhämtningsprocessen, utveckla ett överväldigande engagemang i någon typ av sysselsättning, samt att personer som under tiden de använde heroin saknade ett överbryggande socialt kapital, har möjlighet att skapa ett sådant efter att de slutat använda heroin.
The study aims to investigate how to stop using heroin without replacing heroin with use of other opioid preparations and without receiving substitution treatment with the opioid preparations methadone or buprenorphine. The research review shows that it is possible to quit heroin addiction without substitution treatment, but it is difficult to prove that certain specific treatment methods create this result. The empirical material consists of in-depth interviews with ten people who share the experience of being addicted to heroin and having stopped using heroin without receiving substitution therapy. As a theoretical point of view, a synthesis of several sociological and social psychological theories and concepts of analysis is used to explain the relationship between human behavior and the social context in which human beings belong and relate. The study shows that a successful recovery from heroin addiction involves secondary socialization into social communities organized around phenomenas other than heroin use, which enables the former heroin user to refrain from heroin and other opioid use. The study also shows that an important component of the recovery process is, especially during the first phase of the recovery process, developing an overwhelming involvement to some type of pursuit, and that people who when they used heroin lacked any sort of bridging social capital, are able to create such after they stopped using heroin.

La dépendance aux opioïdes est un problème majeur de santé publique dont la prévalence et l’incidence ne cessent d’augmenter. Sa prise en charge pharmacologique repose sur une approche substitutive basée sur la prescription des médicaments de substitution aux opioïdes (MSO), buprénorphine (BHD) et méthadone (MTD), commercialisés depuis 1995-1996 en France. Leur efficacité clinique a largement été démontrée en réduisant la consommation d’héroïne, la mortalité par overdose et en améliorant la qualité de vie des patients. Néanmoins, en parallèle, des problématiques en lien avec le mésusage des MSO ont émergé, pouvant conduire à des conséquences péjoratives pour les patients. La première partie de cette thèse a donc consisté à étudier le mésusage des MSO chez des patients dépendants aux opioïdes en France à travers l’identification d’un comportement de nomadisme médical, en exploitant les données nationales de l’EGB selon deux approches : 1/ une étude transversale répétée estimant la prévalence annuelle du mésusage des MSO entre 2004 et 2014 : la prévalence du nomadisme médical de la BHD a significativement diminué entre 2004 et 2014 (12,6 % vs 3,9 %, alors que celle de la MTD est restée faible sans évolution significative sur la période d’étude (0,2 % en 2004 à 0,5 % en 2014) ; 2/une étude de cohorte visant à estimer l’incidence du mésusage des MSO chez les patients dépendants aux opioïdes et identifier les facteurs de risque associés à ce mésusage : l'incidence à un an était de 8,4 % [IC 95 % : 7,0–10,1] dans le groupe BHD et de 0 % dans le groupe MTD, comparativement à 0,2 % [0,1-0,2] pour le groupe des diurétiques (contrôle négatif). Les facteurs associés au nomadisme médical étaient le sexe féminin (HR : 1,74 [1,20–2,54]), la précarité socio-économique (HR : 2,95 [2,07-4,44]), les comorbidités psychiatriques (HR : 1,43 [1,06–1,94]), les coprescriptions d’hypnotiques (HR : 1,90 [1,39–2,61]), d’antalgiques opioïdes faibles (HR : 1,48 [1,09–1,99]) et de morphine (HR : 1,69 [1,02–2,80]). Parmi les nombreuses motivations justifiant ce mésusage des MSO, l’existence d’une douleur mal soulagée est fréquemment retrouvée. En effet, la douleur constitue une problématique importante chez les patients dépendants aux opioïdes car elle reste encore trop souvent sous-diagnostiquée et sous-estimée, alors que sa prévalence est plus élevée qu’en population générale. Sa prise en charge adéquate est d’autant plus importante qu’elle va contribuer à une amélioration et un meilleur équilibre de la pathologie addictive. Aucune donnée française n’est disponible concernant la prévalence des phénomènes douloureux chez les patients MSO ainsi que la description des profils pharmaco-thérapeutiques antalgiques dans la vraie vie.Ces problématiques autour de la douleur ont fait l’objet des deuxièmes et troisièmes chapitres de cette thèse. La deuxième partie de ce manuscrit s’est effectivement attachée à estimer la prévalence de la douleur chez les patients dépendants aux opioïdes en France à travers une double approche : 1/ une étude de prévalence classique de terrain, incluant un échantillon représentatif de 509 patients dépendants aux opioïdes recrutés dans 12 centres de soins en addictologie : la prévalence de la douleur aiguë a été estimée à 42,0 % [37,7–46,3] et celle de la douleur chronique à 33,2 % [29,1–37,3] sans différence significative entre BHD et MTD ; 2/ une approche alternative originale, basée sur l’application de la méthode de capture-recapture aux données exhaustives du SNIIRAM : en 2015-2016, la prévalence de la douleur chronique était estimée à 31,1 % [28,0–34,9] chez les patients dépendants aux opioïdes traités par MSO vs 8,6 % [7,08–10,7] dans la population contrôle de patients non dépendants. (...)
Opioid dependence is a major public health problem with increasing prevalence and incidence. Its pharmacological management is based on opioid substitution treatment (OST) (buprenorphine (HDB) and methadone (MTD)), marketed since 1995-1996 in France. Their clinical efficacy has been widely demonstrated by reducing heroin use, overdose mortality and improving patients' quality of life. Nevertheless, at the same time, problems related to the misuse of OST have emerged, which may lead to negative consequences for patients. The first part of this work consisted in studying the misuse of OST in opioid-dependent patients in France through the identification of doctor shopping, using the national EGB database according to two approaches: 1/ a repeated cross-sectional study estimating the annual prevalence of OST misuse between 2004 and 2014: the prevalence of HDB doctor shopping decreased significantly between 2004 and 2014 (12.6 % vs 3.9 %, p<0.001), while that of MTD remained low with no significant change over the study period (0.2 % in 2004 to 0.5 % in 2014); 2/a cohort study to estimate the incidence of OST misuse in opioid-dependent patients and identify the risk factors associated with this misuse: the one-year incidence was 8.4 % [95 % CI: 7.0-10.1] in the HDB group and 0 % in the MTD group, compared to 0.2 % [95 % CI: 0.1-0.2] for the diuretic group (negative control). Factors associated with doctor shopping were female gender (HR: 1.74 [1.20-2.54]), low socio-economic status (HR: 2.95 [2.07-4.44]), psychiatric comorbidities (HR : 1.43 [1.06-1.94]), coprescriptions of hypnotics (HR : 1.90 [1.39-2.61]), weak opioid analgesics (HR : 1.48 [1.09-1.99]) and morphine (HR : 1.69 [1.02-2.80]). Among the many reasons underlying this OST misuse, the existence of poorly relieved pain is frequently found. Indeed, pain is a major problem among opioid-dependent patients because it is still too often underdiagnosed and underestimated, while its prevalence is much higher than in the general population. Its adequate management is all the more important as it will contribute to an improvement and a better balance of the addictive pathology. No french data are available concerning the estimation of the prevalence of pain in OST patients and the description of associated pharmaco-therapeutic analgesic profiles in a real life setting.These issues around pain were the subject of the second and third chapters of this work. The second part of this manuscript focused on estimating the prevalence of pain among opioid-dependent patients in France using a dual approach: 1/ a traditional field prevalence study, including a representative sample of 509 opioid-dependent patients recruited from 12 addiction care centers: the prevalence of acute pain was estimated at 42.0 % [95 % CI: 37.7 - 46.3] and that of chronic pain at 33.2 % [29.1 - 37.3] with no significant difference between BHD and MTD; 2/ an original alternative approach, based on the capture-recapture method to the exhaustive SNIIRAM database: in 2015-2016, the prevalence of chronic pain was estimated at 31.1 % [28.0 - 34.9] in OST patients vs 8.6 % [7.08 - 10.7] in the control population of non-dependent patients. This method has demonstrated its major interest, given not only the speed and reliability of the estimates obtained, but also the ease of implementation and lower cost compared to studies or field surveys, while overcoming the traditional limitations of the latter in terms of representativeness and generalization of results. (...)

Background: Opioid dependence is a chronic disease. Substitution treatment for opioid addiction involves a lot of rules and control that can lead to stigmatization. Purpose: To describe the experience of control and stigma in people with substitution treatment during opioid dependence. Method: A literature review with qualitative content analysis inspired by Graneheim & Lundman (2004). The study is based on 14 scientific articles that were applied mainly through the databases Cinahl and Pubmed. Result: Two main themes with eight sub-themes emerged. The most prominent in the result was that people with substitution treatment feel stamped as a drug addict. They can also feel suspicious and less credible. Having substitution treatment is associated with shame. One does not always dare to tell the surroundings that one has treatment. Within the framework of treatment, they feel controlled and supervised. Conclusion: People with substitution treatment experience stigma in terms of discrimination, preconceived opinions and reduced credibility. Stigma arises in several different contexts, such as work, friends and family, but also in health care and even in substitution treatment. This is because this form of treatment includes a number of rules and controls that make you feel controlled and supervised. This risks contributing to further stigmatization.

Uvod: Temperament predstavlja skup psiholoških osobina, to jest način, brzinu i jačinu umnog i emotivnog reagovanja svojstven pojedincu, odnosno njegovu narav, ćud, prirodu. Savremena istraživanja premorbidnog afektivnog tipa temperamenta, govore u prilog njegovog značaja u etiologiji i kliničkoj evaluaciji bolesti zavisnosti. Cilj: Utvrditi i uporediti temperament kod osoba obolelih od mentalnog poremećaja i poremećaja ponašanja zbog upotrebe opijata i zdrave populacije. Materijal i metode: Istraživanje je urađeno po tipu studije preseka, i obuhvatalo je 200 ispitanika, podeljenih u dve grupe. Ispitivanu grupu činilo je 100 stabilnih zavisnika od opijata na supstitucionoj terapiji metadonom, starosti od 18 do 40 godina, bez komorbidne bolesti iz kruga psihotičnih poremećaja. U kontrolnu grupu uvršteno je 100 zdravih osoba što sličnijih sociodemografskih karakteristika sa ispitivanom grupom. Njihov temperament je određivan TEMPS-A upitnikom samoprocene. Rezultati: Utvrđeno je statistički značajno češće postojanje dominantog temperamenta kod zavisnika, kao i prisustvo depresivnog, ciklotimnog, razdražljivog i anksioznog temperamenta, koji govore u prilog osnovne razlike između zdrave populacije i populacije sa mentalnim poremećajem i poremećajem ponašanja zbog upotrebe opijata. Zaključak: Afektivni temperament, kao premorbidna karakteristika ličnosti, ima uticaja na nastanak i razvoj zavisnosti od opijata. Stoga je od značaja da se uzmu u obzir osobine hipertimnog temperamenta kao protektivnog ili depresivnog, ciklotimnog, radražljivog i anksioznog temperamenta kao rizičnih faktora u etiologiji, prevenciji i terapiji bolesti zavisnosti.
Introduction: Temperament is a set of psychological characteristics, ie the speed and strength of mind and emotional reactions peculiar to the individual, or his character, temperament, nature. Modern research of the premorbid affective temperament is in favor of its significance in the etiology and clinical evaluation of substance abuse. The Aim: To determine and compare the temperament of people suffering from mental and behavioral disorders due to use of opioids and healthy population. Materials and Methods: The study was cross-sectional, and 200 subjects were included and divided into two groups. The study group included stable opiate addicts on substitution therapy with methadone, aged 18 to 40 years, without co-morbid psychotic disorders. The Control group consisted of 100 healthy individuals with similar sociodemographic data as the Study group. Their temperament was determined with the TEMPS-A auto-questionnaire. Results: Statistical significance of a dominant temperament was more frequently found in the subjects with opioid dependence, as well as in depressive, cyclothymic, anxious and irritable temperament, which leads to the fundamental differences between a healthy population and a population with mental and behavioral disorders due to the use of opioids. Conclusion: Affective temperament, as a premorbid personality trait, has an impact on the occurence and development of opiate dependence. Therefore, it is essential to take into account the characteristics of a hyperthymic temperament as a protective factor or depressive, cyclothymic, irritable and anxious temperament as risk factors in etiology, prevention and treatment of addiction.

In Australia, the demand for prescribers to service opioid substitution treatment (OST) patients exceeds the interest of general practitioners in fulfilling this prescribing role. One response to meet unmet prescribing demands which has been introduced internationally is the use of pharmacist prescribing for a range of chronic medical conditions, including for OST. In this thesis, I explore a policy proposal for pharmacists to prescribe OST collaboratively (co-prescribing) with doctors. To examine this policy and its implications, I collected data from three sources: face-to-face interviews with 14 OST patients, three focus group interviews with 18 South Australian pharmacists and a study tour of pharmacist prescribing in Alberta, Canada and California, USA. A total of 28 key informants were met with during the study tour. This included people based in a range of research/academic units (5), policy/governance bodies (3), clinical sites where pharmacist prescribing was practised (12) and sites which provided an understanding of the health care system (8). My key findings are as follows. First, OST patients had varied experiences with the existing model of care. They reported varying levels of treatment access, varied degrees of pharmacist supervision and a lack of continuity of care from clinic doctors. They also displayed a range of attitudes toward the need for privacy. Although most patients valued privacy to some degree, not all did: indeed, the same layout was experienced and perceived differently by different patients. Second, the current model of OST care draws on a prescription approach to pharmacy practice, whereas co-prescribing is more aligned with patient-centred care. Under the current model of care, pharmacists are limited in their ability to actively respond to OST patient needs because their activities are primarily focused on the prescription directions. In contrast, pharmacist co-prescribing can deliver aspects of patient-centred care that cannot be provided as effectively through conventional care. It offers flexibility for the pharmacist to respond to the patient’s needs. This includes enhanced patient participation in treatment decisions, access to treatment and respect/privacy. Co-prescribing also offers continuity of treatment care due to the therapeutic relationship which already exists between a pharmacist and a patient from supervised dosing. Third, the experience of Albertan and Californian pharmacist prescribers suggests that it should be possible for Australian pharmacists to pursue similar responsibilities. These roles are possible in both hospital and community pharmacy settings, provided key facilitators are addressed. My research acknowledges that there are various challenges for pharmacist prescribing. However, the perspectives of the patients and pharmacists in my study, in conjunction with insights from Alberta and California, can be used to formulate a strategy for collaborative prescribing for OST patients in South Australia.
Thesis (Ph.D.) -- University of Adelaide, School of Population Health, 2014

碩士
國立成功大學
公共衛生研究所
101
Background: Recent years have seen increased concern being given to the life-saving effect of Opioid Substitution Treatment (OST) on heroin abusing population and OST have been implemented in Taiwan since 2006, evidence-base research is helpful for the future direction of OST strategies. Objective: To investigate the mortality among heroin users and related risk factors. The current study also aims to examine reductions in mortality related to OST. Material and Methods: A cohort of heroin users (N=1283) who had been evaluated were recruited from 2006-2008. These subjects were followed through December 31, 2011(longest following period: 71 months). We divided the cohort to receiving OST or not (OST group, N=983 and non-OST group, N=300) through the National MMT system. Record linkage performed to identify the death of these patients was managed by computerized files of Death Certification System. Crude mortality rate was calculated according to age, sex, receiving OST or not, period in-or out-of-treatment and medication type. Survival analysis was conducted to compare between heroin users receiving OST or not. The mortality risk among the heroin users after seeking OST was also examined using Cox regression model. Results: Compared with non-OST group, the characteristics OST group were: older age (37.8±7.7:36.6±11.7, p 〈0.05), lower educational level (two-thirds below junior high school), longer length of heroin use (6.9±4.3:5.7±5.2, p〈0.001), higher proportion of criminal records( illegal drugs offense：91.5%:74.1%,p〈0.001;Property offense：46.5%:26.1%, p〈0.001.), ever needle/syringe sharing (78.3%:40.8%,p〈0.001), IDUs (Injection drug users) (91.0%:84.5%,p=0.0016), HCV-seropositive (91.4%:86.4%,p=0.038) and HIV-seropositive (18.1%:6.3%,p〈0.001).The result of survival analysis showed that the all-cause mortality rate per 1000 person-year among OST group (15.5/1000 py) was lower than non-OST group (23.9/1000 py).After adjustment for significant covariates using the Cox regression model, all-cause mortality rate among OST group still had better survival outcome(Adjusted Harzard Ratio: 0.47; 95% CI: 0.28 – 0.79).However, the mortality rate directly related to suicide among OST group was significantly higher than non-OST group, (3.88/1000 py: 0.7/1000 py, p 〈 0.05). The survival analysis among OST group showed that the all-cause mortality relative risk between out-of-OST and in-OST period was 7. Conclusions: The all-cause mortality rate among OST group is significantly lower than non-OST group. Among OST group, the survival outcome among in-OST period is better than out-of-OST period. The life-saving effect of enrollment and continued participation in OST still exists under the circumstances that harm reduction strategies in Taiwan is more attractive for HIV carrier and ex-prisoner. However, mortality from suicide among OST group is higher than non-OST. In addition to increasing the availability and access of OST program, suicide prevention program should be given high priority in order to prevent mortality among this high risk population.

INTRODUCTION: Drug overdose death is now the leading cause of mortality among homeless adults in Boston, with opioids implicated in a majority of those deaths. Harm reduction interventions help minimize the risks associated with substance use, and are critical in supporting individuals with substance use disorder. Medical monitoring programs are an effective harm reduction strategy that work to prevent fatal drug overdoses and keep people safe while still actively using. METHODS: Visit data from the Supportive Place for Observation and Treatment (SPOT) was compiled and analyzed. The two measures of interest were the count of referrals to substance use disorder treatment and the count of visits prior to the first referral to treatment. Chi-square tests of independence, odds ratios, and binary logistic regression models were used to describe the association between factors of interest and referrals to substance use disorder treatment. RESULTS: Gender and age did not show any significant association to a connection to treatment. Overdose history (Adjusted Odds Ratio 6.59), reported stimulant use (AOR 2.59), and documented health or harm reduction education (AOR 5.14) were all associated with increased odds of being referred to substance use disorder treatment. Heavy sedation (AOR 0.55) was associated with decreased odds of a treatment referral.When examining factors associated with rapid connection to treatment, male gender (OR 1.87) was associated with increased odds, while overdose history (AOR 0.42) was associated with decreased odds. DISCUSSION: The two most impactful factors associated with increased odds of connecting to substance use disorder treatment were reported overdose history and documented education. Both of these factors suggests that a strength of SPOT is its ability to form and maintain meaningful connections with participants. One way that SPOT could improve referral outcomes would be to increase its ability to engage participants, such as through the recruitment of more harm reduction specialists or peer recovery coaches.

Prescription opioid use is highly prevalent and may be replacing heroin as the predominant illicit opioid that is used. Little is known about specific prescription opioid use characteristics, or issues faced by these individuals in treatment. The major aims of the two studies comprising this thesis were: 1) to systematically and quantitatively assess different occasions of use for the prescription opioid hydromorphone; and 2) to evaluate how current substance use and psychiatric symptoms may be related in a population of prescription opioid users enrolled in a low-threshold Methadone Maintenance Treatment (MMT) program. Eighty-two participants from a low-threshold MMT program in Halifax, Nova Scotia were interviewed regarding their lifetime and current substance use, specific past occasions of hydromorphone use, and current psychiatric symptoms. A subsample of 26 participants was interviewed a second time, one day later, to assess reliability of participants’ self-report on the above-mentioned study measures. It was found that many variables were reliably reported between the two interviews by the subsample. With regards to the first major thesis aim, hydromorphone was found to be a prevalent, highly-favoured prescription opioid in the sample. Characteristics of initial, but not later, hydromorphone use varied by prescription status at initiation. Later use of hydromorphone shared many characteristics previously documented with heroin. With regards to the second major thesis aim, participants reported high rates of current substance use and psychiatric symptoms. Current substance use and psychiatric symptoms appeared to be related; notably, non-prescribed benzodiazepine use predicted depression and anxiety symptoms, and general anxiety predicted non-prescribed benzodiazepine use. In summary, while the results may not be representative of all prescription opioid users, or MMT clients, the thesis presented novel findings with a unique and vulnerable population. The findings supplement the existing literature in terms of describing how prescription opioids may be used during specific occasions, and in describing psychiatric and substance use issues faced by prescription opioid users enrolled in low-threshold MMT in Nova Scotia.

Background: In Kazakhstan, opioid substitution therapy (OST) has been a controversial topic since its introduction in 2008. Aim: To examine and analyse factors influencing approach towards OST among OST patients, opioid-dependent drug users who could re-consider engagement in this therapeutic method, as well as attitudes of selected key organisations and their representatives. Methods: A survey method complemented by semi-structured individual and group interviews has been selected. One hundred respondents participated in the study between October and December 2015. The first group consisted of 46 OST patients. The second group consisted of 54 respondents who met criteria for opioid dependence. This group included patients of residential treatment centres, former OST patients and current injecting drug users. Key persons were interviewed about their attitudes. Results: Patients receiving OST, with the average treatment duration of 29.4 months, reported improved health, improved social functioning and financial well-being, as well as reduction of their involvement in crime. This group showed better results in all examined categories. Most (80 %) were satisfied with the treatment, even though a number of shortcomings have been reported. All OST patients considered necessary to expand the availability...

Background: Substitution treatment has become a stable part of the addiction services system for drug users. In the beginning, it primarily reacted to healthcare complications related to intravenous substance use and was an alternative for those not able to keep an abstinence. It is proved that only pharmacotherapy is not enough intervention and that it is key to add counseling or therapy as it becomes similarly effective as abstinence-oriented treatment where we work on lifestyle changes in clients. Objective: Identification of effective factors leading to an increase in quality of life from the perspective of clients in substitution treatment in CADAS SANANIM z.ú. Methods: A semi-structured interview and a standardized WHOQOL-BREF questionnaire of the World Health Organization were used to obtain the required data. The descriptive method of thematic (focal) analysis was used to process data from the interviews, and data from the questionnaire was evaluated according to the instructions of the User's Guide of the Czech version of the WHO quality of life. Sample: The research participants consisted of 11 clients of the substitution program in CADAS SANANIM z.ú., who have been in treatment for at least 5 years and are included in the stabilization phase category. I contacted 15 clients, which I...

This research added an innovative, critical component to the current problem gambling treatment approaches available in Australia. It targeted a susceptible and significant group of people who experience gambling-related harm but find it difficult to stop gambling and not to start again. Relapse in problem gambling and treatment dropout is common, with a rate of up to 70% being generally accepted. To date, gambling interventions specifically targeting risk factors for relapse have not been the focus of many studies. The author of this thesis, who has lived experience with problem gambling, designed a structured group program targeting two identified risk factors for gambling relapse: 1) lack of social connectedness, and 2) lack of leisure substitution. Between 2009 and 2016, four versions of this program were trialled. All program participants were supported by a group of volunteers, most of whom had lived experience with problem gambling and were participants in previous program versions. Four versions of the program were evaluated using a multi-method approach. Quantitative data were collected using validated psychosocial measures. Journaled observation by the author, anecdotal evidence and journaled participants quotes were documented by the author in various project reports and are used in this thesis to support the qualitative findings. The results of the quantitative data revealed significant improvement for participants in the areas of social connectedness, self-efficacy, and mental health. Importantly, the results also indicated that the program supported the goals of either abstinence from, or control over, gambling behaviour for program completers. It is concluded that this innovative program helped to reconnect people to activities other than gambling and to a supportive community and, in so doing, effectively achieved the research objectives. An extra qualitative study ‘Volunteer study’ was conducted to explore if the aspect of ‘volunteering’ made a positive contribution to sustain behavioural changes that were achieved by previous program participation. This exploratory study utilised 14 in-depth semi-structured interviews with current volunteers of the trialled relapse-focused programs from studies 1-4. This part of the research indicated that volunteering for any of the peer support relapse focused programs provided significant benefits to an individual’s recovery from problem gambling. The sample was a small convenience sample, so it is not possible to generalise the findings but offers an opportunity to further explore the importance of volunteering in recovery.

This diploma thesis describes the origins of harm reduction (HR) in the Czech drug policy. It focuses on the role of HR in national strategies and the development of syringe and needle program and substitution treatment. The aim of the thesis is to describe and explain how the HR approach was developed in the Czech environment. Using the framework of policy diffusion, the author explains the mechanisms by which harm reduction was transferred from abroad. Thesis describes the history of drug policy and the development of the harm reduction approach in the world. This information forms the context in which the author advocates HR development in the Czech Republic's drug policy after 1989. By analysing expert texts and expert interviews she explains how the first national strategies were formed in which HR has been included since 1993. Similarly, it deals with the beginnings of syringe exchange, which has been in operation since 1986, and substitution treatment that was first used in 1992 and has been officially operational since 1997. The mechanisms of diffusion of HR from abroad to the Czech Republic are defined. In all three areas, the mechanism of learning is defined. Substitution treatment and national strategies are also defined by the mechanism of emulation. To a lesser extent, a mechanism of...