Self-Schema, Attachment Style, and Treatment Outcome of Patients in an Opiate Maintenance Treatment Unit

The aim of this study was to explore self-schemas and attachment style among patients in a methadone or buprenorphine maintenance treatment program of opiate dependence, in relation to treatment outcome (relapse in substance use). The study included 84 patients (21 women and 63 men) in a psychiatric clinic in Malmö, Sweden, providing maintenance treatment of opiate dependence. Three self-report instruments were employed, Young Schema Questionnaire Short version (YSQ-S) and Young Parenting Inventory (YPI) for studying self-schemas and Experiences in Close Relationships–Relationship Structures questionnaire (ECR-RS) for studying attachment style. Demographical data and relapse in substance abuse were registered. The study demonstrated, unsurprisingly, that an insecure attachment style was more common in the group of patients compared to available general population reference data. Significant correlations were found between attachment style and core beliefs about the self (self-schemas). Memories of parenting experiences from childhood (YPI) showed correlations with ongoing self-schemas (YSQ-S). Treatment outcome, defined as relapses in substance abuse, was associated to a minor degree with self-schemas but showed no correlation with attachment style. Patients who did not work or study had more maladaptive self-schemas and insecure attachment style, and a higher incidence of relapse in abuse than patients who were working or studying.

CRHCeA→VTA inputs inhibit the positive ensembles to induce negative effect of opiate withdrawal

Plasticity of neurons in the ventral tegmental area (VTA) is critical for establishment of drug dependence. However, the remodeling of the circuits mediating the transition between positive and negative effect remains unclear. Here, we used neuronal activity-dependent labeling technique to characterize and temporarily control the VTA neuronal ensembles recruited by the initial morphine exposure (morphine-positive ensembles, Mor-Ens). Mor-Ens preferentially projected to NAc, and induced dopamine-dependent positive reinforcement. Electrophysiology and rabies viral tracing revealed the preferential connections between the VTA-projective corticotrophin-releasing hormone (CRH) neurons of central amygdala (CRHCeA→VTA) and Mor-Ens, which was enhanced after escalating morphine exposure and mediated the negative effect during opiate withdrawal. Pharmacologic intervention or CRISPR-mediated repression of CRHR1 in Mor-Ens weakened the inhibitory CRHCeA→VTA inputs, and alleviated the negative effect during opiate withdrawal. These data suggest that neurons encoding opioid reward experience are inhibited by enhanced CRHCeA→VTA inputs induced by chronic morphine exposure, leading to negative effect during opiate withdrawal, and provide new insight into the pathological changes in VTA plasticity after drug abuse and mechanism of opiate dependence.

A service evaluation of the use and outcomes of inpatient detoxification for the treatment of alcohol and opiate dependence within a community addictions service

AimsThe 2012 Health and Social Care Act transferred Addictions commissioning from the NHS to local authorities, leading to cuts of up to 30-50% of budgets and having the greatest impact on inpatient detox services. In a system with such limited capacity, effectively triaging access to detox services and optimising the efficacy of each detox has become increasingly important. NICE offers limited guidelines to assist with making these decisions, focused on assessing the severity of dependence and risk, but provides little detail on specific predictors of success. Our aim is to evaluate the nature of cases referred for inpatient alcohol or opiate detox and their treatment outcomes. This will help develop our understanding of the factors which influence achieving abstinence, and inform future decision-making regarding suitability for inpatient detox and post-detox planning. Conclusions will form part of a review of the local alcohol care pathway guidelines.MethodA retrospective case note review of all inpatient detox admissions between April 2019-March 2020 (n = 113 patients) is being undertaken. Our data collection tool extracts quantitative and qualitative data based on criteria from Alcohol use disorders (NICE, 2017), Opiate detoxification (NICE, 2019) and local pathway guidelines.ResultPreliminary analysis of data from November 2019–March 2020 (43 patients) showed that a clearly documented rationale for inpatient detox was recorded in 95% of cases. 100% of cases had a recorded AUDIT score, whilst SADQ scores were recorded in 50% of cases. 33% of cases were admitted to rehab post detox, and 19% were prescribed anti-craving medication. Abstinence at one year was confirmed in 21% of cases. 28% of clients received a second detox within one year. The rationale for inpatient detoxes in this population is to be reported.ConclusionPreliminary data may highlight an opportunity to improve pre detox decision-making and post detox care, with confirmed abstinence in only 21% of clients at one year after detox. The low proportion of completed SADQ scores before accessing detox could offer an opportunity to improve client assessment, and the small proportion of clients prescribed anti-craving medication highlights an area of post detox care which could also be improved. The main limitation of this study is the lack of linked analysis of outcome to specific predictors, which is something that could be explored in future. It would also be valuable to gain survey data on the experience of accessing detox from a service user perspective.

Use of clonidine in the management of opiate withdrawal in community patients

AimsClonidine has been used to alleviate symptoms of opiate withdrawal. No validated prescribing schedules exist for the use of Clonidine in opiate detoxification in community patients. We have devised a Clonidine prescribing schedule for adult outpatients seeking opiate detoxification.BackgroundOpiate cessation following prolonged use produces a central noradrenergic (NA) response in the locus coeruleus (LC), causing symptoms that can result in reinstatement of use. Pharmacotherapies for withdrawal are thought to work through decreased NA release in the LC by agonising pre-synaptic alpha-2 adrenoceptors. Clonidine has been used since the 1970s. However, it is off-license in the UK, and superseded by Lofexidine. Though both cause hypotension, this is less marked with Lofexidine, which may be anxiolytic and considered better tolerated. Lofexidine is no longer available in the UK. Specialists may need to resort to Clonidine for those seeking opiate detoxification.MethodWe performed a feasibility study with the primary outcome being tolerability of an outpatient clonidine schedule. Patients (n = 7) were aged between 18 and 65 years (mean 32). Six were prescribed buprenorphine as opiate substitution (OST), and one methadone.Exclusion criteria were in keeping with BNF contraindications.An ECG was obtained for each patient before treatment. A urine drug screen and Clinical Opiate Withdrawal Scale were taken to confirm opiate dependence and withdrawal. Patients self-monitored withdrawal using the Subjective Opiate Withdrawal Scale and daily blood pressure measurements. Standard adjuvants for withdrawal were prescribed.A test dose of 100mcg Clonidine was given to assess for hypotension. If tolerant they received 100mcg QDS, reducing over eight days.Patients were contacted by their recovery worker twice during the period.ResultFive of the seven completed the course, two dropped out due to hypotension. No other adverse effects warranting discontinuation were encountered. Patients reported fatigue and light-headedness as their most troublesome side-effects. Of 3 patients who returned SOWS scores, 2 reported decline by 21/64 and 14/64 respectively. One reported an increase of 49/64 over 8 days. 3 of the 5 subjects who completed the course were not abstinent at completion, citing opiate withdrawal symptoms as causative.ConclusionThere is scope for the safe use of clonidine in the community for motivated individuals. Adequate monitoring of heart rate and blood pressure is required. Starting doses at 100mcg QDS appear well tolerated. Prescribers may wish to reduce this over a longer period to encourage completion and improve tolerability. Further research is needed.

Interaction between methadone and clarithromycin as the suspected cause of an opioid toxidrome

A 40-year-old patient was admitted through the acute medical take with pleuritic chest pain and rigours. He had a medical history of opiate dependence and was receiving 60 mg of methadone once daily. He was diagnosed with a community-acquired pneumonia and treated with amoxicillin and clarithromycin. After administration of only two concomitant doses of methadone and oral clarithromycin, he developed an opioid toxidrome with type-2 respiratory failure, a decreased level of consciousness and pinpoint pupils. The patient was treated with naloxone and his symptoms improved. Retrospectively, it was suspected that an interaction between clarithromycin and methadone might have contributed to the toxidrome. Respiratory failure has not been previously prescribed for this combination of medication and is of high importance for physicians and pharmacists around the world.

719 The Routine Use of Opioid Medication for Post-Operative Pain Relief Can Risk Long Term Dependence, In Patients Previously Opiate Naive

Introduction Post-operative pain relief commonly involves opiates. Rising concerns about misuse has increased scrutiny of prescribing practices. In the UK, 12.5% of prescriptions are for opiates. In the US, the Department of Health and Human Services has declared an epidemic of opiate misuse. We aimed to evaluate opiate prescribing practices post-operatively, within a UK teaching hospital, and establish the risk of prolonged opiate use. Method A pan-speciality retrospective observational cohort study was performed. Patients who underwent surgery in the year 2018 were included. Patients were opiate naïve if their admission Medicine reconciliation and GP record described no opiates for the previous year. Endpoints: the proportion of patients discharged with opiates and the proportion of patients remaining on opiates at 1- and 2-years post admission. Results 20526 operations were performed on 17524 patients, across pan-specialities. 8772 patients were discharged on opiates. 673 required further opiates from their GP after discharge, of which 331 were previously opiate naive. At 1 year post op, 180 previously naive patients remained on opiates. Conclusions Attention needs to be given to the risk of developing opiate dependence post-operatively. An evidence-based approach should support clinicians in preventing an opiate crisis in the UK.

N-Oleoylglycine and N-Oleoylalanine Do Not Modify Tolerance to Nociception, Hyperthermia, and Suppression of Activity Produced by Morphine

The endogenous amide N-Oleoylglycine (OlGly) and its analog N-Oleoylalanine (OlAla), have been shown to interfere with the affective and somatic responses to acute naloxone-precipitated MWD in male rats. Here we evaluated the potential of a single dose (5 mg/kg, ip) which alleviates withdrawal of these endogenous fatty acid amides to modify tolerance to anti-nociception, hyperthermia, and suppression of locomotion produced by morphine in male Sprague-Dawley rats. Although rats did develop tolerance to the hypolocomotor and analgesic effects of morphine, they did not develop tolerance to the hyperthermic effects of this substance. Administration of neither OlGly nor OlAla interfered with the establishment of morphine tolerance, nor did they modify behavioral responses elicited by morphine on any trial. These results suggest that the effects of OlGly and OlAla on opiate dependence may be limited to naloxone-precipitated withdrawal effects.