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Prescription monitoring programs: Best practice and Canadian program review
Abstract / Drug and Alcohol Dependence 156 (2015) e183–e245
the amount spent on cocaine as a predictor of smoking (p = 0.01). Specifically, patients receiving MAS-XR spent $43 more on cocaine to increase their smoking by 1 cigarette, while patients receiving placebo spent $56 more on cocaine for the same result. Conclusions: Cocaine use correlates with smoking habits in both MAS-XR and placebo treated patients. For those who continue to use cocaine, MAS-XR with concurrent cocaine use may trigger greater smoking among ADHD/cocaine dependent smokers when compared to the placebo group. Financial Support: NIDA:1R25DA03516101 RFMH:1RO1DA23652/RO1DA23651. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.562 Modulation of reinstated polydrug (cocaine/heroin) seeking by noradrenergic ␣2 agonists Roger D. Spealman 1,∗ , Jack Bergman 2 1
New England Primate Research Center, Harvard Medical School, Southborough, MA, United States 2 McLean Hospital, Harvard Medical School, Belmont, MA, United States Aims: Noradrenergic ␣2 agonists can alleviate opioid withdrawal and have been proposed for prevention of relapse to stimulant abuse. We investigated the potential of these drugs for attenuating relapse to polydrug (cocaine/heroin) abuse using a nonhuman primate model of reinstated drug seeking. Methods: Squirrel monkeys were trained to respond under concurrent second-order FR10 (FR5:S) schedules of i.v. cocaine/heroin (10:1) self-administration and milk delivery. Responding on the drug-associated lever subsequently was reduced to <10% of baseline by discontinuing drug injections and presentations of the drug-paired stimulus, while keeping the concurrent schedule of milk delivery intact. We next determined the degree to which drug seeking could be reinstated by: (1) restoring the drug-paired stimulus, (2) priming with a 10:1 cocaine/heroin mixture, or (3) priming + restoration of the drug-paired stimulus. Each condition was studied after pretreatment with vehicle or doses of ␣2 agonists that had no significant effects on an inventory of unconditioned behaviors: 0.1 mg/kg clonidine, 0.1 mg/kg lofexidine, 1.0 mg/kg guanfacine, and 0.03 mg/kg brimonidine. Results: Pretreatment with each ␣2 agonist attenuated reinstatement of drug-seeking induced by cocaine/heroin priming and had less effect on reinstatement induced by the drug-paired stimulus. Clonidine, lofexidine, and guanfacine also attenuated the more pronounced reinstatement induced by priming + restoration of the drug-paired stimulus. Additionally, clonidine and lofexidine reduced % responding on the drug-associated lever when reinstatement was induced by priming alone and/or priming + restoration of the drug-paired stimulus. Conclusions: The profile of effects seen with clonidine and lofexidine (attenuation of reinstated responding with a reduction in % responding on drug lever) suggests a selective effect of these ␣2 agonists on reinstated drug seeking and encourages further evaluation of their potential for polydrug relapse prevention. Financial Support: NIH grants DA031299, RR00168 and OD011103. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.563
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Applying SBIRT to new settings: Preliminary findings of substance use disorder risk in community mental health settings Suzanne E. Spear 2,∗ , Mitch Karno 3 , Suzette Glasner-Edwards 3 , R. Rawson 3 , Richard Saitz 1 , Blanca Dominguez 3 1 Community Health Sciences, Boston University and Boston Medical Center, Boston, MA, United States 2 Health Sciences, California State University, Northridge, Northridge, CA, United States 3 Psychiatry, UCLA Integrated Substance Abuse Programs, Los Angeles, CA, United States
Aims: Screening, Brief Intervention, and Referral to Treatment (SBIRT) has not yet been tested in community mental health treatment settings despite the elevated risk of substance use disorders (SUD) among individuals with mental health disorders. This presentation reports on preliminary findings of SUD risk among 334 adult participants treated in community mental health clinics in Southern California. SUD risk was calculated from the AUDIT and DAST-10 screening tools. Methods: All participants are currently enrolled in a randomized controlled trial of SBIRT. Participants were recruited from four outpatient clinics and one inpatient clinic. High risk for SUDs was defined by scores on the AUDIT (≥13 for women and ≥15 for men) and the DAST-10 (≥3 for women and men). Associations between SUD risk and presence of mood disorders, anxiety disorders, and psychotic disorders were examined using chi-square tests. Results: Results showed that 37% of participants were at high risk for alcohol disorders and 66% of participants were at high risk for illicit drug use disorders. Alcohol disorder risk was significantly associated with mood disorders (2 = 13.25, p < .01) and anxiety disorders (2 = 8.6, p < .05). Illicit drug use disorder risk was significantly associated with anxiety disorders (2 = 25.96, p < .001). Presence of psychotic disorders was not associated with SUD risk. Conclusions: High rates of SUD risk in this community mental health sample were found. Participants with mood and/or anxiety disorders were found to be at high risk of SUDs. Subsequent research will test the efficacy of SBIRT for reducing SUD risk and linking participants with possible SUDs to treatment. Financial Support: Supported by NIDA grant R01DA032733. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.564 Prescription monitoring programs: Best practice and Canadian program review Beth Sproule 1,2 1
Centre for Addiction and Mental Health, Toronto, ON, Canada 2 University of Toronto, Toronto, ON, Canada Aims: Prescription monitoring programs (PMPs) are one important component of an overall strategy in addressing prescription drug abuse. The objectives of this review were to examine research evidence to support best practices in PMPs and to review PMPs in Canada. Methods: As an update to a previous review, a search from 2012 to May 2014 was conducted using PubMed, PsycINFO, Project Cork and Google Scholar to identify articles about the effectiveness of PMPs. Search terms included: prescription drug monitoring, prescription monitoring, doctor shopping, multiple prescribers, unsolicited reporting, proactive reporting and controlled substance monitoring. Grey literature sources included individual PMP websites, PMP organization websites and Google. Information on the
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Abstract / Drug and Alcohol Dependence 156 (2015) e183–e245
features and practices of the PMPs in Canada was obtained by reviewing program websites and telephone interviews conducted with key contacts from each program. Results: PMPs have varied features and practices, including models of administrative oversight, drugs targeted for monitoring, methods of data collection, types of interventions and degree of information sharing. There are very few research studies evaluating the effectiveness of PMP features or overall performance; primarily observational studies are available. Several best practice recommendations have been suggested based on opinion and experience. In Canada, there are currently seven provinces operating some form of a PMP and two provinces with programs in development; all have different histories and features and are not linked. Conclusions: There is limited supporting research evidence for most aspects of PMPs at this time, although there is growing research attention in the area, and the number of research reports is increasing each year. As programs across Canada continue to be developed and expanded, further work is needed to evaluate the various features of PMPs to determine their impact, and to establish the overall value of PMPs in promoting the safe and effective use of prescription products that are associated with significant harms. Financial Support: Alberta Health. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.565 Health related issues among people who inject drugs in Australia Jennifer Stafford ∗ , Lucy Burns National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia Aims: The Illicit Drug Reporting System (IDRS) monitors the price, purity and availability and use of illicit drugs annually in Australia. The IDRS focuses mainly on: heroin and other opioids, methamphetamines, cocaine and cannabis. The IDRS also looks at other issues related to drug use including injection-related problems and mental health. This presentation provides a closer look at health-related issues among people who inject drugs interviewed in the 2014 IDRS. Methods: The IDRS involves the collection and analysis of three data sources: (1) interviews with people who inject drugs (IDRS), (2) interviews with experts who work with drug users such as treatment personnel and (3) existing databases on drug-related issues such as customs and overdose data. Results: Nationally, around 900 people who inject drugs were interviewed for the IDRS in 2014. Less than one-fifth of people who injected drugs reported lending a needle or using a needle after somebody else. Around one-quarter reported sharing injecting equipment (not including needles), around half re-used their own needle and over half re-used injecting equipment. Over half reported an injection-related issue in the last month, mainly scarring/bruising. Self-reported mental health problems in the last six months were reported by around half of the national sample. The most common mental health problem reported was depression followed by anxiety. IDRS participants reported higher levels of distress on the Kessler Psychological Distress Scale 10 compared to the Australian general population. Conclusions: A greater understanding of the health-related issues among people who inject drugs regularly is required to better inform policy decisions and treatment delivery.
Financial Support: The IDRS Project is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvement Grants Fund. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.566 Does urban size and region predict outpatient substance abuse treatment completion? Gerald Stahler ∗ , Jeremy Mennis Geography & Urban Studies, Temple University, Philadelphia, PA, United States Aims: This study examines the influence of urban size and region on the likelihood of treatment completion for outpatient settings using the 2011 SAMHSA TEDS-D dataset. Methods: Logistic regression was employed using treatment completion as the dependent variable (N = 897,888). Two geographic variables served as independent variables. ‘City size’ is a five-class ordinal variable representing the population of the U.S. Census metropolitan or micropolitan region in which the subject resides, ranging from areas with a population of less than 50,000 to greater than 750,000. ‘Geographic division’ distinguishes among the ten U.S. Census-defined regional divisions of the U.S. (e.g. Mid-Atlantic, New England). The Mid-Atlantic division (New York, Pennsylvania, and New Jersey), which is the division with the highest number of subjects in the data set, served as the reference category. We also controlled for the subject’s age, race, sex, primary substance use problem, and severity of use. Results: The resulting model had an overall percentage correct = 60.4%, and a Receiver Operating Curve (ROC) analysis resulted in an Area Under the Curve = 0.63, p < 0.005). Results indicate that larger city size is associated with a greater likelihood of treatment completion, and while the city size odds ratio is relatively small (OR = 1.05, p < 0.005), it is of greater magnitude than the odds ratio for sex (where males are significantly more likely to complete treatment). Geographic division was also highly significant, with certain divisions such as the Mountain division (e.g. Colorado, Utah) showing a particularly higher likelihood of treatment completion (OR = 2.07, p < 0.005) compared to the Mid- Atlantic division. Other divisions, such as the East North Central division (e.g., Ohio and Michigan) showed a significantly lower likelihood (OR = 0.73, p < 0.005). Conclusions: Treatment effectiveness at a system level may be improved by examining these geographic variations in outpatient outcomes. Further research needs to identify the reasons for these locational differences in treatment completion. Financial Support: None. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.567 Effects of varenicline and GZ-793A on methamphetamine and food self-administration under a multiple schedule of reinforcement in rats Dustin J. Stairs 1,∗ , Megan Kangiser 1 , Markus N. Pfaff 1 , Sarah Ewin 1 , Linda P. Dwoskin 2 1 Psychology, Creighton University, Omaha, NE, United States 2 Pharmaceutical Sciences, University of Kentucky, Lexington, KY, United States
Aims: Currently there is no FDA pharmacological treatment for methamphetamine (METH) addiction. A widely accepted
the amount spent on cocaine as a predictor of smoking (p = 0.01). Specifically, patients receiving MAS-XR spent $43 more on cocaine to increase their smoking by 1 cigarette, while patients receiving placebo spent $56 more on cocaine for the same result. Conclusions: Cocaine use correlates with smoking habits in both MAS-XR and placebo treated patients. For those who continue to use cocaine, MAS-XR with concurrent cocaine use may trigger greater smoking among ADHD/cocaine dependent smokers when compared to the placebo group. Financial Support: NIDA:1R25DA03516101 RFMH:1RO1DA23652/RO1DA23651. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.562 Modulation of reinstated polydrug (cocaine/heroin) seeking by noradrenergic ␣2 agonists Roger D. Spealman 1,∗ , Jack Bergman 2 1
New England Primate Research Center, Harvard Medical School, Southborough, MA, United States 2 McLean Hospital, Harvard Medical School, Belmont, MA, United States Aims: Noradrenergic ␣2 agonists can alleviate opioid withdrawal and have been proposed for prevention of relapse to stimulant abuse. We investigated the potential of these drugs for attenuating relapse to polydrug (cocaine/heroin) abuse using a nonhuman primate model of reinstated drug seeking. Methods: Squirrel monkeys were trained to respond under concurrent second-order FR10 (FR5:S) schedules of i.v. cocaine/heroin (10:1) self-administration and milk delivery. Responding on the drug-associated lever subsequently was reduced to <10% of baseline by discontinuing drug injections and presentations of the drug-paired stimulus, while keeping the concurrent schedule of milk delivery intact. We next determined the degree to which drug seeking could be reinstated by: (1) restoring the drug-paired stimulus, (2) priming with a 10:1 cocaine/heroin mixture, or (3) priming + restoration of the drug-paired stimulus. Each condition was studied after pretreatment with vehicle or doses of ␣2 agonists that had no significant effects on an inventory of unconditioned behaviors: 0.1 mg/kg clonidine, 0.1 mg/kg lofexidine, 1.0 mg/kg guanfacine, and 0.03 mg/kg brimonidine. Results: Pretreatment with each ␣2 agonist attenuated reinstatement of drug-seeking induced by cocaine/heroin priming and had less effect on reinstatement induced by the drug-paired stimulus. Clonidine, lofexidine, and guanfacine also attenuated the more pronounced reinstatement induced by priming + restoration of the drug-paired stimulus. Additionally, clonidine and lofexidine reduced % responding on the drug-associated lever when reinstatement was induced by priming alone and/or priming + restoration of the drug-paired stimulus. Conclusions: The profile of effects seen with clonidine and lofexidine (attenuation of reinstated responding with a reduction in % responding on drug lever) suggests a selective effect of these ␣2 agonists on reinstated drug seeking and encourages further evaluation of their potential for polydrug relapse prevention. Financial Support: NIH grants DA031299, RR00168 and OD011103. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.563
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Applying SBIRT to new settings: Preliminary findings of substance use disorder risk in community mental health settings Suzanne E. Spear 2,∗ , Mitch Karno 3 , Suzette Glasner-Edwards 3 , R. Rawson 3 , Richard Saitz 1 , Blanca Dominguez 3 1 Community Health Sciences, Boston University and Boston Medical Center, Boston, MA, United States 2 Health Sciences, California State University, Northridge, Northridge, CA, United States 3 Psychiatry, UCLA Integrated Substance Abuse Programs, Los Angeles, CA, United States
Aims: Screening, Brief Intervention, and Referral to Treatment (SBIRT) has not yet been tested in community mental health treatment settings despite the elevated risk of substance use disorders (SUD) among individuals with mental health disorders. This presentation reports on preliminary findings of SUD risk among 334 adult participants treated in community mental health clinics in Southern California. SUD risk was calculated from the AUDIT and DAST-10 screening tools. Methods: All participants are currently enrolled in a randomized controlled trial of SBIRT. Participants were recruited from four outpatient clinics and one inpatient clinic. High risk for SUDs was defined by scores on the AUDIT (≥13 for women and ≥15 for men) and the DAST-10 (≥3 for women and men). Associations between SUD risk and presence of mood disorders, anxiety disorders, and psychotic disorders were examined using chi-square tests. Results: Results showed that 37% of participants were at high risk for alcohol disorders and 66% of participants were at high risk for illicit drug use disorders. Alcohol disorder risk was significantly associated with mood disorders (2 = 13.25, p < .01) and anxiety disorders (2 = 8.6, p < .05). Illicit drug use disorder risk was significantly associated with anxiety disorders (2 = 25.96, p < .001). Presence of psychotic disorders was not associated with SUD risk. Conclusions: High rates of SUD risk in this community mental health sample were found. Participants with mood and/or anxiety disorders were found to be at high risk of SUDs. Subsequent research will test the efficacy of SBIRT for reducing SUD risk and linking participants with possible SUDs to treatment. Financial Support: Supported by NIDA grant R01DA032733. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.564 Prescription monitoring programs: Best practice and Canadian program review Beth Sproule 1,2 1
Centre for Addiction and Mental Health, Toronto, ON, Canada 2 University of Toronto, Toronto, ON, Canada Aims: Prescription monitoring programs (PMPs) are one important component of an overall strategy in addressing prescription drug abuse. The objectives of this review were to examine research evidence to support best practices in PMPs and to review PMPs in Canada. Methods: As an update to a previous review, a search from 2012 to May 2014 was conducted using PubMed, PsycINFO, Project Cork and Google Scholar to identify articles about the effectiveness of PMPs. Search terms included: prescription drug monitoring, prescription monitoring, doctor shopping, multiple prescribers, unsolicited reporting, proactive reporting and controlled substance monitoring. Grey literature sources included individual PMP websites, PMP organization websites and Google. Information on the
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Abstract / Drug and Alcohol Dependence 156 (2015) e183–e245
features and practices of the PMPs in Canada was obtained by reviewing program websites and telephone interviews conducted with key contacts from each program. Results: PMPs have varied features and practices, including models of administrative oversight, drugs targeted for monitoring, methods of data collection, types of interventions and degree of information sharing. There are very few research studies evaluating the effectiveness of PMP features or overall performance; primarily observational studies are available. Several best practice recommendations have been suggested based on opinion and experience. In Canada, there are currently seven provinces operating some form of a PMP and two provinces with programs in development; all have different histories and features and are not linked. Conclusions: There is limited supporting research evidence for most aspects of PMPs at this time, although there is growing research attention in the area, and the number of research reports is increasing each year. As programs across Canada continue to be developed and expanded, further work is needed to evaluate the various features of PMPs to determine their impact, and to establish the overall value of PMPs in promoting the safe and effective use of prescription products that are associated with significant harms. Financial Support: Alberta Health. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.565 Health related issues among people who inject drugs in Australia Jennifer Stafford ∗ , Lucy Burns National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia Aims: The Illicit Drug Reporting System (IDRS) monitors the price, purity and availability and use of illicit drugs annually in Australia. The IDRS focuses mainly on: heroin and other opioids, methamphetamines, cocaine and cannabis. The IDRS also looks at other issues related to drug use including injection-related problems and mental health. This presentation provides a closer look at health-related issues among people who inject drugs interviewed in the 2014 IDRS. Methods: The IDRS involves the collection and analysis of three data sources: (1) interviews with people who inject drugs (IDRS), (2) interviews with experts who work with drug users such as treatment personnel and (3) existing databases on drug-related issues such as customs and overdose data. Results: Nationally, around 900 people who inject drugs were interviewed for the IDRS in 2014. Less than one-fifth of people who injected drugs reported lending a needle or using a needle after somebody else. Around one-quarter reported sharing injecting equipment (not including needles), around half re-used their own needle and over half re-used injecting equipment. Over half reported an injection-related issue in the last month, mainly scarring/bruising. Self-reported mental health problems in the last six months were reported by around half of the national sample. The most common mental health problem reported was depression followed by anxiety. IDRS participants reported higher levels of distress on the Kessler Psychological Distress Scale 10 compared to the Australian general population. Conclusions: A greater understanding of the health-related issues among people who inject drugs regularly is required to better inform policy decisions and treatment delivery.
Financial Support: The IDRS Project is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvement Grants Fund. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.566 Does urban size and region predict outpatient substance abuse treatment completion? Gerald Stahler ∗ , Jeremy Mennis Geography & Urban Studies, Temple University, Philadelphia, PA, United States Aims: This study examines the influence of urban size and region on the likelihood of treatment completion for outpatient settings using the 2011 SAMHSA TEDS-D dataset. Methods: Logistic regression was employed using treatment completion as the dependent variable (N = 897,888). Two geographic variables served as independent variables. ‘City size’ is a five-class ordinal variable representing the population of the U.S. Census metropolitan or micropolitan region in which the subject resides, ranging from areas with a population of less than 50,000 to greater than 750,000. ‘Geographic division’ distinguishes among the ten U.S. Census-defined regional divisions of the U.S. (e.g. Mid-Atlantic, New England). The Mid-Atlantic division (New York, Pennsylvania, and New Jersey), which is the division with the highest number of subjects in the data set, served as the reference category. We also controlled for the subject’s age, race, sex, primary substance use problem, and severity of use. Results: The resulting model had an overall percentage correct = 60.4%, and a Receiver Operating Curve (ROC) analysis resulted in an Area Under the Curve = 0.63, p < 0.005). Results indicate that larger city size is associated with a greater likelihood of treatment completion, and while the city size odds ratio is relatively small (OR = 1.05, p < 0.005), it is of greater magnitude than the odds ratio for sex (where males are significantly more likely to complete treatment). Geographic division was also highly significant, with certain divisions such as the Mountain division (e.g. Colorado, Utah) showing a particularly higher likelihood of treatment completion (OR = 2.07, p < 0.005) compared to the Mid- Atlantic division. Other divisions, such as the East North Central division (e.g., Ohio and Michigan) showed a significantly lower likelihood (OR = 0.73, p < 0.005). Conclusions: Treatment effectiveness at a system level may be improved by examining these geographic variations in outpatient outcomes. Further research needs to identify the reasons for these locational differences in treatment completion. Financial Support: None. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.567 Effects of varenicline and GZ-793A on methamphetamine and food self-administration under a multiple schedule of reinforcement in rats Dustin J. Stairs 1,∗ , Megan Kangiser 1 , Markus N. Pfaff 1 , Sarah Ewin 1 , Linda P. Dwoskin 2 1 Psychology, Creighton University, Omaha, NE, United States 2 Pharmaceutical Sciences, University of Kentucky, Lexington, KY, United States
Aims: Currently there is no FDA pharmacological treatment for methamphetamine (METH) addiction. A widely accepted