Background: Severe mental illness (SMI - psychotic and bipolar disorders) is common among individuals with opioid use disorder (OUD). This study examined the impact of SMI on opioid agonist treatment (OAT) retention, and SMI and OAT on all-cause mortality. Methods: A retrospective cohort study of 14763 individuals receiving OAT for the first time in New South Wales, Australia, 2006-2017. OAT records were linked to hospital, mental health treatment, and custodial information. Multivariable Cox regression models were used to compare OAT cessation/retention and all-cause mortality among those with/without SMI, adjusting for potential confounders. Results: There were 1989 (13.5%) individuals with SMI and 763 (5.2%) deaths. The risk of treatment cessation during a first OAT episode was 16% higher for individuals with SMI [adjusted hazard ratio (aHR) 1.16, 95% confidence interval (CI) 1.09-1.23]. Among those with multiple OAT episodes, differences in retention between those with/without SMI were most notable in the first three treatment episodes; this difference was attenuated between episodes four to five. Although SMI increased mortality risk [aHR 1.35; 95% CI 1.14-1.60] and being in OAT decreased mortality risk [aHR 0.24; 95% CI 0.20-0.29], OAT status did not modify the effect of SMI on overall mortality risk. Conclusions: Comorbid SMI and OUD significantly reduces OAT retention during early episodes of treatment and is associated with increased mortality risk. There is no differential treatment effect on mortality among those with and without SMI. Interventions to identify, support, and engage individuals with SMI in OAT are needed early after commencing treatment.
BackgroundIn January 2023, following a 20-year ban, the New South Wales (NSW) Needle and Syringe Program (NSP) Guidelines permitted NSPs to provide winged infusion sets (‘butterflies’) and larger-volume syringes (‘barrels’) commonly used for injecting methadone liquid intravenously.ApproachThe Kirketon Road Centre (KRC) integrated the distribution of ‘butterflies and barrels’ (referred to as ‘butterfly packs’) into its service delivery in April 2023 and developed resources in collaboration with the Uniting Medically Supervised Injecting Centre (MSIC) and the NSW Users and AIDS Association (NUAA). This case report presents an audit of service delivery and self-reported client outcomes following the introduction of ‘butterfly packs’.OutcomesSince April 2023, KRC has been consistently supplying ‘barrels’ and ‘butterflies’ to clients who inject methadone. The proportion of NSP visits by clients who reported methadone as the last drug injected increased significantly after the program’s introduction (from 2.2 to 4.0 methadone-related attendances per month), and so did the amount of corresponding injecting equipment and verbal education sessions. Among 18 survey respondents, the majority reported improved health or safety since accessing butterfly packs (89%).ConclusionEquipment for intravenous methadone administration can be safely and efficiently distributed by NSP programs. Access to harm reduction services should be based on vulnerability and need, with services tailored accordingly. The policy reversal allowing ‘butterflies and barrels’ and service innovations such as KRC’s program have addressed a longstanding gap, advancing equity in harm reduction for people who inject methadone in NSW.
BACKGROUND AND AIMS:Hip fractures are a leading cause of morbidity and mortality among older adults, with significant consequences for recovery and refracture risk. While recovery experiences have been explored and interventions established, limited understanding exists of how individual, social and cultural factors influence engagement with recovery and secondary prevention in multicultural systems. We explored these factors among culturally diverse older adults and caregivers following low trauma hip fracture. METHODS:A qualitative study embedded within a prospective cohort at a metropolitan Australian trauma hospital. Participants included older adults with recent low-trauma hip fracture and their caregivers, purposively sampled for cultural diversity. Semi-structured interviews were conducted in English, Arabic, Assyrian or Vietnamese. Data were thematically analysed using a two-step inductive-deductive approach, mapping codes to Andersen's Behavioural Model before theme development. RESULTS:Twenty participants (mean age 74 years, 60% women, 75% culturally diverse) were interviewed. Three interconnected themes emerged: (i) 'normalisation of pathological ageing', shaping expectations and engagement with preventive care; (ii) 'cultural orientations' shaping motivations, expectations and family roles; and (iii) 'care continuity,' with refracture prevention clinics valued but access hampered by logistical and system barriers. These themes interacted across individual, social and health system levels to shape recovery trajectories and refracture prevention. CONCLUSIONS:Recovery and refracture prevention after hip fracture are strongly shaped by age-related beliefs, cultural context and care structures. By examining cross-cultural experiences in a multicultural setting, this study highlights the need for person-centred, culturally responsive and better-coordinated models to optimise engagement and outcomes in diverse ageing populations.
INTRODUCTION:Methadone-to-buprenorphine transfers (MBT) are increasingly common as buprenorphine use expands. Evidence describing patient experience of withdrawal during MBT in real-world populations is limited. This study aimed to characterise withdrawal trajectories during MBT and examine whether psychosocial and clinical factors influence the severity or timing of withdrawal. METHODS:This analysis used data from a prospective, non-randomised clinical trial comparing low-dose and stop-and-start MBT techniques (n = 117). Covariates included methadone dose, duration on methadone, transfer setting, study arm, withdrawal expectancy, psychological distress, substance use and unstable housing. Withdrawal was assessed daily using the Clinical Opioid Withdrawal Scale (COWS) and Short Opiate Withdrawal Scale. RESULTS:Ninety-four participants (80.3%) completed transfer. Withdrawal followed a consistent trajectory across the cohort, peaking around Day 5. Psychosocial and clinical characteristics-including unstable housing, substance use, psychological distress and methadone dose-were not associated with withdrawal severity or timing. Compared with stop-and-start transfer, low-dose transfer was associated with a delayed and larger increase in objective withdrawal: peak COWS occurred 2.3 days later (95% CI 0.3-4.3) and the largest one-day increase was 3.8 points higher (95% CI 0.5-7.0). DISCUSSION AND CONCLUSIONS:Patient factors often considered barriers to MBT were not associated with withdrawal severity or timing. Low-dose transfer was associated with a delayed and slightly higher withdrawal peak but did not reduce overall transfer success. These findings suggest that withdrawal during MBT follows a broadly similar trajectory across patients with differing psychosocial complexity. Planning for expected withdrawal, rather than selecting patients based on perceived complexity, may be more clinically relevant.
