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CORK Bibliography: Heroin and Opiates

203 citations. January 2007 to present

Prepared: January 2008

Agrawal A; Lynskey MT; Madden PAF; Bucholz KK; Heath AC. A latent class analysis of illicit drug abuse/dependence: Results from the National Epidemiological Survey on Alcohol and Related Conditions. Addiction 102(1): 94-104, 2007. (53 refs.)

We examine the co-occurrence of abuse/dependence across different illicit drugs and test associations between these classes and major psychiatric disorders. Latent class analyses were used to characterize polysubstance abuse/dependence (AB/D) in 43 093 individuals who participated in the National Epidemiological Survey on Alcohol and Related Conditions. Multinomial logistic regression was performed to examine the association between the classes of life-time illicit drug AB/D and gender, age and race, as well as life-time Diagnostic and Statistical Manual version IV (DSM-IV) alcohol abuse/dependence, nicotine dependence, major depressive disorder, generalized anxiety disorder, panic disorder, social phobia and antisocial personality disorder. Five latent classes were identified: no AB/D (class 1: 92.5%), cannabis AB/D only (class 2: 5.8%), stimulants + hallucinogen AB/D (class 3: 0.6%), prescription drug AB/D (class 4: 0.6%) and polysubstance AB/D (class 5: 0.5%). Major depressive disorder and nicotine dependence were associated most strongly with class 5. Anxiety disorders were associated strongly with the prescription drug AB/D class while alcohol AB/D and ASPD were associated with classes 2, 3, 4 and 5 when compared to the reference class (class 1). Significant heterogeneity exists in this US population for polysubstance AB/D patterns with evidence for a subgroup with high rates of sedative, tranquilizer and opiate AB/D and a history of anxiety disorders, a stimulant/hallucinogens group, a high-risk group with elevated rates of all psychiatric disorders and a milder cannabis AB/D only group. Replication of such classes across other samples has significant implications, such as characterizing risk groups that may be etiologically diverse.

Ahmadi J; Pridmore S; Alimi A; Cheraghi A; Arad A; Parsaeyan H et al. Epidemiology of opium use in the general population. American Journal of Drug and Alcohol Abuse 33(3): 483-491, 2007. (12 refs.)

Aims: To evaluate the prevalence of opium use in the Fars province, Iran. Method: A household survey of a representative sample of 3840 people aged 15 years and over. Researchers assessed opium use disorders using a semistructured interview and the Research Version of the Structured Clinical Interview for DSM-IV Axis I, during 2003. Results: Mean age of the sample was 33.9 years (SD = 15). Of the participants, 689 (17.9%) admitted use of opium one or more times during their lives (28.4% of men and 7.4% of women). Three hundred thirty-nine (8.8 %) were current opium users (14.3 % of men and 3.3 % of women). Opium ever-use and current-use were not functions of marital status. Both opium ever-use and current-use are found across the educational, occupational and income spectrums. Both peaked in the 40-49 age category, suggesting that first use usually occurs before 40 years of age and that current use extends across all age groups. Conclusion: Men are at greater risk than women. This report provides useful information for health planning. Prevention programs should focus on those under 40 years of age, and treatment is required across all age groups.

Anglin MD; Conner BT; Annon J; Longshore D. Levo-alpha-acetylmethadol (LAAM) versus methadone maintenance: 1-year treatment retention, outcomes and status. Addiction 102(9): 1432-1442, 2007. (44 refs.)

Aims: To compare levo-alpha-acetylmethadol (LAAM) and methadone maintenance (MM) on treatment retention, drug use during treatment and at follow-up, and abstinence. Design A two-group experimental design with patients assigned randomly (2 : 1) to receive fully subsidized LAAM or MM for 52 weeks. Settings: A community clinic providing maintenance treatment in Los Angeles, California. Participants: A total of 315 treatment-seeking patients willing to be assigned randomly to treatment condition; 289 (91.7%) were interviewed at 52 weeks. Intervension LAAM or MM, plus ancillary services available to all patients. Medication dose varied according to clinical judgement. Findings Treatment retention and status at 52-week follow-up, weekly clinical urinalysis, self-reported drug use and research urinalysis on samples collected at follow-up. Measurements LAAM participants were more likely to complete the planned 52 weeks (57.4%) than MM participants (46.2%) and were less likely to be discharged for arrest/incarceration. LAAM produced fewer during treatment clinic opiate-positive samples (M = 48.8) than MM (M = 62.3). Further, 24.4% on LAAM compared to 11.8% on MM were able to sustain at least 12 weeks of abstinence during the last 24 weeks of treatment. Opiate use at follow-up was lowest (50.9%) among LAAM participants in maintenance treatment. No adverse events, cardiological or otherwise, were observed with LAAM administration. Conclusions LAAM is an effective medication for the treatment of opiate dependence in community clinics with numerous behavioral and clinical advantages. LAAM is more effective than MM in promoting retention and extended reduction in and abstinence from opiate use while in treatment.

Arnold-Reed DE; O'Neil P; Holman CDJ; Bulsara MK; Rodiguez C; Gawthorne G et al. A comparison of mental health hospital admissions in a cohort of heroin users prior to and after rapid opiate detoxification and oral naltrexone maintenance. American Journal of Drug and Alcohol Abuse 33(5): 655-664, 2007. (20 refs.)

Mental health (MH) hospital admissions were investigated in a cohort (N 1184) of heroin dependent persons using linked health records. All MH in-patient admissions were extracted 36 months before to 36 months after commencing rapid opioid detoxification (ROD) and oral naltrexone. Results show that the incidence rate ratio (IRR) of drug-related and other MH admissions peaked in the 3 months immediately prior to treatment. All categories subsequently declined to baseline levels by 36 months following treatment. The authors conclude that treatment for heroin dependence reduces risk of MH admissions.

Baca CT; Grant KJ. What heroin users tell us about overdose. Journal of Addictive Diseases 26(4): 63-68, 2007. (26 refs.)

This study describes overdose experiences of heroin users, both the overdoses they themselves experienced, as well as those that they witnessed. A structured interview was performed with 101 current heroin users in Albuquerque, New Mexico from January 7, 2002 to February 26, 2002. Heroin-related overdoses were found to be common in this sample of heroin users. Three or more persons were reported to be present during 80 of the 95 most recently witnessed overdoses. An ambulance was called in only 42 of the 95 witnessed overdoses. Seventy-five percent of the respondents who witnessed an overdose stated concern over police involvement was an important reason for delay or absence of a 911 call for help. One hundred of the 101 respondents reported willingness, if trained, to use rescue breathing and to inject naloxone to aid an overdose victim. New methods need to he found to reduce heroin overdose death. Scientific studies are needed on the efficacy of take-home naloxone.

Badger GJ; Bickel WK; Giordano LA; Jacobs EA; Loewenstein G; Marsch L. Altered states: The impact of immediate craving on the valuation of current and future opioids. Journal of Health Economics 26(5): 865-876, 2007. (33 refs.)

Based on prior research showing that people underestimate the influence of motivational states they are not currently experiencing, we predicted and found that heroin addicts would value an extra dose of the heroin substitute Buprenorphine more highly when they were currently craving (right before receiving BUP) than when they were currently satiated (right after receiving BUP)-even when the extra BUP was to be received 5 days later. If addicts cannot appreciate the intensity of craving when they are not currently experiencing it, as these results suggest, it seems unlikely that those who have never experienced craving could predict its motivational force. Under-appreciation of craving by non-addicts may contribute to initial decisions to experiment with drugs.

Ball SA. Comparing individual therapies for personality disordered opioid dependent patients. Journal of Personality Disorders 21(3): 305-321, 2007. (53 refs.)

Within a psychotherapy development research project, thirty male (50%) and female (50%) personality disordered outpatients receiving methadone maintenance were randomly assigned to receive one of two 6-month manual-guided individual psychotherapies, Dual Focus Schema Therapy (DFST) or 12 Step Facilitation Therapy (12FT). All participants met diagnostic criteria for at least one personality disorder with antisocial, borderline, avoidant, and dependent being the most common. There were no significant differences between the two therapies for retention, utilization, or reductions in psychiatric symptoms or psychosocial impairment. Both therapy conditions demonstrated significant reductions in various severity indicators. Participants demonstrated more rapid decreases in the frequency of their substance use over six months of DFST in comparison to 12FT. DFST also was associated with a stronger therapeutic alliance between therapists and participants. Contrary to predictions, 12FT demonstrated better reduction of dysphoric affect than did DFST. DFST shows initial promise as the first time-limited manual-guided psychotherapeutic approach for the full range of personality disorders encountered in substance abuse patients.

Ballantyne JC; LaForge KS. Opioid dependence and addiction during opioid treatment of chronic pain (vol 129, pg 235, 2007) (Correction). Pain 131(3): 350-350, 2007. (1 refs.)

Throughout the long history of opiold drug use by humans, it has been known that opioids are powerful analgesics, but they can cause addiction. It has also been observed, and is now substantiated by multiple reports and studies, that during opioid treatment of severe and short-term pain, addiction arises only rarely. However, when opioids are extended to patients with chronic pain, and therapeutic opioid use is not confined to patients with severe and short-lived pain, compulsive opiold seeking and addiction arising directly from opioid treatment of pain become more visible. Although the epidemiological evidence base currently available is rudimentary, it appears that problematic opioid use arises in some fraction of opioid-treated chronic pain patients, and that problematic behaviors and addiction are problems that need to be addressed. Since the potentially devastating effects of addiction can substantially offset the benefits of opioid pain relief, it seems timely to reexamine addiction mechanisms and their relevance to the practice of long-term opioid treatment for pain. This article reviews the neurobiological and genetic basis of addiction, its terminology and diagnosis, the evidence on addiction rates during opioid treatment of chronic pain and the implications of biological mechanisms in formulating rational opioid treatment regimes.

Ballantyne JC; LaForge KS. Opioid dependence and addiction during opioid treatment of chronic pain. (review). Pain 129(3): 235-255, 2007. (216 refs.)

This article covers the neurobiology of addiction, genetics, comments on addiction terminology, the relationship of chronic pain and addiction and the impact of psychiatric co-morbidity, as well as responding to addiction risk during paintreatment. Conclusion: As experience of treating chronic pain with opioids grew, it became clear that there are difficulties with applying the definitions and criteria developed for addiction in illicit drug users to pain patients. Opioid-treated pain patients often develop overt physical dependence and analgesic tolerance with no behavioral change, therefore these must be considered separate phenomena from addiction. New definitions specific to pain patients account for this, but are in a sense misleading because unlike standard definitions that recognize the integrated nature of addiction processes, they place a conceptual separation between tolerance, dependence and the behavioral component. It is becoming accepted, knowing that continued drug use results in integrated biological adaptations, that the more subtle manifestations of these adaptations - psychological dependence, resulting in emotional withdrawal (anhedonia and dysphoria) and motivational withdrawal (short-term craving) - are also important and distinct from addiction (a state of learned drug seeking) . Opioid-treated pain patients must undergo the same initial physiological adaptations as illicit users. Yet in pain patients, the clinical picture of progression from use to problematic use to addiction differs markedly from that in illicit users. Continued use in an illicit setting often progresses rapidly to addiction, to the extent that dependence and addiction are indistinguishable, and this rapid progression is likely accounted for by the circumstances and motivations associated with illicit use. In pain patients, we see a different picture. If the progression from simple dependence through problematic use to addiction occurs, it is more subtle and insidious, so that addiction emerges as a distinct and separate syndrome, but is less obvious and much more difficult to identify.

Balousek S; Plane MB; Fleming M. Prevalence of interpersonal abuse in primary care patients prescribed opioids for chronic pain. Journal of General Internal Medicine 22(9): 1268-1273, 2007. (24 refs.)

Background: Interpersonal abuse is associated with clinical problems including chronic pain disorders. Objectives: The objective of this study is to describe 30-day and lifetime prevalence of emotional, physical, and sexual abuse found in men and women prescribed opioids for chronic pain. Design: Cross-sectional interview is the design of this study. Participants: Patients, 1,009, currently prescribed opioids for chronic noncancer pain. They were recruited from the practices of 235 Family Physicians and Internists in Wisconsin. The most common pain diagnoses were arthritis, low back pain, headache, and fibromyalgia/myofascial pain. Measurement: Data for this secondary analysis on rates of interpersonal abuse were based on 3 questions from the Addiction Severity Index (ASI) regarding 30-day and lifetime emotional, physical, and sexual abuse. Results: Forty-seven percent of women and 22% of men reported a history of lifetime physical abuse. Thirty -five percent of women and 10% of men reported lifetime sexual abuse. Binary logistic regression identified the following variables associated with lifetime physical abuse: female gender (RR 2.81, CI 2.01-3.94), age 31-50 (RR1.77, CI 1.30-2.41), Caucasian (RR1.67, CI 1.19-2.35), increased psychiatric symptoms as measured by the ASI (RR 2.14, CI 1.56-2.94), and lifetime suicide attempts (RR 3.98, CI 2.76-5.74). Conclusions: This study reports prevalence of abuse in both men and women prescribed opioids for chronic pain in primary care settings. Subjects who report experiencing interpersonal abuse also report significantly higher rates of suicide attempts and score higher on the ASI psychiatric scale. Screening patients taking opioids for chronic pain for interpersonal abuse may lead to a better understanding of contributors to their physical and mental health.

Basu S; Bruce RD; Barry DT; Altice FL. Pharmacological pain control for human immunodeficiency virus-infected adults with a history of drug dependence. Journal of Substance Abuse Treatment 32(4): 399-409, 2007. (54 refs.)

Clinicians treating human immunodeficiency virus (HIV)-infected patients with substance use disorders often face the challenge of managing patients' acute or chronic pain conditions while keeping in mind the potential dangers of prescription opiate dependence. in this clinical review, we critically appraise the existing data concerning barriers to appropriate treatment of pain among HIV-infected patients with substance use disorders. We then analyze published studies concerning the choice of pharmacological pain control regimens for acute and chronic pain conditions in HIV-infected patients, keeping in mind HIV-specific issues related to drug interactions and substance use disorders. We summarize this information in the form of flowcharts for physicians approaching HIV-infected patients who present with complaints of pain, providing evidence-based guidance for the structuring of pain management services and for addressing aberrant drug-taking behaviors.

Bearre L; Sturt P; Bruce G; Jones BT. Heroin-related attentional bias and monthly frequency of heroin use are positively associated in attenders of a harm reduction service. Addictive Behaviors 32(4): 784-792, 2007. (31 refs.)

The relationship between heroin-related attentional bias (AB) and a proxy for dependence severity (monthly frequency of heroin use-injecting or inhaling) was measured in individuals attending a heroin harm reduction service. A flicker change blindness paradigm was employed in which change detection latencies were measured to either a heroin-related or to a neutral change made to a stimulus array containing an equal number of heroin-related and neutral words. Individuals given the heroin-related change to detect showed a positive relationship between heroin-related AB and the proxy for dependence severity; those given the neutral change showed a negative relationship. Both findings complement each other - and are consistent with the sending of more attention to heroin-related stimuli than neutral, the more severe is the dependence.

Bell SC; Hanes RD. A microfluidic device for presumptive testing of controlled substances. Journal of Forensic Sciences 52(4): 884-888, 2007. (11 refs.)

A simple microfluidic device (MFD) has been developed to perform multiple color and crystal tests for controlled substance analysis. The MFD method uses less sample and reagents and generates less waste than traditional spot plate methods while performing several tests simultaneously. This methodology provides significantly more analytical information for a single sample analysis. The current generation device is the size of a microscope slide with four analytical channels: one for microcrystal tests and three for color tests. The optimized devices were subjected to a rigorous validation study using comparative replicate analyses and several operators. Target analytes were methamphetamine, amphetamine, cocaine, and oxycodone and color test reagents used were the Marquis, Simon, and cobalt thiocyanate. For the crystal tests, platinic chloride was used. The validation study showed the MFD's limits of detection to be in the picogram range. Positive tests results were observed in complex mixtures in which the controlled substance was present at concentrations of 5-10% (w/w). The microcrystal reagents showed greater sensitivity than color test reagents when used in the device. Reagent use and waste generation using the devices was 95% less that that used and generated using the traditional methods. The device performance was also shown to be operator independent.

Berg ML; Idrees U; Ding R; Nesbit SA; Liang HK; McCarthy ML. Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department. Drug and Alcohol Dependence 86(2/3): 239-244, 2007. (13 refs.)

Objectives: To examine the use of buprenorphine for the treatment of opioid withdrawal in an emergency department (ED) setting. Methods: The medical records of all adult patients who presented to the study ED during a 10 week period for opioid withdrawal were abstracted. Subjects were categorized as receiving buprenorphine, symptomatic treatment or no pharmacologic treatment for their opioid withdrawal. The three groups were compared by patient and service characteristics, withdrawal symptoms and outcomes. Results: Of the 11,019 patients who presented to the ED during the 10 week study period, 158 (1.4%) were eligible. Subjects were more likely to receive buprenorphine (56%) compared to symptomatic treatment only (26%) or no pharmacologic treatment (18%). Subjects who received buprenorphine were more likely to have a history of suicide ideation (34% versus 12% p < 0.05) compared to subjects who received symptomatic treatment(s) and were less likely to present with a gastrointestinal complaint (9% versus 25% p < 0.05). Subjects who received buprenorphine were less likely to return to the same ED within 30 days for a drug-related visit (8%) compared to those who received symptomatic treatment (17%) (p < 0.05). Conclusions: Buprenorphine was a common treatment for opioid withdrawal in this ED without any documented adverse outcomes. Given that it did not result in an increase in drug-related return ED visits and its proven efficacy in other settings, a prospective evaluation of its potential value to ED patients who present with opioid withdrawal is warranted.

Bernstein KT; Bucciarelli A; Piper TM; Gross C; Tardiff K; Galea S. Cocaine- and opiate-related fatal overdose in New York City, 1990-2000. BMC Public Health 7: article 31, 2007. (49 refs.)

Background: In New York City (NYC), the annual mortality rate is higher for accidental drug overdoses than for homicides; cocaine and opiates are the drugs most frequently associated with drug overdose deaths. We assessed trends and correlates of cocaine- and opiate-related overdose deaths in NYC during 1990-2000. Methods: Data were collected from the NYC Office of the Chief Medical Examiner (OCME) on all fatal drug overdoses involving cocaine and/or opiates that occurred between 1990-2000 (n = 8,774) and classified into three mutually exclusive groups (cocaine only; opiates-only; cocaine and opiates). Risk factors for accidental overdose were examined in the three groups and compared using multinomial logistic regression. Results: Overall, among decedents ages 15-64, 2,392 (27.3%) were attributed to cocaine only and 2,825 (32.2%) were attributed to opiates-only. During the interval studied, the percentage of drug overdose deaths attributed to cocaine only fell from 29.2% to 23.6% while the percentage of overdose deaths attributed to opiates-only rose from 30.6% to 40.1%. Compared to New Yorkers who fatally overdosed from opiates-only, fatal overdose attributed to cocaine-only was associated with being male (OR = 0.71, 95% CI 0.62-0.82), Black (OR = 4.73, 95% CI 4.08-5.49) or Hispanic (OR = 1.51, 95% CI 1.29-1.76), an overdose outside of a residence or building (OR = 1.34, 95% CI 1.06-1.68), having alcohol detected at autopsy (OR = 0.50, 95% CI 0.44-0.56) and older age (55 64) (OR = 2.53 95% CI 1.70-3.75). Conclusion: As interventions to prevent fatal overdose become more targeted and drug specific, understanding the different populations at risk for different drug-related overdoses will become more critical.

Best D; Manning V; Strang J. Retrospective recall of heroin initiation and the impact on peer networks. Addiction Research & Theory 15(4): 397-410, 2007. (26 refs.)

Initiation to heroin use is an event that is evidently memorable for the individual - even many years later. The current exploratory study assesses heroin initiation among a cohort of long-term substance users to assess the effects of heroin use on peer networks. Participants were able to recollect the occasion of their initiation in considerable detail and were able to recall and describe the peer networks in which they were involved at the time. Initiation into heroin use had had a profound effect on these networks, fragmenting groups between those who initiated and continued to use and those who did not. However, even among the continued users, there was a more gradual rupture, with loosening of social bonds outside family and the closest friendship dyads. Heroin initiation is a critical event that has received little research attention, yet its impact on social functioning is reported here as dramatic and influential in shaping the users' self-perceptions and identity.

Blake S; Ruel B; Seamark C; Seamark D. Experiences of patients requiring strong opioid drugs for chronic non-cancer pain: A patient-initiated study. British Journal of General Practice 57(535): 101-108, 2007. (21 refs.)

Background: Chronic non-cancer pain is an increasing problem in health care. This study was initiated by a patient wanting to discover more about the experiences of other patients requiring strong opioid analgesia for such pain. Aim: To determine the attitudes and experiences of patients receiving long-term strong opioid medication for chronic non-cancer pain in primary rare. Design of study: Qualitative study using interpretative phenomenological analysis. Setting: A semi-rural general practice in southwest England. Method The study data came from a focus group and 10 individual patient interviews. A patient researcher was involved in the design, conduct, and analysis of the project. Results: The impact of pain affected participants in every aspect of their daily lives. Attitudes to strong opioid medication were both positive and negative. Concerns about starting medication usually centred on fears of addiction, being seen as an addict, or that the patients may have a more serious condition than they had previously thought. However, these fears were tempered by an appreciation of the benefits that strong opioids brought in terms of pain relief and consequent gains in a nearer-to-normal existence. The data did not produce any evidence of addictive behaviour or of tolerance despite these initial fears. Patients adopted a trade off approach, balancing pain relief with medication side effects, accepting more pain for a reduction in sedation and nausea. All patients described coping strategies they developed themselves and learned from outside influences, such as pain clinic courses and support from the GP. There was realism that total pain relief was not possible, but that a balance could be struck. Conclusion: Chronic non-cancer pain is associated with high levels of distress and psychosocial impairment. Patients in this study appreciated the benefits of strong opioid medication, having come to terms with fears of addiction and learned coping strategies. These findings should encourage GPs to consider strong opioid medication for patients with severe chronic pain in line with published evidence-based guidelines.

Bradvik L; Frank A; Hulenvik P; Medvedeo A; Berglund M. Heroin addicts reporting previous heroin overdoses also report suicide attempts. Suicide and Life-Threatening Behavior 37(4): 475-481, 2007. (24 refs.)

Nonfatal heroin overdoses and suicide attempts are both common among heroin addicts, but there is limited knowledge about the association between them. The sample in the present study consisted of 149 regular heroin users in Malmo, Sweden. Out of these 98 had taken an unintentional heroin overdose at some time and 51 had made at least one attempt to commit suicide (but not using heroin). Suicide attempts were significantly more common among those who had taken unintentional overdoses as compared with those who had never taken any overdose (p < 0.01). The more overdoses, the greater the risk of suicide attempt.

Bramness JG; Kornor H. Benzodiazepine prescription for patients in opioid maintenance treatment in Norway. Drug and Alcohol Dependence 90(2/3): 203-209, 2007. (44 refs.)

Background: Opioid maintained patients report high levels of anxiety, but the use of benzodiazepines among these patients has been associated with negative outcomes such as increased risk of overdose and death and poorer retention in programmes. Previous research has used interview or urine analysis to assess benzodiazepine use. In this study a prescription database was applied. Methods: The Norwegian Prescription Database covers all prescriptions for the entire population from 1 January 2004. Benzodiazepine prescriptions to patients receiving methadone (N= 1364) or buprenorphine (N= 805) in 2004 and 2005 were studied. Type and amount of drugs received were investigated. Results: Overall 40% of the patients received at least one prescription for a benzodiazepine drug. Oxazepam was the most frequently prescribed drug. Female patients, methadone-maintained patients and patients in the liberal programmes received a prescription more often. Prescribed doses were high and highest in the liberal programmes. Older patients received more hypnotics. Dose of maintenance drug was positively related to amount of anxiolytics prescribed. Conclusions: This study showed that more benzodiazepines were prescribed to opioid maintenance treatment patients than previously shown by investigations using interview or urine analysis. The doses prescribed were generally high. In light of the negative outcomes following benzodiazepine use in these patients, Norwegian doctors need to review their prescription practices.

Braye K; Harwood T; Inder R; Beasley R; Robinson G. Poppy seed tea and opiate abuse in New Zealand. Drug and Alcohol Review 26(2): 215-219, 2007. (18 refs.)

The opium poppy Papaver somniferum contains an array of opiates. There is a variety of methods of preparation that can be used by people with opiate dependence, with patterns of use determined by numerous factors including cost, safety, potency and legal status. The objective of this study was to determine the frequency and nature of poppy seed tea ( PST) use by opiatedependent patients in the form of a written questionnaire. The study took place at the Community Alcohol and Drug Clinic, Wellington, New Zealand, and comprised 24 opiate- dependent patients attending the clinic. A total of 11 of 24 (46%) patients reported having used PST. In five patients currently using PST it represented the major source of opiates, and two had managed to withdraw from use of other opiates with regular PST use. Patients reported a median onset of action of 15 minures and an effect lasting a median of 24 hours. The major limitation of PST use was the foul taste. PST is used commonly by opiatedependent patients attending an alcohol and drug clinic in New Zealand. The use of PST as the major source of opiates could be considered favourably within 'harm reduction' philosophies, because of its low cost, legal availability and oral route of administration. Conversely, there is the potential for PST to act as a 'gateway drug' by inducing opioid dependence and introducing people to the culture of drug abuse.

Brigham GS; Amass L; Winhusen T; Harrer JM; Pelt A. Using buprenorphine short-term taper to facilitate early treatment engagement. Journal of Substance Abuse Treatment 32(4): 349-356, 2007. (43 refs.)

The U.S. Federal Food and Drug Administration approved buprenorphine for drug abuse treatment in 2002, and it became available for clinical use in early 2003. Maryhaven, a community treatment program, participated in a National Institute on Drug Abuse Clinical Trials Network trial evaluating buprenorphine-naloxone (BNX; Suboxone) short-term taper for medically managed opioid withdrawal and later adopted this treatment. In a retrospective review, the first 64 patients treated with a BNX taper were compared with two groups of patients treated with clonidine before and after the implementation of the BNX program. Significantly more patients (about 80%) receiving BNX continued in further treatment compared to about 30% of those receiving clonidine. Patient outcomes are discussed in the context of the critical need for treatment continuation following detoxification. Common questions of potential adopters of the BNX taper are presented and addressed. Overall, BNX was readily integrated into the existing treatment service.

Brooner RK; Kidorf MS; King VL; Stoller KB; Neufeld KJ; Kolodner K. Comparing adaptive stepped care and monetary-based voucher interventions for opioid dependence. Drug and Alcohol Dependence 88(Supplement 2): S14-S23, 2007. (49 refs.)

This 6-month randomized clinical trial (with 3-month follow-up) used a 2 x 2 design to compare the independent and combined effectiveness of two interventions designed to improve outcomes in treatment-seeking opioid-dependent patients (n=236): motivated stepped care (MSC) and contingent voucher incentives (CVI). MSC is an adaptive treatment strategy that uses principles of negative, reinforcement and avoidance to motivate both attendance to varying levels of counseling services and brief periods of abstinence [Brooner, R.K., Kidorf, M., 2002. Using behavioral reinforcement to improve methadone treatment participation. Sciences. Pract. Perspect. 1, 38-46; Brooner, R.K., Kidorf, M.S., King, V.L., Peirce, J.M., Bigelow, G.E., Kolodner, K., 2004. A modified "stepped care" approach to improve attendance behavior in treatment seeking opioid abusers. J. Substance. Abuse Treat. 27, 223-232]. In contrast, CVI [Higgins, S., Delaney, D.D., Budney, A.J., Bickel, W.K., Hughes, J.R., Foerg, B.A., Fenwick, J.W., 1991. A behavioral approach to achieving initial cocaine abstinence. Am. Psychiatr. 148, 1218-1224] relies on positive reinforcement to motivate drug abstinence. The results showed that the combined approach (MSC + CVI) was associated with the highest proportion of drug-negative urine samples during both the randomized and 3-month follow-up arms of the evaluation. The CVI-only and the MSC-only conditions evidenced similar proportions of drug-negative urine samples that were both significantly greater than the standard care (SC) comparison group. Voucher-based reinforcement was associated with better retention, while adaptive stepped-based care was associated with better adherence to scheduled counseling sessions. These results suggest that both CVI and MSC are more effective than routine care for reducing drug use in opioid dependent outpatients, and that the overall benefits of MSC are enhanced further by adding positive reinforcement.

Butler T; Boonwaat L; Hailstone S; Falconer T; Lems P; Ginley T et al. The 2004 Australian prison entrants' blood-borne virus and risk behaviour survey. Australian and New Zealand Journal of Public Health 31(1): 44-50, 2007. (28 refs.)

Objectives: To assess the prevalence of blood-borne viruses and associated risk factors among prison entrants at seven Australian prisons across four States. Design: Consecutive cross-sectional design. Voluntary confidential testing of all prison entrants for serological markers of human immunodeficiency virus (HIV), hepatitis C (HCV) and hepatitis B (HBV) over 14 consecutive days in May 2004. Demographic data and data related to risks for blood-borne virus transmission, such as sexual activity, body piercing, tattooing, and injecting drug use, were collected. Results: National prevalence for HIV was 1%, hepatitis B core antibody 20%, and hepatitis C antibody 34%. Fifty-nine per cent of participants had a history of injecting drug use. Among injecting drug users, the prevalence of HIV was 1%, hepatitis C antibody 56%, and hepatitis B core antibody 27%. Forty-one per cent of those screened reported a previous incarceration. In the multivariate model, Queensland and Western Australian (WA) prison entrants were significantly less likely to test positive to HCV than those in New South Wales (NSW). Amphetamine was the most commonly injected drug in Queensland, Tasmania and WA. In NSW, heroin was the most common drug injected. In the multivariate analysis a history of injecting drug use, being aged 30 years or more, and a prior incarceration were positively associated with hepatitis C infection. For hepatitis B core antibody, age over 30 years and a history of injecting drug use were associated with an increased risk. Conclusions: The findings support the view that prisoner populations are vulnerable to blood-borne virus infection, particularly hepatitis B and C. Prisoner populations should be included in routine surveillance programs so as to provide a more representative picture of blood-borne virus epidemiology in Australia.

Butler SF; Venuti SW; Benoit C; Beaulaurier RL; Houle B; Katz N. Internet surveillance: Content analysis and monitoring of product-specific Internet prescription opioid abuse-related postings. Clinical Journal of Pain 23(7): 619-628, 2007. (24 refs.)

Objectives: This study describes the development of a systematic approach to the analysis of Internet chatter as a means of monitoring potentially abusable opioid analgesics. Methods: Message boards dedicated to drug abuse were selected using specific inclusion criteria. Threaded discussions containing 48,293 posts were captured. A coding system was created to compare content of posts related to 3 opioid analgesics: Kadian, Vicodin, and OxyContin. Results: The number of posts containing mentions of the target drugs were significantly different [OxyContin (1813) > Vicodin (940) > Kadian (27), P < 0.001]. Analyses revealed that these differences were not simply a reflection of the availability of each product (ie, number of prescriptions written). Reliability tests indicated that the content coding system achieved good interrater reliability coefficients (average K across all categories = 0.76, range = 0.52 to 1.0). Content analysis of a sample of 234 randomly selected posts indicated that the proportion of Internet posts endorsing abuse of Kadian was statistically significantly less than OxyContin (45.5% vs. 68.4%, P 0.036, not adjusted for multiple comparisons). Discussion: These results suggest that a systematic approach to postmarketing surveillance of Internet chatter related to pharmaceutical products is feasible and yields reliable information about the quantity of discussion of specific products and qualitative information regarding the nature of the discussions. Kadian was associated with fewer Internet mentions than either OxyContin or Vicodin. This investigation stands as a first attempt to establish systematic methods for conducting Internet surveillance.

Chandra S. Economic manifestations of opiate addiction: Evidence from historical data from colonial Indonesia. Drug and Alcohol Dependence 90(Supplement 1): S69-S84, 2007. (45 refs.)

The aim of this paper is to demonstrate, using an example, the utility of historical data to illuminate important questions in the field of drug dependence research. The literature on the consumption of addictive substances often characterizes users as being one of two types: "addicts" and "casual users". An econometric characterization of the responses of opium consumers in the late-colonial Netherlands Indies to changes in the price of opium and other important variables is provided, which explicitly acknowledges the existence of different types of opium smokers, as modeled in the underlying theory. The results reveal systematic differences between the behavior of groups of high-intensity consumers and groups of low-intensity consumers. While the findings show that both groups showed similar total price elasticities, the high-intensity consumers were affected predominantly via changes in the number of users rather than in per capita consumption. In the course of the analysis, various analytic methods that are new to the field of drug dependence research are introduced.

Chiang S-C; Chan H-Y; Chang Y-Y et al. Psychiatric comorbidity and gender difference among treatment-seeking heroin abusers in Taiwan. Psychiatry and Clinical Neurosciences 61(1): 105-113, 2007. (39 refs.)

The objectives of the present study were to estimate the psychiatric comorbidity of Taiwanese heroin users seeking treatment and to identify the gender differences in psychiatric comorbidity and drug use behavior. Subjects were interviewed using a structured questionnaire on drug use behavior and the Mini International Neuropsychiatric Interview for psychiatric disorders. Of the subjects, 58.5% of the male and 62.5% of the female subjects had at least one non-substance-use axis I psychiatric disorder or antisocial personality disorder. Compared to male subjects, female subjects were younger, were less educated, had higher rates of unemployment and had earlier onset of illicit drug use. Female subjects were 11-fold more likely than male subjects to exhibit suicidal behavior. Among heroin abusers in the present study, female subjects were more widely exposed to unfavorable social factors and had substantially higher incidence of suicidal behavior than male subjects. Drug treatment centers should be aware of these gender differences and pay particular attention to comorbid depressive disorders and suicidal behavior of female heroin abusers.

Cicero TJ; Dart RC; Inciardi JA; Woody GE; Schnoll S; Munoz A. The development of a comprehensive risk-management program for prescription opioid analgesics: Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS (R)). Pain Medicine 8(2): 157-170, 2007. (31 refs.)

Objective. Beginning in the late 1990's a marked increase in abuse of OxyContin(R) emerged, which led to the development and establishment of a proactive surveillance program to monitor and characterize abuse, named the Researched Abuse, Diversion and Addiction Related Surveillance (RADARS(R)) System. The main goal of RADARS(R) was to develop proactive, timely and geographically sensitive methods to assess the abuse and diversion of OxyContin(R), along with a number of other Schedule II and III opioids with the aim of using this information to guide risk reduction interventions. Thus, its major focus was the detection of abuse of OxyContin(R) and other commonly prescribed opioid analgesics at the three-digit ZIP code level across the country utilizing a number of different detection systems. Methods. The detection systems selected were: (1) Quarterly-surveys of drug abuse experts who are knowledgeable about cases of prescription drug abuse; (2) Surveys of law enforcement agencies that detect diversion of prescription drugs; and (3) Poison Control Center reports of intentional misuse or abuse of prescription opioids. Collectively, the three systems provide overlapping coverage of over 80% of the nation's 973 three-digit ZIP codes. Results. Preliminary results indicate that prescription drug abuse is prevalent nationwide, but it seems to be heavily localized in rural, suburban and small urban areas. Our results also indicate that hydrocodone and extended and immediate release oxycodone products are by far the most widely abused drugs in the country, but the abuse of all prescription opioids seems to have grown over the 14 quarters since the inception of RADARS(R). Conclusion. The next step in these studies is to develop regionally specific, risk-minimization strategies, which is the goal of all risk-management programs. If successful, RADARS(R) will serve as a prototype of such programs for any new drug approved thathas measurable abuse potential.

Cicero TJ; Surratt H; Inciardi JA; Munoz A. Relationship between therapeutic use and abuse of opioid analgesics in rural, suburban, and urban locations in the United States. Pharmacoepidemiology and Drug Safety 16(8): 827-840, 2007. (38 refs.)

Purpose: The goal of these studies was to determine the relationship between prescribed use of opioid analgesics and their non-medically related use (abuse) at a regional level across the country. Methods To gather information about prescription drug abuse, we asked 233 drug abuse treatment specialists to provide us Quarterly reports on the number of cases of prescription opioid analgesic abusers who used opioid analgesics to get high in the past 30 days. Results and Conclusions We found that there was a very strong correlation between therapeutic exposure to opioid analgesics, as measured by prescriptions filled, and their abuse. There were, however, geographical loci that represented outliers in which abuse was disproportionately high relative to therapeutic use (> 95th percentile), most of which were in very small urban, suburban, and rural areas. The rank order of abuse shows that buprenorphine products, extended release (ER) oxycodone and methadone are the most intensely abused prescription opioid analgesics, with hydrocodone the least abused, when the data are corrected for degree of exposure, i.e., cases/1000 persons filling a prescription. If, on the other hand, one uses the number of cases/100000 population, hydrocodone ranked as high as ER oxycodone and all other drugs grouped together at very low levels of abuse. Since the latter conclusion ignores therapeutic exposure, we conclude that the rate of abuse of highly efficacious opioid analgesics is best expressed as cases of abuse/1000 persons filling a prescription, which yields the best possible estimate of the risk-benefit ratio of these drugs.

Clatts MC; Giang LM; Goldsamt LA; Yi H. Novel heroin injection practices: Implications for transmission of HIV and other bloodborne pathogens. American Journal of Preventive Medicine 32(6, Supplement S): S226-S233, 2007. (22 refs.)

Background: This paper describes injection risk in an out-of-treatment population of young heroin users in Hanoi, Vietnam, including use of a soft-tissue portal known as a "cay ma" (injection sac). Methods: Data from a large cross-sectional survey (N=1270) are used to describe the prevalence of this practice and its association with disease. Additionally, data from an ethnographic substudy on injectors serve to elaborate injectors' rationales for this injection practice. Results: This practice was common in this sample, appearing soon after initiation of habitual injection. Injectors report that this allows rapid and reliable access to a vein; strategic advantages in a dense urban environment where rapid injection, typically in public settings, is necessary to avoid discovery or arrest. Additionally, this practice is believed to mitigate risk for vein damage from co-morbid promethazine hydrochloride injection. Conclusions: This practice may draw lymphocytes to injection sites, thereby increasing risk for transmission of bloodborne pathogens. Structural and behavioral interventions are needed for young heroin users in Vietnam.

Collins ED; Horton T; Reinke K; Amass L; Nunes EV. Using buprenorphine to facilitate entry into residential therapeutic community rehabilitation. Journal of Substance Abuse Treatment 32(2): 167-175, 2007. (33 refs.)

For opioid-dependent patients, the need for detoxification has been a barrier to entry into long-term residential treatment. This report describes a retrospective observational cohort study with the first 38 opioid-dependent patients entering First Step, a 14-day buprenorphine-naloxone (Suboxone) detoxification regimen integrated into a long-term residential therapeutic community (TC) program. Eighty-nine percent (34 of 38) of First Step patients completed a 14-day buprenorphine taper protocol, 50% (19 of 38) completed an initial 3- to 4-weck stay, and 39% (15 of 38) completed at least 3 months of residential treatment at the TC. Retention did not differ significantly in a demographically matched concurrently admitted control group without impending opioid withdrawal, in which 65% (24 of 37) completed an initial 3- to 4-week stay (p =.20) and 57% (21 of 37) completed at least 3 months of treatment (p --.14). Withdrawal symptoms were mild, and there were no instances of precipitated withdrawal. The findings suggest the potential for buprenorphine to serve as a bridge, improving the viability of long-term residential treatment for managing opioid dependence.

Collins GB; McAllister MS. Buprenorphine maintenance: A new treatment for opioid dependence. Cleveland Clinic Journal of Medicine 74(7): 514-520, 2007. (39 refs.)

Buprenorphine (Subutex) is a safe and effective treatment for opioid dependence, and has very low potential for abuse, especially when it is combined with naloxone (Narcan) in a single sublingual tablet (Suboxone). New regulations allow physicians who are certified in buprenorphine therapy to offer it in their offices, a development that can substantially increase patient access to treatment.

Comer SD; Sullivan MA; Hulse GK. Sustained-release naltrexone: Novel treatment for opioid dependence. Expert Opinion on Investigational Drugs 16(8): 1285-1294, 2007. (99 refs.)

The devastating costs of opioid abuse and dependence underscore the need for effective treatments for these disorders. At present, several different maintenance medications exist for treating opioid dependence, including methadone, buprenorphine and naltrexone. Of these, naltrexone is the only one that possesses no opioid agonist effects. Instead, naltrexone occupies opioid receptors and prevents or reverses the effects produced by opioid agonists. Despite its clear pharmacologic effectiveness, its clinical effectiveness in treating opioid dependence has been disappointing, primarily due to non-compliance with taking the medication. However, the recent availability of sustained-release formulations of naltrexone has renewed interest in this medication. The present paper describes the development of sustained-release naltrexone formulations and discusses the clinical issues associated with their use in treating opioid dependence.

Copenhaver MM; Bruce RD; Altice FL. Behavioral counseling content for optimizing the use of buprenorphine for treatment of opioid dependence in community-based settings: A review of the empirical evidence. American Journal of Drug and Alcohol Abuse 33(5): 643-654, 2007. (35 refs.)

There is growing empirical evidence of buprenorphine's effectiveness in treating opioid dependence in community-based settings in the U. S. Decades of research indicates that in order for buprenorphine to have a sizable effect, it must be appropriately supported by behavioral counseling. Studies to date have not established the optimal behavioral counseling content for supporting buprenorphine treatment. The objective of this article is: 1) to review evidence of the key treatment-relevant issues posed by opioid-dependent patients in community-based settings in the U. S.; and 2) to review behavioral counseling content that may optimize the use of buprenorphine for treating opioid dependence in such settings. Evidence points toward the use of behavioral counseling aimed at enhancing patients' motivation during treatment entry followed by an emphasis on improving coping/relapse prevention skills during the primary phase of treatment.

Darke S; Havard A; Ross J; Williamson A; Mills KL; Teesson M. Changes in the use of medical services and prescription drugs among heroin users over two years. Drug and Alcohol Review 26(2): 153-159, 2007. (25 refs.)

The study aimed to determine patterns of use of medical services and prescriptions for pharmaceuticals among 438 heroin users interviewed for the Australian Treatment Outcome Study (ATOS) at baseline, 12 and 24 months. Drug use declined markedly, and there were significant improvements in health. There were declines in the proportion of participants who had attended a general practitioner (GP) (baseline: 60%, 12 months: 53%, 24 months: 52%), who had an ambulance attendance ( 11%, 7%, 5%), and who were treated in an accident and emergency department (11%, 6%, 5%). While there was no decrease in the proportion who obtained a prescription (47%, 45%, 46%), there was a decrease in the mean number of reported prescriptions obtained (2.3, 1.0, 0.9). There were also differences across follow- up in the reported types of medications obtained, with a significant decrease in the proportion obtaining psychotropic medications (38%, 21%, 19%). In particular, there were large declines in the proportion who reported benzodiazepines (30%, 12%, 10%) or narcotic analgesics (8%, 3%, 4%) on prescription. While ATOS participants continued to be frequent users of health services, the cohort reported reduced levels of drug- seeking and risk commensurate with their reductions in drug use.

Darke S; Ross J; Williamson A; Mills KL; Havard A; Teesson M. Borderline personality disorder and persistently elevated levels of risk in 36-month outcomes for the treatment of heroin dependence. Addiction 102(7): 1140-1146, 2007. (27 refs.)

Aims: To determine the effects of borderline personality disorder (BPD) on 36-month outcomes for the treatment of heroin dependence. Design: Longitudinal cohort study. Setting Sydney, Australia. Participants A total of 429 heroin users enrolled in the Australian Treatment Outcome Study, interviewed at 36-month follow-up. Findings: The BPD group enrolled in significantly more different treatment episodes across follow-up, but there was no difference in the cumulative number of treatment days received. At 36 months, there were no group differences in sustained or current heroin abstinence, daily heroin use or level of polydrug use. BPD patients maintained significantly higher levels of crime, injection-related health problems, heroin overdose, major depression and poorer global mental health. In contrast to 12-month follow-up, at 36 months there were no group differences in the proportions who attempted suicide over the preceding 12 months or had recently borrowed used injection equipment. Conclusions The clinical picture provided some cause for optimism since 12-month follow-up. Despite this, BPD patients maintained elevated risk levels across a number of domains. The fact that these risks were maintained indicates that this is a group that requires specific clinical attention for BPD-related risks.

Darke S; Ross J; Mills KL; Williamson A; Havard A; Teesson M. Patterns of sustained heroin abstinence amongst long-term, dependent heroin users: 36 months findings from the Australian Treatment Outcome Study (ATOS). Addictive Behaviors 32(9): 1897-1906, 2007. (23 refs.)

Aims: To determine patterns of past month, 12 month and sustained 36 month heroin abstinence. Methods: As part of a longitudinal cohort study, 429 heroin users re-interviewed at 36 month follow-up for the Australian Treatment Outcome Study (ATOS). Results: The proportion who had sustained heroin abstinence since baseline declined from 14% at 12 months to 8% at 36 months. The proportion who reported abstinence over the preceding 12 months, however, increased significantly from 14% at 12 months to 40% at 36 months. There were no significant gender differences in the proportions reporting sustained 36 month abstinence. Females, however, were significantly more likely to have maintained abstinence over the 12 months preceding 36 month follow-up. Independent predictors of sustained abstinence over 36 months were fewer treatment episodes since baseline, not committing crime at baseline and higher levels of global psychological distress. Conclusions: Despite a decline in the proportion who had maintained complete heroin abstinence over 36 months, there were substantial increases in 12 month abstinence patterns. The results illustrate the importance of stable treatment retention.

Darke S; Ross J; Teesson M. The Australian Treatment Outcome Study (ATOS): What have we learnt about treatment for heroin dependence? Drug and Alcohol Review 26(1): 49-54, 2007. (31 refs.)

Opioids make the single largest contribution to illicit drug related mortality and morbidity worldwide In this paper we reflect upon what has been learnt regarding treatment outcome and the natural history of heroin use from the Australian Treatment Outcome Study (ATOS). We focus on what we knew prior to ATOS, what A TOS revealed that is novel, and the implications for research, practice and policy. ATOS provided strong evidence for sustained improvement attributable to treatment across the three years of the study. It is argued that treatment for heroin dependence is money well spent, and leads to clear and sustained benefits to both heroin users and society.

Darke S; Williamson A; Ross J; Mills KL; Havard A; Teesson M. Patterns of nonfatal heroin overdose over a 3-year period: Findings from the Australian Treatment Outcome Study. Journal of Urban Health 84(2): 283-291, 2007. (22 refs.)

To determine annual patterns and correlates of nonfatal heroin overdose across 3 years, data were analyzed on 387 heroin users recruited for the Australian Treatment Outcome Study (ATOS), interviewed at 12, 24, and 36 months. A heroin overdose across follow-up was reported by 18.6%, and naloxone bad been administered to 11.9%. Annual rates of overdose declined between baseline and 12 months and then remained stable. Previous overdose experience was strongly related to subsequent overdose. Those with a history of overdose before ATOS were significantly more likely to overdose during the study period. In particular, there was a strong association between overdose experience in any 1 year and increased overdose risk in the subsequent year. This is the first study to examine long-term annual trends in nonfatal heroin overdose. While overdose rates declined after extensive treatment, substantial proportions continued to overdose in each year, and this was strongly associated with overdose history.

Davoli M; Pasqualini F; Belleudi V; Bargagli AM; Perucci CA. Changing pattern of drug abuse among patients entering treatment in Lazio, Italy, between 1996 and 2003: Transition from heroin to cocaine use. European Addiction Research 13(4): 185-191, 2007. (11 refs.)

Aim: This study describes temporal changes of the pattern of substance abuse among drug users in treatment in Lazio, Italy. Methods: We used individual data from the surveillance system of drug users of the Lazio region. We measured temporal changes in: the number of drug users in treatment, main and any substance of abuse, and mode of referral to treatment. Results: Among new clients, the proportion of heroin use decreased from 78.2% in 1996 to 37.6% in 2003 (p < 0.0001), while cocaine use increased from 4.1% in 1996 to 30.1% in 2003 (p < 0.0001). In 2003, any use of cocaine was reported by 43.1% of new cases as compared to 38.9% taking heroin, 36.8% cannabis and 5.3% other substances, 41.9% using more than one substance. In 2003, 37.7% of new patients were referred to treatment by the police as compared to 10.4% in 1996. Conclusions: Heroin use has been replaced by cocaine among people coming to treatment centres for the first time. The main mode of access to treatment of new cocaine and cannabis users occurred through mandatory referral by the police. Routine surveillance systems of treatment demand are essential to monitor temporal trends of patterns of drug use in order to plan proper treatment strategies.

De Jong CAJ; Roozen HG; van Rossum LGM; Krabbe PFM; Kerkhof JFM. High abstinence rates in heroin addicts by a new comprehensive treatment approach. American Journal on Addictions 16(2): 124-130, 2007. (35 refs.)

In this multi-center, naturalistic study, the effectiveness of naltrexone maintenance combined with the Community Reinforcement Approach (CRA) was investigated in detoxified, opioid-dependent patients (N = 272). Patients were recruited from methadone maintenance programs. With intention-to-treat analysis, 10 months of treatment yielded abstinence rates of 28% and 32% at 10 and 16 months after detoxification. The cumulative abstinence rate at 16 months was 24%. Quality of life, craving, general psychopathology, use of other psychoactive substances, and addiction severity of the abstinent group significantly improved when compared to the relapsed group. This abstinence-oriented approach appears to be a feasible goal, and remains an important option next to long-term methadone maintenance in the management of opioid dependence.

de la Fuente L; Toro C; Brugal MT; Vallejo F; Soriano V; Barrio G et al. Poor validity of self-reported HBV vaccination among young heroin users in Spain supports the policy "don't ask, draw a blood sample, vaccinate and try to schedule another visit". Journal of Clinical Virology 38(1): 87-90, 2007. (14 refs.)

Objectives: To assess the validity of self-reported hepatitis B virus vaccination status in young heroin users. Study design: Cross-sectional study among 949 street-recruited young injection heroin users (IHUs) and non-injection heroin users (NIHUs) in Madrid, Barcelona and Seville. Face-to-face interviews and dried blood spot tested for anti-HBc and anti-HBs. The validity of self-reported vaccination status was assessed comparing with the serological status. The percentage of agreement with the kappa (K) statistic and the positive predictive value were calculated. Results: The percentage of agreement between self-reported and serologic vaccination status was 51.9% overall, with little difference by city (53.1% in Barcelona, 49.0% in Madrid and 51.5% in Seville) or between IHUs (51.3%) and NIHUs (53.0%). All the K scores were lower than 0.1. The positive predictive value of self-reports was less than 25% in all categories analysed, except in the city of Barcelona (37%). Among those who indicated that they had been vaccinated, 31% were actually susceptible. Conclusions: In areas with a high prevalence of infection and rising coverage of vaccination the policy "don't ask, take a blood sample, give a dose of vaccine and try to schedule another visit" should be recommended in clinical practice.

Dickson S; Park A; Nolan S; Kenworthy S; Nicholson C; Midgley J et al. The recovery of illicit drugs from oral fluid sampling devices. Forensic Science International 165(1): 78-84, 2007. (11 refs.)

Testing for drugs in oral fluid is a convenient procedure for determining recent drug use. A number of issues are still to be resolved and this paper investigates the effects of storage systems on drug stability and recovery using three different collection devices supplied by Cozart, Immunalysis and Microgenics (third party). Drugs were analysed using a range of immunoassay systems followed by MS confirmation and quantitation. The reproducibility of the weight of specimen collected was excellent (CV < 10%) for the three collection devices tested. Of the three systems studied, only the Cozart product gave acceptable recovery of THC from drug-spiked oral fluid. A combination of Cozart, Immunalysis and Diagnostix immunoassays with the Cozart collection system gave the most sensitive and discriminating screening assays for the drugs studied, namely THC, benzodiazepines, methamphetamine and morphine. Storage at either 5 degrees C or room temperature had no significant effect on drug recoveries.

DiFrancesco R; Fischl MA; Donnelly J; Zingman BS; McCance-Katz EF; Moody DE. Buprenorphine assay and plasma concentration monitoring in HIV-infected substance users. Journal of Pharmaceutical and Biomedical Analysis 44(1): 188-195, 2007. (34 refs.)

The availability of buprenorphine (BUP) provides an alternative approach to the treatment of opioid addiction with methadone, an agent that has many drug-drug interactions when combined with antiretroviral therapy (ART). However, due to limited long-term pharmacokinetic studies in HIV-infected patients, the clinical use of BUP, a CYP450-3A4 substrate, will require that studies be conducted to examine safety, tolerability and pharmacokinetics when these drugs are taken for chronic treatment. One clinical approach could include plasma concentration monitoring to avoid under- or overdosing BUP secondary to drug interactions with ART. The measurement of BUP and its active metabolite, norbuprenorphine (NBUP) facilitates the addition of BUP to ART in an attempt to avoid drug toxicity as described in a recent report by Bruce et al. Therefore, our objective was to validate a BUP assay and integrate its application into an ongoing antiretroviral (ARV) plasma concentration monitoring program. A chromatographic method for monitoring BUP and its active metabolite, NBUP was investigated. An assay was developed that would facilitate BUP and ARV measurement from a single 3 mL blood sample (0.75 mL plasma required) in conjunction with a previously validated multiple ARV HPLC method. The method measures BUP and NBUP over the range from 0.25 to 50 ng/mL with mass spectrometry detection. Inter- and intra-assay variation was <= 11%, across the concentration range. The method quantitates BUP and NBUP plasma concentrations within the range of expected values from current BUP dosing guidelines. Use of this combined BUP and ARV plasma concentration monitoring approach for a representative patient receiving BUP, atazanavir and efavirenz demonstrated its clinical application.

Dijkstra BAG; De Jong CAJ; Bluschke SM; Krabbe PFM; van der Staak CPF. Does naltrexone affect craving in abstinent opioid-dependent patients? Addiction Biology 12(2): 176-182, 2007. (41 refs.)

Naltrexone blocks the opioid receptors that modulate the release of dopamine in the brain reward system and therefore blocks the rewarding effects of heroin and alcohol. It is generally assumed that naltrexone leads to reduction of craving, but few studies have been performed to prove this. The purpose of the present study was to examine the effect of the administration of naltrexone on craving level after rapid opioid detoxification induced by naltrexone. A naturalistic study was carried out in which patients were followed during 10 months after rapid detoxification. Data about abstinence, relapse, and naltrexone use were collected by means of urine specimens. Craving was measured by the visual analogue scale craving, the Obsessive Compulsive Drug Use Scale, and the Desires for Drug Questionnaire. Results showed that patients who relapsed in opioid use experienced obviously more craving than abstinent people. Patients who took naltrexone did not experience significant less craving than those who did not. These results suggest that the use of opioids is associated with increased craving and that abstinence for opioids is associated with less craving, independent of the use of naltrexone. This is in contrast to the general opinion. Because of the naturalistic design of the study, no firm conclusions can be drawn, but the results grounded the needs of an experimental study.

Dijkstra BAG; Krabbe PFM; Riezebos TGM; van der Staak CPF; De Jong CAJ. Psychometric evaluation of the Dutch version of the Subjective Opiate Withdrawal Scale (SOWS). European Addiction Research 13(2): 81-88, 2007. (23 refs.)

Aim: To evaluate the psychometric properties of the Dutch version of the 16-item Subjective Opiate Withdrawal Scale (SOWS). The SOWS measures withdrawal symptoms at the time of assessment. Methods: The Dutch SOWS was repeatedly administered to a sample of 272 opioid-dependent inpatients of four addiction treatment centers during rapid detoxification with or without general anesthesia. Examination of the psychometric properties of the SOWS included exploratory factor analysis, internal consistency, test-retest reliability, and criterion validity. Results: Exploratory factor analysis of the SOWS revealed a general pattern of four factors with three items not always clustered in the same factors at different points of measurement. After excluding these items from factor analysis four factors were identified during detoxification ('temperature dysregulation', 'tractus locomotorius', 'tractus gastro-intestinalis' and 'facial disinhibition'). The 13-item SOWS shows high internal consistency and test-retest reliability and good validity at different stages of withdrawal. Conclusion: The 13-item SOWS is a reliable and valid instrument to assess opioid withdrawal during rapid detoxification. Three items were deleted because their content does not correspond directly with opioid withdrawal symptoms.

Donoghoe MC; Bollerup AR; Lazarus JV; Nielsen S; Matic S. Access to highly active antiretroviral therapy (HAART) for injecting drug users in the WHO European Region 2002-2004. International Journal of Drug Policy 18(4): 271-280, 2007. (36 refs.)

Providing equitable access to highly active antiretroviral treatment (HAART) to injecting drug users (IDUs) is both feasible and desirable. Given the evidence that IDUs can adhere to HAART as well as non-IDUs and the imperative to provide universal and equitable access to HlV/AlDS treatment for all who need it, here we examine whether IDUs in the 52 countries in the WHO European Region have equitable access to HAART and whether that access has changed over time between 2002 and 2004. We consider regional and Country differences in IDU HAART access; examine preliminary data regarding the injecting status of those initiating HAART and the use of opioid substitution therapy among HAART patients, and discuss how HAART might be better delivered to injecting drug users. Our data adds to the evidence that IDUs in Europe have poor and inequitable access to HAART, with only a relatively small improvement in access between 2002 and 2004. Regional and country comparisons reveal that inequities in IDU access to HAART are worst in eastern European countries.

Druid H; Strandberg JJ; Alkass K; Nystrom I; Kugelberg FC; Kronstrand R. Evaluation of the role of abstinence in heroin overdose deaths using segmental hair analysis. Forensic Science International 168(2-3): 223-226, 2007. (22 refs.)

In the body heroin is rapidly metabolized to 6-acetylmorphine and morphine. Victims of lethal heroin overdose often present with fairly low blood concentrations of morphine. Reduced tolerance due to abstinence has been proposed to account for this finding. The aim of the present study was to examine the role of abstinence in drug-related deaths by comparing recent and past exposure to opioids using segmental hair analysis with the postmortem blood morphine concentrations in deceased heroin users. The study included 60 deceased drug addicts in the Stockholm area, Sweden. In 32 cases, death was not related to heroin intake. In 18 of the 28 heroin fatalities, opioids were absent in the most recent hair segment, suggesting a reduced tolerance to opioids. However, the blood morphine levels were similar to those found in the 10 subjects that showed continuous opioid use. Hair and blood analysis disclosed an extensive use of additional drugs that directly or indirectly may influence the opioid system. The results suggest that abstinence is not a critical factor for heroin overdose death. Obviously tolerant subjects die after intake of similar doses. Other factors, particularly polydrug use, seem to be more causally important for these deaths.

Dunbar NM; Harruff RC. Necrotizing fasciitis: Manifestations, microbiology and connection with black tar heroin. Journal of Forensic Sciences 52(4): 920-923, 2007. (17 refs.)

A 10-year review of records of the King County Medical Examiner's Office found 87 deaths due to necrotizing fasciitis and related necrotizing soft tissue infections. In 64 of these cases there were sufficient details to provide an analysis of the manifestations, microbiology, and source of infection. One half (32) of the cases were due to injection of black tar heroin, the nearly exclusive form of heroin in the Northwest United States. Of those due to black tar injection, 24 were clostridial infections with various species represented, eight of which were Clostridium sordellii. Of the 32 cases not associated with drug injection, streptococcal species predominated, with Streptococcus pyogenes isolated in 14 cases. Only three of 32 cases not associated with injection drug use were clostridial infections. These differences were statistically significant. Staphylococcus aureus was isolated from 14 cases; two were methicillin-resistant strains. Overall, 28 of the 64 cases were polymicrobial infections, 15 due to black tar injection and 13 not associated with drug injection. This study supports the conclusion that necrotizing fasciitis due to black tar heroin injection is predominantly a clostridial disease, and in this way differs significantly from necrotizing fasciitis due to other causes.

Ebejer KA; Winn J; Carter JF; Sleeman R; Parker J; Korber F. The difference between drug money and a "lifetime's savings"'. Forensic Science International 167(2-3): 94-101, 2007. (18 refs.)

In many countries, monies suspected of being associated with drug trafficking can be seized by the authorities. One of the ways of investigating this association is through the analysis of seized banknotes for traces of controlled drugs. We report three studies which may assist the expert in assessing whether banknotes contaminated with diamorphine are part of the general population of notes in circulation or whether they show unusual contamination patterns which require explanation. Study 1 is based on three plausible contamination scenarios as they may occur during the various stages of an illicit drug transaction and seizure. It shows that notes which have been in direct contact with visible traces of diamorphine show significantly higher contamination to those in more indirect contact with the drug. Study 2 investigates the transfer of diamorphine from one highly contaminated note to other notes in a bundle over a period of 10 weeks with and without agitation. It was found that the total amount of drug transferred was smaller than 6% and no more than 4 out of a bundle of 10 previously clean notes became lightly contaminated. Based on extensive background data, study 3 proposes a probabilistic model to assess whether an observed proportion of diamorphine bearing banknotes is likely to have been contaminated by chance. The model predicts that there is only a 0.3% chance that a bundle of 100 notes from the general banknote population contains more than six contaminated specimens. Jointly, the three studies give useful indications for the spread of contamination throughout a sample and the amounts of heroin which may be expected given plausible contamination scenarios.

Ehlers CL; Wall TL; Corey L; Lau P; Gilder DA; Wilhelmsen K. Heritability of illicit drug use and transition to dependence in Southwest California Indians. Psychiatric Genetics 17(3): 171-176, 2007. (56 refs.)

Objective: Native Americans have high rates of drug use and dependence yet little is known concerning its etiology or clinical course. These analyses were conducted to describe the heritability of the use of a variety of illicit drugs, as well as the conditional probability of transitioning from use to dependence for each drug class in a community sample of Native American men and women. Methods: The sample included 460 participants (1190 men and 270 women), recruited through community effort, from eight contiguous Indian reservations in Southern California. Participants were assessed using the Semi-Structured Assessment for the Genetics of Alcoholism. The Semi-Structured Assessment for the Genetics of Alcoholism interview retrospectively asks about the initial use and drug dependence of the following illicit drug classes: marijuana, cocaine, stimulants, sedatives, opiates, hallucinogens, and solvents. Heritability of initial use was determined using SOLAR (http: www.sfbr.orglsolarl). Results: Ninety-one percent of this select Indian population had tried at least one of the illicit drug classes. The most commonly tried substance was marijuana (88%), followed by stimulants (60%), cocaine (44%), hallucinogens (34%), and solvents (20%). The heritability of initiation of drug use ranged from 0.14 for cocaine to 0.59 for marijuana. The conditional probability of transition from initiation to drug dependence ranged from 0.66 for stimulants to 0.06 for hallucinogens. Conclusions: These findings suggest that heritability of the initiation of substance use, in Southwest California Indians, may be similar to other population samples. In this population, however, high rates of dependence on marijuana, opiates, and stimulants are seen once initiation of the use of the substance has occurred.

Ehret GB; Desmeules JA; Broers B. Methadone-associated long QT syndrome: improving pharmacotherapy for dependence on illegal opioids and lessons learned for pharmacology. (review). Expert Opinion on Drug Safety 6(3): 289-303, 2007. (129 refs.)

Methadone is used as the pharmacologic mainstay for substitution for illegal opiates and as analgesic for chronic or cancer-related pain. Given the benefits of methadone substitution for illicit opioids, the finding of an association between methadone and prolongation of cardiac depolarization (QT prolongation) and torsades de pointes is of great concern. QT prolongation can occur with many drugs and is a potentially lethal adverse drug reaction, necessitating risk monitoring and therapeutic alternatives in some patients. Recent studies suggest that QT prolongation with methadone is context dependent: occurrence is more frequent with high doses of methadone, concomitant administration of CYP3A4 inhibitors, hypokalemia, hepatic failure, administration of other QT prolonging drugs and pre-existing heart disease. The valued benefit of methadone substitution therapy on the one hand and the increased cardiovascular risk in particular situations on the other illustrate the difficulties in dealing with drug-induced QT prolongation in general.

Engeland A; Skurtveit S; Morland J. Risk of road traffic accidents associated with the prescription of drugs: A registry-based cohort study. Annals of Epidemiology 17(8): 597-602, 2007. (24 refs.)

PURPOSE: The aim of this study was to examine the risk of a car driver being involved in a road traffic accident while using prescribed drugs. We used data from population-based registries. METHODS: Information on prescriptions, road traffic accidents, and emigrations/deaths was obtained from population-based registries. The incidence of accidents in the exposed person-time was compared with the incidence in the unexposed person-time, by the standardized incidence ratio (SIR). All Norwegians ages 18-69 between April 2004 and September 2005 (3.1 million), were included in the study. RESULTS: A total of 13,000 road traffic accidents with personal injuries were registered. The risk of being involved in an accident was somewhat increased in users of prescribed drugs in the first seven days after the date of dispensing (SIR for both sexes combined = 1.4; 95% confidence interval: 1.3-1.5). The risk was markedly increased in users of natural opium alkaloids (2.0; 1.7-2.4), benzodiazepine tranquillizers (2.9; 2.5-3.5), and benzodiazepine hypnotics (3.3; 2.1-4.7). Somewhat increased or unchanged SIRs were found for nonsteroidal antiiflammatory drugs 0.5; 1.3-1.9), selective beta-2-adrenoreceptor agonists (i.e., antiasthmatics, 1.5; 1.0-2.1), calcium receptor antagonists (0.9; 0.5-1.5), and penicillin (1.1; 0.8-1.5). CONCLUSIONS: The increased risk of being involved in a road accident as driver while receiving prescribed opiates and benzodiazepines supported the results from other studies.

Ersche KD; Sahakian BJ. The neuropsychology of amphetamine and opiate dependence: Implications for treatment. (review). Neuropsychology Review 17(3): 317-336, 2007. (248 refs.)

Chronic use of amphetamines and/or opiates has been associated with a wide range of cognitive deficits, involving domains of attention, inhibitory control, planning, decision-making, learning and memory. Although both amphetamine and opiate users show marked impairment in various aspects of cognitive function, the impairment profile is distinctly different according to the substance of abuse. In light of evidence showing that cognitive impairment in drug users has a negative impact on treatment engagement and efficacy, we review substance-specific deficits on executive and memory function, and discuss possibilities to address these during treatment intervention.

Exley C; Ahmed U; Polwart A; Bloor RN. Elevated urinary aluminium in current and past users of illicit heroin. Addiction Biology 12(2): 197-199, 2007. (12 refs.)

The use of illicit heroin is associated with aberrant neurology of unknown aetiology and various psychiatric illnesses. Aluminium, which is a proven neurotoxin, is present in significant amounts in illicit heroin and may also be volatilized and inhaled following the vaporization of heroin off aluminium foil ('Chasing the Dragon'). The purpose of this study was to establish if the use of illicit heroin was associated with an increase in the body burden of aluminium. We have used graphite furnace atomic absorption spectrometry to measure the aluminium and iron contents of the urine of current and past users of illicit heroin and used these data to estimate body burdens of aluminium. Urinary excretion of aluminium is the most effective non-invasive indicator of the body burden of aluminium and was found to be significantly (P < 0.001) higher in users of illicit heroin, range 14-3382 nmol/mmol creatinine (mean +/- SD; 222 +/- 491 nmol/mmol creatinine), than in a normal non-drug abusing control population, range 23-74 nmol/mmol creatinine (mean +/- SD; 43 +/- 19 nmol/mmol creatinine). Exposure to aluminium from the use of illicit heroin may be of particular significance because the urinary excretion of iron, another major contaminant of illicit heroin, in users (mean +/- SD; 53 +/- 63 nmol/mmol creatinine) was not significantly different (P > 0.05) from the control population (mean +/- SD; 38 +/- 18 nmol/mmol creatinine). We have shown for the first time that the use of illicit heroin may be a significant contributor to the body burden of aluminium. Further research will be required to determine if adventitious aluminium has a role in heroin use-related neuropathology and neurology.

Farrell LJ; Kerrigan S; Logan BK. Recommendations for toxicological investigation of drug impaired driving. Journal of Forensic Sciences 52(5): 1214-1218, 2007. (6 refs.)

Investigation of a suspected alcohol or drug impaired driving (DUID) case ideally contains several key elements, including a trained officer documenting observations of driving and subject behavior, and collection of a biological specimen for comprehensive toxicology testing. There is currently no common standard of practice among forensic toxicology laboratories in the United States as to which drugs should be tested for, and at what analytical cutoff. Having some uniformity of practice among laboratories would ensure that drugs most frequently associated with driving impairment were consistently evaluated, that appropriate methods were used to screen and confirm the presence of drugs, and that more accurate data were collected on the extent of drug use among drivers. A survey of United States laboratories actively involved in providing analytical support to the Drug Evaluation and Classification Program identified marijuana, benzodiazepines, cocaine, prescription and illicit opiates, muscle relaxants, amphetamines, CNS depressants, and sleep aids used as hypnotics, as being the most frequently encountered drugs in these cases. This manuscript presents recommendations as to what specific members of these drug classes should at a minimum be tested for in the investigation of suspected DUID cases. Additionally we include recommendations for analytical cutoffs for screening and confirmation of drugs in blood and urine. Adopting these guidelines would ensure that the most common drugs would be detected, that laboratories could compare epidemiological findings between jurisdictions, and that aggregate national statistics on alcohol and drug use in drivers involved in fatal injury collisions were representative of the true rates of drug use in the driving population.

Fields HL. Understanding how opioids contribute to reward and analgesia. Regional Anesthesia and Pain Medicine 32(3): 242-246, 2007. (37 refs.)

Opioids acting at the mu opioid (MOP) receptor produce powerful analgesia. They also produce an intensely rewarding effect that can lead to addiction. The analgesic effect of MOP receptor agonists derives from a direct inhibitory effect on pain transmission at the spinal-cord level and through activation of a descending pain-modulatory pathway. The rewarding effect of MOP agonists is the result of their actions in the mesostriatal dopamine pathway classically associated with both natural and drug rewards. Both the analgesic and rewarding effect of MOP agonists are best understood in the context of decision making under conditions of conflict. Pain is one of many competing motivational states, and endogenous opioids suppress responses to noxious stimuli in the presence of conflicting motivations, such as hunger or a threatening predator. When a food reward is available, MOP agonists microinjected into the mesostriatal circuit promote its consumption, while concomitantly suppressing responses to noxious stimulation. The mesostriatal "reward" circuit, thus, appears to perform a function critical to decision making and can either amplify or suppress responses to noxious stimuli.

Fischer B; Rehm J. Illicit opioid use in the 21st century: Witnessing a paradigm shift? (review). Addiction 102(4): 499-501, 2007. (26 refs.)

The authors of this editorial note the historical emphasis upon heroin as "the" illicit drug of concern, and a virtual caricature of the nature of the drug problem, and review the treatment approaches, particularly the emergence of drug substitution therapy. It is noted that increasingly heroin use is declining, with prescription opioids now being more widely used which in turn also changes the face of the drug trade. Questions are raised as how to best tackle the misuse of these prescription medications without placing the legitimate use for pain management at risk.

Fishbein DH; Krupitsky E; Flannery BA; Langevin DJ; Bobashev G; Verbitskaya E et al. Neurocognitive characterizations of Russian heroin addicts without a significant history of other drug use. Drug and Alcohol Dependence 90(1): 25-38, 2007. (90 refs.)

Research on the neurocognitive characteristics of heroin addiction is sparse and studies that do exist include polydrug abusers; thus, they are unable to distinguish neurocognitive effects of heroin from those of other drugs. To identify neurocognitive correlates specific to heroin addiction, the present study was conducted in St. Petersburg, Russia where individuals typically abuse and/or become addicted to only one substance, generally alcohol or heroin. Heroin addicts were recruited from an inpatient treatment facility in St. Petersburg. Three comparison groups included alcoholics. addicts who used both alcohol and heroin, and non-abusers. Psychiatric, background, and drug history evaluations were administered after detoxification to screen for exclusion criteria and characterize the sample. Executive Cognitive Functions (ECF) that largely activate areas of the prefrontal cortex and its circuitry measured include complex visual pattern recognition (Paired Associates Learning), working memory (Delayed Matching to Sample), problem solving (Stockings of Cambridge), executive decision making (Cambridge Decision Making Task), cognitive flexibility (Stroop Color-Word Task) and response shifting (Stop Change Task). In many respects, the heroin addicts were similar to alcohol and alcohol + heroin dependent groups in neuroeognitive deficits relative to controls. The primary finding was that heroin addicts exhibited significantly more disadvantageous decision making and longer deliberation times while making risky decisions than the other groups. Because the nature and degree of recovery from drug abuse are likely a function of the type or pattern of neurocognitive impairment, differential drug effects must be considered.

Ford JD; Hawke J; Alessi S; Ledgerwood D; Petry N. Psychological trauma and PTSD symptoms as predictors of substance dependence treatment outcomes. Behaviour Research and Therapy 45(10): 2417-2431, 2007. (56 refs.)

Psychological trauma and post-traumatic stress disorder (PTSD) may complicate and reduce the effectiveness of treatment for substance use disorders (SUDs). This study assessed trauma history and symptoms of simple and complex PTSD at baseline in a randomized trial of contingency management (CM) compared to standard treatment (ST) with 142 cocaine- or heroin-dependent outpatients. History of exposure to each of eight types of psychological trauma was unrelated to treatment outcome, except for witnessed assaults and emotional abuse. Complex PTSD symptoms were inversely associated with short-term treatment outcomes, and PTSD symptoms were positively related to long-term outcome, independent of the effects of demographics, psychological distress, baseline substance use status, and treatment modality. Complex PTSD symptoms warrant further study as a potential negative prognostic factor in SUD interventions.

Forrester MB. Oxycodone abuse in Texas, 1998-2004. Journal of Toxicology and Environmental Health. Part A. Current Issues 70(5-6): 534-538, 2007. (15 refs.)

Oxycodone is frequently abused, and this abuse appears to be increasing. The purpose of this study was to describe the patterns of oxycodone abuse identified by Texas poison control centers. All oxycodone calls received by Texas poison control centers during 1998-2004 were identified. Annual trends and geographic distributions were determined for drug identification (ID) calls and abuse calls. The distribution of abuse calls was then compared to the distribution of all other types of human exposure calls for a variety of factors. Both drug ID and abuse calls involving oxycodone increased over the 7-yr period. The numbers of abuse calls were higher than expected in the central part of Texas, while drug ID calls were higher than expected in eastern and central Texas. A higher proportion of oxycodone abuse than other types of oxycodone exposures involved males, adolescents, exposures at other residences and public areas, referral by the poison control center to a health care facility, and some sort of clinical effect. Oxycodone abuse calls in Texas are increasing. The proportion of calls varies by geographic region. Oxycodone abuse calls differ from other types of exposures with respect to both demographic factors and clinical management and outcome.

Galldiks N; Nolden-Hoverath S; Kosinski CM; Stegelmeyer U; Schmidt S; Dohmen C et al. Rapid geographical clustering of wound botulism in Germany after subcutaneous and intramuscular injection of heroin. Neurocritical Care 6(1): 30-34, 2007. (16 refs.)

Background: Wound infections due to Clostridium botulinum in Germany are rare and occur predominantly in heroin injectors, especially after subcutaneous or intramuscular injection of heroin ("skin popping"), which is; contaminated with spores of C. botulinum. We report a rapid geographical clustering of cases in Germany in a region between Cologne, Bonn, and Aachen with wound botulism and consecutive systemic C. botulinum intoxication in intravenous drug users (IDUs) within 6 weeks in October and November 2005. Patients: A group of 12 IDUs with wound botulism after "skin popping." Results: Clinical data were available in 11 (92%) of 12 patients; in 7 (58%) of the 12 cases, there was cranial nerve involvement including mydriasis, diplopia, dysarthria, and dysphagia, followed by progressing symmetric and flaccid paralysis of proximal muscles of the neck, arms, trunk, and respiratory muscles. Mechanical respiratory support was necessary. Five of the IDUs were treated with antitoxin, but mechanical respiratory support could not be avoided. The mean ventilation duration was 27.4 days (range 6-77 days). In 4 patients (33%), mechanical ventilation could be avoided; two were treated with antitoxin. Conclusions: This report describes rapid geographical clustering of wound botulism with severe respiratory complications in IDUs after "skin popping," which has not previously been reported either in Germany or any other European country. Based on these observations and those in other European countries, we conclude that there is a trend towards "skin popping," suggesting a change in injection practices in IDUs. Secondly, we conclude that the total number of cases with wound botulism is likely to increase because "skin popping" is the main risk factor.

Galynker II; Eisenberg D; Matochik JA; Gertmenian-King E; Cohen L; Kimes AS et al. Cerebral metabolism and mood in remitted opiate dependence. Drug and Alcohol Dependence 90(2/3): 166-174, 2007. (41 refs.)

Background: Opiate-dependent individuals are prone to dysphoria that may contribute to treatment failure. Methadone-maintenance therapy (MMT) may mitigate this vulnerability, but controversy surrounds its long-term use. Little is known about the neurobiology of mood dysregulation in individuals receiving or removed from MMT. Methods: Fifteen opiate-abstinent and 12 methadone-maintained, opiate-dependent subjects, who lacked other Axis I pathology, and 13 control subjects were compared on the Cornell Dysthymia Rating Scale (CDRS) and regional cerebral glucose metabolism (rCMRglc) using [F-18]fluorodeoxyglucose positron emission tomography. Results: CDRS scores showed no group differences. Opiate-abstinent subjects had lower rCMRglc than control subjects in the bilateral perigenual anterior cingulate cortex (ACC), left mid-cingulate cortex, left insula and right superior frontal cortex. Methadone-maintained subjects exhibited lower rCMRglc than control subjects in the left insula and thalamus. In opiate-abstinent subjects, rCMRglc in the left perigenual ACC and mid-cingulate cortex correlated positively with CDRS scores. Conclusions: In remitted heroin dependence, opiate-abstinence is associated with more widespread patterns of abnormal cortical activity than MMT. Aberrant mood processing in the left perigenual ACC and mid-cingulate cortex, seen in opiate-abstinent individuals, is absent in those receiving MMT, suggesting that methadone may improve mood regulation in this population.

Ghiculescu RA; Kubler PA; Gleeson P. Drug utilization evaluation of i.v. paracetamol at a large teaching hospital. Internal Medicine Journal 37(9): 620-623, 2007. (9 refs.)

Background: I. v. paracetamol has recently become available in Australia for the treatment of pain when the oral or rectal administration route is not accessible. Our primary aim was to assess compliance with prescribing guidelines and our secondary aim to evaluate the safety of i.v. paracetamol use (4 g/day) and the effect of patient comorbidities on drug safety. Methods: Eighty-five consecutive patients were identified through the pharmacy dispensing system at a 900-bed, metropolitan, primary care and tertiary referral hospital over a period of 7 months from December 2005 to June 2006. Cross-sectional evaluation by patient interview, review of medical records and pathology parameters were carried out. The study has been approved by the Royal Brisbane and Women's Hospital Human Research Ethics Committee. Results: I.v. paracetamol was given for pain following abdominal surgery (90%) and musculoskeletal pain (10%). The comorbid conditions included severe renal impairment (9.4%), alcohol dependence (3.5%), pre-existing liver failure (2.4%) and malnutrition (18.8%). Prescribing guidelines were not adhered to in 25% of patients. The main cause for discordance observed in 90% of this group was the administration of i.v. paracetamol despite the presence of an alternative route of administration. Eight patients received i.v. paracetamol despite not having had a surgical procedure. Twelve patients received i.v. paracetamol for longer than 48 h; no injection site reactions or toxicity were noted. Conclusion: A lack of concordance between i.v. paracetamol use and prescribing guidelines was identified. There were no new safety concerns.

Ghitza UE; Epstein DH; Preston KL. Nonreporting of cannabis use: Predictors and relationship to treatment outcome in methadone maintained patients. Addictive Behaviors 32(5): 938-949, 2007. (30 refs.)

Underreporting of drug use is common and influenced by multiple factors. Cannabis (THC) use nonreporting and its relationship to heroin and cocaine use were investigated in 690 patients enrolled in 25-to 29-week clinical trials of contingency management plus methadone maintenance. Urine specimens and self-reports of drug use were collected 3 times/week. Potential predictors of THC use nonreporting were analyzed by multiple logistic regression; relationships between THC use nonreporting and % cocaine- and opiate-positive urines were analyzed by multiple regression. Compared to non-THC users (n = 317), patients with THC-positive urines (n = 373) were more likely to be male and have more years of THC use, but were not different on other characteristics. Nonreporting to user ratios were: THC 191/373 (51.2%); opiates 17/686 (2.5%); cocaine 21/681 (3.1%). Predictors of THC use nonreporting were low rate of THC-positive urines during treatment, fewer days of THC use in the last 30 before treatment, African-American race, and absence of antisocial personality disorder. Nonreporting of THC use was associated with significantly greater opiate and cocaine use. Contingency management decreased cocaine use in THC nonreporters to the level of reporters. Nonreporting of THC use is a significant predictor of greater cocaine and heroin use. This association can be eliminated with contingency management therapy.

Ghitza UE; Epstein DH; Schmittner J; Vahabzadeh M; Lin JL; Preston KL. Randomized trial of prize-based reinforcement density for simultaneous abstinence from cocaine and heroin. Journal of Consulting and Clinical Psychology 75(5): 765-774, 2007. (44 refs.)

To examine the effect of reinforcer density in prize-based abstinence reinforcement, heroin/cocaine users (N = 116) in methadone maintenance (100 mg/day) were randomly assigned to a noncontingent control group (NonC) or to I of 3 groups that earned prize draws for abstinence: manual drawing with standard prize density (MS) or computerized drawing with standard (CS) or high (CH) density. Probabilities (prizes/draw) were standard (50%) and high (78%); prize density was double blind. Mean prize values were CH, $286; CS, $167; MS, $139; and NonC, $171. Outcomes were % opioid/cocaine-negative urines during the 12-week intervention and then 8 weeks postintervention as well as diagnosis of dependence up to 6 months poststudy. CH had significantly more negative specimens than did NonC during intervention and had more than all groups during postintervention treatment: Mean % negative (95% confidence interval) during postintervention treatment adjusted for baseline drug use and dropout were CH, 55% (14%-90%); CS, 7% (1%-27%); MS, 4% (1%-12%); and NonC, 3% (1%-10%). Current cocaine dependence diagnoses after treatment were significantly lower in contingent compared with noncontingent groups. Computerized drawing with higher-density prizes enhanced reduction of cocaine use; abstinence reinforcement had long-term therapeutic benefits.

Gibson AE; Degenhardt LJ; Hall WD. Opioid overdose deaths can occur in patients with naltrexone implants. Medical Journal of Australia 186(3): 152-153, 2007. (14 refs.)

From Australian coronial records, we identified five deaths involving implantable naltrexone between 2000 and 2004. One man died from acute narcotism with a naltrexone implant in place and a blood naltrexone level of 0.3 mg/L. A woman died of combined drug effect (including naltrexone) accompanied by severe pain from a naltrexone implant site. These cases indicate that patients can die from opioid overdose with a naltrexone implant and blood naltrexone levels higher than reported blockade levels.

Glatt SJ; Bousman C; Wang RS; Murthy KK; Rana BK; Lasky-Su JA; Zhu SC; Zhang RM; Li JH; Zhang B; Li JX; Lyons MJ; Faraone SV; Tsuang MT. Evaluation of OPRM1 variants in heroin dependence by family-based association testing and meta-analysis. Drug and Alcohol Dependence 90(2/3): 159-165, 2007. (41 refs.)

OPRM1, which codes for the mu-opioid receptor, is the most frequently studied candidate gene for opioid dependence. Despite numerous allelic association studies, no definitive conclusion has been reached regarding the role of OPRM1 polymorphisms in determining risk for opioid dependence. We attempted to resolve this by conducting a family-based association study and meta-analysis which may be more robust and powerful, respectively, than traditional case-control analyses. First, we genotyped three single nucleotide polymorphisms (SNPs) of OPRM1 in 1208 individuals from 473 Han Chinese families ascertained on the basis of having two or more siblings with DSM-IV-defined opioid dependence. The Val6Ala and Arg 1 1 1 His SNPs were detected, but with low minor allele frequencies (0.002 and 0.001, respectively). The Asn40Asp SNP was more informative (minor allele frequency: 0.419), but no significant evidence was observed for either a dominant (p = 0.810) or additive (p = 0.406) effect of this polymorphism on risk for opioid dependence. In addition, a meta-analysis of case-control studies of opioid dependence was performed, and found a similar lack of evidence for an association with the Asn40Asp SNP (p = 0.859). Although a role of OPRM1 polymorphisms ill determining risk for opioid dependence cannot be entirely discounted, a major contribution of the Asn40Asp polymorphism seems unlikely. Further analysis is warranted in samples from specific ancestral groups. In addition, it is critical that other OPRM1 variants, including all haplotype-tagging and amino-acid-coding SNPs, be tested for an influence on risk for opioid dependence, since the Asn40Asp polymorphism is only one of several hundred known mutations in the gene.

Greenwald M; Johanson C-E; Bueller J; Chang Y; Moody DE; Kilbourn M et al. Buprenorphine duration of action: Mu-opioid receptor availability and pharmacokinetic and behavioral indices. Biological Psychiatry 61(1): 101-110, 2007. (64 refs.)

Background: Buprenorphine (BUP) is effective in the treatment of opioid dependence when given on alternating days, probably as a result of long-lasting occupation of [mu] opioid receptors ([mu]ORs). This study examined the duration of action of BUP at [mu]ORs and correlations with pharmacokinetic and pharmacodynamic outcomes in 10 heroin-dependent volunteers. Methods: Availability of [mu]OR (measured with positron emission tomography and [11C]-carfentanil), plasma BUP concentration, opioid withdrawal symptoms, and blockade of hydromorphone (HYD; heroin-like agonist) effects were measured at 4, 28, 52, and 76 hours after omitting the 16 mg/d dose of BUP in a study reported elsewhere. Results: Relative to heroin-dependent volunteers maintained on BUP placebo, whole-brain [mu]OR availability was 30%, 54%, 67%, and 82% at 4, 28, 52, and 76 hours after BUP. Regions of interest showed similar effects. Plasma concentrations of BUP were time dependent, as were withdrawal symptoms, carbon dioxide sensitivity and extent of HYD blockade. Availability of [mu]OR was also correlated with BUP plasma concentration, withdrawal symptoms, and HYD blockade. Conclusions: Together with our previous findings, it appears that [mu]OR availability predicts changes in pharmacokinetic and pharmacodynamic measures and that about 50%-60% BUP occupancy is required for adequate withdrawal symptom suppression (in the absence of other opioids) and HYD blockade.

Gruber SA; Silveri MM; Yurgelun-Todd DA. Neuropsychological consequences of opiate use. (review). Neuropsychology Review 17(3): 299-315, 2007. (102 refs.)

Approximately 3.7 million individuals have used heroin and other opiate substances in their lifetime. Despite increasing knowledge of the effects of heroin, it remains the most abused opiate and use among adults has recently increased. The empirical literature examining the neurocognitive effects of acute and chronic opioid use remains limited; however, findings to date suggest that the use of opiates has both acute and long-term effects on cognitive performance. Neuropsychological data indicate deficits in attention, concentration, recall, visuospatial skills and psychornotor speed with both acute and chronic opioid use. The long-term effects of opiate use appear to have the greatest impact on executive functions, including the ability to shift cognitive set and inhibit inappropriate response tendencies. Factors that contribute to addiction and recovery are also discussed, as it is difficult to disentangle the effects of opiate use on cognitive performance from other factors that may affect neurobehavioral measures.

Gual A. Dual diagnosis in Spain. Drug and Alcohol Review 26(1): 65-71, 2007. (14 refs.)

Our aim is to describe the current situation regarding the diagnosis and treatment of addiction in a variety of settings in Spain. Four-hundred and twenty-seven physicians known to treat addicted patients in non-private settings were recruited and agreed to participate. Each physician provided clinical and anonymous information on the first 6 consecutive patients who attended on a scheduled day. A total of 2361 patients were interviewed (92.1%) and data were obtained concerning gender, age, work, educational level, civil status, addiction diagnosis, type of treatment and psychiatric comorbidity. Seven-hundred and ninety-eight out of 2361 addicts (33.8%) presented with a dual diagnosis. Depression was the most prevalent disorder (21.6%), followed by anxiety disorders (11.7%). Comorbidity was found to be related to age, female gender, divorce and widowhood, and higher educational levels. Alcoholics who abused other drugs showed the highest rates of comorbidity (48.5%), while opiate addicts were at the lower end of the spectrum (27.4%). No differences were found related to the treatment setting, the doctor's medical specialty, or the geographical area. Finally, doctors tended to perceive that dual diagnosis was related to a worse psychiatric prognosis but not to higher relapse rates. Antidepressants were the most commonly prescribed drugs (62.4% of comorbid patients) and anticraving agents were prescribed equally to comorbid and non-comorbid patients. Within the limitations of a descriptive study, our data show that comorbidity is a common clinical problem in patients who access addiction treatment. Affective and anxiety disorders are the most common comorbid diseases, and comorbidity rates seem to be unrelated to regional differences, medical settings or doctor's professional background. Dual diagnosis patients thus account for one third of the clinical workload of addiction specialists in Spain.

Hagan IG; Burney K. Radiology of recreational drug abuse. Radiographics 27(4): 919-U10, 2007. (75 refs.)

Recreational drug abuse is increasing throughout the world. Use of these drugs may result in a diverse array of acute and chronic complications involving almost any body organ, and imaging frequently plays a vital role in detection and characterization of such complications. The nature of the complications depends to a large extent on the drug used, the method of administration, and the impurities associated with the drug. Radiologically demonstrable sequelae may be seen after use of opiates, cocaine, amphetamines and their derivatives such as 3,4-methylenedioxymethamphetamine ("ecstasy"), marijuana, and inhaled volatile agents including amyl nitrite ("poppers") and industrial solvents such as toluene. Cardiovascular complications include myocardial infarction, cardiomyopathy, arterial dissection, false and mycotic aneurysms, venous thromboembolic disease, and septic thrombophlebitis. Respiratory complications may involve the upper airways, lung parenchyma, pulmonary vasculature, and pleural space. Neurologic complications are most commonly due to the cerebrovascular effects of illicit drugs. Musculoskeletal complications are dominated by soft-tissue, bone, and joint infections caused by intravenous drug use. Awareness of the imaging features of recreational drug abuse is important for the radiologist because the underlying cause may not be known at presentation and because complications affecting different body systems may coexist. Intravenous drug abuse in particular should be regarded as a multisystem disease with vascular and infective complications affecting many parts of the body, often synchronously. Discovery of one complication should prompt the radiologist to search for coexisting pathologic conditions, which may alter management.

Hakansson A; Medvedeo A; Andersson M; Berglund M. Buprenorphine misuse among heroin and amphetamine users in Malmo, Sweden: Purpose of misuse and route of administration. European Addiction Research 13(4): 207-215, 2007. (35 refs.)

Buprenorphine misuse by injecting drug users was assessed in a survey of 350 needle exchangers, either amphetamine (57%) or heroin users (42%). 89% of heroin users and 24% of amphetamine users reported using buprenorphine at some time during the previous year. Most users reported illicit acquisition. Among illicit users, 87% of heroin users reported intake for withdrawal treatment or self-detoxification, and 11% for euphoria. Euphoria seeking was more common among amphetamine users (62%, p < 0.001). Intravenous misuse was reported by 43% of illicit users, and snorting by 29%. Sole sublingual intake was more common among heroin users than among amphetamine users (46 vs. 20%, p < 0.05), and less common among patients reporting euphoria seeking (20 vs. 46%, p < 0.05).

Hallinan R; Byrne A; Dore GJ. Harm reduction, hepatitis C and opioid pharmacotherapy: An opportunity for integrated hepatitis C virus-specific harm reduction. Drug and Alcohol Review 26(4): 437-443, 2007. (39 refs.)

While harm reduction advocates, policy makers and practitioners have a right to be proud of the impact of interventions such as needle and syringe programmes on HIV risk, we can be less sanguine about the ongoing high levels of HCV transmission among injecting drug users (IDUs) and the expanding burden of hepatitis C virus (HCV)-related liver disease. In this Harm Reduction Digest Drs Byrne and Hallinan from the Redfern Clinic and Dr Dore from the National Centre in HIV Epidemiology and Clinical Research offer a model of integrated HCV prevention and treatment services within the setting of opioid pharmacotherapy. In their experience, this common-sense approach provides an opportunity to reduce the burden of HCV and improve overall patient management. They believe that the key elements of a HCV-specific harm reduction model include: regular HCV testing; clinical assessment and determination of need for HCV treatment referral; use of broader HCV treatment inclusion criteria; and flexibility in opioid pharmacotherapy dosing. In an environment when our macro harm reduction interventions seem to have, at best, modest impact on HCV transmission, good clinical practice may be our most effective strategy against the HCV epidemic. This paper provides some practical suggestions as to how this can be done.

Hariharan J; Lamb GC; Neuner JM. Long-term opioid contract use for chronic pain management in primary care practice. A five year experience. Journal of General Internal Medicine 22(4): 485-490, 2007. (27 refs.)

BACKGROUND: The use of opioid medications to manage chronic pain is complex and challenging, especially in primary care settings. Medication contracts are increasingly being used to monitor patient adherence, but little is known about the long-term outcomes of such contracts. OBJECTIVE: To describe the long-term outcomes of a medication contract agreement for patients receiving opioid medications in a primary care setting. DESIGN: Retrospective cohort study. SUBJECTS: All patients placed on a contract for opioid medication between 1998 and 2003 in an academic General Internal Medicine teaching clinic. MEASUREMENTS: Demographics, diagnoses, opiates prescribed, urine drug screens, and reasons for contract cancellation were recorded. The association of physician contract cancellation with patient factors and medication types were examined using the Chi-square test and multivariate logistic regression. RESULTS: A total of 330 patients constituting 4% of the clinic population were placed on contracts during the study period. Seventy percent were on indigent care programs. The majority had low back pain (38%) or fibromyalgia (23%). Contracts were discontinued in 37%. Only 17% were cancelled for substance abuse and noncompliance. Twenty percent discontinued contract voluntarily. Urine toxicology screens were obtained in 42% of patients of whom 38% were positive for illicit substances. CONCLUSIONS: Over 60% of patients adhered to the contract agreement for opioids with a median follow-up of 22.5 months. Our experience provides insight into establishing a systematic approach to opioid administration and monitoring in primary care practices. A more structured drug testing strategy is needed to identify nonadherent patients.

Havens JR; Oser CB; Leukefeld CG; Webster JM; Martin SS; O'Connell DJ et al. Differences in prevalence of prescription opiate misuse among rural and urban probationers. American Journal of Drug and Alcohol Abuse 33(2): 309-317, 2007. (15 refs.)

We compared the prevalence of prescription opiate misuse among 2 cohorts of felony probationers (N = 1525). Multiple logistic regression was utilized to determine the independent correlates of prescription opiate misuse among rural (n = 782) and urban (n = 743) probationers participating in an HIV-intervention study. After adjustment for differences in demographic and drug use characteristics, rural participants were almost five times more likely than their urban counterparts to have misused prescription opiates. The prevalence of prescription opiate misuse was significantly higher among the rural probationers; however, given the paucity of illicit opiates and relatively recent emergence of prescription opiates in rural areas, rural substance abuse treatment may be ill-prepared to treat prescription opiate misuse.

Highfield DA; Schwartz RP; Jaffe JH; O'Grady KE. Intravenous and intranasal heroin-dependent treatment-seekers: Characteristics and treatment outcome. Addiction 102(11): 1816-1823, 2007. (31 refs.)

Aims: This study compared the characteristics of intravenous (i.v.) and intranasal (i.n.) heroin users seeking methadone treatment, and their response to treatment. Participants: A total of 319 heroin-dependent adults. Design: Participants were assigned randomly to receive interim methadone treatment or to a waiting list control on a 3 : 2 basis. Analyses were conducted by dividing participants into two groups based on their route of heroin ingestion: i.v. or i.n. Setting A methadone clinic in Baltimore City, Maryland. Intervention: Interim methadone treatment consisted of providing an adequate and stable dose of methadone, but no psychosocial services, to heroin-dependent adults for up to 120 days while they awaited an opening for comprehensive methadone treatment. Measures: Addiction Severity Index, Texas Christian University AIDS Risk Assessment, a questionnaire on treatment entry and a urine drug test were collected at baseline and at entry into a comprehensive treatment program, or at 120 days after baseline assessment, whichever came first. Findings At baseline, over 60% of participants were i.n. users and had been for an average of over 12 years; i.v. users, compared to i.n. users, were more likely to have ever used cocaine, to have used cocaine in the past 30 days, to have more medical complications and to report more income generated from criminal behavior. Both i.v. and i.n. users reduced their self-reported days of heroin use, cocaine use and days of criminal activity in response to interim methadone treatment. Conclusions: Despite differences in baseline characteristics, i.n. and i.v. heroin-dependent individuals did not differ in their response to interim methadone treatment.

Hojsted J; Sjogren P. Addiction to opioids in chronic pain patients: A literature review. (review). European Journal of Pain 11(5): 490-518, 2007. (135 refs.)

Opioids have proven very useful for treatment of acute pain and cancer pain, and in the developed countries opioids are increasingly used for treatment of chronic non-malignant pain patients as well. This literature review aims at giving an overview of definitions, mechanisms, diagnostic criteria, incidence and prevalence of addiction in opioid treated pain patients, screening tools for assessing opioid addiction in chronic pain patients and recommendations regarding addiction problems in national and international guidelines for opioid treatment in cancer patients and chronic non-malignant pain patients. The review indicates that the prevalence of addiction varied from 0% up to 50% in chronic non-malignant pain patients, and from 0% to 7.7% in cancer patients depending of the subpopulation studied and the criteria used. The risk of addiction has to be considered when initiating long-term opioid treatment as addiction may result in poor pain control. Several screening tools were identified, but only a few were thoroughly validated with respect to validity and reliability. Most of the identified guidelines mention addiction as a potential problem. The guidelines in cancer pain management are concerned with the fact that pain may be under treated because of fear of addiction, and the guidelines in management of non-malignant pain patients include warnings of addiction. According to the literature, it seems appropriate and necessary to be aware of the problems associated with addiction during long-term opioid treatment, and specialised treatment facilities for pain management or addiction medicine should be consulted in these cases.

Hser YI. Predicting long-term stable recovery from heroin addiction: Findings from a 33-year follow-up study. Journal of Addictive Diseases 26(1): 51-60, 2007. (43 refs.)

Heroin addiction is increasingly being recognized as a chronic relapsing condition, but relatively little is known about long-term recovery processes among addicts who attain and maintain long periods of abstinence. This study is to identify predictors of long-term stable recovery from heroin addiction based on 242 heroin addicts that have been followed for more than 30 years. Results showed that recovery and non-recovery groups did not differ in deviant behaviors and family/school problems in their earlier lives. Both groups tried formal treatment and self-directed recovery ("self-treatment"), often many times. While the non-recovered addicts were significantly more likely to use substances in coping with stressful conditions, to have spouses who also abused drugs, and to lack non-drug-using social support, stable recovery ten years later was predicted only by ethnicity, self-efficacy, and psychological distress. These findings suggest that in addition to early intervention to curtail heroin addiction, increasing self-efficacy and addressing psychological problems are likely to enhance the odds of maintaining long-term stable recovery.

Hughes K. Migrating identities: the relational constitution of drug use and addiction. Sociology of Health & Illness 29(5): 673-691, 2007. (28 refs.)

This paper aims to develop a properly social conceptualisation of addiction through drawing on analyses of rich, in-depth data from ex/users of heroin. Practices of addiction are considered as in and of themselves constitutive of particular identities, ways of being, and ways of being with and for others. The discussion seeks to demonstrate how heroin use is predicated upon, and productive of, purposeful drug-using relationships in which users produce and reproduce the conditions for continued use (e.g. scoring, grafting, using). Accordingly, the concept of 'dependence' is here reconfigured to encompass both dependence on the provision (and ingestion) of drugs and, simultaneously, dependence upon diverse configurations of users, clinicians, support workers, and so on. The paper makes a critical departure from existing debates in which addiction, even if conceived as a social practice, is nonetheless understood at the level of 'the individual'. It is argued that this tendency towards ontological individualism leads towards conceiving the problem of addiction as residing predominantly in the individual negotiation and, ultimately, resolution of identity narratives. The analyses presented here explore how the migration from addict to non-addict involves more than identity work. Theorisations of t