Preventing opioid overdoses in Europe:a critical assessment of known risk factors and preventative measures

This report is the outcome of a project into opioid overdoses. The remit was to focus on finding practical methods of overdose prevention. In order to fulfil this remit, a critical review of existing knowledge on overdose prevention was conducted. The report adds value to existing information by developing a methodology to classify and analyse risk and protective factors stratified by those involved (drug users, observers and organisations). The report then assesses the extent to which risk and protective factors can be potentially modified at different levels, e.g. individual, treatment setting, organisational and strategic. The report therefore has the potential to be updated as new information emerges

An unusual case of intertrigo in an adult caused by purely cutaneous Langerhans cell histiocytosis

We report a case of persistent intertrigo in an adult, eventually diagnosed as cutaneous Langerhans cell histiocytosis (LCH). It is known that LCH has a predilection for intertriginous areas, however purely cutaneous disease as in our case, is uncommon and usually other systems are affected. Following the report, literature of similar cases is reviewed to determine possible outcomes and to decide on the best possible treatment options.peer-reviewe

Profiles of visuospatial memory dysfunction in opioid exposed and dependent populations

Background . Chronic opioid exposure is common world-wide, but behavioural performance remains under-investigated. This study aimed to investigate visuospatial memory performance in opioid-exposed and dependent clinical populations and its associations with measures of intelligence and cognitive impulsivity. Methods . We recruited 109 participants: (i) patients with a history of opioid dependence due to chronic heroin use (n = 24), (ii) heroin users stabilised on methadone maintenance treatment (n = 29), (iii) participants with a history of chronic pain and prescribed tramadol and codeine (n = 28) and (iv) healthy controls (n = 28). The neuropsychological tasks from the Cambridge Neuropsychological Test Automated Battery included the Delayed Matching to Sample (DMS), Pattern Recognition Memory, Spatial Recognition Memory, Paired Associate Learning, Spatial Span Task, Spatial Working Memory and Cambridge Gambling Task. Pre-morbid general intelligence was assessed using the National Adult Reading Test. Results . As hypothesised, this study identified the differential effects of chronic heroin and methadone exposures on neuropsychological measures of visuospatial memory (p < 0.01) that were independent of injecting behaviour and dependence status. The study also identified an improvement in DMS performance (specifically at longer delays) when the methadone group was compared with the heroin group and also when the heroin group was stabilised onto methadone. Results identified differential effects of chronic heroin and methadone exposures on various neuropsychological measures of visuospatial memory independently from addiction severity measures, such as injecting behaviour and dependence status.PostprintPeer reviewe

Compulsivity in opioid dependence

This study was part funded by an unrestricted educational grant provided by Schering-Plough and a grant by an Anonymous Trust. Study support was also provided by the Scottish Mental Health Research Network. AB has received educational grants from Schering Plough and he has received research project funding from Schering-Plough, Merck Serono, and Indivior.Objective: This study aimed to investigate the relationship between compulsivity versus impulsivity and structural MRI abnormalities in opioid dependence. Method: We recruited 146 participants: i) patients with a history of opioid dependence due to chronic heroin use (n=24), ii) heroin users stabilised on methadone maintenance treatment (n=48), iii) abstinent participants with ahistory of opioid dependence due to heroin use (n=24) and iv) healthy controls(n=50). Compulsivity was measured using Intra/Extra-Dimensional (IED) Task and impulsivity was measured using the Cambridge Gambling Task (CGT).Structural Magnetic Resonance Imaging (MRI) data were also obtained. Results: As hypothesised, compulsivity was negatively associated with impulsivity (p<0.02). Testing for the neural substrates of compulsivity versus impulsivity, we found a higher compulsivity/impulsivity ratio associated with significantly decreased white matter adjacent to the nucleus accumbens, bed nucleus of stria terminalis and rostral cingulate in the abstinent group,compared to the other opioid dependent groups. In addition, self-reported duration of opioid exposure correlated negatively with bilateral globus pallidus grey matter reductions. Conclusion: Our findings are consistent with Volkow & Koob’s addiction models and underline the important role of compulsivity versus impulsivity inopioid dependence. Our results have implications for the treatment of opioid dependence supporting the assertion of different behavioural and biological phenotypes in the opioid dependence and abstinence syndromes.PostprintPeer reviewe

Chronic heroin use disorder and the brain:current evidence and future implications

The incidence of chronic heroin use disorder, including overdose deaths, has reached epidemic proportions. Here we summarise and evaluate our knowledge of the relationship between chronic heroin use disorder and the brain through a narrative review. A broad range of areas was considered including causal mechanisms, cognitive and neurological consequences of chronic heroin use and novel neuroscience-based clinical interventions. Chronic heroin use is associated with limited or very limited evidence of impairments in memory, cognitive impulsivity, non-planning impulsivity, compulsivity and decision-making. Additionally, there is some evidence for certain neurological disorders being caused by chronic heroin use, including toxic leukoencephalopathy and neurodegeneration. However, there is insufficient evidence on whether these impairments and disorders recover after abstinence. Whilst there is a high prevalence of comorbid psychiatric disorders, there is no clear evidence that chronic heroin use per se causes depression, bipolar disorder, PTSD and/or psychosis. Despite the growing burden on society from heroin use, knowledge of the long-term effects of chronic heroin use disorder on the brain remains limited. Nevertheless, there is evidence for progress in neuroscience-based interventions being made in two areas: assessment (cognitive assessment and neuroimaging) and interventions (cognitive training/remediation and neuromodulation). Longitudinal studies are needed to unravel addiction and neurotoxic mechanisms and clarify the role of pre-existing psychiatric symptoms and cognitive impairments.PostprintPeer reviewe

Investigating the effect of Alcohol Brief Interventions within Accident & Emergency departments using data informatics methodology

Funding: NHS Fife R&D, NHS Education for Scotland and the Medical School, University of St Andrews supported the project.Background: Alcohol Brief Interventions (ABI) have been implemented throughout Scotland since 2008 aiming to reduce hazardous drinking through a Scottish government funded initiative delivered in a range of setting including Accident and Emergency (A&E) departments. Purpose: To study the extent to Alcohol Brief Interventions (ABI) is associated with later health service use. Method: An opportunistic informatics approach was applied. A unique patient identifier was used to link patient data with core datasets spanning two years previous and two years post ABI. Variables included inpatient attendance, outpatient attendance, psychiatric admissions, A&E attendance and prescribing. Patients (N = 1704) who presented at A&E departments reported an average alcohol consumption of more than 8 units daily received the ABI. Fast Alcohol Screening Test (FAST) was used to assess patients for hazardous alcohol consumption. Multilevel linear modelling was employed to predict post-intervention utilisation using pre-ABI variables and controlling for person characteristics and venue. Results: Significant decrease in A&E usage was found at one and two years following the ABI intervention. Previous health service use was predictive of later service use. A single question (Item 4) on the FAST was predictive of A&E attendance at one and two years. Conclusions:  This investigation and methodology used provides support for the delivery of the ABI. However it cannot be ascertained as to whether this is due to the ABI, or simply as a result of making contact with a specialist in the addiction field.PostprintPeer reviewe

Alcohol policies in Malawi: inclusion of WHO “best buy” interventions and use of multi-sectoral action

Background Harmful use of alcohol is one of the most common risk factors for Non-Communicable Diseases and other health conditions such as injuries. World Health Organization has identified highly cost-effective interventions for reduction of alcohol consumption at population level, known as “best buy” interventions, which include tax increases, bans on alcohol advertising and restricted access to retailed alcohol. This paper describes the extent of inclusion of alcohol related “best buy” interventions in national policies and also describes the application of multi-sectoral action in the development of alcohol policies in Malawi. Methods The study was part of a multi-country research project on Analysis of Non-Communicable Disease Preventive Policies in Africa, which applied a qualitative case study design. Data were collected from thirty-two key informants through interviews. A review of twelve national policy documents that relate to control of harmful use of alcohol was also conducted. Transcripts were coded according to a predefined protocol followed by thematic content analysis. Results Only three of the twelve national policy documents related to alcohol included at least one “best buy” intervention. Multi-Sectoral Action was only evident in the development process of the latest alcohol policy document, the National Alcohol Policy. Facilitators for multi-sectoral action for alcohol policy formulation included: structured leadership and collaboration, shared concern over the burden of harmful use of alcohol, advocacy efforts by local non-governmental organisations and availability of some dedicated funding. Perceived barriers included financial constraints, high personnel turnover in different government departments, role confusion between sectors and some interference from the alcohol industry. Conclusions Malawi’s national legislations and policies have inadequate inclusion of the “best buy” interventions for control of harmful use of alcohol. Effective development and implementation of alcohol policies require structured organisation and collaboration of multi-sectoral actors. Sustainable financing mechanisms for the policy development and implementation processes should be considered; and the influence of the alcohol industry should be mitigated

Baseline executive functions and receiving cognitive rehabilitation can predict treatment response in people with opioid use disorder

TR and AF have received supports from the Cognitive Science and Technologies Council (CSTC) of Iran and Tehran University of Medical Sciences (TUMS) for the ongoing Clinical Trial with NECOREDA.Background Impaired cognitive functions, particularly executive function, predicts poor treatment success in people with substance use disorders. The current study investigated the effect of receiving adjunct cognitive rehabilitation and baseline executive function (EF) measures on treatment response among people with opioid use disorder (OUD). Method The analysis sample consisted of 113 participants with OUD who were discharged from a compulsory court-mandated methadone maintenance treatment (MMT) and followed for 3 months. We used the Backward digit span/Auditory verbal learning, Stroop, and Trail making tests to assess the three measures of EF, including working memory, inhibition, and shifting, respectively. Treatment response was operationalized as (1) treatment retention and (2) the number of positive urine tests for morphine during 3-month follow-up periods. The study used Cox's proportional hazards model and linear mixed model to identify predictive factors. Results Lower Stroop interference scores predicted increased length of stay in treatment (χ2 = 33.15, P < 0.001). The linear mixed model showed that scores on auditory verbal learning test and group intervention predicted the number of positive urine tests during a 3-month follow-up. Conclusion Working memory and inhibitory control, as well as receiving cognitive rehabilitation, could be potentially considered as predictors of treatment response for newly MMT admitted patients with OUD. Assessment of EF before treatment initiation may inform treatment providers about patient's cognitive deficits that may interfere with therapeutic interventions.PostprintPeer reviewe

Chronic pain, prescribed opioids and overdose risk: a qualitative exploration of the views of affected individuals and family members

It has been estimated that chronic non cancer pain (CNCP) affects more than 30% of people worldwide. Correspondingly, prescriptions for individuals experiencing CNCP have increased in recent years. While opioids can minimize pain, they also pose a risk of overdose. In 2019 in Scotland, prescription analgesics contributed to, or were implicated in, approximately 19% of drug related deaths. The experiences of those prescribed opioids for CNCP and family members, particularly their perceptions of overdose risk, are under-explored in the literature. This study aimed to address this gap by exploring how individuals and family members perceive the issue of overdose in relation to opioid analgesics, and their views of overdose prevention and potential interventions. Lived experiences from 12 individuals and family members living in Scotland were shared via in-depth qualitative interviews and analysed using NVivo and Framework. Coding was iterative and deductive. Analysis generated five themes: (1) living with pain and experiencing stigma; (2) taking more medication than prescribed; (3) side effects of medication; (4) overdose risk and prevention: the role of prescribers; and (5) attitudes towards naloxone to address overdose risk. Study findings have implications for the development of interventions and broader responses to reduce overdose risk among this group