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Background and Aims: Federal, state and local US governments have sought interventions to reduce deaths due to opioid overdoses by increasing the availability of naloxone. The Affordable Care Act (ACA) expanded Medicaid coverage to low‐income, childless adults, potentially giving this group financial access to naloxone. The aims of this paper are: (1) to describe the changes in the amount of Medicaid‐covered naloxone used between 2009 and 2016 and (2) to quantify the differential change in the amount of dispensed naloxone between states that expanded their Medicaid programs and states that did not. Design A quasi‐experimental approach based on states' ongoing choice to expand their Medicaid program to all adults with incomes between 100 and 138% of the federal poverty line (FPL), starting in 2014. As of 2018, 37 states had expanded and 14 states had not. Estimation of the policy impact relies on a difference‐in‐difference method. Setting: US state Medicaid programs. Participants and measurements: Data are from the Medicaid Drug Rebate Program and include all dispensed prescriptions of naloxone through the Medicaid program. State/quarters with fewer than 10 prescriptions are suppressed; n = 1632. Findings Prior to Medicaid expansion, the number of Medicaid‐covered naloxone prescriptions was very similar in expansion and non‐expansion states. On average, states that expanded Medicaid had 78.2 (95% confidence interval = 16.0–140.3, P = 0.02) more prescriptions per year for naloxone compared with states that did not expand Medicaid coverage, a nearly 10 increase over the pre‐expansion years. Medicaid expansion contributed to this growth in Medicaid‐covered naloxone more than other state‐level naloxone policies. Conclusions: Medicaid accounts for approximately a quarter of naloxone sales. Medicaid expansion generated 8.3% of the growth in naloxone units from 2009 to 2016, holding other factors constant. [ABSTRACT FROM AUTHOR]

The article discusses the potential benefits and risks of long-acting naltrexone in the treatment of opioid-dependent pregnant women. Three specific risks of the treatment are stated including direct effects of naltrexone on fetus, precipitated withdrawal during induction of naltrexone in regular drug users, and women's exposure to opioid relapse and overdose when they stop taking naltrexone after giving birth. The author hopes that the paper will stimulate interest in this challenging field.

ABSTRACT The present paper considers naltrexone to treat opioid dependence during pregnancy. The public health problem of opioid dependence and its treatment during pregnancy is reviewed first. Next, the naltrexone and opioid dependence treatment literature is summarized, with overviews of the pre-clinical and clinical research on prenatal naltrexone exposure. Finally, considerations and recommendations for future medication research for the treatment of opioid dependence in pregnant women are provided. The efficacy of long-acting injectable naltrexone relative to placebo, its blockade of opioid agonist euphoric effects, its lack of abuse and tolerance development and its modest adverse effect profile make it a potential medication for opioid-dependent pregnant women. However, it is not without seriously concerning potential drawbacks, including the difficulty surrounding medication induction that may lead to vulnerability with regard to relapse, physical dependence re-establishment, increased risk behaviors, treatment dropout and resulting opioid overdose. Before embarking on future research with this medication, the benefits and risks for the mother-embryo/fetus/child dyad should be weighed carefully. Should future research be conducted, a multi-level commitment to proactive ethical research is needed to reach the ultimate goal of improving the lives of women and children affected by opioid dependence. [ABSTRACT FROM AUTHOR]

In this article the author discusses a study on long-term heroin assisted treatment (HAT). He states that the paper highlights that HAT can be delivered safely and effectively for patients over extended periods of time. He raises a number of questions regarding the continuing uncertainties of the treatment approach such as how long should it be continued and whether there should be a greater emphasis on encouraging patients to revert back to conventional treatment modalities.

Background and Aims Recently, there has been a growing interest in using opium tincture (OT) for treating opioid dependence in certain regions. We aimed to assess the evidence on its safety and efficacy for this indication. Methods We searched several databases (CENTRAL, Medline, EMBASE, Web of Science, PsychINFO, ProQuest Dissertation and Theses Database, Iran Medex, and who.int/trialsearch) with no language or publication date limitations. Two reviewers selected randomized controlled trials (RCT), cohort/case-control/cross-sectional studies and case-series on safety or efficacy of OT for treating opioid dependence and then extracted reported measures of mentioned outcomes from selected studies. We used the Effective Public Health Practice Project (EPHPP) Quality Assessment tool for appraisal. Results From nine selected studies; in three RCTs and one cohort analytical analysis on detoxification, 110 patients were treated with 15-140 morphine equivalents/day (mEq/d) of OT; in four prospective and one retrospective uncontrolled case-series on long-term/maintenance treatment, 570 patients were treated with 100-400 mEq/d of OT. Only two studies on detoxification included a comparison: one concluded equal efficacy of OT and methadone in suppressing withdrawal symptoms ( P = 0.32) and the other concluded OT to be less efficacious than buprenorphine/naloxone in suppressing withdrawal [OT = 12.20, 95% confidence interval (CI) = 11.00, 13.40]; control: 5.20 (95% CI = 4.69, 5.71) and craving (OT = 303.0, 95% CI = −144.664, 750.664; control: 0.0) but not significantly different ( P = 0.26) in retaining participants in treatment. No major adverse events were reported. Conclusions Conclusive recommendations about the safety and efficacy of opium tincture for treating opioid dependence are not possible at this time. [ABSTRACT FROM AUTHOR]

The author discusses the article "Naltrexone in the treatment of opioid-dependent pregnant women: the case for a considered and measured approach to research" by H. E. Jones and colleagues in the April 2012 issue. The author hopes that the paper will initiate an international project enabling a gradual increase of knowledge on naltrexone treatment efficiency with the possibility of detecting early signs of long-term developmental problems.

Background and aims: The province of British Columbia (BC) Canada has experienced a rapid increase in illicit drug overdoses and deaths during the last 4 years, with a provincial emergency declared in April 2016. These deaths have been driven primarily by the introduction of synthetic opioids into the illicit opioid supply. This study aimed to measure the combined impact of large‐scale opioid overdose interventions implemented in BC between April 2016 and December 2017 on the number of deaths averted. Design We expanded on the mathematical modelling methodology of our previous study to construct a Bayesian hierarchical latent Markov process model to estimate monthly overdose and overdose‐death risk, along with the impact of interventions. Setting and Cases: Overdose events and overdose‐related deaths in BC from January 2012 to December 2017. Interventions: The interventions considered were take‐home naloxone kits, overdose prevention/supervised consumption sites and opioid agonist therapy Measurements Counterfactual simulations were performed with the fitted model to estimate the number of death events averted for each intervention and in combination. Findings Between April 2016 and December 2017, BC observed 2177 overdose deaths (77% fentanyl‐detected). During the same period, an estimated 3030 (2900–3240) death events were averted by all interventions combined. In isolation, 1580 (1480–1740) were averted by take‐home naloxone, 230 (160–350) by overdose prevention services and 590 (510–720) were averted by opioid agonist therapy. Conclusions: A combined intervention approach has been effective in averting overdose deaths during British Columbia's opioid overdose crisis in the period since declaration of a public health emergency (April 2016–December 2017). However, the absolute numbers of overdose deaths have not changed. [ABSTRACT FROM AUTHOR]

Abstract: Background and aim: This is a follow‐up study of a previously published randomized clinical trial conducted in Norway that compared extended‐release naltrexone (XR‐NTX) to buprenorphine–naloxone (BP‐NLX) over 3 months. At the conclusion of the trial, participants were offered their choice of study medication for an additional 9 months. While BP‐NLX was available at no cost through opioid maintenance treatment programmes, XR‐NTX was available only through study participation, accounting for why almost all participants chose XR‐NTX in the follow‐up. The aim of this follow‐up study was to compare differences in outcome between adults with opioid dependence continuing XR‐NTX and those inducted on XR‐NTX for a 9‐month period, on measures of effectiveness, safety and feasibility. Design: In this prospective cohort study, participants were either continuing XR‐NTX, changed from BP‐NLX to XR‐NTX or re‐included into the study and inducted on XR‐NTX treatment. Setting: Five urban, out‐patient addiction clinics in Norway. Participants: Opioid‐dependent adults continuing (n = 54) or inducted on (n = 63) XR‐NTX. Intervention: XR‐NTX administrated as intramuscular injections (380 mg) every fourth week. Measurements: Data on retention, use of heroin and other illicit substances, opioid craving, treatment satisfaction, addiction‐related problems and adverse events were reported every fourth week. Findings: Nine‐month follow‐up completion rates were 51.9% among participants continuing XR‐NTX in the follow‐up and 47.6% among those inducted on XR‐NTX. Opioid abstinence rates were, respectively, 53.7 and 44.4%. No significant group differences were found in use of heroin and other opioids. Conclusions: Opioid‐dependent individuals who elect to switch from buprenorphine–naltrexone treatment after 3 months to extended‐release naltrexone treatment for 9 months appear to experience similar treatment completion and abstinence rates and similar adverse event profiles to individuals who had been on extended‐release naltrexone from the start of treatment. [ABSTRACT FROM AUTHOR]

In this article the author explores whether or not take-home naloxone (THN), an opioid antagonist, availability might increase opioid use. Naloxone saves lives by preventing opioid overdose. A discussion of how to measure unintended consequences of THN is also offered as is a look at policy response.

Abstract: Background and Aims: Extended‐release naltrexone (XR‐NTX), a μ‐opioid receptor antagonist for prevention of relapse to opioid dependence, has demonstrated efficacy compared with placebo and comparative effectiveness with buprenorphine–naloxone. We report outcomes for XR‐NTX in Vivitrol's Cost and Treatment Outcomes Registry. Design: Observational, open‐label, single‐arm, multi‐center registry assessing baseline characteristics and clinical and health‐related quality‐of‐life outcomes associated with XR‐NTX treatment in clinical practice. Setting: 32 US treatment centers from 2011 to 2013. Participants: Patients with opioid dependence who were prescribed XR‐NTX treatment and then enrolled into the registry. Measurements: Monthly visits were evaluated for the full population and for patient ubgroups retrospectively, defined by injection number, focusing on the period between baseline and month 6 (1‐, 2/3‐ or 6‐XR‐NTX). Findings: Of 403 enrolled patients, 395 were analyzed. Most patients (n = 349) received out‐patient care. On average, patients received five injections (median = 3; range = 1–25). The median number of injections administered within 6 months was higher in patients who at baseline were employed (three versus two unemployed, P = 0.02) or had private insurance (five versus two self‐payment, P = 0.005; versus two state‐funded, P < 0.001). The 1‐, 2/3‐ and 6‐XR‐NTX groups had 132, 152 and 111 patients, respectively. At baseline, the 6‐XR‐NTX patients were more likely to meet normal/minimal mental illness criteria and attend school and less likely to report recent drug use. Within 6 months, the 6‐XR‐NTX group demonstrated improvements in employment, mental health and psychosocial functioning, and decreases in opioid craving, drug use and drug‐related behavior. Conclusions: Among opioid‐dependent people receiving XR‐NTX treatment, better mental health, higher education and lower recent drug use at baseline are associated with greater treatment duration; in turn, longer treatment duration is associated with lower relapse rates and improved outcomes generally. [ABSTRACT FROM AUTHOR]

Background and aims Prescription opioid overdose is a leading cause of injury-related morbidity and mortality in the United States. We aimed to identify characteristics associated with clinical severity in emergency department patients with prescription opioid overdose. Design This was a secondary data analysis of adult prescription opioid overdoses from a large prospective cohort of acute overdoses. We examined elements of a typical emergency department evaluation using a multivariable model to determine which characteristics were associated with clinical severity, specifically severe respiratory depression (SRD). Setting This study was conducted at two urban academic emergency departments in New York City, USA. Participants Adult patients who presented with acute prescription opioid overdose between 2009 and 2013 were included in the current study. We analyzed 307 patients (mean age = 44.7, 42% female, 2.0% mortality). Measurements Patient demographics, reported substances ingested, suspected intent for ingesting the substance, vital signs, laboratory data, treatments including antidotes and intubation and outcome of death were recorded by trained research assistants. Intent was categorized into four mutually exclusive categories: suicide, misuse, therapeutic error and undetermined. The primary outcome was SRD, defined as administration of either (a) naloxone or (b) endotracheal intubation (ETI). Findings A total of 109 patients suffered SRD with 90 patients receiving naloxone alone, nine ETI alone and 10 both naloxone and ETI. The most common opioids were oxycodone ( n = 124) and methadone ( n = 116). Mean age was higher in patients with SRD (51.1 versus 41.1, P < 0.001). Opioid misuse was associated with SRD in the multivariable analysis [odds ratio (OR) = 2.07, 95% confidence interval (CI) = 1.21-3.55]. The unadjusted relative risk of SRD was high for fentanyl (83.3% SRD) and lowest for codeine (3.6% SRD). Conclusion In emergency department patients in the United States with prescription opioid overdose, worse clinical severity was associated with opioid misuse, increased with age and was widely variable, depending on the specific opioid medication involved. [ABSTRACT FROM AUTHOR]

Background and Aims It has been suggested that distributing naloxone to people who inject drugs (PWID) will lead to fewer attendances by emergency medical services at opioid-related overdose incidents if peer administration of naloxone was perceived to have resuscitated the overdose victim successfully. This study evaluated the impact of a national naloxone programme (NNP) on ambulance attendance at opioid-related overdose incidents throughout Scotland. Specifically, we aimed to answer the following research questions: is there evidence of an association between ambulance call-outs to opioid-related overdose incidents and the cumulative number of 'take-home naloxone' (THN) kits in issue; and is there evidence of an association between ambulance call-outs to opioid-related overdose incidents in early adopter (pilot) or later adopting (non-pilot) regions and the cumulative number of THN kits issued in those areas? Design Controlled time-series analysis. Setting Scotland, UK, 2008-15. Participants Pre-NNP implementation period for the evaluation was defined as 1 April 2008 to 31 March 2011 and the post-implementation period as 1 April 2011 to 31 March 2015. In total, 3721 ambulance attendances at opioid-related overdose were recorded for the pre-NNP implementation period across 158 weeks (mean 23.6 attendances per week) and 5258 attendances across 212 weeks in the post-implementation period (mean 24.8 attendances per week). Intervention Scotland's NNP; formally implemented on 1 April 2011. Measurements Primary outcome measure was weekly incidence (counts) of call-outs to opioid-related overdoses at national and regional Health Board level. Data were acquired from the Scottish Ambulance Service (SAS). Models were adjusted for opioid replacement therapy using data acquired from the Information Services Division on monthly sums of all dispensed methadone and buprenorphine in the study period. Models were adjusted further for a control group: weekly incidence (counts) of call-outs to heroin-related overdose in the London Borough area acquired from the London Ambulance Service. Findings There was no significant association between SAS call-outs to opioid-related overdose incidents and THN kits in issue for Scotland as a whole (coefficient 0.009, 95% confidence intervals = −0.01, 0.03, P = 0.39). In addition, the magnitude of association between THN kits and SAS call-outs did not differ significantly between pilot and non-pilot regions (interaction test, P = 0.62). Conclusions The supply of take-home naloxone kits through a National Naloxone Programme in Scotland was not associated clearly with a decrease in ambulance attendance at opioid-related overdose incidents in the 4-year period after it was implemented in April 2011. [ABSTRACT FROM AUTHOR]

The author discusses the article "Dual dilemma – should naltrexone be used in the treatment of opioid-dependent pregnant women?" by Maxine L. Stitzer in the January 2013 online issue. According to the author, the discussion has found common ground which includes the need for research on naltrexone for the treatment of opioid-dependent pregnant women considering the short and long-term teratogenic effects and the ethical concerns should be paramount to the research.

This section offers news briefs on relating to addiction as of June 2016. It announces the implementation of the Cigarettes and Other Tobacco Products (Packaging and Labelling) Amendment Rules 2014 in India. It reports the prescription drug monitoring to be introduced in Victoria to prevent overdoses, as well as the ruling by the Texas Supreme Court upholding a state Supreme Court decision to impose a special tax on cigarette makers.

Aims To estimate the prevalence and burden of disease attributable to opioid dependence globally, regionally and at country level. Methods Multiple search strategies: (i) peer-reviewed literature searches; (ii) systematic searches of online databases; (iii) internet searches; (iv) consultation and feedback from experts. Culling and data extraction followed protocols. Dis Mod- MR, the latest version of the generic disease modelling system, a Bayesian meta-regression tool, imputed prevalence by age, year and sex for 187 countries and 21 regions. Disability weight for opioid dependence was estimated through population surveys and multiplied by prevalence data to calculate the years of life lived with disability ( YLDs). Opioid dependence premature mortality was computed as years of life lost ( YLLs) and summed with YLDs to calculate disability-adjusted life years ( DALYs). Results There were 15.5 million opioid-dependent people globally in 2010 [0.22%, 95% uncertainty interval (UI) = 0.20-0.25%]. Age-standardized prevalence was higher in males (0.30%, 95% UI = 0.27-0.35%) than females (0.14%, 95% UI = 0.12-0.16%), and peaked at 25-29 years. Prevalence was higher than the global pooled prevalence in Australasia (0.46%, 95% UI = 0.41-0.53%), western Europe (0.35%, 95% UI = 0.32-0.39) and North America (0.30%, 95% UI = 0.25-0.36). Opioid dependence was estimated to account for 9.2 million DALYs globally (0.37% of global DALYs) in 2010, a 73% increase on DALYs estimated in 1990. Regions with the highest opioid dependence DALY rates were North America (292.1 per 100 000), eastern Europe (288.4 per 100 000), Australasia (278.6 per 100 000) and southern sub- Saharan Africa (263.5 per 100 000). The contribution of YLLs to opioid dependence burden was particularly high in North America, eastern Europe and southern sub- Saharan Africa. Conclusion Opioid dependence is a substantial contributor to the global disease burden; its contribution to premature mortality (relative to prevalence) varies geographically, with North America, eastern Europe and southern sub-Saharan Africa most strongly affected. [ABSTRACT FROM AUTHOR]

Aims This study investigates the relationship between frequency of attendance at Narcotics Anonymous and Alcoholics Anonymous (NA/AA) meetings and substance use outcomes after residential treatment of drug dependence. It was predicted that post-treatment NA/AA attendance would be related to improved substance use outcomes. Methods Using a longitudinal, prospective cohort design, interviews were conducted with drug-dependent clients ( n = 142) at intake to residential treatment, and at 1 year, 2 years and 4–5 years follow-up. Data were collected by structured interviews. All follow-up interviews were carried out by independent professional interviewers. Findings Abstinence from opiates was increased throughout the 5-year follow-up period compared to pre-treatment levels. Clients who attended NA/AA after treatment were more likely to be abstinent from opiates at follow-up. Abstinence from stimulants increased at follow-up but (except at 1-year follow-up) no additional benefit was found for NA/AA attendance. There was no overall change in alcohol abstinence after treatment but clients who attended NA/AA were more likely to be abstinent from alcohol at all follow-up points. More frequent NA/AA attenders were more likely to be abstinent from opiates and alcohol when compared both to non-attenders and to infrequent (less than weekly) attenders. Conclusions NA/AA can support and supplement residential addiction treatment as an aftercare resource. In view of the generally poor alcohol use outcomes achieved by drug-dependent patients after treatment, the improved alcohol outcomes of NA/AA attenders suggests that the effectiveness of existing treatment services may be improved by initiatives that lead to increased involvement and engagement with such groups. [ABSTRACT FROM AUTHOR]

The article presents news on addiction. Figures released by the U.S. Centers for Disease Control and Prevention and Great Britain's Office for National Statistics indicate that smoking rates declined between 2005 and 2013 in the U.S. and between 2012 and 2013 in Great Britain. A "BBC News" report indicated that Harsh Vardham, India's Health Minister, announced new regulations which require health warnings to cover 85% of the surface of tobacco packages beginning on April 1, 2015.The World Health Organization (WHO) has released new guidelines titled "Community Management of Opioid Overdose".

The author discusses pregnancy and the potential role of opioid antagonists in the treatment of opioid dependence, particularly in comparison to opioid agonist maintenance treatment (OAMT). The author says that OAMT outperforms all other treatments. He concludes that if long-acting opioid antagonists do turn out to have similar or better treatment outcomes to OAMT in the non-pregnant opioid-dependent population, it will generate interest in them from pregnant opioid-dependent women.

An editorial is presented which addresses the authors' views about the potential expansion of access to medicinal cannabis (medical marijuana) as a means of reducing opioid overdose deaths in the U.S. and Canada. According to the article, ecological studies do not show that medical cannabis use directly reduces opioid use. Increased access to methadone- and buprenorphine-assisted treatments for opioid dependence is assessed.

The article presents author's views regarding accessment of opioid substitution therapy in prison. He discusses several facts which includes utility in reducing heroin use, injecting and syringesharing in prison and increasing post-release treatment entry and retention, absence of effective transitional programmes and increase in the risk of vulnerable people between the prison health services and community health services.