Background: Nicotine dependence and trait impulsivity are associated with the severity and progression of substance use disorders, particularly opioid and amphetamine use disorders. However, the precise magnitude of the correlation between these aspects remains unclear. In this study, the mediating role of trait impulsivity between nicotine dependence and addiction severity was explored among Chinese participants with methamphetamine use disorder (MUD). Methods: This study screened 1230 participants from five drug rehabilitation centres in China. After semi-structured interviews and standardized tests, 163 participants were analysed and divided into three groups based on MUD severity. Trait impulsivity was evaluated using the Chinese version of Barratt Impulsiveness Scale, 11th version. Results: The mediation analyses revealed that the positive direct effect of nicotine dependence on MUD severity was 0.308 (95% CI: 0.206, 0.412), and the positive indirect effect of nicotine dependence on MUD severity via impulsivity was 0.067 (95% CI: 0.027, 0.120), accounting for 17.87% of the total effect. However, the parallel multiple mediation analysis indicated that the indirect effects via motor impulsivity and non-planning impulsivity were invalid (P>0.05). The positive indirect effect via attentional impulsivity was 0.040 (95% CI: 0.003, 0.086), accounting for 10.67% of the total effect. Conclusions: Trait impulsivity, especially attentional impulsivity, mediated the positive effects of nicotine dependence on MUD severity in Chinese participants from rehabilitation centres. Cognitive instability and sustained attention deficits may represent a shared vulnerability that exacerbates the severity of polysubstance use. Future longitudinal studies including individuals with opioid use disorder are warranted to validate the proposed causal pathways.
This paper is a response to Ulmer's recent argument in HARCP for using opiate maintenance as something of a last resort for patients with alcohol use disorder (AUD) who had not responded to evidence-based treatments. It does not oppose opiate-assisted treatment (OAT) in principle but presents the case for advising a trial of well-supervised disulfiram (DSF) with appropriate psychosocial support before indefinite treatment with an alternative euphoriant. While Ulmer's support for supervised DSF (SDSF) is welcomed, this paper also questions some of his assumptions about its modes of action and explains why SDSF is by far the most effective drug for obtaining the lengthy periods of abstinence in the real world that are often a crucial therapeutic goal. Finally, it emphasises the importance (and widespread neglect) of placebo and nonspecific effects in the treatment of AUD, as with most conditions..
People with opioid use disorder (OUD) smoke tobacco at rates far exceeding those of the general population. This makes cigarettes one of the leading causes of preventable morbidity and premature mortality in this population. Although contemporary addiction medicine has substantially reduced drug related deaths and improved long-term survival, smoking is still largely neglected within opioid treatment services, where clinical priorities understandably focus on opioid dependence and its immediate complications. Consequently, many people survive opioid addiction only to develop tobacco-related cardiovascular disease, chronic respiratory disease and cancer. This narrative review integrates current evidence from toxicology, clinical psychopathology and implementation science to examine the role of tobacco harm reduction in the management of OUD. Evidence consistently shows that most tobacco-related disease results from exposure to the products of tobacco combustion rather than nicotine itself. Electronic cigarettes and nicotine pouches markedly reduce exposure to carcinogens, carbon monoxide and other toxic combustion products while maintaining nicotine delivery, thereby offering substantially lower-risk alternatives to combustible cigarettes. The review also proposes that distinguishing physiological nicotine dependence from the broader behavioural syndrome of addiction may help clinicians individualise treatment strategies, particularly among people with psychiatric comorbidity, polysubstance use and recurrent relapse. This conceptual distinction should be regarded as a hypothesis to guide future clinical research rather than as an evidence-based treatment model. Clinical studies conducted in highly disadvantaged populations demonstrate that integrating tobacco harm reduction into addiction services is both feasible and acceptable. Even when cigarettes are replaced by lower risk products only gradually and complete abstinence is not achieved abruptly, or at all, substantial reductions in cigarette consumption, decreased exposure to tobacco smoke and greater patient engagement represent clinically meaningful indicators of therapeutic progress. Tobacco harm reduction should therefore be regarded as an essential component of comprehensive addiction medicine. Embedding evidence-based nicotine harm reduction within routine opioid treatment offers a realistic opportunity to reduce one of the principal remaining causes of preventable death among people receiving treatment for OUD.
Background: Highly potent synthetic opioids, particularly fentanyl and its analogues, have been increasingly implicated in fatal overdoses and frequently appear on illicit markets as novel psychoactive substances (NPS) designed to evade regulatory controls. In Sweden, drug poisoning deaths involving fentanyl analogues emerged during a "cluster outbreak" 2015-2018. Methods: This register-based study include 7,408 individuals who died from psychoactive substance poisoning in Sweden 2012- 2020. Individual-level data from the forensic registers were linked to national health-, prescription-, and demographic registers. Results: The 2015-2018 fentanyl analogue cluster outbreak disproportionately affected younger men and often involved polysubstance use. Nearly half of them have had contact with health care for substance use disorder in proximal time. The overdoses frequently occurred in emergency units or in private residence settings. Conclusions: The results needed to be discussed out of the contextual frame in Sweden during this years to understand the cluster outbreak. During 2015-2018 the problem with fentanyl-analogues was heightened by media and political attention which accelerated regulatory classification of new psychoactive substances, strengthened law enforcement, and peer-driven risk communication on drug related sites at internet helped to contain the outbreak. These findings highlight the importance of identifying risk-groups, coordinated, multi-level preventive strategies to mitigate harms from emerging synthetic opioids.
Background: Providing healthcare, including Agonist Opioid Treatment (AOT), to people who use opioids (PWUO) remains challenging, particularly within marginalised communities. A remote model of AOT incorporating telemedicine was introduced during the COVID-19 pandemic, creating new opportunities to engage both existing and newly presenting patients in treatment. This process evaluation study explores the acceptability, feasibility, and effectiveness of this model, with particular focus on its potential for long-term integration into opioid dependence treatment services. Methods: An embedded mixed-methods study was conducted involving aggregated anonymised data of demographic and treatment characteristics and a qualitative study using semi-structured interviews with service users (n=11) and service providers (n =9) involved with the new remote service. Interviews were audio-recorded, transcribed verbatim, and analysed using reflexive thematic analysis as described by Braun and Clarke. Results: A total of 101 individuals started their treatment in the remote clinic. Qualitative analysis on service users' interviews identified three themes: a) Access, Flexibility, and Integration into Daily Life, b) Perceived effectiveness and satisfaction with care and c) Confidentiality, reduced stigma and therapeutic relationships. Qualitative analysis on service providers' interviews identified four themes: a) Reduced waiting times and improved treatment retention, b) Need for structured training, guidance and clinical governance, c) Enhanced engagement and therapeutic relationships and d) Implementation challenges and suggestions. Conclusions: Remote models of AOT provision can be delivered effectively and safely to large numbers of people who use opioids, with high levels of patient satisfaction. Service providers' views were more mixed with some concerns around confidentiality and clinical safety. A hybrid model of care may be the more appropriate model in the long-term but further research is required
