Internet Mental Health


Internet Mental Health Quality of Life Scale (Client Version)

Internet Mental Health Quality of Life Scale (Therapist Version)

Big 5 Factors Of Mental Illness And Code For This Disorder
(The "6th Big Factor" of Mental Health, "Physical Health", Is Coded Normal or Green)

  • Opioid use disorder is the continued use of an opioid despite clinically significant distress or impairment.

  • Typically includes a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and a physical withdrawal state.


    Lasts for years


Occupational-Economic Problems:

  • Causes significant impairment in academic or occupational functioning

  • Eventually may lose everything and require financial assistance (due to poverty)


  • Suspiciousness, social withdrawal


  • Intoxicated behavior, impaired driving

  • Impulsivity, dangerous risk taking, irresponsibility, hyperactivity (but usually is psychomotor slowing)

  • Hostility, crime, theft, prostitution, drug-dealing

  • High risk of divorce and child abuse/neglect

Impaired Intellect:

  • Impaired cognitive functioning (concentration, memory, motivation, judgment)

  • Drowsiness (being "on the nod"), psychomotor slowing, can progress to coma

  • Inattention can progress to ignoring potentially harmful events

  • Can cause confusion, hallucinations


  • Initial euphoria followed by apathy (and often depressed mood)

Physical Symptoms:

  • Denial of addiction; tuberculosis; sexual dysfunction; high death rate (overdose; illness; accidental injury; suicide); needle users get viral infections (90% get hepatitis C, 10%-60% get HIV) and bacterial infections (cellulitis, endocarditis)

  • Physical signs of opioid intoxication are: drowsiness, slurred speech, pupillary constriction, and decreased level of consciousness

  • Severe opioid intoxication causes: respiratory depression, hypotension, and hypothermia

  • Sexual impairment; sleep disorder

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Click Here For Free Diagnosis

Limitations of Self-Diagnosis

Self-diagnosis of this disorder is often inaccurate. Accurate diagnosis of this disorder requires assessment by a qualified practitioner trained in psychiatric diagnosis and evidence-based treatment.

However, if no such professional is available, our free computerized diagnosis is usually accurate when completed by an informant who knows the patient well. Computerized diagnosis is less accurate when done by patients (because they often lack insight).

Example Of Our Computer Generated Diagnostic Assessment

Opioid Use Disorder 304.00

This diagnosis is based on the following findings:

  • Abused an opioid in the past 5 years (still present)

  • Greater use of an opioid than intended (still present)

  • There is a persistent desire or unsuccessful efforts to cut down or control use of an opioid (still present)

  • A great deal of time is spent in obtaining an opioid, using it, or recovering from its effects (still present)

  • Craving, or a strong desire or urge to use an opioid (still present)

  • Recurrent use of an opioid resulted in a failure to fulfill major role obligations at work, school or home (still present)

  • Continued use of an opioid despite having persistent social problems that it made worse (still present)

  • Important social, occupational, or recreational activities are given up or reduced because of use of an opioid (still present)

  • Developed tolerance to an opioid (still present)

  • Developed withdrawal symptoms to an opioid (still present)

Treatment Goals:

  • Goal: stop opioid use because using more than intended.

  • Goal: stop opioid use because it is getting out of control.

  • Goal: stop opioid use in order to prevent wasting so much time using the opioid, or recovering from its use.

  • Goal: stop opioid use in order to decrease craving for the opioid.

  • Goal: stop opioid use so that she can better fulfill major role obligations at work, school or home.

  • Goal: stop opioid use in order to improve the opioid-related social problems.

  • Goal: stop opioid use in order to increase time spent on important social, occupational, or recreational activities.

  • Goal: stop opioid use in hazardous situations in order to prevent injury.

  • Goal: stop opioid use in order to prevent further worsening of current opioid-related physical or emotional problems.

  • Goal: stop opioid use because tolerance to the opioid is developing.

  • Goal: stop opioid use because opioid withdrawal symptoms are developing.

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Dependence Syndrome Due To Use Of Opioids F12 - ICD10 Description, World Health Organization
Repeated use of opioids that typically includes a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state.
Opioid Use Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with opioid use disorder needs to meet all of the following criteria:

  • A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

    • Opioids are often taken in larger amounts or over a longer period than was intended.

    • There is a persistent desire or unsuccessful efforts to cut down or control opioid use.

    • A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.

    • Craving, or a strong desire or urge to use opioids.

    • Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.

    • Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.

    • Important social, occupational, or recreational activities are given up or reduced because of opioid use.

    • Recurrent opioid use in situations in which it is physically hazardous.

    • Opioid use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

    • Tolerance, as defined by either of the following:

      • A need for markedly increased amounts of opioids to achieve intoxication or desired effect.

      • A markedly diminished effect with continued use of the same amount of an opioid.

    • Withdrawal, as manifested by either of the following:

      • The characteristic opioid withdrawal syndrome:

        • Presence of either of the following:

          • Cessation of (or reduction in) opioid use that has been heavy and prolonged (i.e., several weeks or longer).

          • Administration of an opioid antagonist after a period of opioid use.

        • Three (or more) of the following developing within a minutes to several days after the cessation of (or reduction in) opioid use:

          • Dysphoric mood.

          • Nausea or vomiting.

          • Muscle aches.

          • Lacrimation or rhinorrhea.

          • Pupillary dilation, piloerection, or sweating.

          • Diarrhea.

          • Yawning.

          • Fever.

          • Insomnia.

      • Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.

  • Specify if:

    • In early remission: After full criteria for opioid use disorder were previously met, none of the criteria for opioid use disorder have been met for at least 3 months but for less than 12 months (with the exception that the criterion, "Craving, or a strong desire or urge to use opioid," may be met).

    • In sustained remission: After full criteria for opioid use disorder were previously met, none of the criteria for opioid use disorder have been met at any time during a period of 12 months or longer (with the exception that the criterion, "Craving, or a strong desire or urge to use opioid," may be met).

  • Specify if:

    • On maintenance therapy: The individual is taking a prescribed agonist medication, such as methadone or buprenorphine and none of the criteria for opioid use disorder have been met for that class of medication (except tolerance to, or withdrawal from, the agonist).

    • In a controlled environment: This additional specifier is used if the individual is in an environment where access to opioids is restricted.

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The Current Opioid Overdose Epidemic In North America

Opioids are a class of drugs that include the illegal drug heroin as well as powerful pain relievers available legally by prescription, such as methadone, oxycodone (OxyContin®), hydrocodone (Vicodin®), fentanyl (Actiq®), codeine, morphine, and many others.

Regular use - even as prescribed by a doctor - can produce dependence, and when misused or abused, opioid pain relievers can lead to fatal overdose. The current epidemic of prescription opioid abuse has led to increased use of heroin.

According to the Centers for Disease Control and Prevention (CDC):

    "The United States is experiencing an epidemic of drug overdose (poisoning) deaths. Since 2000, the rate of deaths from drug overdoses has increased 137%, including a 200% increase in the rate of overdose deaths involving opioids (opioid pain relievers and heroin)... The sharp increase in deaths involving synthetic opioids, other than methadone, in 2014 coincided with law enforcement reports of increased availability of illicitly manufactured fentanyl, a synthetic opioid...

    Since 2000, the age-adjusted drug overdose death rate has more than doubled, from 6.2 per 100,000 persons in 2000 to 14.7 per 100,000 in 2014... In 2014, 61% (28,647) of drug overdose deaths involved some type of opioid, including heroin... More persons died from drug overdoses in the United States in 2014 than during any previous year on record. From 2000 to 2014 nearly half a million persons in the United States have died from drug overdoses. In 2014, there were approximately one and a half times more drug overdose deaths in the United States than deaths from motor vehicle crashes.

    Opioids, primarily prescription pain relievers and heroin, are the main drugs associated with overdose deaths. In 2014, opioids were involved in 28,647 deaths, or 61% of all drug overdose deaths; the rate of opioid overdoses has tripled since 2000. The 2014 data demonstrate that the United States' opioid overdose epidemic includes two distinct but interrelated trends: a 15-year increase in overdose deaths involving prescription opioid pain relievers and a recent surge in illicit opioid overdose deaths, driven largely by heroin.

    Natural and semisynthetic opioids, which include the most commonly prescribed opioid pain relievers, oxycodone and hydrocodone, continue to be involved in more overdose deaths than any other opioid type...

    Drug overdose deaths involving heroin continued to climb sharply, with heroin overdoses more than tripling in 4 years. This increase mirrors large increases in heroin use across the country and has been shown to be closely tied to opioid pain reliever misuse and dependence. Past misuse of prescription opioids is the strongest risk factor for heroin initiation and use, specifically among persons who report past-year dependence or abuse.

    The increased availability of heroin, combined with its relatively low price (compared with diverted prescription opioids) and high purity appear to be major drivers of the upward trend in heroin use and overdose.

    The rate of drug overdose deaths involving synthetic opioids nearly doubled between 2013 and 2014. This category includes both prescription synthetic opioids (e.g., fentanyl and tramadol) and non-pharmaceutical fentanyl manufactured in illegal laboratories (illicit fentanyl)...

    Illicit fentanyl is often combined with heroin or sold as heroin. Illicit fentanyl might be contributing to recent increases in drug overdose deaths involving heroin. Therefore, increases in fentanyl-associated deaths might represent an emerging and troubling feature of the rise in illicit opioid overdoses that has been driven by heroin....

    Opioid pain reliever prescribing has quadrupled since 1999 and has increased in parallel with overdoses involving the most commonly used opioid pain relievers."

The most commonly prescribed opioid analgesics are oxycodone (OxyContin®), fentanyl (Actiq®) and methadone. Prince died of an accidental fentanyl overdose.

In 2013 in New York City, 44% of drug-related deaths were due to opioid pain relievers, and 29% of drug-related deaths were due to heroin.

U.S. National Institute of Drug Abuse

Methadone Is The Most Common Cause Of Drug Poisoning

Methadone was the most common cause of drug poisoning deaths that occurred among Washington State residents between 2003 and 2010. Methadone accounted for 27% of all the drug poisoning deaths, was followed by alcohol, opiate (unspecified), cocaine, oxycodone (OxyContin®), and methamphetamine.

Prescription drugs were named on more than twice as many death certificates as were illicit drugs. Methadone was the most often named prescription drug on death certificates, followed by oxycodone (OxyContin®), morphine, diphenhydramine, and hydrocodone (Vicodin®). (Diphenhydramine is often used as an euphoriant to potentiate the effects of opiates.)

More Drug Deaths Due To OxyContin Than Heroin

In the United States toxicity deaths due to oxycodone (OxyContin®) have grown to exceed those due to heroin. Many (perhaps the majority) who are dependent on oxycodone, have never used illicit drugs. Increased sales of oxycodone closely paralleled the increase in deaths due to this drug.

Increased Death Due To Illicit Fentanyl

Drug dealers are now illegally producing fentanyl and adding it to OxyContin, heroin, and cocaine to produce "a better high". A few grains of illicit fentanyl can be lethal, and there is no way of knowing the fentanyl concentration in fentanyl-spiked drugs. Since fentanyl is 100 times more powerful than morphine; fentanyl-spiked heroin is extremely addictive and potentially very lethal.

Drug dealers lack the scientific equipment required to ensure that the trace amount of illicit fentanyl they add to other street drugs isn't lethal.

The concentration of fentanyl varies dramatically in the fentanyl-spiked street drugs. One batch of fentanyl-spiked heroin may not be lethal, but the next batch could have a lethal dose of fentanyl. The person buying fentanyl-spiked street drugs has no way of knowing its concentration of fentanyl. Even their drug dealer doesn't know that.

Playing Lethal Russian Roulette With Fentanyl- or Carfentanyl-Spiked Street Drugs

Drug dealers are now spiking street drugs with carfentanyl - a variant of fentanyl that is 100 times more potent than fentanyl. That means that carfentanyl is 10,000 times more potent than morphine; thus 10,000 times more deadly. Inhaling the dust of carfentanyl can be lethal.

Drug dealers prefer spiking street drugs with carfentanyl because a few grams of carfentanyl (smuggled in from laboratories in China) can "spike" thousands of doses of other drugs sold on the street (e.g., OxyContin, cocaine, heroin). As with illicit fentanyl spiking, the drug dealer has no way of ensuring that the carfentanyl dose added to the street drug isn't lethal.

Thus taking fentanyl- or carfentanyl-spiked street drugs is like playing lethal Russian roulette. Even taking your first dose of a fentanyl- or carfentanyl-spiked street drug could prove lethal.

The more one uses these spiked street drugs, the greater the chance of getting a fatal illicit fentanyl or carfentanyl dose. Drug dealers are starting to spray carfentanyl on marijuana to produce a "better high". Thus even some marijuana sold on the street now can have a lethal carfentanyl dose.

As carfentanyl-spiking of street drugs becomes more common; it will end the argument about "making all recreational drugs legal". Carfentanyl-spiked street drugs (including illicit OxyContin, cocaine and heroin) will become so unpredictably lethal that a sane person would never touch them.

Diagnostic Features

Opioid Use Disorder is a condition characterized by the harmful consequences of repeated opioid use, a pattern of compulsive opioid use, and (sometimes) physiological dependence on opioid (i.e., tolerance and/or symptoms of withdrawal). This disorder is only diagnosed when opioid use becomes persistent and causes significant academic, occupational or social impairment. Opioid Use Disorder often leads to a fatal opioid overdose.

Opioid Intoxication causes significant psychological and social impairment (e.g., initial euphoria followed by apathy, depressed mood, psychomotor agitation or slowing, impaired judgment). Intoxication causes pupillary constriction (or dilation in a severe overdose), and one or more of the following: drowsiness (being "on the nod"), slurred speech, or impairment in attention/memory. Drowsiness may progress to coma. Inattention may progress to ignoring potentially harmful events. In rare instances, intoxication may cause hallucinations with intact reality testing or auditory, visual or tractile illusions occurring in the absence of a delirium.

Opioid Withdrawal only occurs after the cessation of (or reduction in) heavy and prolonged opioid use. This withdrawal syndrome includes three or more of the following: dysphoric mood, nausea/vomiting, muscle aches, tearing/runny nose, pupillary dilation/piloerection/sweating, diarrhea, yawning, fever, insomnia. Opioid Withdrawal can also be caused by administration of an opioid antagonist (e.g., naloxone or naltrexone) or opioid partial agonist (e.g., buprenorphine) after a period of opioid use. Heroin withdrawal starts within 6-12 hours after the last dose, and peaks within 1-3 days and gradually subsides over 5-7 days. Less acute withdrawal symptoms can last for weeks to months (e.g., anxiety, depressed mood, apathy, and insomnia).

Social Complications

Opioid Use Disorder is often associated with criminal behavior (e.g., drug dealing, prostitution, theft). Marital abuse/divorce, child abuse/neglect, unemployment, poverty and homelessness often result from this disorder.

Medical Complications

Opioid use often causes severe constipation, erectile dysfunction in males, and infertility and irregular menses in females. Injecting opioids eventually severely damages the veins (causing "tracks"). Injecting directly into subcutaneous tissue ("skin-popping") often causes cellulitis, abscesses and circular scars. Use of contaminated needles may cause bacterial endocarditis, hepatitis, and HIV infection. Up to 90% of individuals who inject opioids may get hepatitis C infections. HIV infection rates are as high as 60% among heroin users in some areas of America or Russia. Intravenous opioid users, especially those having HIV, have an increased risk of having tuberculosis. Death often results from overdose, accidents, injuries, AIDS, or other general medical complications. Physiological dependence on opioids may occur in about half of the infants born to females with opioid use disorder. These infants then go through potentially life-threatening withdrawal.

Suicide Risk

Opioid withdrawal causes brief, but severe, episodes of depression that can lead to suicide attempts and completed suicide. Accidental opioid overdose is common, and should not be mistaken for a suicide attempt.


Opioid Use Disorder is commonly associated with: viral infections (e.g., HIV, hepatitis C), bacterial infections, other Substance Use Disorders, Major Depressive Disorder, Persistent Depressive Disorder, insomnia (during withdrawal), Antisocial Personality Disorder, and Post-traumatic Stress Disorder.

Associated Laboratory Findings

    Some Opioids Are Detected On Routine Laboratory Drug Abuse Screens

    • Heroin, oxycodone, morphine, codeine, and propoxyphene can be detected on routine drug abuse screens for 12–36 hours after administration.

    Other Opioids Aren't Detected On Routine Laboratory Drug Abuse Screens

    • Methadone, buprenorphine (or buprenorphine/naloxone combination), and LAAM (L-alpha-acetylmethadol) have to be specifically tested for and will not cause a positive result on routine tests for opiates. They can be detected for several days up to more than 1 week.

    • Fentanyl is not detected by standard urine tests but can be identified for several days after its use by more specialized procedures.

    Other Tests

    • Hepatitis: Screening test results for hepatitis A, B, and C virus are positive in as many as 80%–90% of injection opioid users, either for hepatitis antigen (signifying active infection) or for hepatitis antibody (signifying past infection).

    • HIV: Is prevalent in injection opioid users.

    • Liver Damage: Mildly elevated liver function test results are common, either as a result of resolving hepatitis or from toxic injury to the liver due to contaminants that have been mixed with the injected opioid.


In the American community population, the 12-month prevalence of Opioid Use Disorder is 0.37%. The male-to-female ratio is 3:1 for heroin and 1.5:1 for opioids other than heroin (i.e., available by prescription).

U.S. National Institute of Drug Abuse


Opioid Use Disorder usually starts in late teens or early 20s. It usually continues for decades, even though brief periods of abstinence are frequent. Relapse following treatment is common. The long-term mortality rate may be as high as 2% per year.


20%-30% of individuals with Opioid Use Disorder achieve long-term abstinence. A 20-year prospective study of young hospitalized opioid addicts in Oslo, Norway, found that 38% of these opioid addicts had died. Their mortality rate was 23.6 times higher than that of the standard population.

A Spanish study of 5049 patients who started methadone maintenance treatment found that their average life expectancy was 39 years, 38 years lower than that of the general population. Thus research is showing that the death rate for heroin addiction is extremely high.

Comparative Lethality

Chronic users of cigarettes lose 13% of their expected lifespan, chronic users of alcohol lose 29%, chronic users of cocaine lose 44%, chronic users of methadone lose 49%, chronic users of heroin lose 52%, and chronic users of methamphetamine lose 53% of their expected lifespan.

Familial Pattern

The Minority Have An Inherited "Addictive Personality"

A minority of individuals addicted to opioids may have an inherited "addictive personality". These thrill-seeking individuals may have inherited a tendency towards impulsivity, novelty-seeking, dangerous risk-taking and rule-breaking. This would explain why they also have Antisocial and/or Borderline Personality Disorder. These reckless thrill-seekers start taking opioids at parties to "get high". Then they soon become addicted.

The Majority Don't Have An Inherited "Addictive Personality"

The majority of individuals addicted to OxyContin and fentanyl were started by their physician on these pain relievers as a treatment for their non-cancer pain. Their physicians were purposely misinformed by the manufacturers of OxyContin and fentanyl that these heroin-like drugs weren't that addictive. In reality, OxyContin and fentanyl are highly addictive and should never be a first-line treatment for chronic non-cancer pain. Thus the majority of people who became addicted to prescription opioid pain relievers didn't have an "addictive personality". Instead, their addiction was started by their doctor inappropriately prescribing them a highly addictive pain reliever. Once many could no longer afford expensive opioid pain relievers, they switched to much cheaper heroin.

How OxyContin Started This Current North American Opioid Epidemic

About 1 in 5 adults suffer from moderate or severe chronic pain that is not caused by cancer. Some people with this type of pain are treated with opioids (typically with drugs like morphine, codeine, oxycodone, fentanyl, buprenorphine, and methadone either as tablets or as patches placed on the skin). It is not unusual for opioids to be ineffective or to stop working over time, and, sometimes, effective pain relief is not achieved despite doses being increased.

Opioids for the treatment of osteoarthritis or rheumatoid arthritis have been found to be of questionable effectiveness. There is no convincing evidence that opioids are an effective treatment for chronic lower back pain when used for more than four months. In fact, opioids are no more effective than other groups of analgesics for lower back pain such as anti-inflammatories or antidepressants.

OxyContin has been blamed by many for helping to ignite the scourge of opioid abuse in the United States that began with prescription painkillers and has progressed to heroin and fentanyl.

The current opioid epidemic in North America started with physicians being misinformed that a new opioid painkiller, OxyContin, was relatively nonaddictive, lasted 12 hours, and was more effective than other, much cheaper, opioid painkillers. There was little scientific proof for any of these claims.

Addiction And OxyContin's 12-Hour Problem

This misinformation led to prescriptions for OxyContin to skyrocket, as did the number of OxyContin users who became addicted. When many of these newly addicted individuals could no longer afford OxyContin, they switched to heroin which was much cheaper. Drug dealers then started to add illicit fentanyl to heroin "to increase the high". The combination of heroin and illicit fentanyl proved to be highly addictive and often fatal. Prince died of a fentanyl overdose.

John Oliver Uses Humor To Attack Unethical Pharmaceutical Companies

In 2006, Purdue Pharma, the maker of OxyContin, agreed to plead guilty and pay more than $630 million to settle federal charges that it misled doctors and patients about the risks of OxyContin. This fine did little to stop the increasing popularity of OxyContin. In 2014, OxyContin was the most prescribed painkiller, and had global sales of $2.5 billion.

    The secret legal records sealed after the 2006 court case against Purdue Pharma were ordered unsealed in Pike Circuit Court in Kentucky in May 2016 by Judge Steven D. Combs. These legal records can now be used by other nations or U.S. states to sue Purdue Pharma like the U.S. federal government did in 2006.

    Billions of dollars in fines against other pharmaceutical companies for making false claims have done little to decrease their sales. For example, in 2012, GSK was fined $3 billion by the US government for making false claims about its pharmaceutical products.

In 2008 Cephalon, a major manufacturer of fentanyl, was also sued by the U.S. federal government. Cephalon was fined $425 million for false claims made for 3 of its products - especially for its product Actiq. "The FDA approved Actiq, a fentanyl product manufactured as a lollipop, for use only in opioid-tolerant cancer patients (meaning those patients for whom morphine-based painkillers are no longer effective). The drug is a strong and highly addictive narcotic, with significant potential for abuse. Cephalon was allegedly promoting the drug for noncancer patients to use for such maladies as migraines, injuries, and in anticipation of changing wound dressings or radiation therapy."

There is very limited evidence for the effectiveness of opioids in the treatment of chronic non-cancer pain. Thus, in order to stop this opioid epidemic, we must stop physicians from prescribing highly addictive opioid painkillers, like OxyContin and fentanyl, as first-line treatments for chronic non-cancer pain.

Many physicians now believe that the use of opioids like OxyContin and fentanyl should be severely restricted

  • There is little scientific proof that these opioids are effective painkillers for chronic, non-cancer pain since patients quickly develop drug tolerance.

  • These medications are highly addictive.

  • Highly addictive opioids like fentanyl should be only used for chronic cancer pain (or its medical equivalent).

  • Since OxyContin frequently lasts only 5-8 hours; it is little better than extended-release morphine (that is much cheaper).

  • Giving OxyContin only every 12-hours, as the manufacturer directs, causes marked opioid withdrawal symptoms which increase the risk of addiction.

  • When patients become addicted to these medications, and no longer can afford them, they switch to illicit heroin.

  • These opioids, when used with heroin, are frequently lethal.

Shouldn't The Government Just Give Heroin Addicts Free Heroin?

The short answer is no.

Here's what is happening in Vancouver, Canada.

Vancouver now is having 60 or more potentially fatal fentanyl-spiked drug overdoses on some days. Fortunately, most of these overdoses are reversed by first responders quickly administering naloxone (a fentanyl antidote). However, when an addict injects illicit fentanyl-spiked heroin when at home alone, a lethal dose of fentanyl kills the individual so quickly that there is no time (or no one) to give the individual the fentanyl antidote.

Most of Vancouver's fatal overdoses are from fentanyl-spiked heroin. When given the choice between "clean" heroin and fentanyl-spiked heroin, most of Vancouver's heroin addicts gladly risk their lives to acquire fentanyl-spiked heroin. The addict's appetite for more fentanyl-heroin is insatiable. All that stops fentanyl-heroin addicts from using more, is their lack of money.

Since tolerance to illicit fentanyl and carfentanyl spiked heroin soon develops; addicts keep increasing their dose. Eventually they reach a lethal dose. Even nearly dying of an overdose doesn't decrease their desire for more spiked heroin. Recently in Vancouver, one fentanyl-heroin addict overdosed 10 times in one day (each time his life was saved by naloxone administration). Thus no amount of free, government-supplied heroin would deter fentanyl- or carfentanyl-heroin addicts from wanting more.

Fentanyl- and carfentanyl-spiked drugs aren't "recreational drugs" - they are lethal drugs. The arrival of lethal fentanyl- and carfentanyl-spiked "recreational" drugs should permanently end the argument that illicit drugs "should all be legalized".

Could Methadone Maintenance Treatment For Opioid Addiction Stem Our Opioid Overdose Epidemic?

Methadone isn't a "medication" in the usual sense. Methadone is a synthetic heroin-like drug used as a substitute for heroin in the treatment of heroin addiction. This is like giving alcohol to alcoholics as a treatment for their alcoholism. The benefit of methadone is that, unlike heroin, it can be taken as a liquid and doesn't have to be injected.

Recent research has shown that methadone treatment for heroin addiction is largely ineffective.

Methadone maintenance therapy was based on a number of false assumptions:

  • FALSE ASSUMPTION: Methadone maintenance would decrease the criminal activity and mortality associated with heroin addiction:

      Most research studies on the effectiveness of methadone maintenance therapy have serious flaws in their research design. These studies aren't randomized clinical trials of methadone maintenance therapy compared with either placebo maintenance or other non-pharmacological therapy.

      These methodologically flawed studies either have no control group, or they do not randomize the allocation of patients into the experimental vs. control group. Without randomized allocation of experimental vs. control subjects in an experiment; it is impossible to scientifically determine what caused the difference in the two group's outcome.

      Fortunately, eleven studies avoided these serious research design flaws. These eleven studies concluded that maintenance therapy versus no opioid replacement for opioid dependence "does not show a statistically significant superior effect on criminal activity or mortality".

      Surprisingly, these eleven studies showed that a number of therapies (including either receiving methadone or a placebo) were equally effective. This suggests that the most important factor in the success of therapy could be the individual's decision to quit heroin.

      A prospective 15-year follow-up study of 613 methadone maintenance treatment patients in Israel showed that staying in methadone maintenance treatment for more than 1 year did not significantly lower the high mortality rate associated with heroin addiction.

      There was a prospective 4.6 year follow-up study in Spain of 5049 patients who started methadone maintenance treatment. Over that 4.6 years, 20% had died. Of the deaths, 38% were due to AIDS, 35% to overdose and 27% to other causes. The average life expectancy of these methadone maintenance treatment patients was 39 years, 38 years lower than that of the general population.

  • FALSE ASSUMPTION: Methadone would not be illegally sold by the methadone clinic patients:

      On the street, methadone is used by addicts as a heroin-substitute when heroin supplies run short. Thus methadone has a high street value.

      There are increasing reports of methadone clinic patients selling their methadone for money to buy heroin. (This was a very common practice that I observed when I briefly ran a methadone clinic in the 1970s as a psychiatrist in training.) In Maine, most of the methadone fatal overdoses came from methadone clinic patients illegally selling their methadone.

      In the U.S., for profit methadone clinics are a multi-billion dollar industry. Many of these clinics sometimes allow clinic patients to take home their methadone, rather than drinking it in front of staff at the clinic. It is this "carry home" methadone from the clinic that is sold for money by methadone clinic patients. Methadone is potentially a very lethal drug; hence many of the people buying this clinic-diverted methadone overdose and die. These thousands of deaths due to clinic-diverted methadone are never included in the research studies on the safety of methadone maintenance treatment.

  • FALSE ASSUMPTION: Methadone maintenance would improve the quality of life of the heroin addict:

  • FALSE ASSUMPTION: Heroin addicts would stay on their methadone maintenance:

      A treatment for heroin addiction is only effective if the patient stays on the therapy. Perhaps the biggest problem with methadone maintenance treatment is its large drop-out rate.

      An Australian study found that the average patient dropped out after 271 days on methadone maintenance treatment, or after 40 days on buprenorphine maintenance treatment.

      With such a high drop-out rate; how can maintenance treatment with methadone or buprenorphine be effective?

  • FALSE ASSUMPTION: Methadone maintenance treatment would stem the epidemic of opioid overdoses:

      North America is currently experiencing an epidemic of opioid overdoses (of methadone, OxyContin, fentanyl, and heroin).

      Methadone maintenance treatment has done little to stem this opioid epidemic. We must quickly find more effective therapies if we are to control this opioid epidemic.

Notice How All These Charts Erroneously Omit Mention Of Prescription Opioid Pain Relievers

Top 20 Most Harmful Drugs In Britain In 2008

Professor David Nutt published in the Lancet the following rating of Britain's most dangerous drugs. They are listed in descending order from the most harmful.

1. Heroin

Class A drug. Originally used as a painkiller and derived from the opium poppy. There were 897 deaths recorded from heroin and morphine use in 2008 in England and Wales, according to the Office of National Statistics (ONS). There were around 13,000 seizures, amounting to 1.6m tonnes of heroin.

2. Cocaine

Class A. Stimulant produced from the South American coca leaf. Accounted for 235 deaths -- a sharp rise on the previous year's fatalities. Nearly 25,000 seizures were made, amounting to 2.9 tonnes of the drug.

3. Barbiturates

Class B. Synthetic sedatives used for anesthetic purposes. Blamed for 13 deaths.

4. Street methadone

Class A. A synthetic opioid, commonly used as a substitute for treating heroin patients. Accounted for 378 deaths and there were more than 1,000 seizures of the drug.

5. Alcohol

Subject to increasing concern from the medical profession about its damage to health. According to the ONS, there were 8,724 alcohol deaths in the UK in 2007. Other sources claim the true figure is far higher.

6. Ketamine

Class C. A hallucinogenic dance drug for clubbers. There were 23 ketamine-related deaths in the UK between 1993 and 2006. Last year there were 1,266 seizures.

7. Benzodiazepines

Class C. A hypnotic relaxant used to treat anxiety and insomnia. Includes drugs such as diazepam, temazepam and nitrazepam. Caused 230 deaths and 1.8m doses were confiscated in more than 4,000 seizure operations.

8. Amphetamine

Class B. A psychostimulant that combats fatigue and suppresses hunger. Associated with 99 deaths, although this tally includes some ecstasy deaths. Nearly 8,000 seizures, adding up to almost three tonnes of confiscated amphetamines.

9. Tobacco

A stimulant that is highly addictive due to its nicotine content. More than 100,000 people a year die from smoking and tobacco-related diseases, including cancer, respiratory diseases and heart disease.

10. Buprenorphine

An opiate used for pain control, and sometimes as a substitute to wean addicts off heroin. Said to have caused 43 deaths in the UK between 1980 and 2002.

11. Cannabis

Class B. A psychoactive drug recently appearing in stronger forms such as "skunk". [Since this video was made; there is now conclusive proof that cannabis causes a 6.7 fold increase in the risk of developing schizophrenia.] Caused 19 deaths and there were 186,000 seizures, netting 65 tonnes of the drug and 640,000 cannabis plants.

12. Solvents

Fumes inhaled to produce a sense of intoxication. Usually abused by teenagers. Derived from commonly available products such as glue and aerosol sprays. Causes around 50 deaths a year.

13. 4-MTA

Class A. Originally designed for laboratory research. Releases serotonin in the body. Only four deaths reported in the UK between 1997 and 2004.

14. LSD

Class A. Hallucinogenic drug originally synthesized by a German chemist in 1938. Very few deaths recorded.

15. Methylphenidate

Class B drug. Brand name of Ritalin. A psychostimulant sometimes used in the treatment of attention deficit disorders.

16. Anabolic steroids

Class C. Used to develop muscles, notably in competitive sports. Also alleged to induce aggression. Have been blamed for causing deaths among bodybuilders. More than 800 seizures.

17. GHB

Class C drug. A clear liquid dance drug said to induce euphoria, also described as a date rape drug. Can trigger comas and suppress breathing. Caused 20 deaths and 47 seizures were recorded.

18. Ecstasy

Class A. Psychoactive dance drug. Caused 44 deaths, with around 5,000 seizures made.

19. Alykl nitrites

Known as "poppers". Inhaled for their role as a muscle relaxant and supposed sexual stimulant. Reduce blood pressure, which can cause fainting and in some cases death.

20. Khat

A psychoactive plant, the leaves of which are chewed in east Africa and Yemen. Also known as qat. Produces mild psychological dependence. Its derivatives, cathinone and cathine, are Class C drugs in the UK.

Ineffective Therapies

Treating Heroin Addiction With Heroin-Like Drugs

Currently there is a heavy emphasis on treating heroin addiction by supplying heroin addicts with heroin-like drugs as a substitute for their heroin (i.e., maintenance therapy with methadone or buprenorphine).

Maintaining heroin addicts on a heroin-like drug is like giving alcohol to alcoholics as a treatment for their alcoholism. Such heroin substitution therapies are effective in retaining patients in treatment and suppressing heroin use, but they do not decrease criminal behavior or decrease the high mortality rate associated with heroin addiction.

This is exactly the outcome you would expect if you gave alcohol to alcoholics as a treatment for their alcoholism. Supplying alcohol would keep alcoholics coming back for more, and it would decrease the amount of alcohol they would have to buy elsewhere, but it would not decrease the criminal activity or mortality associated with alcoholism.

The previous discussion ("Could Methadone Maintenance Treatment For Opioid Addiction Stem Our Opioid Overdose Epidemic?") summarized the many reasons why maintenance treatment with methadone or other heroin-like drugs is ineffective.

Maintenance therapy with methadone or buprenorphine only decreases the amount of heroin an addict buys on the street; it doesn't stop the addict from buying street heroin. Yet buying potentially lethal "spiked" street heroin risks death. On some days in Vancouver Canada, there are 60 cases a day of potentially fatal overdoses with fentanyl- or carfentanyl-spiked street drugs.

The Vancouver experience is that the more powerful "high" from fentanyl-spiked heroin is irresistible to heroin addicts. Most addicts would quickly sell their "clean" heroin to acquire fentanyl-spiked heroin. Their appetite for fentanyl-spiked heroin is insatiable, and they continue using it even if they have overdosed on it a couple of times that day.

Supplying "clean" opioids as a treatment for opioid addiction just won't work. The longer addicts are using opioids (even if in maintenance treatment), the greater the chance that they will eventually buy a lethal dose of "spiked" opioids on the street.

Thus the goal for successful treatment of heroin (or other opioid) addiction must be total abstinence from street drugs. Otherwise, it is unlikely that these addicts will survive long in today's epidemic of lethal fentanyl- and carfentanyl-spiked street drugs.

Could More "Safe Injection (Or Consumption) Sites" Decrease Our Opioid Overdose Epidemic?

Surprisingly, the answer is no.

For about a decade, Vancouver Canada has experimented with "safe injection sites" where addicts inject themselves under supervision. If the addict overdoses with an opioid at the safe injection site, the staff administers naloxone to reverse the overdose. Unfortunately these "safe injection sites" have been ineffective in countering Vancouver's skyrocketing heroin overdose problem.

Naloxone is an opioid blocker; hence it will reverse a potentially lethal opioid overdose. So why would that be considered ineffective?

The problem with naloxone is that, by being an opioid blocker, it hastens the onset of opioid withdrawal. This opioid withdrawal increases the craving for another dose of opioid. Thus naloxone-induced opioid withdrawal symptoms increase the risk of another overdose.

One opioid addict in Vancouver overdosed 10 times in one day, and each time was revived with naloxone.

Thus reversing opioid overdoses with naloxone doesn't make taking opioids "safe". Naloxone just reverses the immediate opioid overdose, but does nothing to decrease the risk of future overdoses.

Going to a "safe injection (or consumption) site" gives addicts a false sense of security that fentanyl-spiked opioids can be safely taken. But they can't - because the concentration of fentanyl in street opioids (e.g., heroin, "spiked" OxyContin) varies dramatically. An addict's next purchase of a fentanyl-spiked opioid may be lethal - even if the previous day's purchase wasn't. The addict has no way of knowing. Taking fentanyl-spiked opioids is just like playing Russian roulette - the longer you play, eventually your luck runs out. Thus every effort must be made to stop the addict from using fentanyl-spiked opioids.

Vancouver's experience has been that "safe injection (or consumption) sites" have not prevented opioid overdoses from skyrocketing, and may actually have lulled addicts into a false sense of security about continuing to take their lethal opioids.

Effective Therapies

Life-Saving Detoxification

When opioid addicts overdose, just administering naloxone to the addict to reverse the overdose, then leaving the addict on the street should be considered medical malpractice. These addicts suffer from an immediate, life-threatening disease over which they have no control.

As previously discussed (above), methadone maintenance treatment and "safe injection (or consumption) sites" will not stem this opioid overdose epidemic.

The first step in an effective response to this overdose epidemic is to detoxify the addict in a medically supervised detox facility. The severely addicted will refuse such treatment; hence they will have to be required by law to take it. Surely repeated, near fatal, overdoses would justify such involuntary treatment.

Long-Acting Opioid Blocking Drugs

Once opioid addicts have been successfully detoxified in a detox facility; they should be treated with 1-month injections or 6-month implants of naltrexone. Research has shown this to be very effective in producing abstinence in heroin addicts.

The severely addicted may refuse to take a long-acting opioid blocker because this would prevent the "high" they get from taking opioids. The law will have to be changed to require that these desperately ill opioid addicts take 1-month injections or 6-month implants of naltrexone.

Monthly injections of naltrexone (Vivitrol) are being used in Vancouver Canada. Dr. Keith Ahamad is on the Vancouver research team that studied Vivitrol. Dr. Ahamad's research team was very impressed with Vivitrol: “Because it's a once-a-month injection, people are not physically dependent on the medication, so there's no withdrawal and no euphoria, no reinforcing, no abuse potential. And there are very, very few side effects and very, very few drug-drug interactions. There's no risk of overdose and no risk of sedation or all these cognitive side effects that people don't talk about with other medications for opioids addiction.”

Surprisingly, oral naltrexone isn't effective as a treatment for opioid addiction - only the 1-month injection or 6-month implant long-acting forms of naltrexone are effective. Apparently oral naltrexone isn't effective because heroin addicts "forget" to take it (i.e., they don't want to block their heroin "high").

Required Medical Changes

Physicians that have narcotic (i.e., opioid) prescribing privileges should be required to take a course in pain management. These physicians should then be required to pass an exam to test their level of proficiency in pain management with opioids.

Pharmacy database records should be searched to identify any physicians that are over-prescribing opioid pain relievers. Any over-prescribing physicians should lose their licence to prescribe opioids.

Legal Interventions

  • We need a law that permits involuntary detoxification (in a hospital or detox center) for overdosing opioid addicts. This law would be identical to the law that permits involuntary hospitalization and treatment of mentally ill patients that are at high risk of harming themselves or others.

  • Likewise, we need a law that requires that overdosing opioid addicts must continue on a long-acting opioid blocker once they finish their medically-supervised detoxification. This law would be identical to the law (in some nations) that requires that severely ill psychotic patients must continue on their antipsychotic medication as outpatients (i.e., "outpatient committal").

  • U.S. states or other nations should follow the lead of the U.S. federal government, and sue pharmaceutical companies that made false claims about their opioid pain relievers. Thus these proposed legal actions would be similar to the U.S. federal government's successful legal action against oxycodone (OxyContin®) in 2006, and fentanyl (Actiq®) in 2008. The millions of pages of legal documents used in the OxyContin 2006 court case (which resulted in Purdue Pharma being fined $630 million) have been recently unsealed and placed in the public domain.

Essential Non-Pharmaceutical Interventions

Heroin addicts will not stay on any pharmaceutical treatment unless they also have counseling; otherwise they quickly drop out.

Thus counselling that focuses on dealing with their multiple addictions and many psychological problems (e.g., personality disorder plus anger, anxiety and depression) is essential.

Supported housing and government financial assistance often is essential; since many addicts are homeless and/or unemployed. Once addicts have been unemployed for a long time, it is not realistic to enrole them in job retraining until they have a considerable period of sobriety. In these cases, government disability pensions (short- or long-term) are more realistic than job-retraining.

Often an addict's opioid consumption is only limited by how much money the addict has. Thus financial systems must be put in place that ensure that government financial assistance (i.e., welfare payments) do not primarily just go to support the addict's drug habit. Thus governments must do everything possible to minimize the amount of cash handed to an addict in financial assistance.

This could be accomplished by the government directly paying the addict's rent and giving food or meal vouchers instead of cash welfare payments. Likewise, government cash financial assistance could be dispensed on a weekly basis; rather than on a monthly basis. Any large cash payment to an addict dramatically increases the risk of accidental overdose.

Should Illicit Drugs Be Legalized?

The leading causes of death in USA in 2000 were tobacco (435 000 deaths; 18.1% of total US deaths), poor diet and physical inactivity (365 000 deaths; 15.2%), and alcohol consumption (85 000 deaths; 3.5%). Some people argue that illicit drugs should be legalized to decrease the crime associated with these drugs. Historically, tobacco and alcohol were once illegal drugs. Tobacco smoking is now the leading cause of death in America, and alcoholism is the third leading cause of death. Thus legalizing illicit drugs does not make them any less medically and socially harmful. In fact the opposite is true; legalizing illicit drugs increases their use and the harm they cause.

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Personal Stories

The General Opioid Overdose Crisis

Addiction To Prescription Opioid Pain Relievers

Carfentanyl Use

Fentanyl Use

Heroin Use

General Description

North America's Opioid Epidemic

U.S. National Institute On Drug Abuse

In The News (Chronologically Displayed)


Rating Scales


Stages of Learned Behavior

Our survival involves learning what to avoid (i.e., fear) and what to approach (i.e., crave). Both fear and craving are essential for our survival, but both can spiral out of control.

For example, an individual can develop a phobia about snakes in which the fear becomes excessive. This phobia can develop into an obsession in which the individual spends much of the time thinking about snakes, and how to avoid them.

This obsession can develop into a compulsion in which the individual spends much of the time doing superstitious, compulsive, ritual behaviors aimed at avoiding snakes.

Likewise, an individual can develop an excessive craving for alcohol which causes significant distress or disability.

This excessive craving for alcohol can develop into an obsession in which the individual spends much of the time thinking about alcohol, and how to get it.

This obsession can develop into a compulsion in which the individual spends much of the time compulsively drinking, and feeling powerless to resist this craving.

Four Stages of Fear and Craving

Normal Fear:
Is in proportion to the actual danger, and doesn't cause significant distress or disability.
Normal Craving:
Doesn't cause significant distress or disability.
Excessive Fear (Phobia):
Is out of proportion to the actual danger posed, and causes significant distress or disability.
Excessive Craving:
Is not socially acceptable, and causes significant distress or disability (e.g., "I'm drinking too much").
Obsessional Fear:
Persistent, unwanted or obsessional thoughts about the fear develop, which cause significant distress or disability.
Obsessional Craving:
Persistent, unwanted or obsessional thoughts about the craving develop, which cause significant distress or disability (e.g., "I spend much of my time thinking about alcohol, and how to get it").
Compulsive Fear:
Compulsive behaviors develop (aimed at reducing the anxiety associated with the obsession), which the individual finds very hard to resist doing.
Compulsive Craving:
Compulsive behaviors develop (aimed at satisfying the craving), which the individual finds very hard to resist doing (e.g., "I can't stop myself from drinking").

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Treatment Guidelines

World Health Organization Drug Use Disorder Treatment Guidelines

Prescribing Opioids For Chronic Pain - U.S. Surgeon General

Treatment Articles

Treatment Evaluation

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Overcoming Drug Addiction

Self-Help Groups for Drug Addiction

Improving Positive Behavior

Philosophers for the past 2,500 years have taught that it is very beneficial to start the day with goal-setting, and end the day with a brief review.

This habit of planning your day in the morning, and reviewing your day in the evening, is a time-proven technique for more successful living.

Note: When each of the following videos finishes; you must exit YouTube (by manually closing the window) in order to return to this webpage.

International Space Station (For Meditation)

Morning Meditation (5-Minute Video)

Planning My Day (Picture)

Evening Meditation (5-Minute Video)

Life Satisfaction Scale (Video)

Healthy Social Behavior Scale (Video)

Mental Health Scale (Video)

Click Here For More Self-Help

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Research Topics

    "In physical science a first essential step in the direction of learning any subject is to find principles of numerical reckoning and practicable methods for measuring some quality connected with it. I often say that when you can measure what you are speaking about and express it in numbers you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind: it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be."

    Lord Kelvin (1824 – 1907)

  • The best summary on bad research is given by Laura Arnold in this Tedx lecture. If you read nothing else about research, you owe it to yourself to watch this short video - it is excellent!

  • Criteria For High Quality Research Studies

  • It is imperative that medical researchers conduct high quality research studies, otherwise the US Food and Drug Administration (FDA) refuses to licence their new drug or therapy. In 2009, the cost of successfully licensing one new drug or therapy under the FDA scheme was estimated to be US$1,000 million. Thus psychiatric research which leads to FDA approval of a new drug or therapy has to be of the highest quality; however the majority of psychological research studies on new therapies fail to reach these high standards for research. This could explain why two-thirds of psychological research studies can't be replicated. High quality research must meet the following criteria:

    • Randomized Controlled Trial:
      Ask: Was the trial randomized? Was the randomization procedure described and was it appropriate? The best research design is to have research subjects randomly assigned to an experimental or control group. It is essential that confounding factors be controlled for by having a control group or comparator condition (no intervention, placebo, care as usual etc.).

    • Representative Sample:
      Ask: Do the research subjects represent a normal cross-section of the population being studied? Many psychological research studies using university students are flawed because their subjects are not representative of the normal population since they are all W.E.I.R.D. (White, Educated, Intelligent, Rich, and living in a Democracy).

    • Single Blind Trial:
      Ask: Was the treatment allocation concealed? It is essential that the research subjects are kept "blind" as to whether they are in the experimental or control group (in order to control for any placebo effects).

    • Double Blind Trial (Better Than Single Blind Trial):
      Ask: Were blind outcome assessments conducted? In a double blind study, neither the research subjects nor the outcome assessors know if the research subject is in the experimental or control group. This controls for both the placebo effect and assessor bias.

    • Baseline Comparability:
      Ask: Were groups similar at baseline on prognostic indicators? The experimental and control groups must be shown to be comparable at the beginning of the study.

    • Confounding Factors:
      Ask: Were there factors, that weren't controlled for, that could have seriously distorted the study's results? For example, research studies on the effectiveness of mindfulness cognitive therapy in preventing depressive relapse forgot to control for whether the research subjects were also simultaneously receiving antidepressant medication or other psychological treatments for depression.

    • Intervention Integrity:
      Ask: Was the research study protocal strictly followed? The research subjects must be shown to be compliant (e.g., taking their pills, attending therapy) and the therapists must be shown to be reliably delivering the intervention (e.g., staying on the research protocol).

    • Statistical analysis:
      Ask: Was a statistical power calculation described? The study should discuss its statistical power analysis; that is whether the study size is large enough to statistically detect a difference between the experimental and control group (should it occur) and usually this requires at least 50 research subjects in the study.

      Ask: Are the results both statistically significant and clinically significant? The results should be both statistically significant (with a p-value <0.05) and clinically significant using some measure of Effect Size such as Standardized Mean Difference (e.g., Cohen's d >= 0.33). The summary statistics should report what percentage of the total variance of the dependent variable (e.g., outcome) can be explained by the independent variable (e.g., intervention). In clinical studies, the study should report the number needed to treat for an additional beneficial outcome (NNTB), and the number needed to treat for an additional harmful outcome (NNTH).

        Number Needed To Benefit (NNTB): This is defined as the number of patients that need to be treated for one of them to benefit compared with a control in a clinical trial. (It is defined as the inverse of the absolute risk reduction.) Note: Statistically, the NNTB depends on which control group is used for comparison - e.g., active treatment vs. placebo treatment, or active treatment vs. no treatment.

        Number Needed To Harm (NNTH): This is defined as the number of patients that need to be treated for one of them to be harmed compared with a control in a clinical trial. (It is defined as the inverse of the absolute increase in risk of harm.)

        Tomlinson found “an NNTB of 5 or less was probably associated with a meaningful health benefit,” while “an NNTB of 15 or more was quite certain to be associated with at most a small net health benefit.”

      Ask: Does the researcher accept full responsibility for the study's statistical analysis? The researcher should not just hand over the study's raw data to a corporation (that may have $1,000 million invested in the study) to do the statistical analysis.

    • Completeness of follow-up data:
      Ask: Was the number of withdrawals or dropouts in each group mentioned, and were reasons given for these withdrawals or dropouts? Less than 20% of the research subjects should drop out of the study. The intervention effect should persist over an adequate length of time.

    • Handling of missing data:
      Ask: Was the statistical analysis conducted on the intention-to-treat sample? There must be use of intention-to-treat analysis (as opposed to a completers-only analysis). In this way, all of the research subjects that started the study are included in the final statistical analysis. A completers-only analysis would disregard those research subjects that dropped out.

    • Replication of Findings:
      Ask: Can other researchers replicate this study's results? The research study's methodology should be clearly described so that the study can be easily replicated. The researcher's raw data should be available to other researchers to review (in order to detect errors or fraud).

    • Fraud:
      Ask: Is there a suspicion of fraud? In a research study, examine the independent and dependent variables that are always measured as a positive whole number (e.g., a variable measured on a 5-point Likert-type scale ranging from "1 = definitely false to 5 = definitely true" etc.). For each of these variables, look at their sample size (n), mean (M) and standard deviation (SD) before they undergo statistical analysis. There is a high suspicion of fraud in a study's statistics:

      • If the M is mathematically impossible (online calculator): This is one of the easiest ways to mathematically detect fraud. The mean (M) is defined as "the sum (Sum) of the values of each observation divided by the total number (n) of observations". So: M = Sum/n. Thus: (Sum) = (M) multiplied by (n). We know that, if a variable is always measured as a positive whole number, the sum of these observations always has to be a whole number. For these variables to test for fraud: calculate (M) multiplied by (n). This calculates the Sum which MUST be a positive whole number. If the calculated Sum isn't a positive whole number; the reported mean (M) is mathematically impossible - thus the researcher either cooked the data or made a mistake. A recent study of 260 research papers published in highly reputable psychological journals found that 1 in 2 of these research papers reported at least one impossible value, and 1 in 5 of these research papers reported multiple impossible values. When the authors of the 21 worst offending research papers were asked for their raw data (so that its reliability could be checked) - 57% angrily refused. Yet such release of raw data to other researchers is required by most scientific journals. (Here is an example of a research paper filled with mathematically impossible means.)

      • If the SD is mathematically impossible (online calculator): When researchers fraudulently "cook" their data, they may accidently give their data a mean and standard deviation that is mathematically impossible.

      • If the SD/M is very small (i.e., the variable's standard deviation is very small compared to the mean suggesting data smoothing).

      • If the SD's are almost identical (i.e., the variables have different means but almost identical standard deviations).

      • If the 4th digit of the values of the variables aren't uniformly distributed - since each should occur 10% of the time (Benford's Law).

      • If the researcher is legally prevented from publishing negative findings about a drug or therapy because that would violate the "nondisclosure of trade secrets" clause in the research contract (i.e., it is a "trade secret" that the drug or therapy is ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical trials fail to publish their results.

      • If the researcher refuses to release his raw data to fellow researchers (so that they can check its validity). In order to be published in most scientific journals, a researcher must promise to share his raw data with fellow researchers. Thus a researcher's refusal to do so is almost a sure indicator of fraud.

      • If the research study's data contradicts the study's own conclusions - surprisingly, this often occurs.

  • Calling Bullshit In The Age of Big Data - "Bullshit is language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence." Reading the syllabus of this university course should be required reading for every student of mental health. This syllabus is absolutely fantastic!

  • Statistical Methods in Psychology Journals: Guidelines and Explanations - American Psychologist 1999

  • Not All Scientific Studies Are Created Equal - video

  • The efficacy of psychological, educational, and behavioral treatment

  • Estimating the reproducibility of psychological science

  • Psychologists grapple with validity of research

  • Industry sponsorship and research outcome (Review) - Cochrane Library

  • 'We've been deceived': Many clinical trial results are never published - (text and video)

  • Junk science misleading doctors and researchers

  • Junk science under spotlight after controversial firm buys Canadian journals

  • Medicine with a side of mysticism: Top hospitals promote unproven therapies - Are some doctors becoming modern witchdoctors?

  • When Evidence Says No, But Doctors Say Yes

  • Cochrane Reviews (the best evidence-based, standardized reviews available)

Pharmacological Detoxification Interventions

      Opioid Dependence is chronic, episodic illness which requires more than brief hospital or residential care. During detoxification, a combination of pharmaceutical detoxification treatment plus psychosocial treatment is more effective than pharmaceutical detoxification treatment alone. The best detoxification treatment is to use an initial 2-4 mg dose of buprenorphine combined with clonidine, other ancillary medications, and progressively increasing doses of oral naltrexone over 3-5 days up to the target dose of naltrexone.
      After brief detoxification, more than two-thirds of opioid-addicts quickly relapse unless they receive years of treatment with a long-acting opioid blocker (naltrexone) plus psychosocial treatment. To maintain their abstinence, it is essential that recovering addicts: (1) not associate with active alcohol or drug abusers, (2) not use alcohol or any illicit drug, and (3) avoid alcohol or drug-using environments.
  • NOTE:
      Naltrexone should not be confused with naloxone nor nalorphine, which are used in emergency cases of opioid overdose.

  • Opioid detoxification and naltrexone induction strategies: recommendations for clinical practice. (2012) DESIGN: Cochrane literature review. CONCLUSIONS: Among the current detoxification regimens, the available clinical and scientific data suggest that the best approach may be using an initial 2-4 mg dose of buprenorphine combined with clonidine, other ancillary medications, and progressively increasing doses of oral naltrexone over 3-5 days up to the target dose of naltrexone.

  • Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. (2011) DESIGN: Cochrane literature review. SUBJECTS: FINDINGS: Compared to any pharmacological treatment alone, the association of any psychosocial with any pharmacological was shown to significantly reduce dropouts (RR 0.71), use of opiate during the treatment (RR 0.82), use of opiate at follow up (RR 0.66), and clinical absences during the treatment (RR 0.48). Moreover, with the evidence currently available, there are no data supporting a single psychosocial approach. CONCLUSIONS: Psychosocial treatments offered in addition to pharmacological detoxification treatments are effective in terms of completion of treatment, use of opiate, participants abstinent at follow-up and clinical attendance.

  • Transitioning opioid-dependent patients from detoxification to long-term treatment: efficacy of intensive role induction. (2011) DESIGN: 30-day, openly assigned, randomised trial. SUBJECTS: 240 individuals admitted to a 30-day buprenorphine detoxification delivered at a publicly funded outpatient drug treatment clinic. CONCLUSIONS: The current study demonstrated that an easily administered psychosocial intervention can be effective for enhancing patient involvement in detoxification and for enabling their engagement in long-term treatment following detoxification.

  • The potential risks and high cost of using opioid blocking drugs during heavy sedation or anaesthesia to bring on withdrawal outweigh the benefits (2010) DESIGN: Cochrane literature review. SUBJECTS: Nine studies involving 1109 patients. CONCLUSIONS: Heavy sedation compared to light sedation does not confer additional benefits in terms of less severe withdrawal or increased rates of commencement on naltrexone maintenance treatment. Given that the adverse events are potentially life-threatening, the value of antagonist-induced withdrawal under heavy sedation or anaesthesia is not supported. The high cost of anaesthesia-based approaches, both in monetary terms and use of scarce intensive care resources, suggest that this form of treatment should not be pursued.

  • Alpha2-adrenergic agonists for the management of opioid withdrawal. (2009) DESIGN: Cochrane literature review. SUBJECTS: Twenty-four studies, involving 1631 patients. CONCLUSIONS: Clonidine and lofexidine are more effective than placebo for the management of withdrawal from heroin or methadone. No significant difference in efficacy was detected for treatment regimes based on clonidine or lofexidine, and those based on reducing doses of methadone over a period of around 10 days but methadone is associated with fewer adverse effects than clonidine, and lofexidine has a better safety profile than clonidine.

  • Buprenorphine for the management of opioid withdrawal. (2009) DESIGN: Cochrane literature review. SUBJECTS: Twenty-two studies involving 1736 patients. CONCLUSIONS: Buprenorphine is more effective than clonidine or lofexidine for the management of opioid withdrawal. Buprenorphine may offer some advantages over methadone, at least in inpatient settings, in terms of quicker resolution of withdrawal symptoms and possibly slightly higher rates of completion of withdrawal.

  • Post-treatment outcomes of buprenorphine detoxification in community settings: a systematic review. (2008) DESIGN: Literature review. SUBJECTS: 5 studies. FINDINGS: Detoxification completion rates were 65-100%, but relatively few treatment completers were then drug free at their follow-up appointments. In subsequent prescribing, more patients had returned to opioid maintenance than complied with naltrexone. CONCLUSIONS: Buprenorphine is a suitable medication for the process of opiate detoxification but that this newer treatment option has not led to higher rates of abstinence following withdrawal.

  • Using buprenorphine to facilitate entry into residential therapeutic community rehabilitation. (2007) DESIGN: Retrospective observational cohort study. SUBJECTS: 38 opioid-dependent patients entering a 14-day buprenorphine-naloxone (Suboxone) detoxification regimen integrated into a long-term residential therapeutic community program. FINDINGS: 89% of patients completed a 14-day buprenorphine taper protocol, 50% completed an initial 3- to 4-week stay, and 39% completed at least 3 months of residential treatment at the therapeutic community. Withdrawal symptoms were mild, and there were no instances of precipitated withdrawal. CONCLUSIONS: A 14-day buprenorphine-naloxone (Suboxone) detoxification can improve the viability of long-term residential treatment for managing opioid dependence.

  • Outpatient treatment engagement and abstinence rates following inpatient opioid detoxification. (2006) DESIGN: Retrospective cohort analysis. SUBJECTS: 112 male veterans referred to drug-free outpatient treatment following inpatient detoxification. FINDINGS: Most patients (78%) successfully completed acute detoxification, 49% initiated oral naltrexone, and 76% accepted a VA aftercare plan. At 90-day follow-up, only 22% remained in aftercare, and < 3% had toxicology-verified abstinence from opioids. At one-year follow-up, 1 out of 5 had been readmitted for detoxification and 4.5% had died. CONCLUSIONS: Most patients successfully detoxified from opioids, but very few remained engaged and stabilized in abstinence-oriented outpatient treatment.

  • Methadone at tapered doses for the management of opioid withdrawal. (2005) DESIGN: Cochrane literature review. SUBJECTS: Sixteen trials involving 1187 patients. FINDINGS: Comparing methadone versus any other pharmacological treatment (adrenergic agonists, other opioid agonists, or chlordiazepoxide) we observed no clinical difference between the two treatments in terms of completion of treatment. CONCLUSIONS: Slow tapering with temporary substitution of long acting opioids can reduce withdrawal severity. Nevertheless the majority of patients relapsed to heroin use.

  • Inpatient opiate detoxification in Geneva: follow-up at 1 and 6 months. (2000) DESIGN: Retrospective observational study. SUBJECTS: 73 patients admitted for 15-day inpatient detoxification using methadone tapering. FINDINGS: After 1 month, 65% of the patients were using drugs (half of them were dependent again, half of them had used occasionally) and 35% were completely abstinent. After 6 months, 50% were physically dependent again, 13% had lapsed occasionally, 37% were abstinent. Factors associated with treatment failure were: cocaine abuse, presence of legal problems, and short duration of hospital stay. CONCLUSIONS: Six months after 15-day inpatient detoxification, without followup pharmacotherapy, the majority of patients relapsed to heroin use.

Opioid Antagonist Maintenance Therapy With Naltrexone Implants (That Last 6 Months) Or Extended-Release Naltrexone Injections (That Last 1 Month)

      • NALTREXONE IMPLANTS: After 6 months of treatment, 53% of opioid-addicted patients on naltrexone implant treatment remained in treatment without relapse compared with only 11% on placebo. After 6 months, 44% of opioid-addicted patients on naltrexone implant treatment were abstinent from opioids. Mean opioid use was reduced from 18 days during the month preceding treatment to 6 days after 6 months. The 3-year mortality rates of patients on naltrexone implant treatment are similar to those of methadone maintenance treatment. Long-acting naltrexone implants appear to block all opiates and lack hepatotoxicity. Of the patients who received the first naltrexone implant, only 51% accepted a second naltrexone implant. Naltrexone implant therapy patients, compared to buprenorphine, had significantly longer days in treatment per episode (238 days vs. 47), and longer total treatment duration (371 days vs. 162).
      • NALTREXONE EXTENDED-RELEASE INJECTIONS: Over 24-weeks of treatment, opioid-addicted patients on injectable extended-release naltrexone remained abstinent for 90% of the time compared with 35% of the time for the placebo group. Total healthcare costs for patients given injectable extended-release naltrexone were 49% lower than those for methadone.

      In opioid dependence, following detoxification, naltrexone implants and injectable extended-release naltrexone show efficacy for maintaining abstinence, improving retention, decreasing craving, and preventing relapse. . After 6 months, long-acting naltrexone implants can prevent opiate overdose for several additional months.

  • Randomized trial of long-acting sustained-release naltrexone implant vs oral naltrexone or placebo for preventing relapse to opioid dependence. (2012) DESIGN: Six-month double-blind, placebo-controlled, randomized trial. SUBJECTS: 306 opioid-addicted patients recently undergoing detoxification. FINDINGS: By month 6, 52.9% patients in the naltrexone implant + oral placebo (NI+OP) group remained in treatment without relapse compared with 15.7% patients in the placebo implant + oral naltrexone (PI+ON ) group and 10.8% patients in the placebo implant + oral placebo (PI+OP) group. The proportion of urine screening tests yielding negative results for opiates was 63.6% for the NI+OP group; 42.7% for the PI+ON group; and 34.1% for the PI+OP group. CONCLUSIONS: The naltrexone implant is more effective than oral naltrexone or placebo.

  • Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial. (2011) DESIGN: 24-week, double-blind, placebo-controlled, randomised trial. SUBJECTS: 250 opioid-addicted patients recently undergoing detoxification. FINDINGS: The median proportion of weeks of confirmed abstinence was 90% in the injectable extended-release naltrexone (XR-NTX) group compared with 35% in the placebo group. Median retention was over 168 days in the injectable extended-release naltrexone group compared with 96 days in the placebo group. No injectable extended-release naltrexone (XR-NTX) patients died, overdosed, or discontinued owing to severe adverse events. CONCLUSIONS: The injectable extended-release naltrexone (XR-NTX) is more effective than placebo and is very safe.

  • Cost and utilization outcomes of opioid-dependence treatments. (2011) DESIGN: Retrospective claims database analysis. SUBJECTS: 13,316 patients. FINDINGS: Patients given injectable extended-release naltrexone (XR-NTX) had fewer opioid-related and non-opioid-related hospitalizations than patients receiving oral medications. Despite higher costs for XR-NTX, total healthcare costs were not significantly different from those for oral naltrexone or buprenorphine, and were 49% lower than those for methadone. CONCLUSIONS: Patients with opioid dependence who received medication for this disorder had lower hospital utilization and total costs than patients who did not receive pharmacologic therapy. Patients who received extended-release naltrexone (NTX-XR) had lower inpatient healthcare utilization at comparable or lower total costs than those receiving oral medications.

  • Intramuscular extended-release naltrexone: current evidence. (2011) DESIGN: Literature Review. CONCLUSIONS: Injectable extended-release naltrexone (XR-NTX; Vivitrol) safety and tolerability is good, without adverse hepatic impact. Injectable extended-release naltrexone (XR-NTX) use results in cost savings and decreased intensive service utilization relative to oral agents like methadone. In opioid dependence, following detoxification, injectable extended-release naltrexone shows efficacy for maintaining abstinence, improving retention, decreasing craving, and preventing relapse.

  • Recent developments in naltrexone implants and depot injections for opiate abuse: the new kid on the block is approaching adulthood. (2010) DESIGN: Literature Review. CONCLUSIONS: Long-acting naltrexone implants can deliver relapse-preventing serum naltrexone levels for around six months per implant. Naltrexone implants have proven superior to oral naltrexone and placebo implants, or with standard post-detoxification care. After 6 months, long-acting naltrexone implants can prevent opiate overdose for several additional months. The 3-year mortality rates are similar to those of methadone maintenance treatment. Long-acting naltrexone implants appear to block all opiates and lacks hepatotoxicity. Therapy with long-acting naltrexone implants should last for at least 18 months.

  • Challenges to antagonist blockade during sustained-release naltrexone treatment. (2010) DESIGN: Retrospective case file audit over a 6-month period. SUBJECTS: 60 opioid-dependent patients receiving treatment with naltrexone implants. FINDINGS: After 6 months, 44% were abstinent from opioids. Mean opioid use was reduced from 18 days during the month preceding treatment to 6 days after 6 months. Opioid use was associated with use of non-opioid drugs and criminal behavior. CONCLUSIONS: Challenging naltrexone blockade with heroin on at least one occasion is common among sustained-release naltrexone patients, but only a minority of patients use opioids regularly.

  • Retention in naltrexone implant treatment for opioid dependence. (2010) DESIGN: Retrospective case file audit. SUBJECTS: 61 patients were offered a second naltrexone implant after 6 months. FINDINGS: Of the patients who received the first naltrexone implant, 51% accepted a second naltrexone implant. Higher levels of substance misuse and criminal activity during naltrexone treatment were negatively related to subsequent retention. CONCLUSIONS: Rates of retention among opioid-dependent patients receiving naltrexone implant treatment are encouraging and support this as a feasible long-term treatment option.

  • Naltrexone implants after in-patient treatment for opioid dependence: randomised controlled trial. (2009) DESIGN: 6-month, openly assigned, randomised trial. SUBJECTS: 56 abstinence-oriented patients who completed in-patient treatment for opioid dependence were randomly and openly assigned to receive either a 6-month naltrexone implant or their usual aftercare. FINDINGS: Patients receiving naltrexone implants had on average 45 days less heroin use and 60 days less opioid use than controls in the 180-day period. CONCLUSIONS: Naltrexone implant treatment safely and significantly reduces opioid use in a motivated population of patients.

  • Comparative treatment and mortality correlates and adverse event profile of implant naltrexone and sublingual buprenorphine. (2009) DESIGN: Retrospective registry database analysis. SUBJECTS: 255 naltrexone implant therapy and 2,518 buprenorphine patients were followed for 1,322 and 8,030 patient-years, respectively. FINDINGS: Naltrexone implant therapy patients, compared to buprenorphine, had significantly longer days in treatment per episode (238 days vs. 47), and longer total treatment duration (371 days vs. 162). CONCLUSIONS: Naltrexone implant therapy economizes treatment resources without compromising safety concerns.

  • Precipitated withdrawal during maintenance opioid blockade with extended release naltrexone. (2008) DESIGN: Single case report of 17-year-old opioid-addicted female going into painful opioid withdrawal after using oxycodone at the end of her 3rd monthly injection of extended release naltrexone (Vivitrol). CONCLUSIONS: This case suggests that the opioid blockade may be overcome when naltrexone levels drop towards the end of the dosing interval, producing vulnerability to subsequent naltrexone-induced withdrawal.

  • Unplanned admissions to two Sydney public hospitals after naltrexone implants. (2008) DESIGN: Retrospective case file audit over a 12-month period. SUBJECTS: Twelve cases were identified: eight were definitely or probably related to naltrexone implants or the implantation procedure (rapid detoxification). FINDINGS: Six patients had severe opiate withdrawal and dehydration, with an average hospital stay of 2.3 days. One patient had an infection at the implant site, and one an underlying anxiety disorder requiring psychiatric admission. Three patients had analgesia complications, and one had unrelated cardiac arrhythmia. CONCLUSIONS: Naltrexone implants require careful case selection and clinical management.

Opioid Antagonist Maintenance Therapy With Oral Naltrexone

  • Oral naltrexone maintenance treatment for opioid dependence. (2011) DESIGN: Cochrane literature review. SUBJECTS: Thirteen studies, 1158 patients. FINDINGS: Comparing naltrexone versus placebo or no pharmacological treatments, no statistically significant difference were noted for all the primary outcomes considered. CONCLUSIONS: Maintenance therapy with oral naltrexone cannot yet be considered a treatment which has been scientifically proven.

Opioid Agonist Maintenance Therapy With Methadone, Buprenorphine Or Heroin

      Maintenance therapy with methadone, buprenorphine or heroin for opioid dependence increases the retention of patients in treatment when compared to non-pharmacological treatments. Buprenorphine has a higher rate of retention of patients than methadone. There is only weak evidence that these opioid agonists decrease criminal activity or mortality. Treatment with these opioid agonists suffers from a high drop-out rate (half of patients are still in therapy after 3 years). These opioid agonists (especially methadone and heroin) are very addictive and prone to overdose. Treatment with these opioid agonists does not improve the opioid-addict's mental health or quality of life. Most opioid addicts are also addicted to alcohol or other illicit drugs. Personality disorders play a major role in heroin addiction; 72% of heroin addicts have antisocial personality disorder and 47% have borderline personality disorder. Treatment with methadone, buprenorphine or heroin does nothing to combat these other addictions or personality disorders.
      Maintenance therapy with methadone, buprenorphine or heroin is the most effective in retaining patients in treatment and suppressing heroin use but shows weak evidence of effectiveness toward other relevant outcomes.

  • Heroin maintenance for chronic heroin-dependent individuals. (2011) DESIGN: Cochrane literature review. SUBJECTS: Eight studies involving 2007 patients. FINDINGS: Five studies compared supervised injected heroin plus flexible dosages of methadone treatment to oral methadone only and showed that heroin helps patients to remain in treatment (RR 1.44), and to reduce use of illicit drugs. Maintenance with supervised injected heroin does NOT have a protective effect on mortality. Heroin provision can reduce criminal activity and incarceration/imprisonment. Social functioning improved in all the intervention groups with heroin groups having slightly better results. CONCLUSIONS: Due to the higher rate of serious adverse events, heroin prescription should remain a treatment for people who are currently or have in the past failed other maintenance treatments, and it should be provided in clinical settings where proper follow-up is ensured.

  • Maintenance agonist treatments for opiate dependent pregnant women. (2011) DESIGN: Cochrane literature review. SUBJECTS: Three trials with 96 pregnant women. FINDINGS: There was no difference in drop out rate and use of primary substance between methadone and buprenorphine, whereas oral slow morphine seemed superior to methadone in abstaining women from the use of heroin. CONCLUSIONS: We didn't find any significant difference between the drugs compared both for mother and for child outcomes; the trials retrieved were too few and the sample size too small to make firm conclusion about the superiority of one treatment over another.

  • The evidence doesn't justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine. (2011) DESIGN: Retrospective claims database analysis. SUBJECTS: 33,923 Massachusetts opioid-addicted Medicaid beneficiaries receiving either buprenorphine, methadone, drug-free treatment, or no treatment. FINDINGS: Buprenorphine appears to have significantly expanded access to treatment because the drug can be prescribed by a physician and taken at home compared with methadone, which by law must be administered at an approved clinic. Buprenorphine was associated with more relapse-related services but $1,330 lower mean annual spending than methadone when used for maintenance treatment. Mortality rates were similar for buprenorphine and methadone. By contrast, mortality rates were 75 percent higher among those receiving drug-free treatment, and more than twice as high among those receiving no treatment, compared to those receiving buprenorphine. CONCLUSIONS: The evidence does not support rationing buprenorphine to save money or ensure safety.

  • Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. (2009) DESIGN: Cochrane literature review. SUBJECTS: Eleven studies with 1969 patients. FINDINGS: Methadone appeared statistically significantly more effective than non-pharmacological approaches in retaining patients in treatment and in the suppression of heroin use as measured by self report and urine/hair analysis (RR = 0.66), but not statistically different in criminal activity or mortality. CONCLUSIONS: Methadone is an effective maintenance therapy intervention for the treatment of heroin dependence as it retains patients in treatment and decreases heroin use better than treatments that do not utilise opioid replacement therapy. Methadone does not show a statistically significant superior effect on criminal activity or mortality.

  • Buprenorphine and methadone maintenance in jail and post-release: a randomized clinical trial. (2009) DESIGN: Randomized clinical trail. SUBJECTS: 116 heroin-dependent inmates who volunteered to be randomly allocated to either buprenorphine or methadone maintenance before release from jail. FINDINGS: Buprenorphine and methadone maintenance completion rates in jail were equally high, but the buprenorphine group reported for their designated post-release treatment in the community significantly more often than did the methadone group (48% vs. 14%). Buprenorphine patients were less likely than methadone patients to withdraw voluntarily from medication while in jail (3% vs. 16%). CONCLUSIONS: After initiating opioid agonist treatment in jail, continuing buprenorphine maintenance in the community appears to be more acceptable to offenders than continuing methadone maintenance.

  • Feasibility and outcome of substitution treatment of heroin-dependent patients in specialized substitution centers and primary care facilities in Germany: a naturalistic study in 2694 patients. (2008) DESIGN: 12-Month prospective-longitudinal naturalistic study. SUBJECTS: 2694 patients. FINDINGS: The 12-month retention rate was 75%; the mortality rate 1.1%. 4.1% of patients became "abstinent" during follow-up. 7% were referred to drug-free addiction treatment. Concomitant drug use decreased and somatic health status improved. No significant improvements were observed for mental health and quality of life. CONCLUSIONS: The study underlines the overall 12-month effectiveness of various forms of agonist maintenance. Findings reveal relatively high retention rates, low mortality rates, and improvements in most 12-month outcome domains, except for mental health and quality of life.

  • Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. (2008) DESIGN: Cochrane literature review. SUBJECTS: Twenty four studies with 4497 patients. CONCLUSIONS: Buprenorphine is an effective intervention for use in the maintenance treatment of heroin dependence, but it is less effective than methadone delivered at adequate dosages.

  • Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation. (2007) DESIGN: Literature review. CONCLUSIONS: Both flexible-dose methadone maintenance therapy and buprenorphine maintenance therapy are more clinically effective and more cost-effective than no drug therapy in dependent opiate users. In direct comparison, a flexible dosing strategy with methadone maintenance therapy was found be somewhat more effective in maintaining individuals in treatment than flexible-dose buprenorphine maintenance therapy and therefore associated with a slightly higher health gain and lower costs. However, this needs to be balanced by the the possible risk of higher mortality of methadone maintenance therapy.

  • The costs and consequences of three policy options for reducing heroin dependency. (2007) DESIGN: Retrospective Australian database analysis. CONCLUSIONS: If the post-programme abstinence rates are sustained for 2 years, then for an average heroin user the cost of averting a year of heroin use is approximately AUD$5000 for pharmacotherapy maintenance, AUD$11,000 for residential rehabilitation and AUD$52 000 for prison. If the completion rate in pharmacotherapy maintenance was raised above 95% (by the threat of prison for non-completers), the combined model of treatment plus prison may become the most cost-effective option.

  • A randomized controlled trial of interim methadone maintenance. (2006) DESIGN: Randomized, controlled, clinical trial. SUBJECTS: 319 opioid-addicted patients awaiting methadone maintenance therapy. FINDINGS: Significantly more participants assigned to the interim methadone maintenance condition entered comprehensive methadone maintenance treatment by the 120th day from baseline (75.9%) than those assigned to the waiting list control condition (20.8%). CONCLUSIONS: Rapid access to methadone improved entry and outcomes in heroin addicts awaiting methadone treatment.

  • One year outcomes for heroin dependence: findings from the Australian Treatment Outcome Study (ATOS). (2006) DESIGN: Longitudinal prospective cohort study. SUBJECTS: 745 individuals entering treatment (methadone/buprenorphine maintenance therapy; detoxification; residential rehabilitation) and 80 heroin users not seeking treatment. FINDINGS: 80% of the original sample were re-interviewed at 1 year. The majority of those who had entered treatment were heroin abstinent at 1 year (maintenance therapy 65%, detoxification 52%, residential rehabilitation 63%) compared to 25% of the non-treatment sample. The reduction in heroin use among the treatment samples was paralleled by reductions in poly drug use. There were also substantial reductions in risk-taking, crime and injection-related health problems across all treatment groups, and less marked reductions among the non-treatment group. Psychopathology was dramatically reduced among the treatment modalities, while remaining stable among the non-treatment group. CONCLUSIONS: At 1 year, there were impressive reductions in drug use, criminality, psychopathology and injection-related health problems following treatment exposure. The positive findings were associated with a greater "dose" of treatment, and with more treatment stability over the follow-up period.

  • Reductions in heroin use are not associated with increases in other drug use: 2-year findings from the Australian Treatment Outcome Study. (2006) DESIGN: Longitudinal prospective cohort study. SUBJECTS: 615 Australian opioid-addicts in treatment. FINDINGS: At 2-year followup, heroin use had significantly decreased. CONCLUSIONS: There was no evidence for drug substitution in the face of reduced heroin use in this cohort of treatment seekers.

  • Addressing the efficacy of dihydrocodeine versus methadone as an alternative maintenance treatment for opiate dependence: A randomized controlled trial. (2006) DESIGN: Open-label randomized controlled study. SUBJECTS: 235 opioid-addicts. FINDINGS: No significant difference in outcomes was found between randomized groups over time. CONCLUSIONS: Dihydrocodeine is a viable alternative to methadone as a maintenance treatment for opiate dependence.

  • The characteristics of heroin users entering treatment: findings from the Australian treatment outcome study (ATOS). (2005) DESIGN: Longitudinal prospective cohort study. SUBJECTS: 745 individuals entering treatment (methadone/buprenorphine maintenance therapy; detoxification; residential rehabilitation) and 80 heroin users not seeking treatment. FINDINGS: The majority of the sample (55%) were criminally active in the month preceding interview. Injection-related health problems (74%) and a history of heroin overdose (58%) were commonly reported. There were high degrees of psychiatric co-morbidity, with 49% reporting severe psychological distress, 28% having current major depression, 37% having attempted suicide and 42% having a lifetime history of post-traumatic stress disorder. Personality disorders were also prevalent, with 72% meeting criteria for antisocial personality disorder and 47% screening positive for borderline personality disorder.

  • A randomised trial of the cost effectiveness of buprenorphine as an alternative to methadone maintenance treatment for heroin dependence in a primary care setting. (2005) DESIGN: Randomised, open-label, 12-month trial. SUBJECTS: 139 heroin-dependent outpatients. FINDINGS: The estimated mean number of heroin-free days did not differ significantly between those randomised to methadone (225 days), or buprenorphine (222 days) over the year of the trial. CONCLUSIONS: The trial found no significant differences in costs or outcomes between methadone and buprenorphine maintenance.

  • An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research. (2005) DESIGN: Literature review. SUBJECTS: 52 studies with 12,075 participants. Methadone maintenance treatment (MMT) was compared with methadone detoxification treatment (MDT), no treatment, different dosages of MMT, buprenorphine maintenance treatment (BMT), heroin maintenance treatment (HMT), and l-alpha-acetylmethadol (LAAM) maintenance treatment (LMT). FINDINGS: Retention in treatment: MMT is more effective than MDT, no treatment, BMT, LMT, and heroin plus methadone. MMT proved to be less effective than injected heroin alone. High doses of methadone are more effective than medium and low doses. Use of heroin: MMT is more effective than waiting list, less effective than LAAM, and not different from injected heroin. No significant results were available for mortality and criminal activity.. CONCLUSIONS: These findings confirm that MMT at appropriate doses is the most effective in retaining patients in treatment and suppressing heroin use but show weak evidence of effectiveness toward other relevant outcomes.

  • Methadone maintenance at different dosages for opioid dependence. (2003) DESIGN: Cochrane literature review. SUBJECTS: 22 studies with 5994 patients. CONCLUSIONS: Methadone dosages ranging from 60 to 100 mg/day are more effective than lower dosages in retaining patients and in reducing use of heroin and cocaine during treatment.

  • Safety of injectable opioid maintenance treatment for heroin dependence. (2003) DESIGN: Randomized, double-blind, placebo-controlled trail. SUBJECTS: 25 opioid-dependent patients on intravenous (IV) heroin or IV methadone maintenance treatment were randomly assigned to either their individual prescribed IV maintenance dose or placebo. FINDINGS: After heroin injection, marked respiratory depression progressing to a Cheyne-Stokes pattern occurred. Peripheral arterial blood oxygenation decreased to 78.9%. During hypoxia, 7 of the 16 subjects experienced intermittent and somewhat severe bradycardia. Five subjects exhibited paroxysmal EEG patterns. After methadone injection, respiratory depression was less pronounced than after heroin injection. No relevant bradycardia was noted. CONCLUSIONS: Opioid doses commonly prescribed in IV opioid treatment induce marked respiratory and circulatory depression, as well as occasionally irregular paroxysmal EEG activity. The extent of the observed effects raises questions about the appropriateness of IV opioid treatment in the present form.

  • Additional methadone increases craving for heroin: a double-blind, placebo-controlled study of chronic opiate users receiving methadone substitution treatment. (1999) DESIGN: Double-blind, cross-over design was used to compare the effects of a 33% increase in patient's daily dosage of methadone with a matched placebo. SUBJECTS: 18 patients on long-term methadone maintenance therapy. FINDINGS: Additional methadone significantly increased craving for heroin. Patients were unable to distinguish between additional methadone vs. additional placebo treatments. Patients were more alert and more contented following additional placebo than following additional methadone treatments. CONCLUSIONS: Additional methadone may "prime" cravings for heroin in methadone substitution patients.

  • Dose-response effects of methadone in the treatment of opioid dependence. (1993) DESIGN: Randomized, double-blind, placebo-controlled study. SUBJECTS: 247 opioid-dependent patients with a high rate of cocaine use. FINDINGS: By treatment week 20, retention was 52.4% for the 50-mg/day, 41.5% for the 20-mg/day, and 21.0% for the 0-mg/day group. Only the 50-mg/day treatment group had a reduced rate of opioid-positive urine samples (56.4% versus 67.6% and 73.6% for the 20-mg/day and 0-mg/day groups, respectively) and cocaine-positive urine samples (52.6% versus 62.4% and 67.1% for the 20-mg/day and 0-mg/day groups groups, respectively). CONCLUSIONS: In methadone maintenance therapy, only doses 50 mg/day or higher reduce opioid and cocaine use (by 22%).

  • Double-blind comparison of methadone and placebo maintenance treatments of narcotic addicts in Hong Kong. (1979) DESIGN: Randomized, double-blind, placebo-controlled trial. SUBJECTS: 100 heroin addict volunteers were initially admitted to hospital for two weeks for stabilisation on 60 mg of methadone before being assigned at random to two groups: one group received methadone (range 30-130 mg, average 97 mg/day); those in the other group had their dose of methadone reduced at the rate of 1 mg/day and were then maintained on placebo. FINDINGS: After thirty-two weeks 10% of the controls were still on treatment, compared with 76% of those receiving methadone. At the end of the three-year project, only 1 of the original 50 placebo subjects still turned up for treatment (2%), whereas the retention-rate (proportion still on treatment) for methadone subjects was 56%. CONCLUSIONS: At 3-years, methadone maintenance treatment retains only 56% of heroin addicts in treatment, but that is far superior to placebo treatment.

Does Methadone Maintenance Reduce Crime? (Studies Using Self-Reported Crime Are Excluded)

      While in methadone maintenance treatment, 60%-70% of patients are still criminally active, and most are abusing multiple illicit drugs and alcohol. Self-reported crime by heroin addicts is notoriously unreliable. CONCLUSION:
      The only scientific way to prove if methadone maintenance therapy reduces crime is to conduct randomised controlled clinical trials of methadone maintenance therapy compared with either placebo maintenance or other non-pharmacological therapy for the treatment of opioid dependence. In the 11 studies where this was done, it was shown that on average, methadone maintenance treatment does not decrease criminal behavior or mortality. However, for the few patients that stay in methadone maintenance treatment for 1-2 years, it has been shown to decrease criminal activity by about 20%-50%. Thus, for these long-attending methadone maintenance patients, treatment reduces shoplifting from 4 times/day to 3 or 2 times/day.

  • Engagement with opioid maintenance treatment and reductions in crime: a longitudinal national cohort study. (2012) DESIGN: Retrospective database analysis. SUBJECTS: Treatment data on all patients (3221) who started opioid maintenance therapy in Norway between 1997 and 2003 were cross-linked with national criminal records. FINDINGS: During opioid maintenance therapy, rates of criminal convictions for the cohort were reduced to fewer than half of waiting-list levels. Staying in opioid maintenance therapy for 2 years or more was associated with significantly reduced rates of convictions during treatment. Those who left treatment, permanently or temporarily, relapsed into high levels of convictions outside treatment. CONCLUSIONS: Criminal activity appears to be reduced in Norway during opiate maintenance treatment. Younger age and prior history of criminal activity are important risk factors for continued criminal activity during treatment. [Editor: Afghanistan supplies 80% of the world's opium (heroin) supply. In 1999-2001, Australia reported the mortality rate in opioid-addicts decreased 10-fold due to a world-wide decline in heroin availability caused by the Taliban stopping all opium (heroin) production in Afghanistan. Thus this study can't conclude that the observed decline in opioid-addict's criminal activity in their study was solely due to opiate maintenance treatment.]

  • Criminal convictions among dependent heroin users during a 3-year period prior to opioid maintenance treatment: a longitudinal national cohort study. (2011) DESIGN: Retrospective database analysis. SUBJECTS: All heroin users (N = 3,789) in Norway who applied for and were eligible for opioid maintenance treatment (1997-2003) were included. The opioid maintenance treatment records were cross-linked to Norwegian crime statistics. FINDINGS: During observation, 24,478 convictions were recorded among 60.9% of the sample. A large proportion (39.1%) had no convictions, whereas 10% of the sample was responsible for 37.8% of all convictions. Convictions for acquisitive crimes and drug crimes were the most common. CONCLUSIONS: The heavy involvement of heroin users with the criminal justice system provides an opportunity to intervene with dependent offenders. Coordination between treatment providers and police or courts can play an important role in improving outcomes through better access to treatment.

  • The effect of time spent in treatment and dropout status on rates of convictions, cautions and imprisonment over 5 years in a primary care-led methadone maintenance service. (2010) DESIGN: Cohort analysis. SUBJECTS: 108 consecutive heroin users entering a general practitioner-led methadone maintenance therapy (MMT). Ninety were followed-up for the full 5 years. MMT records were cross-linked to criminal conviction and caution rates and time spent in prison, derived from Police National Computer (PNC) criminal records. FINDINGS: The overall reduction in the number of convictions and cautions expected for patients entering MMT in similar primary care settings is 10% for each 6 months retained in treatment. Patients in continuous treatment had the greatest reduction in judicial disposal rates, similar to those who were discharged for positive reasons (e.g. drug free). Patients who had more than one treatment episode over the observation period did no better than those who dropped out of treatment. CONCLUSIONS: Methadone maintenance therapy delivered in a primary care clinic setting is effective in reducing convictions and cautions and incarceration over an extended period. Continuous treatment is associated with the greatest reductions.

  • Naltrexone implants compared to methadone: outcomes six months after prison release. (2010) DESIGN: Randomized clinical trail. SUBJECTS: 46 heroin-dependent inmates who volunteered to be randomly allocated to either naltrexone implants or methadone before release from prison. FINDINGS: Intention-to-treat analyses showed reductions in both groups in frequency of use of heroin and benzodiazepines, as well as criminality, 6 months after prison release.

  • Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. (2009) DESIGN: Cochrane literature review of all randomised controlled clinical trials of methadone maintenance therapy compared with either placebo maintenance or other non-pharmacological therapy for the treatment of opioid dependence. SUBJECTS: Eleven studies with 1969 patients. FINDINGS: Methadone appeared statistically significantly more effective than non-pharmacological approaches in retaining patients in treatment and in the suppression of heroin use as measured by self report and urine/hair analysis (RR = 0.66), but not statistically different in criminal activity or mortality. CONCLUSIONS: Methadone is an effective maintenance therapy intervention for the treatment of heroin dependence as it retains patients in treatment and decreases heroin use better than treatments that do not utilise opioid replacement therapy. Compared to no opioid replacement therapy for opioid dependence, methadone maintenance therapy does not show a statistically significant superior effect on criminal activity or mortality.

  • Medicaid coverage, methadone maintenance, and felony arrests: outcomes of opiate treatment in two states. (2009) DESIGN: Cohort analysis. SUBJECTS: More than 20,000 patients in methadone maintenance treatment (MMT) in USA. CONCLUSIONS: Only clients participating in MMT for many months showed much lower arrest rates than time not in treatment.

  • The impact of substitution treatment in prisons--a literature review. (2007) DESIGN: Literature review. FINDINGS: Prison-based methadone maintenance treatment (PMMT) can reduce drug use and injection in penal institutions. Moreover, PMMT provision can reduce injecting risk behaviours as well as drugs charges and re-admission rates. However, for PMMT to retain patients in treatment and reduce illegal drug use and criminal behavior a sufficiently high dose of methadone (e.g., >60 mg) and the treatment duration lasting the entire period of imprisonment appear crucial. CONCLUSIONS: The authors recommend the provision of PMMT for individuals with long-standing opioid dependence.

  • Patterns of acquisitive crime during methadone maintenance treatment among patients eligible for heroin assisted treatment. (2007) DESIGN: Retrospectively assessed the self-reported illegal activities during 1 month of standard methadone maintenance treatment. SUBJECTS: 51 Dutch patients in methadone maintenance treatment. FINDINGS: In one month, 70% reported criminal activities and 50% reported acquisitive crimes. Offending took place on 20.5 days per month with on average 3.1 offences a day. Acquisitive crime consisted mainly of shoplifting (mean 12.8 days, 2.2 times/day) and theft of bicycles (mean 5.8 days, 2.4 times/day); theft from a vehicle and burglaries were committed less frequently. The majority of these patients (63%) reported to have started offending in order to acquire illicit drugs and alcohol. CONCLUSIONS: During methadone maintenance treatment, shoplifting, thefts and/or other property crimes were committed on average two to three times a day.

  • Patients receiving a prescription for diamorphine (heroin) in the United Kingdom. (2006) DESIGN: A retrospective case-note review was conducted in England and Wales. SUBJECTS: 210 patients' case-notes were reviewed. (Criminal activity was judged from self-reports). FINDINGS: Patients had been receiving a prescription for diamorphine for a median length of six years. The majority were unemployed white males, with a median age of 44 years. Illicit drug use and criminal activity, while low, had not been eliminated totally. CONCLUSIONS: The majority of patients had no serious drug, health or social problems.

  • Revisiting the effectiveness of methadone treatment on crime reductions in the 1990s. (1999) DESIGN: A pre-post methadone treatment study spanning a 6-year time period (1987-1993). SUBJECTS: 126 methadone maintenance treatment patients. FINDINGS: Retention in methadone maintenance treatment has only a slight, though significant, effect on reducing criminal activity during treatment. Two other factors that appear to increase arrest activity are the use of cocaine and prior criminal history. CONCLUSIONS: The fact that arrests did not decrease during a treatment period of 18 months on average requires more investigation in light of the increase in cocaine use in this population.

Does Methadone Maintenance Reduce Mortality?

      Heroin, methadone, and other opioid drugs are very addictive, and potentially very lethal drugs. It is easy to have an accidental fatal overdose on these opioids when they are mixed with alcohol or benzodiazepines. Likewise, it is easy to have an accidental fatal heart attack on these opioids when they are mixed with cocaine or methamphetamine. In America, the majority of drug intoxication deaths are due to opioids, and recently there has been a significant increase in opioid deaths. Heroin users, especially females, have a very high mortality rate; largely due to their high overdose rate. In Spain, the average heroin-addicted patient on methadone maintenance therapy died at age 39. Thus these heroin-addicted patients lost, on average, 38 years of life. Many heroin-addicted individuals abuse alcohol, cocaine and methamphetamine. Thus methadone maintenance therapy for their heroin addiction is, at best, only a partial treatment for their many addictions. CONCLUSION:
      The only scientific way to prove if methadone maintenance therapy reduces mortality is to conduct randomised controlled clinical trials of methadone maintenance therapy compared with either placebo maintenance or other non-pharmacological therapy for the treatment of opioid dependence. In the 11 studies where this was done, it was shown that on average, methadone maintenance treatment does not decrease mortality or criminal behavior. However, research has shown that, for severely heroin-addicted patients, mandatory treatment in a coercive residential setting with methadone maintenance is life-saving..

  • Opium use and mortality in Golestan Cohort Study: prospective cohort study of 50,000 adults in Iran. (2012) DESIGN: Prospective cohort study in north eastern Iran, where opium consumption is exceptionally common. SUBJECTS: 50,045 participants aged 40-75 at baseline. Participants were enrolled between January 2004 and June 2008 and were followed to May 2011. FINDINGS: Opium can be smoked, ingested or injected intravenously (in the form of heroin). Increased mortality was seen for each subtype of opium, with the strongest risk with heroin. Opium consumption was significantly associated with increased risks of deaths from several causes including circulatory diseases and cancer. Opium can have deleterious effects in the long term through causing hypotension, bradycardia, and respiratory depression that can increase myocardial infarct and mortality. Morphine, can result in hepatotoxicity. CONCLUSIONS: About 20 million people in the world use opium or its derivatives, and these individuals are at a substantially increased risk of death.

  • Drug-related death following release from prison: a brief review of the literature with recommendations for practice. (2011) DESIGN: Literature review. SUBJECTS: Prisoners newly released from prison. FINDINGS: Most deaths following release from prison are caused by overdose, usually from opioid use. The risk of death is greatest within the first week of release but, when compared with the general population, continues to be elevated for several weeks. Relative risk estimates suggest that those released from prison are up to 40 times more likely to die than similar individuals from the general population. In-prison pharmacological maintenance treatment with methadone and buprenorphine has been shown to reduce the rate of heroin use, in the period immediately following release, in a small number of randomised controlled trials. CONCLUSIONS: Continuity of care, of any form, is critical in avoiding drug related deaths following release from prison.

  • Treatment of opioid overdose in a physician-based prehospital EMS: frequency and long-term prognosis. (2011) DESIGN: Prospective study of all opioid overdose cases in one physician-based medical emergency care unit (MECU) over a 10-year period between 1994 and 2003 in Copenhagen. SUBJECTS: 4762 cases of acute opioid overdose. FINDINGS: The physician-based prehospital emergency medical service released 2246 patients (69.3%) after treatment, while 675 (20.8%) were admitted to hospital and 322 (9.9%) died. Long-term prognosis was poor with 14% mortality at 1 year. CONCLUSIONS: Long-term mortality is high in these patients and highest in those with advanced age and numerous episodes of opioid overdose.

  • The increasing mortality burden of liver disease among opioid-dependent people: cohort study. (2011) DESIGN: Data linkage study of methadone treatment entrants with the National Deaths Index. SUBJECTS: A cohort of 2489 people entering methadone treatment for heroin dependence in New South Wales, Australia, 1980-85. FINDINGS: There were 8.2 deaths per 1000 Per Year, with standardized mortality ratios (SMRs) of 4.6 (i.e., 4.6 times the standard mortality rate ). Almost one in five (17%) of deaths were from underlying liver-related causes, most commonly viral hepatitis. The overall mortality rate for any liver cause was 1.4 deaths per 1000 Per Year, 17 times higher than that of the general population, with relative elevations more marked for females (SMR 27.9) than males (SMR 14.5). Liver mortality increased over time, becoming the most common cause of death by the end of follow-up. CONCLUSIONS: Liver disease has become the most common cause of mortality among ageing opioid-dependent people.

  • Prehospital treatment of opioid overdose in Copenhagen--is it safe to discharge on-scene? (2011) DESIGN: Prospective study of all opioid overdose cases in one physician-based medical emergency care unit (MECU) over a 10-year period between 1994 and 2003 in Copenhagen. SUBJECTS: 4762 cases of acute opioid overdose. Patients are released on scene if no residual signs of opioid intoxication are found after naltrexone treatment. FINDINGS: Of the 2241 opiod patients whose opioid overdose was treated with naloxone, then released without being sent to hospital, only 14 (0.13%) died within 48 hours. CONCLUSIONS: Prehospital discharge-on-scene after naloxone treatment for an opioid overdose is associated with a low risk of death due to rebound toxicity.

  • Increasing cancer mortality among opioid-dependent persons in Australia: a new public health challenge for a disadvantaged population. (2011) DESIGN: New South Wales opioid substitution therapy (OST) program registrants from 1985 to 2005 were probabilistically linked to the National Death Index. SUBJECTS: 43,789 patients. FINDINGS: Overall, OST registrants were 1.7 times more likely to die of cancer than the general population. These patients were 3.6 times more likely to die of lung cancer, 6.9 times more likely to die of liver cancer, 2.8 times more likely to die of anogenital cancers, but had a significantly reduced risk of dying from breast cancer. CONCLUSIONS: Cancer is an increasingly important cause of death among opioid substitution therapy registrants. This cancer appears due to tobacco, alcohol, and infection with hepatitis C and human papillomavirus.

  • Estimating the risk of fatal arrhythmia in patients in methadone maintenance treatment for heroin addiction. (2011) DESIGN: Retrospective cohort study. SUBJECTS: The study covered 14,500 patient-years (pys) in methadone treatment. FINDINGS: Fatal arrhythmia occurred at a rate of 0.014 per 100 patient-years. Overdose is a more common cause of death. Both potential arrhythmias and overdoses were associated with use of other drugs in addition to methadone - usually, prescription drugs or methamphetamine. CONCLUSIONS: The risk of fatal cardiac arrhythmia in methadone maintenance patients appears to be low. The major risk factor for death was use of prescription drugs, and methamphetamine, in addition to methadone.

  • Deaths of opiate/opioid misusers involving dihydrocodeine, UK, 1997-2007. (2011) DESIGN: Retrospective database analysis of opioid overdose deaths involving dihydrocodeine between 1997 and 2007. SUBJECTS: 584 fatalities. FINDINGS: Although its effectiveness is somewhat controversial, it appears that dihydrocodeine (DHC) is still prescribed in the UK as an alternative to both methadone and buprenorphine for the treatment of opiate addiction. Dihydrocodeine, either alone or in combination, was identified in 6.8% of all opiate/opioid-related deaths during this period. Typical DHC cases identified were white males in their early thirties. In the majority (55%) of overdoses, DHC had not be prescribed to the patient (i.e., DHC was obtained illegally). CONCLUSIONS: Co-administration of DHC with heroin, methadone and benzodiazepines increases the risk of accidental fatal overdose. Prescribers should use alternatives to dihydrocodeine (e.g. methadone, buprenorphine) when managing and treating opiate addiction.

  • Epidemiologic trends and geographic patterns of fatal opioid intoxications in Connecticut, USA: 1997-2007. (2011) DESIGN: Retrospective analysis of data from 1997 to 2007 on all adult accidental/undetermined drug intoxication deaths in CT that were referred to the Office of the Chief Medical Examiner. SUBJECTS: 2900 drug intoxication deaths. FINDINGS: Of the 2900 qualifying deaths, 2231 (77%) involved opioids. Methadone, oxycodone and fentanyl, the most frequently cited prescription opioids, exhibited significant increases in opioid deaths. Prescription opioid-only deaths were more likely to involve other medications (e.g., benzodiazepines) and to have occurred among residents of a suburban or small town location, compared to heroin-involved or methadone-involved deaths. Heroin-only deaths tended to occur among non-Whites, were more likely to involve alcohol or cocaine and to occur in public locations and large cities. CONCLUSIONS: By far, the majority (77%) of drug intoxication deaths in Connecticut are due to opioids, and there has been a significant increase in opioid deaths.

  • Rates and correlates of mortality amongst heroin users: findings from the Australian Treatment Outcome Study (ATOS), 2001-2009. (2011) DESIGN: Prospective cohort study over the period 2001-2009. SUBJECTS: 615 heroin users. FINDINGS: 5% of the heroin users died over this 9 year period. The mean age at death was 34.5 years, and 58% were male. The most common cause of death was overdose (68%). The male mortality rate was 2.95 times higher than the general population. However, the female mortality rate was 18.57 times higher than the general population. Their combined mortality rate was 4.56 times higher than the general population. The mean age at death was 34.5 years, and 58% were male. The most common cause of death was overdose (68%). The only predictor of overdose death was a history of prior overdose. CONCLUSIONS: Heroin users, especially females, have a very high mortality rate; largely due to their high overdose rate. These Australian mortality rates are lower than those reported in North America or Europe.

  • Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies. (2011) DESIGN: Literature review. SUBJECTS: Fifty-eight prospective studies reported mortality rates from opioid-dependent samples. FINDINGS: Opioid addicts have a mortality rate 14.66 times higher than the general population. Females have a higher mortality rate than males. Out-of-treatment periods had a 2.38 times higher mortality risk than in-treatment periods. Overdose was the most common cause of death. Injecting opioids has a higher mortality than smoking or ingesting opioids. CONCLUSIONS: Treatment is clearly protective against mortality among opioid-dependent users.

  • Risk of death during and after opiate substitution treatment in primary care: prospective observational study in UK General Practice Research Database. (2010) DESIGN: Prospective cohort study. SUBJECTS: 5577 primary care opioid-dependent patients prescribed methadone or buprenorphine during 1990-2005. FINDINGS: Opioid-dependent patients had a mortality rate 5.3 times higher than the general population on treatment, and 10.9 times higher than the general population off treatment. Men using opiates had approximately twice the risk of death of women. CONCLUSIONS: Opiate substitution treatment has a greater than 85% chance of reducing overall mortality among opiate users if the average duration approaches or exceeds 12 months. However, there is increased mortality risk at the start of opiate substitution treatment and immediately after stopping treatment.

  • Impact of supervision of methadone consumption on deaths related to methadone overdose (1993-2008): analyses using OD4 index in England and Scotland. (2010) DESIGN: Analysis of annual trends in deaths related to overdose of methadone in Scotland and England between 1993 and 2008. FINDINGS: There was a four-fold decrease in number of deaths with methadone (implicated per million defined daily doses of methadone prescribed in that year) between 1993 and 2008. CONCLUSIONS: Introduction of supervised methadone dosing was followed by substantial declines in deaths related to overdose of methadone in both Scotland and England.

  • Mortality and employment after in-patient opiate detoxification. (2012) DESIGN: Prospective cohort study linking medical records to survival and employment records from the Austrian Social Security Institution. SUBJECTS: 404 pure opioid or poly-substance addicts admitted for voluntary in-patient detoxification between 1997 and 2004. Followup was up to 11 years. FINDINGS: 58.7% completed the detoxification program. Mortality rates were between 13.5 and 17.9 times higher than the general population during the first five years after discharge, thereafter they fell clearly with time. Mortality did not differ statistically significantly between completers and non-completers. The median employment rate was insignificantly higher in completers (12.0%) than in non-completers (5.5%). The odds for being employed were higher in pure opioid addicts than in poly-substance addicts. CONCLUSIONS: The assumption that completers of voluntary in-patient detoxification treatment have a better outcome than non-completers has not been confirmed. Opioid or poly-substance addicts have very high mortality and unemployment rates.

  • Were the changes to Sweden's maintenance treatment policy 2000-06 related to changes in opiate-related mortality and morbidity? (2010) DESIGN: Surveys of all Swedish methadone maintenance treatment units, of buprenorphine and methadone sales, and of mortality and inpatient care in Sweden. FINDINGS: Sales of buprenorphine and methadone and the number of patients in treatment increased more than threefold from 2000 to 2006, with the greatest increase for buprenoprphine, introduced in year 2000. There was a significant 20-30% reduction in opiate-related mortality and inpatient care between 2000-2002 and 2004-2006 but not of other drug-related mortality and inpatient care. However, a significant increase in buprenorphine- and methadone-related mortality occurred. CONCLUSIONS: The liberalization of Sweden's drug policy correlated with an increase in maintenance treatment, a decrease in opiate-related mortality and inpatient care and an increase in deaths with methadone and buprenorphine.

  • Impact of slow-release oral morphine on drug abusing habits in Austria (2010) DESIGN: Retrospective database analysis of opiate maintenance treatment programmes in Austria. FINDINGS: Since 1998 the use of slow-release oral morphine (SROM) has been legally permitted in Austria. Our data show that these morphine preparations are frequently abused and are dominating the black market. The intravenous consumption of SROM has highly dangerous side effects that exceed the risks of needle sharing alone. If dissolved and injected, insoluble contents such as talcum cause microembolisms, leading to severe damages of the inner organs. Slow-release oral morphine has been the main cause of most drug related deaths since its introduction in 1998. CONCLUSIONS: The widespread use of slow-release oral morphine in opiate maintenance treatment programmes should be avoided.

  • Favorable mortality profile of naltrexone implants for opiate addiction. (2010) DESIGN: Prospective follow-up of patients treated with naltrexone implant and buprenorphine. SUBJECTS: 255 naltrexone implant patients were followed for 5.2 years, and 2,518 buprenorphine patients were followed for 3.2 years. FINDINGS: The mortality rate for naltrexone implants was 67.6% that of the mortality rate of buprenorphine.

  • 15-Year survival and retention of patients in a general hospital-affiliated methadone maintenance treatment (MMT) center in Israel. (2010) DESIGN: Prospective 15-year follow-up of methadone maintenance treatment patients. SUBJECTS: 613 patients. FINDINGS: 15.3% of the patients died. Cancer was the primary cause of death for those who remained in treatment, and overdose for those who left MMT. Benzodiazepine abuse reduced both retention and survival, emphasizing the high priority that should be given to stopping it. CONCLUSIONS: Staying in methadone maintenance treatment for more than 1 year did not significantly lower the mortality rate.

  • A comparison of drug overdose deaths involving methadone and other opioid analgesics in West Virginia. (2009) DESIGN: All people dying from unintentional overdoses of methadone or other opioid analgesics (OOA) in West Virginia in 2006. SUBJECTS: 250 overdose deaths. FINDINGS: The methadone group included 87 decedents (34.8), and the OOA group included 163 decedents (65.2%). Most were male. Decedents in the methadone group were significantly younger than those in the OOA group: more than a quarter were 18-24 years of age. For both groups, approximately 50% had a history of pain, and 80% had a history of substance abuse. There was no intergroup difference in the prevalence of benzodiazepines at post-mortem. Methadone was significantly less likely to have ever been prescribed than OOA. Ten (11.5%) of the methadone decedents were enrolled in an opiate treatment program (OTP) at the time of death. CONCLUSIONS: The high prevalence of a substance abuse history and lack of prescriptions suggest that most of the deaths in both groups are related to substance abuse. Physicians should use state prescription drug monitoring programs to monitor the use of controlled substances by their patients.

  • Mortality among clients of a state-wide opioid pharmacotherapy program over 20 years: risk factors and lives saved. (2009) DESIGN: Retrospective database analysis linking the New South Wales (NSW) Pharmaceutical Drugs of Addiction System with data from the National Deaths Index, a record of all deaths in Australia for 1985-2006. SUBJECTS: 42,676 people entering opioid replacement therapy. FINDINGS: Mortality among 42,676 people entering opioid pharmacotherapy was elevated compared to age and sex peers. Drug overdose and trauma were the major contributors. Mortality was higher out of treatment, particularly during the first weeks, and it was elevated during induction onto methadone but not buprenorphine. Overall, mortality was similarly reduced (compared to out-of-treatment) whether patients were receiving methadone or buprenorphine. CONCLUSIONS: It was estimated that the program produced a 29% reduction in mortality across the entire cohort.

  • Overdose deaths following previous non-fatal heroin overdose: record linkage of ambulance attendance and death registry data. (2009) DESIGN: Retrospective cohort design linking ambulance attendance records in Melbourne, Australia over a 5-year period (2000-2005) with a national death register. SUBJECTS: 4884 people. FINDINGS: 3.4% of those patients with a previous non-fatal heroin overdose go on to have a subsequent fatal overdose. Mortality rate decreased 10-fold after 2000 coinciding with widely reported declines in heroin availability. [Editor: Afghanistan provides 80% of the world's opium. In 2000, the Taliban stopped all opium growing in Afghanistan.] Being male, of older age (>35 years) and having been attended multiple times for previous non-fatal overdoses were associated with increased mortality risk. CONCLUSIONS: This study shows the profound effect of macro-level heroin market dynamics on overdose mortality.

  • Comparing retention in treatment and mortality in people after initial entry to methadone and buprenorphine treatment. (2009) DESIGN: Data linkage study comparing retention in treatment and mortality among people entering methadone and buprenorphine treatment for opioid dependence. SUBJECTS: 5992 patients. FINDINGS: Median retention was significantly longer in methadone (271 days) than buprenorphine (40 days). During induction, the risk of death was lower for buprenorphine. Risk of death was lowest during treatment, significantly higher in the first 12 months after leaving both methadone and buprenorphine. Beyond 12 months after leaving treatment, risk of death was non-significantly higher than during treatment. CONCLUSIONS: Buprenorphine was safer during induction. Despite shorter retention in treatment, buprenorphine maintenance was not associated with higher risk of death.

  • Factors associated with mortality in Scottish patients receiving methadone in primary care: retrospective cohort study. (2009) DESIGN: Retrospective cohort study of patients prescribed methadone in Scotland between January 1993 and February 2004. SUBJECTS: 2378 patients. FINDINGS: 181 (8%) people died. Overuse of methadone, history of psychiatric admission, history of prescription of benzodiazepines, and increasing comorbidity were all associated with an increase in mortality. Drug dependence was identified as the principal cause of death in 60 (33%) people. CONCLUSIONS: These methadone patients had a high death rate. One-third of the deaths were due to drug overdoses or complications, and the remainder of the deaths were due to accidents or other medical illnesses.

  • Comparing overdose mortality associated with methadone and buprenorphine treatment. (2009) DESIGN: Data linkage study for 9-month period comparing overdose mortality associated with methadone and buprenorphine treatment for opioid dependence. SUBJECTS: 13,718 patients in methadone treatment and 2716 patients in buprenorphine treatment. FINDINGS: There were 60 (0.4%) sudden deaths positive for methadone (32 in-treatment) and 7 (0.3%) buprenorphine-positive decedents (none in treatment). Most out-of-treatment deaths occurred in people with known histories of drug misuse. Forty-three methadone positive cases - 19/32 in treatment, and 24/28 out-of-treatment - and 2 of the 7 buprenorphine-positive deaths were due to overdose. The risk of overdose death per thousand people in treatment was lower for buprenorphine than for methadone (RR 4.25). CONCLUSIONS: In this short-term study, buprenorphine was associated with lower overdose risk than methadone.

  • Mortality among opiate users: opioid maintenance therapy, age and causes of death. (2009) DESIGN: Data on all opiate dependents in Norway (1997-2003) enrolled in opioid maintenance therapy (OMT). SUBJECTS: 3789 patients. FINDINGS: Overall death rate was 1.9%. Deaths were due to drug overdose (54%), somatic (32%) and traumatic causes (14%). Overdose deaths among all age groups were reduced during opioid maintenance therapy. Deaths during OMT were most likely to be due to somatic causes. CONCLUSIONS: The high prevalence among older patients of deaths due to somatic causes has implications for screening, treatment and referral.

  • Psychiatric comorbidity reduces quality of life in chronic methadone maintained patients. (2009) DESIGN: Diagnostic evaluation of chronic methadone maintained patient. SUBJECTS: 193 middle-aged patients in long-term methadone maintenance treatment (MMT). FINDINGS: Psychiatric comorbidity was documented in 78% of the patients. Mood disorders (60%) and anxiety disorders (46%) were the most common diagnoses. Additional substance use disorders were diagnosed in 70% of the MMT patients. A probable personality disorder was documented for (125) 65% of the patients. Antisocial personality disorder was diagnosed in 66 (34.2%) of these patients. Quality of Life was severely diminished to a level comparable to that for patients with chronic psychiatric and/or somatic disorders. CONCLUSIONS: The quality of life for MMT patients is generally low. The present results showed a high rate of psychiatric comorbidity for this patient group.

  • Methadone- and heroin-related deaths in Florida. (2008) DESIGN: Florida Department of Law Enforcement data were analyzed to examine trends in deaths related to or caused by methadone and/or heroin between 2001-2006. FINDINGS: Mortalities associated with methadone use increased steadily as mortalities associated with heroin decreased steadily. CONCLUSIONS: Methadone possesses high abuse potential and documented mortality risks.

  • Mortality in opioid-maintained patients after release from an addiction clinic. (2008) DESIGN: Retrospective cohort study. SUBJECTS: 269 opioid-dependent patients enrolled in synthetic opioid maintenance therapy from 1998 to 1999 originally at the Addiction Clinic and then discharged to general practitioners. FINDINGS: From 29 fatalities, 37.9% died of intoxication with illicit substances, 34.5% related to AIDS and 27.6% of somatic complications. The mortality rate was 29 times higher than that of the standard population (i.e., SMR 29.13). A higher lifetime frequency of hospitalization, less working days and a lack of social relationships were factors associated with high mortality. CONCLUSIONS: Although great efforts were undertaken in locating patients, about 45% of the target group could not be located.

  • Mortality of drug users attending public treatment centers in Italy 1998-2001: a cohort study (2007) DESIGN: Cohort follow-up study of heroin users attending Public Treatment Centers (PTCs) in Italy enrolled between 1998-2000 and followed-up in 2001. The observation time is mainly for the time these patient were in treatment. SUBJECTS: 10,376 patients (8881 men and 1495 women). FINDINGS: 190 (1.8%) deaths occurred during the study period (153 men and 37 women): 70 deaths were due to overdose (36.8%), 38 to AIDS (20.0%), 30 to violence (15.8%). For women, the mortality rate was 22.8 times higher than that of the standard population (i.e., SMR 22.8). For men, the mortality rate was 6.7 times higher than that of the standard population (i.e., SMR 6.7). CONCLUSIONS: In Italy, approximately 13% of deaths in people in their 30s can be attributed to heroin addiction (i.e., 14.4% of deaths in people aged 30-34, 12.8% at age 35-39, and 10.7% at age 25-29).

  • A 20-year prospective study of mortality and causes of death among hospitalized opioid addicts in Oslo. (2008) DESIGN: Prospective 20-year folow-up cohort study among all hospitalized opioid addicts treated for self-poisoning or admitted for voluntary detoxification in Oslo between 1980 and 1981. SUBJECTS: 185 opioid addicts. Their median age was 24 years; with a range from 16 to 41, and 53% were males. FINDINGS: During a period of 20 years, 70 (37.8%) opioid addicts died. Their mortality rate was 23.6 times higher than that of the standard population (i.e., SMR 23.6). The Standard Mortality Ratio (SMR) remained high during the whole period, ranging from 32.4 in the first five-year period, to 13.4 in the last five-year period. There were no significant differences in SMR between self-poisonings and those admitted for voluntarily detoxification. The SMR was 5.4 for cardiovascular diseases, and 4.3 for cancer. The SMR was 13.2 for accidents, 10.7 for suicides, and 28.6 for other violent deaths. CONCLUSIONS: The risk of death among opioid addicts was significantly higher for all causes of death compared with the general population, implying a poor prognosis over a 20-year period for this young patient group.

  • Mortality prior to, during and after opioid maintenance treatment (OMT): a national prospective cross-registry study. (2008) DESIGN: Pospective cross-registry study with up to 7 years follow-up. SUBJECTS: All opiate dependents in Norway who applied for OMT (a total of 3789 subjects) were cross-linked with data from the death registry from Statistics Norway. A baseline was established from the waiting list mortality rate. Intention-to-treat was investigated by analysing mortality among the entire population that started OMT. FINDINGS: In the "intention-to-treat" perspective, the mortality risk was reduced to RR 0.6 compared with pre-treatment. The patients who left the treatment programme showed a high-mortality rate, particularly males. CONCLUSIONS: OMT significantly reduces risk of mortality also when examined in an intention-to-treat perspective. Studies that evaluate effects of OMT only in patients retained in treatment tend to overestimate benefits.

  • Risk of fatal overdose during and after specialist drug treatment: the VEdeTTE study, a national multi-site prospective cohort study. (2007) DESIGN: Prospective cohort study of 10,454 heroin users entering treatment 1998-2001 in Italy followed-up for almost 1 year in treatment and 3 months out of treatment. SUBJECTS: 10,454 heroin users entering treatment 1998-2001 in Italy. FINDINGS: There were 41 overdose deaths, 10 during treatment and 31 out of treatment, generating annual mortality rates of 0.1% and 1.1% and SMRs of 3.9 and 21.4, respectively. The risk of a fatal overdose was 2.3% in the month immediately after treatment and 0.77% in the subsequent period. CONCLUSIONS: The considerable excess mortality risk in the month following treatment indicates the need for greater health education of drug users and implementation of relapse and overdose death prevention programmes.

  • Cocaine- and opiate-related fatal overdose in New York City, 1990-2000. (2007) DESIGN: Retrospective registry analysis: data were collected from the NYC Office of the Chief Medical Examiner on all fatal drug overdoses involving cocaine and/or opiates that occurred between 1990-2000. Overdoses were classified into three mutually exclusive groups (cocaine only; opiates-only; cocaine and opiates). SUBJECTS: 8,774 fatal overdoses. FINDINGS: 40.5% of the fatal overdoses were attributed to cocaine and opiates, 32.2% were attributed to opiates-only, and 27.3% were attributed to cocaine only. During the interval studied, the percentage of drug overdose deaths attributed to cocaine only fell from 29.2% to 23.6% while the percentage of overdose deaths attributed to opiates-only rose from 30.6% to 40.1%.

  • Observed patterns of illicit opiate overdose deaths in Chicago, 1999-2003. (2007) DESIGN: Retrospective registry analysis. Examined data from every death certificate filed between 1999 and 2003 to identify all Chicago residents' accidental deaths involving acute intoxication with illicit opiates, OD, or opiate poisoning. FINDINGS: OD incidence peaked in 2000 and then declined markedly by 2003. Over the 2000-2003 period, overall incidence of fatal OD declined by 34%. Over this period, the sharpest observed declines occurred among African-Americans and Hispanics/Latinos. The opiate-related fatality incidence also declined among non-Hispanic whites. CONCLUSIONS: In 2003, illicit opiate-related OD accounted for 35% of all accidental deaths to Chicago adults aged 18-64, with 45% of OD deaths occurring among African-American men.

  • Years of potential life lost among heroin addicts 33 years after treatment. (2007) DESIGN: Longitudinal, prospective study following male heroin addicts in California for more than 33 years. SUBJECTS: 581 male heroin addicts. FINDINGS: 33 years after treatment, 48.5% were confirmed as deceased by death certificates. On average, addicts in this cohort lost 18.3 years of potential life before age 65 (22.3% of the years lost was due to heroin overdose, 14.0% due to chronic liver disease, and 10.2% to accidents). CONCLUSIONS: The total years of potential life lost among addicts was much higher than that in the national population; within the cohort, premature mortality was higher among Whites and Hispanics compared to African American addicts.

  • One-year mortality rates of patients receiving methadone and buprenorphine maintenance therapy: a nationally representative cohort study in 2694 patients. (2006) DESIGN: Prospective cohort study: opioid dependent patients in substitution treatment either with methadone or buprenorphine at baseline were monitored over a 12-month period. SUBJECTS: 2694 opioid dependent patients. FINDINGS: 60.4% were still in treatment after 12 months. The overall mortality rate was 1.04%. In total, 28 patients of the initial sample deceased within the 1-year follow-up period. Eleven (0.4%) of these deaths are due to a fatal intoxication. Three patients (0.1%) died of human immunodeficiency virus/acquired immunodeficiency syndrome, and 3 (0.1%) committed suicide. Thirteen of these patients (4 with overdose/polyintoxication) were not in substitution treatment at the time of death. The mortality rate was similar in methadone as compared with buprenorphine patients. CONCLUSIONS: The mortality rate of approximately 1% confirms that maintenance treatment could be regarded as a fairly safe treatment.

  • Trends in opioid-related fatal overdoses in Massachusetts, 1990-2003. (2006) DESIGN: Retrospective registry analysis. Massachusetts death files for the years 1990-2003 were used to identify all poisoning deaths and opioid-related poisoning deaths. FINDINGS: From 1990 to 2003, opioid-related fatal poisoning rates increased by 529% from 1.4 per 100,000 in 1990 to 8.8 per 100,000 in 2003. The proportion of total poisoning deaths associated with opioids rose from 28% in 1990 to 69% in 2003. CONCLUSIONS: Since 1997, poisoning, particularly from heroin and other opioids, has been the leading cause of injury mortality in Massachusetts.

  • Drug-related mortality and its impact on adult mortality in eight European countries. (2006) DESIGN: Retrospective cohort study: Opiate users in eight drug treatment centres in Europe during 1990-1998 were followed up through national or local mortality registries. FINDINGS: The mortality rate for male opioid users in Barcelona was 21.1 times that of the standard population (i.e., standardized mortality ratio [SMR] 21.1). The mortality rate for female opioid users in Barcelona was 53.7 times that of the standard population (i.e., SMR 53.7), and in Rome it was 37.7 times that of the standard population (i.e., SMR 37.7). The highest drug-related mortality rate was 10 per 1,000 person-years in Barcelona; the rates were approximately 7 per 1,000 person-years in Denmark, London, Rome, and Vienna, and <3.5 per 1,000 person-years for the others cohorts. The mortality rate for AIDS was <2 per 1,000 person-years in all the cohorts except Lisbon, Rome, and Barcelona, for which it was approximately 6 per 1,000 person-years. CONCLUSIONS: For opioid users, Barcelona and Rome have significantly higher drug-related and AIDS-related mortality rates compared to 6 other European cities. Overall, European opioid users have very high drug-related and AIDS-related mortality rates.

  • Mortality in heroin-assisted treatment in Switzerland 1994-2000. (2005) DESIGN: Retrospective registry analysis: 7-year (1994 to 2000) follow-up of all participants in heroin-assisted treatment in Switzerland. FINDINGS: Over the 7-year period, the crude death rate of patients in heroin-assisted treatment, and including one month after discharge from treatment, was 1% per year. The standardized mortality ratio for the entire observation period was 9.7, with females having higher standardized mortality ratios (SMR 17.2) than males (SMR 8.4). There was no clear time trend. CONCLUSIONS: Mortality in heroin-assisted treatment was low compared to the mortality rate of Swiss opioid users 1990s (estimated to be between 2.5 and 3%). It was also low compared to mortality rates of opioid users in other maintenance treatments in other countries as reported in the literature. The SMR was also lower than that reported in the only meta-analysis in the literature: 13.2. The low mortality rate is all the more noteworthy as heroin-assisted treatment in Switzerland included only refractory opioid addicts with existing severe somatic and/or mental problems.

  • Evaluating the impact of methadone maintenance programmes on mortality due to overdose and aids in a cohort of heroin users in Spain. (2005) DESIGN: Prospective cohort study of all heroin-addicted patients who started methadone maintenance treatment between 1992 and 1997. Follow-up assessments were carried out every 9 months until 2000. SUBJECTS: 5049 patients followed for an average of 4.6 years. FINDINGS: Fifty per cent were in methadone maintenance treatment (MT) during the study period; of the total cohort 1005 (19.9%) patients died. Of the deaths: 38.4% were due to AIDS, 34.7% to overdose and 27% to other causes. Overall mortality decreased from 5.9 deaths per 100 person-years in 1992 to 1.6 in 1999. Globally, life expectancy at birth was 39 years, 38 years lower than that of the general population. The main factor for overdose mortality was not being in MT at the time of death [relative ratio (RR) = 7.1]; other factors were being a current injector at baseline and being HIV positive. For AIDS mortality, the main factor was the calendar year (RR for 1996 versus 1999 = 4.6), the next major factor was more than 10 years of heroin consumption, followed by not being in MT, being unemployed, then having a prison record. CONCLUSIONS: The observed mortality decline could be linked to the effectiveness of low-threshold methadone maintenance treatment. The life expectancy of heroin users increased by 21 years during the study period. [Editor: Afghanistan supplies 80% of the world's opium (heroin) supply. In 1999-2000, Australia reported the mortality rate in opiod-addicts decreased 10-fold due to a world-wide decline in heroin availability caused by the Taliban stopping all opium (heroin) production in Afghanistan. Thus this study can't conclude that the observed mortality decline at the end of their study period (2000) was solely due to "the effectiveness of low-threshold methadone maintenance treatment".]

  • Drug-use pattern, comorbid psychosis and mortality in people with a history of opioid addiction. (2005) DESIGN: Prospective cohort study comparing the 15-year mortality of people with a history of intravenous narcotics addiction that had achieved stable abstinence, with the mortality associated with continued drug use. SUBJECTS: 188 persons (122 men and 66 women). FINDINGS: About 32% had died during the 15-year follow-up. The 15-year mortality associated with stable abstinence from injecting narcotics was reduced by 56% when compared with the perceived worst drug-use pattern. Hospitalization for comorbid psychosis was not independently associated with mortality in this sample. The standard mortality rates (SMRs) were clearly elevated. Even for those that achieved stable abstinence from injecting narcotics, their mortality rate was at least 7-times higher than that of the standard population. CONCLUSIONS: People who had achieved stable abstinence from injecting narcotics use were at lower risk of premature death than people with continued drug use. A residual observed excess mortality in people who had apparently achieved stable abstinence from drug use is consistent with the view of drug addiction as a chronic disease.

  • Changes in mortality, arrests, and hospitalizations in nonvoluntarily treated heroin addicts in relation to methadone treatment. (1998) DESIGN: Prospective cohort study analyzing the mortality, hospitalizations, and arrests in a cohort of severe intravenous heroin users divided into three groups: those in methadone treatment, those discharged from treatment, and those who never received treatment. SUBJECTS: 101 heroin users, of whom 56 were HIV-seropositive. Because of intensive drug misuse, they underwent coercive residential treatment in Stockholm during the 3-year period 1986-1988. FINDINGS: The mortality was lower in the methadone group, and all seven deaths were related to HIV-infection. Outside the program, 24 of 29 persons died from external violence and poisoning. CONCLUSIONS: Coercive residential treatment giving methadone maintenance for severe intravenous heroin users was dramatically more effective than no treatment.

Does Opioid Abstinence Reduce Mortality?

      FINDINGS: At 15-year followup, 32% of individuals with opioid use disorder have died. Abstinence from opioid use reduces this 15-year mortality rate by 56%. However, at 15-year followup, even those that become abstinent still have a 7-fold elevation in standardized mortality rate. CONCLUSION: Opioid use disorder is a chronic and very lethal disorder. However, the mortality rate can be halved by stopping opioid use. However, even off opioids, these individuals still have mortality rates 7-times higher than the standard population.

  • Drug-use pattern, comorbid psychosis and mortality in people with a history of opioid addiction. (2005) This Danish study compared the 15-year mortality of people with a history of opioid dependence that had achieved stable abstinence, with the mortality associated with continued drug use. About 32% had died during the 15-year follow-up. Abstinence from opioid use reduced the 15-year mortality by 56% when compared with the mortality rate of those without abstinence. Even in the stably abstinent group, the standardized mortality rate was significantly elevated by at least seven-fold in both genders.

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Which Behavioral Dimensions Are Involved?

Research has shown that there are 5 major dimensions (the "Big 5 Factors") of personality disorders and other mental disorders. There are two free online personality tests that assess your personality in terms of the "Big 5 dimensions of personality.

This website uses these 5 major dimensions of human behavior to describe all mental disorders. (This website adds one more dimension, "Physical Health", but our discussion will focus on the first 5 major dimensions.)

These major dimensions of human behavior seem to represent the major dimensions whereby our early evolutionary ancestors chose their hunting companions or spouse. To maximize their chance for survival, our ancestors wanted companions who were agreeable, conscientious, intelligent, sociable, emotionally stable, and physically healthy.

Dimensions of Human Behavior That Are Abnormal In Opioid Use Disorder

Agreeableness Antagonism       Antagonism
Conscientiousness Disinhibition       Disinhibition
Intellect Decreased Intellect       Decreased Intellect
Sociability (Extraversion) Detachment       Detachment
Emotional Stability Negative Emotion       Negative Emotion

The 5 Major Dimensions of Mental Illness

The Big 5 Factors or dimensions of mental illness each has a healthy side and an unhealthy side. Thus the Big 5 Factors are: (1) Agreeableness vs. Antagonism, (2) Conscientiousness vs. Disinhibition, (3) Intellect vs. Decreased Intellect, (4) Sociability (Extraversion) vs. Detachment (Introversion), and (5) Emotional Stability vs. Negative Emotion.

The Following Will Only Discuss The Dimensions of Mental Illness That Are Abnormal In This Disorder

The problems that are diagnostic of this disorder are highlighted in   Pink  . Other problems that are often seen in this disorder are highlighted in   Yellow  .

Treatment Goals for Individuals With Antagonism

Description: Agreeableness is synonymous with compassion and politeness. Compassion reflects empathy, sympathy, and caring for others. Politeness reflects respect for others. Agreeable people are interested in others, and they make people feel comfortable. The Agreeableness dimension measures the behaviors that are central to the concept of LOVE and JUSTICE.
Descriptors: Compassionate, polite, trustworthy, friendly, considerate, generous, helpful, altruistic.
Language Characteristics: Pleasure talk, agreement, compliments, empathy, few personal attacks, few commands or global rejections, many self-references, few negations, few swear words, few threats, many insight words.
MRI Research*: Agreeableness was associated with increased volume in regions that process information about the intentions and mental states of other individuals.
"I am helpful and unselfish with others."
"I have a forgiving nature."
"I am generally trusting."
"I am considerate and kind to almost everyone."
"I like to cooperate with others."
"I don't find fault with others."
"I don't start quarrels with others."
"I am not cold and aloof."
"I am not rude to others."
"I feel other's emotions."
"I inquire about others' well-being."
"I sympathize with others' feelings."
"I take an interest in other people's lives."
"I like to do things for others."
"I respect authority."
"I hate to seem pushy."
"I avoid imposing my will on others."
"I rarely put people under pressure."
Description: Antagonism is synonymous with competition and aggression. Antagonistic people are self-interested, and do not see others positively.
Descriptors: Callous, disrespectful, unfriendly, suspicious, uncooperative, malicious.
Language Characteristics: Problem talk, dissatisfaction, little empathy, many personal attacks, many commands or global rejections, few self-references, many negations, many swear words, many threats, little politeness, few insight words.
* Callousness:
"It's no big deal if I hurt other people's feelings."
"Being rude and unfriendly is just a part of who I am."
"I often get into physical fights."
"I enjoy making people in control look stupid."
"I am not interested in other people's problems."
"I can't be bothered with other's needs."
"I am indifferent to the feelings of others."
"I don't have a soft side."
"I take no time for others."
* Deceitfulness:
"I don't hesitate to cheat if it gets me ahead."
"Lying comes easily to me."
"I use people to get what I want."
"People don't realize that I'm flattering them to get something."
* Manipulativeness:
"I use people to get what I want."
"It is easy for me to take advantage of others."
"I'm good at conning people."
"I am out for my own personal gain."
* Grandiosity:
"I'm better than almost everyone else."
"I often have to deal with people who are less important than me."
"To be honest, I'm just more important than other people."
"I deserve special treatment."
* Suspiciousness:
"It seems like I'm always getting a “raw deal” from others."
"I suspect that even my so-called 'friends' betray me a lot."
"Others would take advantage of me if they could."
"Plenty of people are out to get me."
"I'm always on my guard for someone trying to trick or harm me."
* Hostility:
"I am easily angered."
"I get irritated easily by all sorts of things."
"I am usually pretty hostile."
"I always make sure I get back at people who wrong me."
"I resent being told what to do, even by people in charge."
"I insult people."
"I seek conflict."
"I love a good fight."
("Agreeableness vs. Antagonism" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.

Treatment Goals for Individuals With Disinhibition

Description: Conscientiousness is synonymous with being self-disciplined, industrious and orderly. The Conscientiousness dimension measures the behaviors that are central to the concept of SELF-CONTROL.
Descriptors: Conscientious, self-disciplined, competent, dutiful, achievement striving, deliberate, careful.
Language Characteristics: Many positive emotion words (e.g. happy, good), few negative emotion words (e.g. hate, bad), more perspective, careful to check that information is conveyed correctly, straight to the point, formal, few negations, few swear words, few references to friends, few disfluencies or filler words, many insight words, not impulsive.
MRI Research*: Conscientiousness was associated with increased volume in the lateral prefrontal cortex, a region involved in planning and the voluntary control of behavior.
"I do a thorough job. I want everything to be 'just right'. I want every detail taken care of."
"I am careful."
"I am a reliable hard-worker."
"I am organized. I follow a schedule and always know what I am doing."
"I like order. I keep things tidy."
"I see that rules are observed."
"I do things efficiently. I get things done quickly."
"I carry out my plans and finish what I start."
"I am not easily distracted."
Rigid Perfectionism
"Even though it drives other people crazy, I insist on absolute perfection in everything I do."
"I simply won't put up with things being out of their proper places."
"People complain about my need to have everything all arranged."
"People tell me that I focus too much on minor details."
"I have a strict way of doing things."
"I postpone decisions."
Disinhibition (Impulsive, Disorderly)
Description: Disinhibition is synonymous with being impulsive, disorganized, and laid-back.
Descriptors: Impulsive, disorganised, unreliable, careless, forgetful.
Language Characteristics: Few positive emotion words, many negative emotion words, less perspective, less careful, more vague, informal, many negations, many swear words, many references to friends (e.g. pal, buddy), many disfluencies or filler words, few insight words, impulsive.
* Irresponsibility:
"I've skipped town to avoid responsibilities."
"I just skip appointments or meetings if I'm not in the mood."
"I'm often pretty careless with my own and others' things."
"Others see me as irresponsible."
"I make promises that I don't really intend to keep."
"I often forget to pay my bills."
* Impulsivity:
"I usually do things on impulse without thinking about what might happen as a result."
"Even though I know better, I can't stop making rash decisions."
"I feel like I act totally on impulse."
"I'm not good at planning ahead."
* Distractibility:
"I can't focus on things for very long."
"I am easily distracted."
"I have trouble pursuing specific goals even for short periods of time."
"I can't achieve goals because other things capture my attention."
"I often make mistakes because I don't pay close attention."
"I waste my time ."
"I find it difficult to get down to work."
"I mess things up."
"I don't put my mind on the task at hand."
* Reckless Risk Taking:
"I like to take risks."
"I have no limits when it comes to doing dangerous things."
"People would describe me as reckless."
"I don't think about getting hurt when I'm doing things that might be dangerous."
* Hyperactivity:
"I move excessively (e.g., can't sit still; restless; always on the go)."
"I'm starting lots more projects than usual or doing more risky things than usual."
* Over-Talkativeness:
"I talk excessively (e.g., I butt into conversations; I complete people's sentences)."
"Often I talk constantly and cannot be interrupted."
* Elation:
"I feel very happy or exhilarated."
"I'm feeling a rush of good feelings."
("Conscientiousness vs. Disinhibition" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.

Treatment Goals for Individuals With Decreased Intellect

Description: Intellect (or "Openness To Experience") is one's capacity for thinking and acquiring knowledge. It is synonymous with being open-minded and creative. Open-minded individuals constantly ask "why" the world is as it is. Whereas closed-minded individuals just accept the world as it is without asking "why". The Intellect dimension measures the behaviors that are central to the concept of WISDOM - having curiosity, experience, knowledge, and good judgment. Open-minded people are usually creative, sophisticated, intellectual, curious and interested in art. Their curiosity propels them to try new things, and ask novel questions. High intellect is associated with better: longevity, school and creative performance.
Descriptors: Creative, intellectual, imaginative, curious, cultured, complex.
Language Characteristics: Many positive emotion words (e.g. happy, good), high meaning elaboration, more perspective, politeness, few self-references, complex sentence constructions, few causation words, many inclusive words (e.g. with, and), few third person pronouns, many tentative words (e.g. maybe, guess), many insight words (e.g. think, see), few filler words and within-utterance pauses, stronger uncommon verbs.
MRI Research*: Intellect did not have any significant correlation with the volume of any localized brain structure.
Relationship To General Intelligence: Research has shown that Intellect can be separated into 2 factors: Openness and Intellect. Intellect was independently associated with general intelligence (g) and with verbal and nonverbal intelligence about equally. Openness was independently associated only with verbal intelligence.
Example: This video shows how we see what we want to see. What we pay attention to (or what we believe about the world) blinds us to reality. (Exit YouTube after first video.)
"I am original, and come up with new ideas."
"I am curious about many different things."
"I am quick to understand things."
"I can handle a lot of information."
"I like to solve complex problems."
"I have a rich vocabulary."
"I think quickly and formulate ideas clearly."
"I enjoy the beauty of nature."
"I believe in the importance of art."
"I love to reflect on things."
"I get deeply immersed in music."
"I see beauty in things that others might not notice."
"I need a creative outlet."
Description: Decreased Intellect (or "Closed To Experience") is synonymous with being closed-minded and uncreative. Closed-minded individuals just accept the world as it is without asking "why"; whereas open-minded individuals constantly ask "why" the world is as it is. Decreased Intellect is associated with narrow-mindedness, unimaginativeness and ignorance.
Descriptors: Narrow-minded, conservative, ignorant, simple.
Language Characteristics: Few positive emotion words, low meaning elaboration, less perspective, less politeness, few positive emotion words, many self-references, simple sentence construction, many causation words (e.g. because, hence), many third person pronouns, few tentative words, few insight words, many filler words and within-utterance pauses, milder verbs.
"I prefer work that is routine."
"I have difficulty understanding abstract ideas."
"I think slowly."
"People find it hard to follow my logic or understand my thoughts."
"I avoid philosophical discussions."
"I avoid difficult reading material."
"People find it hard to follow my logic or understand my thoughts."
"I have few artistic interests."
"I seldom notice the emotional aspects of paintings and pictures."
"I do not like poetry."
"I seldom get lost in thought."
"I seldom daydream."
* Memory Impairment
"I have difficulty learning new things, or remembering things that happened a few days ago."
"I often forget a conversation I had the day before."
"I often forget to take my medications, or to keep my appointments."
* Impaired Reasoning:
"My judgment or ability to solve problems isn't good."
"I have difficulty understanding abstract ideas."
"I think slowly."
"People find it hard to follow my logic or understand my thoughts."
* Eccentricity:
"I often have thoughts that make sense to me but that other people say are strange."
"Others seem to think I'm quite odd or unusual."
"My thoughts are strange and unpredictable."
"My thoughts often don’t make sense to others."
"Other people seem to think my behavior is weird."
"I have several habits that others find eccentric or strange."
"My thoughts often go off in odd or unusual directions."
* Unusual Beliefs and Experiences:
"I often have unusual experiences, such as sensing the presence of someone who isn't actually there."
"I've had some really weird experiences that are very difficult to explain."
"I have seen things that weren’t really there."
"I have some unusual abilities, like sometimes knowing exactly what someone is thinking."
"I sometimes have heard things that others couldn’t hear."
"Sometimes I can influence other people just by sending my thoughts to them."
"I often see unusual connections between things that most people miss."
* Perceptual Dysregulation:
"Things around me often feel unreal, or more real than usual."
"Sometimes I get this weird feeling that parts of my body feel like they're dead or not really me."
"It's weird, but sometimes ordinary objects seem to be a different shape than usual."
"Sometimes I feel 'controlled' by thoughts that belong to someone else."
"Sometimes I think someone else is removing thoughts from my head."
"I have periods in which I feel disconnected from the world or from myself."
"I can have trouble telling the difference between dreams and waking life."
"I often 'zone out' and then suddenly come to and realize that a lot of time has passed."
"Sometimes when I look at a familiar object, it's somehow like I'm seeing it for the first time."
"People often talk about me doing things I don't remember at all."
"I often can't control what I think about."
"I often see vivid dream-like images when I’m falling asleep or waking up."
("OPENNESS TO EXPERIENCE vs. BEING CLOSED TO EXPERIENCE" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.

Treatment Goals for Individuals With Detachment

Description: Sociability (Extraversion) is synonymous with being enthusiastic and assertive. Assertiveness encompasses traits relating to leadership, dominance, and drive. Enthusiasm encompasses both sociability and the tendency to experience and express positive emotion. Extraverts tend to engage in social interaction; they are enthusiastic, risk-taking, talkative and assertive. The Sociability (Extraversion) dimension measures the behaviors that are central to the concept of SOCIABILITY and LEADERSHIP.
Descriptors: Sociable, gregarious, sociable, excitement seeking, active, spontaneous, optimistic, talkative.
Language Characteristics: Many topics, higher verbal output, think out loud, pleasure talk, agreement, compliment, positive emotion words, sympathetic, concerned about hearer (but not empathetic), simple constructions, few unfilled pauses, few negations, few tentative words, informal language, many swear words, exaggeration (e.g. "I'm really smart" ), many words related to humans (e.g. "man", "pal"). poor vocabulary.
MRI Research*: Sociability (extraversion) was associated with increased volume of medial orbitofrontal cortex, a region involved in processing reward information.
"I'm talkative"
"I'm not reserved."
"I'm full of energy."
"I generate a lot of enthusiasm."
"I'm not quiet."
"I have an assertive personality."
"I'm not shy or inhibited."
"I am outgoing and sociable."
"I make friends easily."
"I warm up quickly to others."
"I show my feelings when I'm happy."
"I have a lot of fun."
"I laugh a lot."
"I take charge."
"I have a strong personality."
"I know how to captivate people."
"I see myself as a good leader."
"I can talk others into doing things."
"I am the first to act."
Attention Seeking
"I like to draw attention to myself."
"I crave attention."
"I do things to make sure people notice me."
"I do things so that people just have to admire me."
"My behavior is often bold and grabs peoples' attention."
Description: Detachment is synonymous with being reserved and quiet.
Descriptors: Detached, shy, passive, solitary, moody, joyless.
Language Characteristics: Single topic, doesn't think out loud, problem talk, dissatisfaction, negative emotion words, not sympathetic, elaborated sentence constructions, many unfilled pauses, formal language, many negations, many tentative words (e.g. maybe, guess), few swear words, little exaggeration, few words related to humans, rich vocabulary.
* Social Withdrawal:
"I don’t like to get too close to people."
"I don't deal with people unless I have to."
"I'm not interested in making friends."
"I don’t like spending time with others."
"I say as little as possible when dealing with people."
"I keep to myself."
"I am hard to get to know."
"I reveal little about myself."
"I do not have an assertive personality."
"I lack the talent for influencing people."
"I wait for others to lead the way."
"I hold back my opinions."
* Intimacy Avoidance:
"I steer clear of romantic relationships."
"I prefer to keep romance out of my life."
"I prefer being alone to having a close romantic partner."
"I'm just not very interested in having sexual relationships."
"II break off relationships if they start to get close."
* Loss of Interest or Pleasure:
"I often feel like nothing I do really matters."
"I almost never enjoy life."
"Nothing seems to make me feel good."
"Nothing seems to interest me very much."
"I almost never feel happy about my day-to-day activities."
"I rarely get enthusiastic about anything."
"I don't get as much pleasure out of things as others seem to."
* Restricted Emotions:
"I don't show emotions strongly."
"I don't get emotional."
"I never show emotions to others."
"I don't have very long-lasting emotional reactions to things."
"People tell me it's difficult to know what I'm feeling."
"I am not a very enthusiastic person."
("Sociability vs. Detachment" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.

Treatment Goals for Individuals With Negative Emotion

Description: Emotional Stability is synonymous with being calm and emotionally stable. The Emotional Stability dimension measures the behaviors that are central to the concept of COURAGE - having calm composure and endurance when confronting adversity. High emotional stability is associated with better: longevity, leadership, job [team] performance, and marital success. (This dimension appears to measure the behaviors that differentiate safety from danger.)
Descriptors: Calm, even-tempered, peaceful, confident
Language Characteristics: Pleasure talk, agreement, compliment, low verbal productivity, few repetitions, neutral content, calm, few self-references, many short silent pauses, few long silent pauses, many tentative words, few aquiescence, little exaggeration, less frustration, low concreteness.
"I am relaxed, and I handle stress well."
"I am emotionally stable, and not easily upset."
"I remain calm in tense situations."
"I rarely get irritated."
"I keep my emotions under control."
"I rarely lose my composure."
"I am not easily annoyed."
"I seldom feel blue."
"I feel comfortable with myself."
"I rarely feel depressed."
"I am not embarrassed easily."
Description: Degree to which people experience persistent anxiety or depression and are easily upset. (This could be thought of as high threat sensitivity or low stress tolerance.)
Descriptors: Emotionally unstable, anxious, separation-insecure, depressed, self-conscious, oversensitive, vulnerable.
Language Characteristics: Problem talk, dissatisfaction, high verbal productivity, many repetitions, polarised content, stressed, many self-references, few short silent pauses, many long silent pauses, few tentative words, more aquiescence, many self references, exaggeration, frustration, high concreteness.
Research: Lower scores on Emotional Stability are associated with unhappiness, dysfunctional relationships, and mental health problems. *MRI research found that Low Emotional Stability (= Negative Emotion or Neuroticism) was associated with increased volume of brain regions associated with threat, punishment, and negative emotions.
* Emotional Instability:
"I get emotional easily, often for very little reason."
"I get emotional over every little thing."
"My emotions are unpredictable."
"I never know where my emotions will go from moment to moment."
"I am a highly emotional person."
"I have much stronger emotional reactions than almost everyone else."
"My emotions sometimes change for no good reason."
"I get angry easily."
"I get upset easily."
"I change my mood a lot."
"I am a person whose moods go up and down easily."
"I get easily agitated."
"I can be stirred up easily."
* Anxiety:
"I worry about almost everything."
"I'm always fearful or on edge about bad things that might happen."
"I always expect the worst to happen."
"I am a very anxious person."
"I get very nervous when I think about the future."
"I often worry that something bad will happen due to mistakes I made in the past."
"I am filled with doubts about things."
"I feel threatened easily."
"I am afraid of many things."
* Separation Insecurity:
"I fear being alone in life more than anything else."
"I can't stand being left alone, even for a few hours."
"I’d rather be in a bad relationship than be alone."
"I'll do just about anything to keep someone from abandoning me."
"I dread being without someone to love me."
* Submissiveness:
"I usually do what others think I should do."
"I do what other people tell me to do."
"I change what I do depending on what others want."
* Perseveration:
"I get stuck on one way of doing things, even when it's clear it won't work."
"I get stuck on things a lot."
"It is hard for me to shift from one activity to another."
"I get fixated on certain things and can’t stop."
"I feel compelled to go on with things even when it makes little sense to do so."
"I keep approaching things the same way, even when it isn’t working."
* Depressed Mood:
"I have no worth as a person."
"Everything seems pointless to me."
"I often feel like a failure."
"The world would be better off if I were dead."
"The future looks really hopeless to me."
"I often feel just miserable."
"I'm very dissatisfied with myself."
"I often feel like nothing I do really matters."
"I know I'll commit suicide sooner or later."
"I talk about suicide a lot."
"I feel guilty much of the time."
"I'm so ashamed by how I've let people down in lots of little ways."
"I am easily discouraged."
"I become overwhelmed by events."
("Emotional Stability vs. Negative Emotion" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.

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