Effectiveness and Safety of Low-Threshold Opioid-Agonist Treatment in Hard-To-Reach Populations with Opioid Dependence

Objectives: Opioid-use disorder is related to premature death worldwide. Opioid-agonist treatment (OAT) is an effective treatment for opioid dependence. OAT delivery platforms may influence treatment access and outcomes, especially for the most vulnerable groups. The aim of this study was to determine the effectiveness and safety of low-threshold OAT compared to the standard treatment. Methods: Patients with diagnosed opioid dependence undergoing low-threshold OAT at the Bergen delivery platform in Norway were enrolled in a cohort study in 2014–2019. A national OAT cohort was the reference group. The main outcomes were treatment retention, the use of illicit opioids, non-fatal overdose, overdose death, and all-cause mortality during the first year following treatment initiation and the full treatment period. Additionally, healthcare utilization in the periods before and during OAT was investigated. Results: Compared to the reference cohort, the low-threshold cohort (n = 128, mean age: 38 years, women: 28%) showed treatment retention rates of 95% versus 92%, illicit opioid use of 7% versus 10%, non-fatal overdose of 7% versus 6%, and death at 1.0% versus 1.3%, respectively. The incident rate ratios (IRRs) for healthcare utilization increased substantially during the OAT period compared to the period before; the IRR increased by 3.3 (95% confidence interval (CI): 2.8, 3.9) and 3.4 (95% CI: 3.1, 3.9) for all in- and outpatient healthcare, respectively. Conclusions: Low-threshold OAT was at least as effective and safe as the standard OAT in terms of treatment retention, the use of illicit opioids, non-fatal overdose, and death. Healthcare utilization increased during the OAT compared to the period before. Lowering the threshold for OAT entrance within proper delivery platforms should be broadly considered to reduce harm and improve healthcare access among patients with opioid dependence.publishedVersio

Need to optimise infant feeding counselling: A cross-sectional survey among HIV-positive mothers in Eastern Uganda

<p>Abstract</p> <p>Background</p> <p>The choice of infant feeding method is important for HIV-positive mothers in order to optimise the chance of survival of their infants and to minimise the risk of HIV transmission. The aim of this study was to investigate feeding practices, including breastfeeding, in the context of PMTCT for infants and children under two years of age born to HIV-positive mothers in Uganda.</p> <p>Methods</p> <p>In collaboration with The Aids Support Organisation Mbale, we conducted a cross-sectional survey involving 235 HIV-positive mothers in Uganda. Infant feeding practices, reasons for stopping breastfeeding, and breast health problems were studied. Breastfeeding duration was analysed using the Kaplan-Meier method based on retrospective recall.</p> <p>Results</p> <p>Breastfeeding was initiated by most of the mothers, but 20 of them (8.5%) opted exclusively for replacement feeding. Pre-lacteal feeding was given to 150 (64%) infants and 65 (28%) practised exclusive breastfeeding during the first three days. One-fifth of the infants less than 6 months old were exclusively breastfed, the majority being complementary fed including breast milk. The median duration of breastfeeding was 12 months (95% confidence interval [CI] 11.5 to 12.5). Adjusted Cox regression analysis indicated that a mother's education, socio-economic status, participation in the PMTCT-program and her positive attitude to breastfeeding exclusively, were all associated with a reduction in breastfeeding duration. Median duration was 3 months (95% CI 0–10.2) among the most educated mothers, and 18 months (95% CI 15.0–21.0) among uneducated mothers. Participation in the PMTCT program and being socio-economically better-off were also associated with earlier cessation of breastfeeding (9 months [95% CI 7.2–10.8] vs. 14 months [95% CI 10.8–17.2] and 8 months [95% CI 5.9–10.1] vs. 17 months [95% CI 15.2–18.8], respectively). The main reasons for stopping breastfeeding were reported as: advice from health workers, maternal illness, and the HIV-positive status of the mother.</p> <p>Conclusion</p> <p>Exclusive breastfeeding was uncommon. Exclusive replacement feeding was practised by few HIV-positive mothers. Well-educated mothers, mothers who were socio-economically better-off and PMTCT-attendees had the shortest durations of breastfeeding. Further efforts are needed to optimise infant feeding counselling and to increase the feasibility of the recommendations.</p

The Role of Physical Activity in Opioid Substitution Therapy: A Systematic Review of Interventional and Observational Studies

ABSTRACT BACkgROund: Use of physical activity in the treatment and follow-up of people receiving opioid substitution therapy is an understudied area of research. Therefore, the objective of this systematic review was to synthesize the currently available research on the role of physical activity in opioid substitution therapy and proper adaptions for the group. MeThOdS: A systematic search was performed on PsycINFO, EMBASE, MEDLINE, CINAHL, and Web of Science until September 2021 (PROSPERO-reg.no: CRD42020109873). The inclusion criteria were studies involving physical activity interventions for opioid substitution patients. Reference lists of relevant studies were screened to identify additional relevant studies. Data extracted were compiled into tables and descriptively presented. ReSulTS: The search yielded 2105 unique records. A total of 10 studies were included, whose methodological quality ranged from satisfactory to very good. Study quality was assessed using a 7-/8-point quality score. The agreement between the reviewers, assessed with Cohen’s kappa, was 0.91. Overall, the results suggest that physical activity increases physical fitness of patients in opioid substitution therapy and decreases substance use. The minority of studies in this field are of high quality with sufficient power. COnCluSIOnS: The findings of this systematic review suggest beneficial effects of physical activity on physical fitness, substance use, and mental health for patients in opioid substitution therapy. Although the findings are quite consistent across studies, high-quality studies and sufficiently powered clinical trials are needed to confirm and validate the findings and to conclude on the degree of impact. keywORdS: Opioid maintenance treatment, exercise, medication-assisted treatmentpublishedVersio

Changes in substance use during outpatient treatment for substance use disorders: a prospective Norwegian cohort study from 2016 to 2020

Background Continuous use of amphetamines, alcohol, benzodiazepines, cannabis, cocaine, or opioids contributes to health impairments, increased morbidity, and overdose deaths among patients with substance use disorders (SUDs). This study evaluates the impact of inpatient detoxification, injecting substance use, age, and gender on substance use over time among patients undergoing outpatient SUD treatment. Methods We used data from a cohort of SUD patients in Norway obtained from health assessments of self-reported substance use and sociodemographic and clinical factors. A total of 881 substance use measurements, including substances and frequency of use, were assessed for 708 SUD patients in 2016–2020. Of those, 171 patients provided two or more substance use measurements. The total substance use was calculated, creating a substance use severity index (SUSI), ranging from zero (no use) to one (daily use of all substances). We defined baseline as the first substance use measurement when the measurements were listed chronologically. Time was defined as years from baseline. We used a linear mixed model to analyze the SUSI at baseline and over time, and its associations with inpatient detoxification, injecting substance use, gender, and age, presented with coefficients and 95% confidence intervals (CI). Results No longitudinal changes in the SUSI were found compared with baseline (change in SUSI (cSUSI): 0.04, 95% CI: − 0.05;0.13, p = 0.397). Likewise, “inpatient detoxification” was not associated with changes in the SUSI compared with “no inpatient detoxification” (cSUSI: 0.00, 95% CI: − 0.04;0.04, p = 0.952). However, injecting substances were associated with a higher SUSI than not injecting substances at baseline (difference in SUSI: 0.19, 95% CI: 0.16;0.21, p = < 0.001), and starting to inject substances was associated with increasing SUSI over time compared with not starting to inject substances (cSUSI: 0.11, 95% CI: 0.07;0.15, p = < 0.001). Gender was not significantly associated with changes in the SUSI (cSUSI: − 0.04, 95% CI: − 0.07;0.00, p = 0.052), while patients over 60 years of age had a lower SUSI than those under the age of 30 at baseline (difference in SUSI: − 0.08, 95% CI: − 0.14;− 0.01, p = 0.018), with no change over time (cSUSI: − 0.05, 95% CI: − 0.16;0.05, p = 0.297). Conclusion The present study demonstrates that inpatient detoxification was not associated with substance use changes over time for patients undergoing outpatient SUD treatment. Otherwise, injecting substance use was a particular risk factor for a high level of substance use. Future research needs to evaluate the impact of other treatment approaches on substance use, ideally in randomized controlled trials.publishedVersio

Vitamin D status and associations with substance use patterns among people with severe substance use disorders in Western Norway

Chronic and harmful substance use is associated with a cluster of harms to health, including micronutrient deficiencies. Maintaining adequate levels of vitamin D is important for musculoskeletal and other aspects of health. In this prospective longitudinal cohort study, 666 participants drawn from outpatient opioid agonist therapy (OAT) clinics and community care clinics for substance use disorder in Western Norway were assessed annually for determination of serum 25-hydroxyvitamin D [s-25(OH)D] levels. Fifty-seven percent were deficient at baseline (s-25(OH)D < 50 nmol/l), and 19% were severely deficient (s-25(OH)D < 25 nmol/l). Among those deficient/severely deficient at baseline, 70% remained deficient/severely deficient at the last measurement (mean duration 714 days). Substance use patterns and dosage of opioids for OAT were not associated with vitamin D levels. One exception was found for cannabis, where consumption on a minimum weekly basis was associated with lower levels at baseline (mean difference: −5.2 nmol/l, 95% confidence interval [CI]: −9.1, − 1.3), but without clear time trends (mean change per year: 1.4 nmol/l, CI: − 0.86, 3.7). The high prevalence of sustained vitamin D deficiency in this cohort highlights the need for targeted monitoring and supplementation for this and similar at-risk populations.publishedVersio

Association of maternal HIV‐1 severity with dental caries: an observational study of uninfected 5‐ to 7‐yr‐old children of HIV‐1‐infected mothers without severe immune suppression

Treatment programs to prevent perinatal and postnatal HIV-1 transmission have become available in sub-Saharan Africa, leading to an emerging population of HIV-1 exposed uninfected (HEU) children. Exposure to HIV-1 in utero and during breastfeeding may increase the risk of morbidity and mortality in HEU children. This study estimated the association of the severity of maternal HIV-1 infection as assessed by CD4 count and viral load at baseline (7 d postpartum), with dmft count of their 5- to 7-yr-old HEU offspring. A follow-up study was conducted of HIV-1-infected mother–HEU children pairs (n = 164) from the Ugandan site of the ANRS 12341-PROMISE- PEP trial (ClinicalTrials.gov, number NCT00640263). HIV-1-infected mothers were interviewed and the HEU children were examined for caries using the World Health Organization's survey methods for field conditions and the dmft index. Directed acyclic graphs and negative binomial regression were used for analyses. The prevalence of 1 or more dmft was 48%. Negative binomial regression showed no association between the dmft count and maternal CD4 counts 7 d postpartum but a 10% lower dmft count with longer breastfeeding duration was found. Maternal CD4 count at birth was not associated with the dental caries experience in uninfected children born to women without severe immune suppression, while there appeared to be a protective effect of high viral load and breastfeeding duration.publishedVersio

Health status and use of medication and their association with migration related exposures among Syrian refugees in Lebanon and Norway: a cross-sectional study

Background The health of forcibly displaced individuals changes along their migration path and estimates of disease burden are essential to develop health care policies and practices adequately corresponding to their health care needs. This study aims to describe the health status and use of medication among Syrian refugees in two different migration phases: in a transit setting and in a recipient country. Further, we aim to investigate the associations between migration related exposures and both chronic pain and mental health among Syrian refugees. Methods This is a cross-sectional study based on survey data collected among 827 adult Syrian refugees in Lebanon and Norway during 2017–2018. The survey instrument included items measuring somatic status (including chronic pain), mental health (using the HSCL-10 and HTQ items), use of medication and migration related exposures. We used descriptive statistics to calculate standardised prevalence proportions and regression analyses to study associations between migration related exposures and health outcomes. Results The response rate was 85%. The mean age in the sample was 33 years and 41% were women. Half of the participants reported that they had never had any health problems. The prevalence of non-communicable diseases was 12%. Headache and musculoskeletal complaints were the most prevalent conditions reported, with 30% reporting chronic pain lasting for more than six months. Symptoms indicating anxiety and/or depression were presented by 35%, while 7% revealed symptoms compatible with post-traumatic stress disorder. Among those reporting non-communicable diseases a substantial share did not seem to receive adequate treatment. Trauma experiences were associated with both chronic pain and anxiety/depression symptoms, and the latter were also associated with migrating without family members. Conclusions Migrant-friendly public health policies and practises should acknowledge migration related risks, address discontinuity in care of chronic conditions and target common complaints such as chronic pain and mental health problems among forcibly displaced individuals.publishedVersio

Risk of Relapse Among Opioid‐Dependent Patients Treated With Extended‐Release Naltrexone or Buprenorphine‐Naloxone: A Randomized Clinical Trial

Background and Objectives Compare the risk of relapse to heroin and other illicit opioids among opioid-dependent patients receiving treatment with extended-release naltrexone (XR-NTX) or buprenorphine-naloxone (BP-NLX). Methods Re-analyzed data from a 12-week multicenter, open-label, randomized treatment study with a subsequent 36-week open-label follow-up study. All patients, N = 143, had completed detoxification and received at least one dose of study medication. Results Of 143 patients (72% men), mean age 36 years, 71 received XR-NTX and 72 BP-NLX. The risk of first relapse and the risk of any relapse to heroin and other illicit opioids were both significantly lower in the XR-NTX group compared with the BP-NLX group (hazard ratio [HR], 0.46; 95% confidence interval [CI], 0.28-0.76; P = .002, and HR, 0.11; 95% CI, 0.04-0.29; P < .001, respectively) and (HR, 0.15; 95% CI, 0.09-0.27; P < .001 and HR, 0.05; 95% CI, 0.03-0.09; P < .001, respectively). There was a stable low risk of relapse among participants receiving XR-NTX in the follow-up. Discussion and Conclusions Compared to BP-NLX, patients on XR-NTX had a substantially reduced risk of relapse to illicit opioids and showed a stable low risk of relapse over time in longer-term treatment. Scientific Significance Our data support XR-NTX as a first-line treatment option for patients with opioid addiction both in short and longer-term treatment. This is the first European study showing that XR-NTX significantly reduces the risk of first and any relapse to heroin use in opioid-dependent patients compared to BP-NLX. Our data contradict previous data from the X:BOT study, showing no significant difference in relapse risk between the groups in a 6-month randomised controlled trial. (© 2021 Authors. The American Journal on Addictions published by Wiley Periodicals LLC on behalf of The American Academy of Addiction Psychiatry). (Am J Addict 2021;30:451–458)publishedVersio

Alcohol Consumption during a Pandemic Lockdown Period and Change in Alcohol Consumption Related to Worries and Pandemic Measures

Whether lockdown related to the COVID-19 pandemic influences alcohol consumption is not well known. This study assesses alcohol consumption and hazardous drinking behavior during the initial phase of pandemic measures in Norway and identifies potential risk factors. A cross-sectional study (N = 25,708) was conducted in Bergen, Norway, following the first six weeks of strict infection control measures. In a model of self-assessed increased alcohol consumption, logistic regression analysis was conducted with independent variables for COVID-19-related worries, joblessness, quarantine, self-reported drinking behavior, age, gender, and occupational situation. These are reported with odds ratios (ORs) with 95% confidence intervals. Fifty-one percent of respondents reported economic or health-related worries due to COVID-19, 16% had been in quarantine, 49% worked/studied from home, 54% reported hazardous drinking behavior, and 13% reported increased alcohol consumption. People aged 30–39 years had elevated odds of increased alcohol consumption during lockdown (OR 3.1, 2.4−3.8) compared to the oldest adults. Increased drinking was more frequent among people reporting economic worries (OR 1.6, 1.4−1.8), those quarantined (OR 1.2, 1.1−1.4), and those studying or working at home (OR 1.4, 1.3−1.6). More than half of respondents reported hazardous drinking behavior. Increased alcohol consumption during lockdown was common among people with economic worries, people in quarantine, and people studying or working at home. These data could be important when adjusting pandemic measures.publishedVersio

Validation of a brief version of the Difficulties in Emotion Regulation Scale (DERS-16) with an older Norwegian population

Emotion regulation is proposed to have a salient role in optimal aging. However, currently used measures of emotion regulation have not been validated for older adults. Therefore, we evaluated the psychometric properties of the Difficulties in Emotion Regulation Scale—short form (DERS-16) in a large Norwegian sample consisting of individuals between 70 and 95 years (n = 2525). Tests of internal consistency, reliability, assessment of intra-domain correlations, and confirmatory factor analyses were performed. Construct validity was further investigated by assessing concurrent associations between DERS-16 and well-established measures of psychological disorders, psychological health, and well-being (five-item version of Geriatric Depression Scale, Geriatric Anxiety Inventory—short form, and OECD guidelines on measuring subjective well-being). All subscales derived from the instrument showed adequate internal consistency. Furthermore, we obtained a theoretically consistent factor structure, in which a bifactor model combining a general emotion regulation factor and five additional domain-specific facet-factors had superior model fit. As expected, difficulties in emotion regulation correlated positively with symptoms of depression and anxiety, and negatively with psychological health and well-being. Associations were generally of moderate strength. We can thus conclude that the DERS-16 demonstrates excellent psychometric properties when used in samples with older adults and may safely be employed in studies of emotion regulation difficulties in the older segment of our population.publishedVersio