Perceptions of extended-release buprenorphine injections for opioid use disorder among people who regularly use opioids in Australia

2019 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction Aims: To examine perceptions of extended-release (XR) buprenorphine injections among people who regularly use opioids in Australia. Design: Cross-sectional survey prior to implementation. XR-buprenorphine was registered in Australia in November 2018. Setting: Sydney, Melbourne and Hobart. Participants. A total of 402 people who regularly use opioids interviewed December 2017 to March 2018. Measurements: Primary outcome concerned the proportion of participants who believed XR-buprenorphine would be a good treatment option for them, preferred weekly versus monthly injections and perceived advantages/disadvantages of XR-buprenorphine. Independent variables concerned the demographic characteristics and features of current opioid agonist treatment (OAT; medication-type, dose, prescriber/dosing setting, unsupervised doses, out-of-pocket expenses and travel distance). Findings: Sixty-eight per cent [95% confidence interval (CI) = 63-73%] believed XR-buprenorphine was a good treatment option for them. They were more likely to report being younger [26-35 versus \u3e 55 years; odds ratio (OR) = 3.16, 95% CI = 1.12-8.89; P = 0.029], being female (OR = 1.67, 95% CI = 1.04-2.69; P = 0.034), \u3c 10 years school education (OR = 1.87, 95% CI = 1.12-3.12; P = 0.016) and past-month heroin (OR = 1.81, 95% CI = 1.15-2.85; P = 0.006) and methamphetamine use (OR = 1.90, 95% CI = 1.20-3.01; P = 0.006). Fifty-four per cent reported no preference for weekly versus monthly injections, 7% preferred weekly and 39% preferred monthly. Among OAT recipients (n = 255), believing XR-buprenorphine was a good treatment option was associated with shorter treatment episodes (1-2 versus ≥ 2 years; OR = 3.93, 95% CI = 1.26-12.22; P = 0.018), fewer unsupervised doses (≤ 8 doses past-month versus no take-aways; OR = 0.50; 95% CI = 0.27-0.93; P = 0.028) and longer travel distance (≥ 5 versus \u3c 5 km; OR = 2.10, 95% CI = 1.20-3.65; P = 0.009). Sixty-nine per cent reported \u27no problems or concerns\u27 with potential differences in availability, flexibility and location of XR-buprenorphine. Conclusions: Among regular opioid users in Australia, perceptions of extended-release buprenorphine as a good treatment option are associated with being female, recent illicit drug use and factors relating to the (in)convenience of current opioid agonist treatment

The efficacy of behavioural activation treatment for co-occurring depression and substance use disorder (the activate study): a randomized controlled trial

Background Epidemiological studies suggest that compared with the general population, mood disorders are up to 4.7 times more prevalent in substance dependent samples. Comorbid substance use disorder (SUD) and depression has been associated with a more severe and protracted illness course and poorer treatment outcomes. Despite this, the development and assessment of behavioural interventions for treating depression among individuals with SUDs have received little empirical attention. Behavioural Activation Treatment for Depression (BATD-R) is an empirically supported treatment for depression that has shown some efficacy among substance users. This paper describes the study protocol of a parallel, single blind, randomised controlled trial to determine the efficacy and feasibility of a modified version of the BATD-R (Activate) in reducing symptoms of depression and substance dependence among individuals in residential rehabilitation (RR) and opioid substitution therapy (OST). Methods/design A sample of approximately 200 individuals with depressive symptomatology in treatment for SUD will be recruited from RR and OST services in New South Wales, Australia. Dynamic random allocation following minimisation methodology will be used to assign participants to one of two groups. The control group will receive treatment as usual (TAU), which will be the model of care provided in accordance with standard practice at participating RR and OST services. The intervention group will receive Activate, comprising 10 individual 60-min therapy sessions with a psychologist employed on the research team, in addition to TAU. Data collection will occur at baseline (pre-intervention), and 3-months and 12-months post baseline. Discussion The association between depression and substance dependence has been well documented, yet practical and effective treatments are scarce. The findings of the present study will contribute significantly to understanding the types of programs that are effective in treating this comorbidity. Trial registration This trial is registered with the Australian and New Zealand Clinical Trials registry, ACTRN12613000876796. Registered on 7 August, 2013. Electronic supplementary material The online version of this article (doi:10.1186/s12888-016-0943-1) contains supplementary material, which is available to authorized users

New Australian guidelines for the treatment of alcohol problems: an overview of recommendations

Summary of recommendations and levels of evidence Chapter 2: Screening and assessment for unhealthy alcohol use Screening Screening for unhealthy alcohol use and appropriate interventions should be implemented in general practice (Level A), hospitals (Level B), emergency departments and community health and welfare settings (Level C). Quantity–frequency measures can detect consumption that exceeds levels in the current Australian guidelines (Level B). The Alcohol Use Disorders Identification Test (AUDIT) is the most effective screening tool and is recommended for use in primary care and hospital settings. For screening in the general community, the AUDIT-C is a suitable alternative (Level A). Indirect biological markers should be used as an adjunct to screening (Level A), and direct measures of alcohol in breath and/or blood can be useful markers of recent use (Level B). Assessment Assessment should include evaluation of alcohol use and its effects, physical examination, clinical investigations and collateral history taking (Level C). Assessment for alcohol-related physical problems, mental health problems and social support should be undertaken routinely (GPP). Where there are concerns regarding the safety of the patient or others, specialist consultation is recommended (Level C). Assessment should lead to a clear, mutually acceptable treatment plan which specifies interventions to meet the patient’s needs (Level D). Sustained abstinence is the optimal outcome for most patients with alcohol dependence (Level C). Chapter 3: Caring for and managing patients with alcohol problems: interventions, treatments, relapse prevention, aftercare, and long term follow-up Brief interventions Brief motivational interviewing interventions are more effective than no treatment for people who consume alcohol at risky levels (Level A). Their effectiveness compared with standard care or alternative psychosocial interventions varies by treatment setting. They are most effective in primary care settings (Level A). Psychosocial interventions Cognitive behaviour therapy should be a first-line psychosocial intervention for alcohol dependence. Its clinical benefit is enhanced when it is combined with pharmacotherapy for alcohol dependence or an additional psychosocial intervention (eg, motivational interviewing) (Level A). Motivational interviewing is effective in the short term and in patients with less severe alcohol dependence (Level A). Residential rehabilitation may be of benefit to patients who have moderate-to-severe alcohol dependence and require a structured residential treatment setting (Level D). Alcohol withdrawal management Most cases of withdrawal can be managed in an ambulatory setting with appropriate support (Level B). Tapering diazepam regimens (Level A) with daily staged supply from a pharmacy or clinic are recommended (GPP). Pharmacotherapies for alcohol dependence Acamprosate is recommended to help maintain abstinence from alcohol (Level A). Naltrexone is recommended for prevention of relapse to heavy drinking (Level A). Disulfiram is only recommended in close supervision settings where patients are motivated for abstinence (Level A). Some evidence for off-label therapies baclofen and topiramate exists, but their side effect profiles are complex and neither should be a first-line medication (Level B). Peer support programs Peer-led support programs such as Alcoholics Anonymous and SMART Recovery are effective at maintaining abstinence or reductions in drinking (Level A). Relapse prevention, aftercare and long-term follow-up Return to problematic drinking is common and aftercare should focus on addressing factors that contribute to relapse (GPP). A harm-minimisation approach should be considered for patients who are unable to reduce their drinking (GPP). Chapter 4: Providing appropriate treatment and care to people with alcohol problems: a summary for key specific populations Gender-specific issues Screen women and men for domestic abuse (Level C). Consider child protection assessments for caregivers with alcohol use disorder (GPP). Explore contraceptive options with women of reproductive age who regularly consume alcohol (Level B). Pregnant and breastfeeding women Advise pregnant and breastfeeding women that there is no safe level of alcohol consumption (Level B). Pregnant women who are alcohol dependent should be admitted to hospital for treatment in an appropriate maternity unit that has an addiction specialist (GPP). Young people Perform a comprehensive HEEADSSS assessment for young people with alcohol problems (Level B). Treatment should focus on tangible benefits of reducing drinking through psychotherapy and engagement of family and peer networks (Level B). Aboriginal and Torres Strait Islander peoples Collaborate with Aboriginal or Torres Strait Islander health workers, organisations and communities, and seek guidance on patient engagement approaches (GPP). Use validated screening tools and consider integrated mainstream and Aboriginal or Torres Strait Islander-specific approaches to care (Level B). Culturally and linguistically diverse groups Use an appropriate method, such as the “teach-back” technique, to assess the need for language and health literacy support (Level C). Engage with culture-specific agencies as this can improve treatment access and success (Level C). Sexually diverse and gender diverse populations Be mindful that sexually diverse and gender diverse populations experience lower levels of satisfaction, connection and treatment completion (Level C). Seek to incorporate LGBTQ-specific treatment and agencies (Level C). Older people All new patients aged over 50 years should be screened for harmful alcohol use (Level D). Consider alcohol as a possible cause for older patients presenting with unexplained physical or psychological symptoms (Level D). Consider shorter acting benzodiazepines for withdrawal management (Level D). Cognitive impairment Cognitive impairment may impair engagement with treatment (Level A). Perform cognitive screening for patients who have alcohol problems and refer them for neuropsychological assessment if significant impairment is suspected (Level A). Summary of key recommendations and levels of evidence Chapter 5: Understanding and managing comorbidities for people with alcohol problems: polydrug use and dependence, co-occurring mental disorders, and physical comorbidities Polydrug use and dependence Active alcohol use disorder, including dependence, significantly increases the risk of overdose associated with the administration of opioid drugs. Specialist advice is recommended before treatment of people dependent on both alcohol and opioid drugs (GPP). Older patients requiring management of alcohol withdrawal should have their use of pharmaceutical medications reviewed, given the prevalence of polypharmacy in this age group (GPP). Smoking cessation can be undertaken in patients with alcohol dependence and/or polydrug use problems; some evidence suggests varenicline may help support reduction of both tobacco and alcohol consumption (Level C). Co-occurring mental disorders More intensive interventions are needed for people with comorbid conditions, as this population tends to have more severe problems and carries a worse prognosis than those with single pathology (GPP). The Kessler Psychological Distress Scale (K10 or K6) is recommended for screening for comorbid mental disorders in people presenting for alcohol use disorders (Level A). People with alcohol use disorder and comorbid mental disorders should be offered treatment for both disorders; care should be taken to coordinate intervention (Level C). Physical comorbidities Patients should be advised that alcohol use has no beneficial health effects. There is no clear risk-free threshold for alcohol intake. The safe dose for alcohol intake is dependent on many factors such as underlying liver disease, comorbidities, age and sex (Level A). In patients with alcohol use disorder, early recognition of the risk for liver cirrhosis is critical. Patients with cirrhosis should abstain from alcohol and should be offered referral to a hepatologist for liver disease management and to an addiction physician for management of alcohol use disorder (Level A). Alcohol abstinence reduces the risk of cancer and improves outcomes after a diagnosis of cancer (Level A)

Detection, evaluation, and diagnosis of alcohol use disorders

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Substance use disorders and depression: An examination of their relationship and the role of repetitive negative thinking as a shared risk factor

Substance use disorders (SUDs) and depression are highly comorbid conditions. This thesis aims to improve understanding of the gender-specific relationship between these disorders by examining outcomes associated with their comorbidity and processes underlying their co-occurrence and persistence.Studies One to Three used data from an 11-year study of heroin dependent individuals (N=615). Study One provided long-term data on depression among this cohort. Current depression prevalence declined from 23.8% to 8.2% over the first three years, but approximated baseline levels at 11-years (20.9%). Over half of those with depression at baseline experienced recurrent depression. Current and recurrent depression were associated with poorer substance use outcomes at 11-years.Study Two examined the potentially reciprocal impact of substance use severity and depressive symptoms on one another over time. A strong concurrent relationship was found between substance use and depressive symptoms at multiple assessments over three years but neither symptom set predicted the other longitudinally, suggesting that their concurrent association may result from shared risk factors.Studies Three and Four examined whether repetitive negative thinking (RNT) is a shared risk factor for substance use, depression and their comorbidity. Study Three focused on rumination, examining its “brooding” and “reflection” subtypes. Higher levels of ruminative brooding were cross-sectionally associated with depression, substance use severity, and comorbid depression and heroin dependence. Ruminative reflection was unrelated to outcomes. Using a treatment-seeking sample experiencing SUD and comorbid depression (n=67), Study Four examined whether different types of RNT predict the persistence of depression and SUD over 3 months. Rumination subtypes were not associated with the persistence of disorders. Higher levels of perseverative thinking predicted the persistence of SUD.Males and females exhibited more similarities than differences in the relationship between substance use and depression, and the effects of RNT. Further research on gender differences is encouraged given the limited research in the broader literature.The high prevalence and recurrence of depression, and its consistent association with greater concurrent substance use severity, highlight the importance of monitoring and addressing depression among substance users. Findings on RNT demonstrate its potential utility as a target for transdiagnostic prevention and treatment interventions for comorbidity

Sexuality and Gender Diverse Populations

This chapter reviews the risk factors and treatment options for sexuality and gender diverse populations. Sexuality is a person’s sense of themselves as a sexual person and usually reflects their sexual attraction and sexual practice. Heterosexual people are sexually attracted to people of the opposite gender, lesbian women are sexually attracted to other women, gay men are sexually attracted to other men, bisexual people are sexually attracted to people of any gender, and queer people are sexually attracted to people of all genders (queer is also an umbrella term for sexuality and gender diverse people). Evidence from three nationally representative surveys suggests 3.2% of Australian adults report a non-heterosexual identity . Gender identity means the sense a person has of having a particular gender. Cisgender people identify with the sex they were assigned at birth, transgender people’s gender does not align with the sex they were assigned at birth. Most transgender people identify as either woman/ female or man/male, however people who feel their gender does not align with either female or male, or exclusively with male or female, use the terms non-binary or gender fluid. There is no reliable evidence on the proportion of gender diverse people in Australia; a systematic review of US population-based surveys provided a population estimate of 0.5%. Establishing an evidence base for patterns of alcohol use and treatment outcomes among sexuality and gender diverse people is challenging. Sexuality and/or gender identity are rarely captured in large surveys and treatment studies, and markers are not included in the Alcohol and Other Drug Treatment Services National Minimum Data Set for all government funded alcohol and other drug treatment specialist services

Affective and anxiety disorders and their relationship with chronic physical conditions in Australia : findings of the 2007 National Survey of Mental Health and Wellbeing

Objective: The aim of this study was to report nationally representative data on the prevalence and patterns of 12 month comorbidity of chronic physical conditions (diabetes, asthma, coronary heart disease, stroke, cancer, arthritis) and DSM-IV affective and anxiety disorders in Australian adults. Method: The 2007 National Survey of Mental Health and Wellbeing (NSMHWB) was a nationally representative household survey of 8841 Australian adults (1685 years) assessing symptoms of ICD-10 mental disorders and the presence of chronic physical conditions. Results: Prevalence of at least one National Health Priority Area chronic physical condition was 32.2% (95%CI = 30.9%33.5%). Among those with chronic physical conditions 21.9% had an affective or anxiety disorder. Affective and anxiety disorders were more common among people with physical conditions than among people without chronic physical conditions (affective OR 1.5; anxiety OR 1.8). Of those with a 12 month affective or anxiety disorder, 45.6% had a chronic physical condition. Physical disorders were more common in those with an affective or anxiety disorder than among people without an affective or anxiety disorder (affective OR 1.6; anxiety OR 2.0). Disability was high in those with an anxiety disorder, an affective disorder and a physical condition and 43.4% were classified as high service users. Conclusions: Comorbidity between chronic physical conditions and affective and anxiety disorders is widespread and is associated with high levels of disability and service use.8 page(s

Health risk and health seeking behaviours among people who inject performance and image enhancing drugs who access needle syringe programs in Australia

Introduction and Aims. People who use performance and image enhancing drugs (PIED) are a growing population in needle syringe programs (NSP) in Australia. Previous international research has identified heterogeneity among the PIED-using population. This study investigated health behaviours among NSP attendees who had recently (last 12 months) injected PIEDs and examined differences among this group according to recent psychoactive drug use. Design and Methods. The Australian Needle and Syringe Program Survey is an annually repeated cross-sectional survey conducted at approximately 50 NSPs nationally. In 2015, respondents provided information on their demographic characteristics, health risk and health monitoring behaviours, and provided a capillary dried blood spot for HIV and hepatitis C virus antibody testing. Univariable and multivariable logistic regressions assessed factors associated with recent (last 12 months) use (all routes of administration) of psychoactive drugs. Results. Among recent PIED injectors (n= 156), 59% had recently used psychoactive substances. Those who had recently used psychoactive drugs were significantly younger, less educated and more likely to have experienced redness at an injection site in the previous 12 months but were more likely to report recent HIV/hepatitis C virus testing. Discussion and Conclusions. This study identified significant differences in demographic characteristics, risk and health seeking behaviour among PIED users who did and did not also use psychoactive substances. There is a need to enhance and tailor harm reduction efforts and to build the capacity of NSP staff to better meet the needs of this diverse group

Prevalence, correlates and comorbidity of DSM-IV Cannabis Use and Cannabis Use Disorders in Australia

Objective: To report nationally representative findings on the prevalence, correlates, psychiatric comorbidity and treatment of DSM-IV Cannabis Use and Cannabis Use Disorders in Australia

Perceptions of extended-release buprenorphine injections for opioid use disorder among people who regularly use opioids in Australia

2019 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction Aims: To examine perceptions of extended-release (XR) buprenorphine injections among people who regularly use opioids in Australia. Design: Cross-sectional survey prior to implementation. XR-buprenorphine was registered in Australia in November 2018. Setting: Sydney, Melbourne and Hobart. Participants. A total of 402 people who regularly use opioids interviewed December 2017 to March 2018. Measurements: Primary outcome concerned the proportion of participants who believed XR-buprenorphine would be a good treatment option for them, preferred weekly versus monthly injections and perceived advantages/disadvantages of XR-buprenorphine. Independent variables concerned the demographic characteristics and features of current opioid agonist treatment (OAT; medication-type, dose, prescriber/dosing setting, unsupervised doses, out-of-pocket expenses and travel distance). Findings: Sixty-eight per cent [95% confidence interval (CI) = 63-73%] believed XR-buprenorphine was a good treatment option for them. They were more likely to report being younger [26-35 versus \u3e 55 years; odds ratio (OR) = 3.16, 95% CI = 1.12-8.89; P = 0.029], being female (OR = 1.67, 95% CI = 1.04-2.69; P = 0.034), \u3c 10 years school education (OR = 1.87, 95% CI = 1.12-3.12; P = 0.016) and past-month heroin (OR = 1.81, 95% CI = 1.15-2.85; P = 0.006) and methamphetamine use (OR = 1.90, 95% CI = 1.20-3.01; P = 0.006). Fifty-four per cent reported no preference for weekly versus monthly injections, 7% preferred weekly and 39% preferred monthly. Among OAT recipients (n = 255), believing XR-buprenorphine was a good treatment option was associated with shorter treatment episodes (1-2 versus ≥ 2 years; OR = 3.93, 95% CI = 1.26-12.22; P = 0.018), fewer unsupervised doses (≤ 8 doses past-month versus no take-aways; OR = 0.50; 95% CI = 0.27-0.93; P = 0.028) and longer travel distance (≥ 5 versus \u3c 5 km; OR = 2.10, 95% CI = 1.20-3.65; P = 0.009). Sixty-nine per cent reported \u27no problems or concerns\u27 with potential differences in availability, flexibility and location of XR-buprenorphine. Conclusions: Among regular opioid users in Australia, perceptions of extended-release buprenorphine as a good treatment option are associated with being female, recent illicit drug use and factors relating to the (in)convenience of current opioid agonist treatment