No abstract

Key Points Question How can physicians identify patients with pain for whom prescription opioids can be safely prescribed? Findings This systematic review found that a history of opioid use disorder or other substance use disorder, a mental health diagnosis, and concomitant prescription of certain psychiatric medications may be associated with an increased risk of prescription opioid addiction. However, only the absence of a mood disorder appeared useful for identifying lower risk, and assessment tools incorporating combinations of patient characteristics and risk factors were not useful. Meaning This study suggests that there are few valid ways to identify patients who can be safely prescribed opioid analgesics.

Assessment tools that use a combination of symptoms and signs are useful for identifying patients at risk of developing severe alcohol withdrawal syndrome. Most studies of these tools were not fully validated, limiting their generalizability.

Background and aims HIV-infected persons with substance use disorders are least likely to benefit from advances in HIV treatment. Integration of extended-release naltrexone (XR-NTX) into HIV clinics may increase engagement in the HIV care continuum by decreasing substance use. We aimed to compare 1) XR-NTX treatment initiation, 2) retention, and 3) safety of XR-NTX versus treatment as usual (TAU) for treating opioid use disorder (OUD) and/or alcohol use disorder (AUD) in HIV clinics. Design Non-blinded randomized trial of XR-NTX versus pharmacotherapy TAU Setting HIV primary care clinics in Vancouver, BC, Canada and Chicago, IL, USA. Participants 51 HIV-infected patients seeking treatment for OUD (n=16), AUD (n=27) or both OUD and AUD (n=8). Measurements Primary outcomes were XR-NTX initiation (receipt of first injection within 4 weeks of randomization) and retention at 16 weeks. Secondary outcomes generated point estimates for change in substance use, HIV viral suppression (HIV RNA pcr < 200 copies/mL), and safety. Findings Two-thirds (68%) of participants assigned to XR-NTX initiated treatment, and 88% of these were retained on XR-NTX at 16 weeks. In comparison, 96% of TAU participants initiated treatment, but only 50% were retained on medication at 16 weeks. Mean days of opioid use in past 30 days decreased from 19 to 10 for TAU (n=12) and from 18 to 13 for XR-NTX (n=10). Mean heavy drinking days decreased from 18 to 7 for TAU (n=11) and 13 to 6 for XR-NTX (n=12). Among those with OUD, HIV suppression improved from 67% to 80% for XR-NTX and 58% to 75% for TAU. XR-NTX was well-tolerated, with no precipitated withdrawals and 1 serious injection site reaction. Conclusions Extended-release naltrexone (XR-NTX) is feasible and safe for treatment of opioid use disorder and alcohol use disorder in HIV clinics. Treatment initiation appears to be lower and retention greater for XR-NTX compared with treatment as usual. (clinicaltrials.gov NCT01908062).

Background HIV infection among persons who inject drugs (PWID) is a major international public health concern. Thus, the need to identify novel protective factors is of utmost importance. We therefore evaluated the impact of methadone maintenance therapy on HIV incidence among PWID in Vancouver, Canada. Methods Data were derived from a prospective cohort of PWID in Vancouver, Canada where methadone is widely available through family physician’s offices and dispensed by community pharmacies. We examined the role of methadone maintenance treatment on time to HIV incidence while adjusting for potential confounders. Findings Overall, 1639 HIV-negative individuals were recruited between May 1996 and May 2013 among whom there were 138 cases of HIV seroconversion during a median of 75·5 (interquartile range: 33·4 – 115·3) months of follow up. In multivariate Cox regression analyses, methadone maintenance therapy (adjusted relative hazard: 0·64 [95% confidence interval: 0·41 – 0·98]) remained independently associated with a reduced hazard of HIV infection after adjusting for socio-demographic characteristics and drug use patterns. Interpretation In this setting, where a low threshold program has made methadone widely available through primary care physicians, the use of methadone was independently associated with a reduced rate of HIV infection. These data reinforce the benefits of low threshold methadone on public health goals such as reducing the spread of HIV. Funding US National Institutes of Health, Canada Research Chair, Canadian Institutes of Health Research. The funder played no role in conducting the study, preparing the results, or the decision to submit for publication.

NCT03033732.

Background and Aims For HIV-positive individuals who use illicit opioids, engagement in methadone maintenance therapy (MMT) can contribute to improved HIV treatment outcomes. However, to our knowledge, the role of methadone dosing in adherence to antiretroviral therapy (ART) has not yet been investigated. We sought to examine the relationship between methadone dose and ART adherence among a cohort of persons who use illicit opioids. Design and Setting We used data from the ACCESS study, an ongoing prospective observational cohort of HIV-positive persons who use illicit drugs in Vancouver, Canada, confidentially linked to comprehensive HIV treatment data in a setting of universal no-cost medical care including medications. We evaluated the longitudinal relationship between methadone dose and the likelihood of ≥ 95% adherence to ART among ART-exposed participants during periods of engagement in MMT. Participants 297 ART-exposed individuals on MMT were recruited between December 2005 and May 2013 and followed for a median of 42.1 months. Measurements We measured methadone dose at ≥ 100 vs < 100 mg/day and the likelihood of ≥ 95% adherence to ART. Findings In adjusted generalized estimating equation (GEE) analyses, MMT dose ≥ 100 mg/day was independently associated with optimal adherence to ART (adjusted odds ratio [AOR] = 1.38; 95% confidence interval [CI]: 1.08 – 1.77, p = 0.010). In a sub-analysis, we observed a dose-response relationship between increasing MMT dose and ART adherence (AOR = 1.06 per 20 mg/day increase, 95% CI: 1.00 – 1.12, p = 0.041). Conclusion Among HIV-positive individuals in methadone maintenance therapy, those receiving higher doses of methadone (≥ 100 mg/day) are more likely to achieve ≥ 95% adherence to antiretroviral therapy than those receiving lower doses.

Background Implementation of evidence-based approaches to the treatment of various substance use disorders is needed to tackle the existing epidemic of substance use and related harms. Most clinicians, however, lack knowledge and practical experience with these approaches. Given this deficit, the authors examined the impact of an inpatient elective in addiction medicine amongst medical trainees on addiction-related knowledge and medical management. Methods Trainees who completed an elective with a hospital-based Addiction Medicine Consult Team (AMCT) in Vancouver, Canada from May 2015–May 2016, completed a nine-item self-evaluation scale before and immediately after the elective. Results A total of 48 participants completed both pre and post AMCT elective surveys. On average, participants were 28 years old (Inter Quartile Range [IQR] = 27–29), and contributed 20 days (IQR = 13–27) of clinical service. Knowledge of addiction medicine increased significantly post elective [mean difference (MD) = 8.63, standard deviation (SD) = 18.44; P = 0.002]. The most and the least improved areas of knowledge were relapse prevention and substance use screening, respectively. Conclusions Completion of a clinical elective with a hospital-based Addiction Medicine Consult Team appears to improve medical trainees’ addiction-related knowledge. Further evaluation and expansion of addiction medicine education is warranted to develop the next generation of skilled addiction care providers.