Cost-effectiveness of diacetylmorphine versus methadone for chronic opioid dependence refractory to treatment

Background:

Although diacetylmorphine has been proven to be more effective than methadone maintenance treatment for opioid dependence, its direct costs are higher. We compared the cost-effectiveness of diacetylmorphine and methadone maintenance treatment for chronic opioid dependence refractory to treatment.

Methods:

We constructed a semi-Markov cohort model using data from the North American Opiate Medication Initiative trial, supplemented with administrative data for the province of British Columbia and other published data, to capture the chronic, recurrent nature of opioid dependence. We calculated incremental cost-effectiveness ratios to compare diacetylmorphine and methadone over 1-, 5-, 10-year and lifetime horizons.

Results:

Diacetylmorphine was found to be a dominant strategy over methadone maintenance treatment in each of the time horizons. Over a lifetime horizon, our model showed that people receiving methadone gained 7.46 discounted quality-adjusted life-years (QALYs) on average (95% credibility interval [CI] 6.91–8.01) and generated a societal cost of $1.14 million (95% CI $736 800–$1.78 million). Those who received diacetylmorphine gained 7.92 discounted QALYs on average (95% CI 7.32–8.53) and generated a societal cost of $1.10 million (95% CI $724 100–$1.71 million). Cost savings in the diacetylmorphine cohort were realized primarily because of reductions in the costs related to criminal activity. Probabilistic sensitivity analysis showed that the probability of diacetylmorphine being cost-effective at a willingness-to-pay threshold of $0 per QALY gained was 76%; the probability was 95% at a threshold of $100 000 per QALY gained. Results were confirmed over a range of sensitivity analyses.

Interpretation:

Using mathematical modelling to extrapolate results from the North American Opiate Medication Initiative, we found that diacetylmorphine may be more effective and less costly than methadone among people with chronic opioid dependence refractory to treatment.Opioid substitution with methadone is the most common treatment of opioid dependence.^1–3 Participation in a methadone maintenance treatment program has been associated with decreases in illicit drug use,⁴ criminality⁵ and mortality.^6,7 However, longitudinal studies have shown that most people who receive opioid substitution treatment are unable to abstain from illicit drug use for sustained periods, either switching from treatment to regular opioid use or continuing to use opioids while in treatment.^8–13 An estimated 15%–25% of the most marginalized methadone clients do not benefit from treatment in terms of sustained abstention from the use of illicit opioids.¹⁴The North American Opiate Medication Initiative was a randomized controlled trial that compared supervised, medically prescribed injectable diacetylmorphine and optimized methadone maintenance treatment in people with long-standing opioid dependence and multiple failed treatment attempts with methadone or other forms of treatment.¹⁵ The trial was conducted in two Canadian cities (Vancouver, British Columbia; and Montréal, Quebec). Both treatment protocols included a comprehensive range of psychosocial services (e.g., addiction counselling, relapse prevention, case management, and individual and group interventions) and primary care services (e.g., testing for blood-borne diseases, provision of HIV treatment, and treatment of acute and chronic physical and mental health complications of substance use) in keeping with Health Canada best practices.¹⁶ The results of the trial confirmed findings of prior studies showing diacetylmorphine to be more effective than methadone maintenance treatment in retaining opioid-dependent patients in treatment^15,17–20 and improving health and social functioning.^19,21,22 Diacetylmorphine treatment has been proposed to reach a specific population of people with opioid dependence refractory to treatment who are at high risk of adverse health consequences and engagement in criminal activities to acquire the illicit drugs.For guiding policy-makers, the North American Opiate Medication Initiative alone does not address all the important considerations for decision-making. In addition to political challenges associated with the therapy,²³ there remains concern over the direct cost of diacetylmorphine over the long term, because it can be as much as 10 times greater than conventional methadone maintenance treatment.²¹ The North American Opiate Medication Initiative was only one year in duration, but a policy to introduce diacetylmorphine might have both positive and negative longer-term implications.We extrapolated outcomes from the North American Opiate Medication Initiative to estimate the long-term cost-effectiveness of diacetylmorphine versus methadone maintenance treatment for chronic, refractory opioid dependence.     

Reprint of: gene susceptibility to oxidative damage: from single nucleotide polymorphisms to function

Oxidative damage to DNA can cause mutations, and mutations can lead to cancer. DNA repair of oxidative damage should therefore play a pivotal role in defending humans against cancer. This is exemplified by the increased risk of colorectal cancer of patients with germ-line mutations of the oxidative damage DNA glycosylase MUTYH. In contrast to germ-line mutations in DNA repair genes, which cause a strong deficiency in DNA repair activity in all cell types, the role of single nucleotide polymorphisms (SNPs) in sporadic cancer is unclear also because deficiencies in DNA repair, if any, are expected to be much milder. Further slowing down progress are the paucity of accurate and reproducible functional assays and poor epidemiological design of many studies. This review will focus on the most common and widely studied SNPs of oxidative DNA damage repair proteins trying to bridge the information available on biochemical and structural features of the repair proteins with the functional effects of these variants and their potential impact on the pathogenesis of disease.     

Leaf vs. epiphyte nitrogen uptake in a nutrient enriched Mediterranean seagrass (Posidonia oceanica) meadow

In situ nitrogen uptake by leaves and epiphytes was studied in a Mediterranean seagrass (Posidonia oceanica) meadow impacted from a fish farm and a pristine meadow, using ¹⁵NH₄ and ¹⁵NO₃ as tracers. In the impacted meadow both leaves and epiphytes yielded higher N concentrations and showed higher specific N uptake, suggesting a linkage between N uptake and its accumulation. Epiphytes took up N faster than leaves in relation to their corresponding biomass, but when assessed per unit area, N uptake was higher in leaves. Leaf N uptake was negatively correlated with epiphyte N uptake. With increasing epiphyte load on leaves, N leaf uptake decreased while N epiphyte uptake increased, indicating that epiphyte overgrowth hinders N uptake by P. oceanica leaves. Epiphyte contribution to total N uptake increased, while that of leaves decreased at the impacted meadow. However, 2-3 times less N was transferred daily from the water column to the benthic compartment, through seagrass and epiphyte uptake on total, at the impacted meadow. Therefore, it is probably still the loss of the key species - the seagrass - which plays the most important role in N cycling in seagrass ecosystems.     

Environmental control on the structure of echinoid assemblages in the Bellingshausen Sea (Antarctica)

The Bellingshausen Sea is one of the most remote and least surveyed seas of the Southern Ocean, so that little was known about benthic communities and those factors that determine community structuring until recently. The present work aims at characterizing the structure and spatial distribution of echinoid assemblages in the Bellingshausen Sea, as well as identifying the environmental factors that determine assemblage structuring. Echinoids were collected at 32 stations using an Agassiz trawl, at depths of 86–3,304?m, during BENTART oceanographic expeditions led in 2003 and 2006. Sediment and bottom water properties were analysed using an USNEL-type box corer and a Neil Brown Instrument System Mark III CTD, respectively. Echinoids were found at all stations, except Peter I Island. Seventeen species were identified, representing 22?% of the echinoid species present in the Southern Ocean and increasing twofold the number of species recorded in the Bellingshausen Sea so far. The echinoid fauna is dominated by the very abundant species Sterechinus antarcticus. Depth is the key factor that determines the nature of echinoid assemblages, which are mainly divided into the continental shelf, the slope and the deep-sea basin. In addition, sediment properties, namely redox values, organic matter and mud content, best match species dispersion on the shelf. Sediment properties affect echinoid distribution depending on species food range and feeding strategy. As it might be expected, sediment properties more strongly influence specialist feeders (Schizasteridae and Cidaridae) than generalists (Echinidae).     

Phenotypic plasticity in the Antarctic nototheniid fish Trematomus newnesi: a guide to the identification of typical, large mouth and intermediate morphs

Trematomus newnesi is a common inshore species with a circum-Antarctic distribution. It provides the only known example of phenotypic plasticity in Antarctic notothenioid fish, existing as populations of typical, large mouth and intermediate morphs that can be difficult to identify. Using specimens from both Potter Cove, King George/25 de Mayo Island, and from McMurdo Sound, we found that the morphometric measurements gape width/head length (HL), upper jaw length/HL and, to a lesser extent, orbit diameter/HL reliably separated the morphs. For use in a key, we converted the ratios into the qualitative characters head shape, head width and upper jaw length relative to middle of the eye. To increase the reliability of the key, we also assessed intra-morph variability in these characters. The key is supplemented with colour photographs illustrating the distinctive features for separation of the morphs. We discovered that, in the case of the specimens from Potter Cove, each morph had a distinct pattern of colouration: typical—trunk blotched, with yellow or orange-brown predominating especially on pectoral and caudal fins; large mouth—trunk blotched, with green predominating especially in pectoral and opercular regions; and intermediate—trunk less blotched, with homogeneous dark brown-grey on trunk, pectoral and caudal fins. We also discuss the ecological implications of colour in the morphs.     

Molecular Characterization of Chronic Lymphocytic Leukemia Patients with a High Number of Losses in 13q14

Background

Patients with chronic lymphocytic leukemia and 13q deletion as their only FISH abnormality could have a different outcome depending on the number of cells displaying this aberration. Thus, cases with a high number of 13q- cells (13q-H) had both shorter overall survival and time to first therapy. The goal of the study was to analyze the genetic profile of 13q-H patients.

Design and Methods:

A total of 102 samples were studied, 32 of which served as a validation cohort and five were healthy donors.

Results

Chronic lymphocytic leukemia patients with higher percentages of 13q- cells (>80%) showed a different level of gene expression as compared to patients with lower percentages (<80%, 13q-L). This deregulation affected genes involved in apoptosis and proliferation (BCR and NFkB signaling), leading to increased proliferation and decreased apoptosis in 13q-H patients. Deregulation of several microRNAs, such as miR-15a, miR-155, miR-29a and miR-223, was also observed in these patients. In addition, our study also suggests that the gene expression pattern of 13q-H cases could be similar to the patients with 11q- or 17p-.

Conclusions

This study provides new evidence regarding the heterogeneity of 13q deletion in chronic lymphocytic leukemia patients, showing that apoptosis, proliferation as well as miRNA regulation are involved in cases with higher percentages of 13q- cells.     

Defects in mitochondrial dynamics and metabolomic signatures of evolving energetic stress in mouse models of familial Alzheimer's disease

Background

The identification of early mechanisms underlying Alzheimer''s Disease (AD) and associated biomarkers could advance development of new therapies and improve monitoring and predicting of AD progression. Mitochondrial dysfunction has been suggested to underlie AD pathophysiology, however, no comprehensive study exists that evaluates the effect of different familial AD (FAD) mutations on mitochondrial function, dynamics, and brain energetics.

Methods and Findings

We characterized early mitochondrial dysfunction and metabolomic signatures of energetic stress in three commonly used transgenic mouse models of FAD. Assessment of mitochondrial motility, distribution, dynamics, morphology, and metabolomic profiling revealed the specific effect of each FAD mutation on the development of mitochondrial stress and dysfunction. Inhibition of mitochondrial trafficking was characteristic for embryonic neurons from mice expressing mutant human presenilin 1, PS1(M146L) and the double mutation of human amyloid precursor protein APP(Tg2576) and PS1(M146L) contributing to the increased susceptibility of neurons to excitotoxic cell death. Significant changes in mitochondrial morphology were detected in APP and APP/PS1 mice. All three FAD models demonstrated a loss of the integrity of synaptic mitochondria and energy production. Metabolomic profiling revealed mutation-specific changes in the levels of metabolites reflecting altered energy metabolism and mitochondrial dysfunction in brains of FAD mice. Metabolic biomarkers adequately reflected gender differences similar to that reported for AD patients and correlated well with the biomarkers currently used for diagnosis in humans.

Conclusions

Mutation-specific alterations in mitochondrial dynamics, morphology and function in FAD mice occurred prior to the onset of memory and neurological phenotype and before the formation of amyloid deposits. Metabolomic signatures of mitochondrial stress and altered energy metabolism indicated alterations in nucleotide, Krebs cycle, energy transfer, carbohydrate, neurotransmitter, and amino acid metabolic pathways. Mitochondrial dysfunction, therefore, is an underlying event in AD progression, and FAD mouse models provide valuable tools to study early molecular mechanisms implicated in AD.     

Daptomycin resistance in enterococci is associated with distinct alterations of cell membrane phospholipid content

Background

The lipopeptide antibiotic, daptomycin (DAP) interacts with the bacterial cell membrane (CM). Development of DAP resistance during therapy in a clinical strain of Enterococcus faecalis was associated with mutations in genes encoding enzymes involved in cell envelope homeostasis and phospholipid metabolism. Here we characterized changes in CM phospholipid profiles associated with development of DAP resistance in clinical enterococcal strains.

Methodology

Using two clinical strain-pairs of DAP-susceptible and DAP-resistant E. faecalis (S613 vs. R712) and E. faecium (S447 vs. R446) recovered before and after DAP therapy, we compared four distinct CM profiles: phospholipid content, fatty acid composition, membrane fluidity and capacity to be permeabilized and/or depolarized by DAP. Additionally, we characterized the cell envelope of the E. faecium strain-pair by transmission electron microscopy and determined the relative cell surface charge of both strain-pairs.

Principal Findings

Both E. faecalis and E. faecium mainly contained four major CM PLs: phosphatidylglycerol (PG), cardiolipin, lysyl-phosphatidylglycerol (L-PG) and glycerolphospho-diglycodiacylglycerol (GP-DGDAG). In addition, E. faecalis CMs (but not E. faecium) also contained: i) phosphatidic acid; and ii) two other unknown species of amino-containing PLs. Development of DAP resistance in both enterococcal species was associated with a significant decrease in CM fluidity and PG content, with a concomitant increase in GP-DGDAG. The strain-pairs did not differ in their outer CM translocation (flipping) of amino-containing PLs. Fatty acid content did not change in the E. faecalis strain-pair, whereas a significant decrease in unsaturated fatty acids was observed in the DAP-resistant E. faecium isolate R446 (vs S447). Resistance to DAP in E. faecium was associated with distinct structural alterations of the cell envelope and cell wall thickening, as well as a decreased ability of DAP to depolarize and permeabilize the CM.

Conclusion

Distinct alterations in PL content and fatty acid composition are associated with development of enterococcal DAP resistance.