Research Article
Saba Alvand Tehran, University of Medical Sciences
Masoumeh Amin-Esmaeili , Johns Hopkins Bloomberg School of Public Health
Hossein Poustchi , Tehran University of Medical Sciences
Gholamreza Roshandel , Golestan University of Medical Sciences
Yasaman Sadeghi, Tehran University of Medical Sciences
Vandad Shari, Tehran University of Medical Sciences
Farin Kamangar, Morgan State University
Sanford M. Dawsey, National Cancer Institute, NIH
Neal D. Freedman, National Cancer Institute, NIH
Christian C. Abnet, National Cancer Institute, NIH
Afarin Rahimi-Movaghar, Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences
Reza Malekzadeh, Tehran University of Medical Sciences
Arash Etemadi (@ arash.etemadi@nih.gov ) National Cancer Institute, NIH
Abstract
Methods: Among 8,500 chronic opiate users at Golestan Cohort Study baseline (2004–2008), we recalled a random sample of 451 subjects in 2017. We used three questionnaires: a questionnaire about current opiate use including type and route of use, the drug use disorder section of the Composite International Diagnostic Interview lifetime version, and the validated the Kessler 10 (K10) questionnaire. We defined OUD presence and severity based on the DSM-5 criteria and used a cutoff of 12 on K10 questionnaire to define psychological distress Results: Mean age was 61.2 ± 6.6 years (84.7% males) and 58% were diagnosed with OUD. Starting opiate use at an early age and living in underprivileged conditions were risk factors of OUD. Individuals with OUD were twice likely to have psychological distress (OR = 2.25; 95%CI: 1.44–3.52) than the users without OUD. In multivariate regression, former and current opiate dose and oral use of opiates were independently associated with OUD. Each ten gram per week increase in opiate dose during the study period almost tripled the odds of OUD (OR = 3.18; 95%CI: 1.79–5.63). Conclusions: Chronic opiate use led to clinical OUD in more than half of the users, and OUD was associated with psychological distress, increasing its physical and mental burden in high-risk groups.
Keywords: Cohort Studies, Iran, Opiate, Opioid use disorder, Opium, Substance-related disorders
Alireza Noroozi
Afarin Rahimi-Movaghar
Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran
Abstract
Nikoo and colleagues found significantly higher adverse events (AEs) among opioid use disorder patients receiving opium tincture (OT) compared with methadone. These findings differ from previous studies using OT and another morphine-based medication, slow-release oral morphine, indicating lower AEs compared with methadone, and suggest a need for further exploration of how to adjust OT treatment protocol.
KEYWORDS: Adverse events, commentary, opium tincture, opioid use disorders, opioid agonist treatment, protocol development
A Six-Year Follow-up of People Who Use Cannabis in Iran – A Case Series
Yasna Rostam-Abadi1, Masoumeh Amin-Esmaeili1,2, Shahab Baheshmat3,1, Ardavan Mohammad Aghaei, Jaleh Gholami 1*I, Afarin Rahimi-Movaghar11
1Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran
2Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
3Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine (SATiM), TehranUniversity of Medical Sciences, Tehran, Iran
Abstract
Background: Frequent cannabis use is associated with adverse health-related outcomes. This study followed up individuals who used cannabis to assess their use and adverse event status. Methods: The eligible individuals, recruited in the Iranian Mental Health Survey (IranMHS), were contacted via telephone calls six years after the index interview. The frequency of cannabis use and the occurrence of selected adverse events were recorded. The baseline status was extracted from the index survey. If any individual was inaccessible, his/her vital status was assessed. Findings: Of the 50 eligible individuals (all male), two had died. Moreover, from among 25 reached participants, 19 reported abstinence from cannabis in the past year, and 18 reported at least one adverse event in the past six years. Violence and imprisonment were the most common events reported.
Conclusion: Six years after the index interview, most of the participants abstained from cannabis. Besides, adverse events were common, emphasizing the need for further investigations on larger samples of cannabis users.
Keywords: Follow-up study; Health survey; Marijuana; Adverse outcomes; Quit
Iran Quality of Care in Medicine Program (IQCAMP): Design and Outcomes
Saeid Shahraz, MD, PhD1*; Sarvenaz Shahin, MD, MPH2; Yosef Farzi, MSc2; Mitra Modirian, MD; Nazila Shahbal,BSc3; Mehrdad Azmin, PhD2; Farnam Mohebi, MD, MPH4; Mohammadreza Naderian, MD, MPH, Masoumeh Amin-Esmaeili, MD, MPH6; Naser Ahmadi, MSc2; Shahedeh Seyfi, MSc2; Hossein Zokaei, MBA Bahram Mohajer, MD, MPH2, Roya Sherafat-Kazemzadeh, MD, PhD8; Abbas Balouchi, PhD; Bita Mesgarpour, PharmD, MPH, PhD10; Mahboubeh Parsaeian, PhD11; Fatemeh Gorgani, MD2225; Roya Samadi, MD9; Saral Rahimi, PharmD; Sahar SaeediMoghadam, PhD2, Maryam Khezrian, MSc2, Ahmad Amin, MD12; Shahab Baheshmat, PhD; Mohammad Reza Beyranvand, MD14; Majid Haghjoo, MD15; Mitra Mahdavi-Mazdeh, MD1613; Masoud Mehrpour, MD, MPH; GhobadMoradi, MD, MPH, PhD18; Soheil Peiman, MD19, Besharat Rahimi, MD202; Afarin Rahimi-Movaghar, MD; Reza Rikhtegar, MD22; Shahin Roshani, MSc2; Mohammad Saadatnia, MD2317; Seyed Mehdi Samimi Ardestani, MD Shahab Khatibzadeh, MD, MPH25*
Abstract
Background: Assessment of quality and cost of medical care has become a core health policy concern. We conducted a nationwide survey to assess these measures in Iran as a developing country. To present the protocol for the Iran Quality of Care in Medicine Program (IQCAMP) study, which estimates the quality, cost, and utilization of health services for seven diseases in Iran. Methods: We selected eight provinces for this nationally representative short longitudinal survey. Interviewers from each province were trained comprehensively. The standard definition of seven high-burden conditions (acute myocardial infarction [MI], heart failure [HF], diabetes mellitus [DM], stroke, chronic obstructive pulmonary (COPD) disease, major depression, and end-stage renal disease [ESRD]) helped customize a protocol for disease identification. With a 3-month follow-up window, the participants answered pre-specified questions four times. The expert panels developed a questionnaire in four modules (demographics, health status, utilization, cost, and quality). The expert panel chose an inclusive set of quality indicators from the current literature for each condition. The design team specified the necessary elements in the survey to calculate the cost of care for each condition. The utilization assessment included various services, including hospital admissions, outpatient visits, and medication. Results: Totally, 156 specialists and 78 trained nurses assisted with patient identification, recruitment, and interviewing. A total of 1666 patients participated in the study, and 1291 patients completed all four visits. Conclusion: The IQCAMP study was the first healthcare utilization, cost, and quality survey in Iran with a longitudinal data collection to represent the pattern, quantity, and quality of medical care provided for high-burden conditions.
Keywords: Cost of illness, Health care utilization, Iran, Non-communicable diseases, Protocol, Quality of health care
STUDY PROTOCOL
Nikolaos Boumparis1*, Alireza Noroozi2, Eisa Naghizadeh2, Andreas Meyer1, Andreas Wenger ,Afarin Rahimi-Movaghar2† and Michael P. Schaub1†1
Abstract
Background The pattern of substance use in Iran is characterized by a high prevalence of opioid use and opioid use disorder (OUD). Although opioid maintenance therapy (OMT) has been introduced in Iran, approximately 50% of people with opioid use disorder remain unreached. Moreover, psychosocial treatment of OUD and common mental health symptoms during OMT is limited. Digital interventions have been shown to improve psychological distress, depression, anxiety, and post-traumatic stress disorder symptoms. In addition, providing psychoeducation and risk reduction counseling to prevent communicable diseases like HIV and infectious hepatitis is common via the Internet. However, despite these promising advances, no smartphone intervention in OMT has been investigated for the treatment of OUD and common comorbid mental health symptoms. Objective We examine the effectiveness of adding a blended smartphone intervention based on community reinforcement approach, motivational interviewing- and cognitive behavioral therapy compared to OMT as usual that aims to improve OMT outcomes and addresses common mental health symptoms in OMT patients in Iran. Method Adults with opioid dependence entering 8 treatment centers in Tehran, Iran will be randomly assigned to receive either OMT plus a smartphone intervention or OMT as usual. The primary outcomes will be the percentage of negative urine tests for illicit, non-prescribed use of opioids (opium, heroin, tramadol) and treatment retention. Secondary outcomes will include the longest period of abstinence from the illicit, non-prescribed use of opioids (opium, heroin, and tramadol) confirmed by urine samples, changes in communicable disease risk-taking behaviors, changes in stress and common mental health symptoms, and client satisfaction. Data analysis will follow the intention-to-treat principle and employ (generalized) linear mixed models. Discussion This study will provide substantial knowledge for designing effective blended interventions for OUD. Moreover, it will investigate if treatment retention and OMT-related outcomes and common mental health symptoms can be improved by adding a smartphone intervention to OMT.
Keywords Opioid use disorder, Opioid maintenance therapy, Transdiagnostic treatment, Common mental health symptoms, Internet-based intervention, Blended treatment
REVIEW
The carcinogenicity of opium consumption: a systematic review and meta‑analysis
Adalberto M. Filho1 • Michelle C. Turner2,3,4 • Saman Warnakulasuriya5 • David B. Richardson, Bayan Hosseini11 • Farin Kamangar 7 • Akram Pourshams 8 • Vikash Sewram 9 • Deirdre Cronin Fenton Arash Etemadi 11 • Deborah C. Glass 12 • Afarin Rahimi‑Movaghar 13 • Mahdi Sheikh 1 • Reza Malekzadeh Mary K. Schubauer‑Berigan 1
Abstract
The carcinogenicity of opium consumption was recently evaluated by a Working Group convened by the International Agency for Research on Cancer (IARC). We supplement the recent IARC evaluation by conducting an extended systematic review as well as a quantitative meta-analytic assessment of the role of opium consumption and risk for selected cancers, evaluating in detail various aspects of study quality on meta-analytic findings. We searched the published literature to identify all relevant studies on opium consumption and risk of selected cancers in humans through 31 October, 2022. Meta-relative risks (mRRs) and associated 95% confidence intervals (CIs) were estimated using random-effects models for studies of cancer of the urinary bladder, larynx, lung, oesophagus, pancreas, and stomach. Heterogeneity among studies was assessed using the I2 statistic. We assessed study quality and conducted sensitivity analyses to evaluate the impact of potential reverse causation, protopathic bias, selection bias, information bias, and confounding. In total, 2 prospective cohort studies and 33 case-control studies were included. The overall pooled mRR estimated for 'ever or regular' versus 'never' use of opium ranged from 1.50 (95% CI 1.13-1.99, I2 = 0%, 6 studies) for oesophageal cancer to 7.97 (95% CI 4.79-13.3, I2 = 62%, 7 studies) for laryngeal cancer. Analyses of cumulative opium exposure suggested greater risk of cancer associated with higher opium consumption. Findings were robust in sensitivity analyses excluding studies prone to potential methodological sources of biases and confounding. Findings support an adverse association between opium consumption and cancers of the urinary bladder, larynx, lung, oesophagus, pancreas and stomach.
Keywords: Cancer; Case–control study; Cohort study; Meta-analysis; Opium.
Six-Year Follow-up of People Who Use Methamphetamine in Iran: A Case Series Study
Ardavan Mohammad Aghaei 1, Jaleh Gholami1, *, Masoumeh Amin-Esmaeili 1, 2, Shahab Baheshmat, Yasna Rostam-Abadi 1 and Afarin Rahimi-Movaghar1
1Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran
2Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
3Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
Abstract
Background: Despite the increased use of methamphetamine, little is known about its adverse events in developing countries. Objectives: This study aimed to investigate the adverse events of methamphetamine use in Iran. Methods: A total of 29 subjects who were recruited in the Iranian Mental Health Survey (IranMHS, a 2011 national household survey) and used methamphetamine more than 5 times in the past year were enrolled in this case series study. Six years after the index interview, eligible participants were contacted to assess their frequency of methamphetamine use in the past year, the incidence of adverse events, and utilization of substance use treatment services. Results: One death was recorded among 29 eligible cases. Of the 13 completed interviews (all male), the majority (n = 10) reported abstinence, and 2 reduced their methamphetamine use in the past year. More than two-thirds (n = 9) of participants experienced at least 1 adverse event. Incarceration and violent behavior were the most common adverse events. Of the 10 individuals with methamphetamine use disorder, none received specific health care treatment. Conclusions: Our participants experienced a high rate of adverse events, and no one with methamphetamine use disorder received specific treatment. Further prospective studies are needed to investigate the causal relationship between methamphetamine use and adverse events.
Keywords: Addiction, Substance Use Disorders, Methamphetamine, Prognosis
Physical Activity Patterns, Circadian Rhythms, and Aggressive and Suicidal Behavior among a Larger Sample of the General Population Aged 15 to 34 Years
Habibolah Khazaie 1, Farid Najafi 2, Azita Chehri 3, Afarin Rahimi-Movaghar 4, Masoumeh Amin-Esmaeili 4, Mahdi Moradinazar 5, Ali Zakiei 1, Yahya Pasdar 5, Annette Beatrix Brühl 6, Serge Brand 1 6 7 8 9 10, Dena Sadeghi-Bahmani 1 11
Abstract
Background: From a psychological perspective, aggressive behavior, non-suicidal selfinjury and suicidal behavior could be considered dysfunctional coping strategies. Poor sleep patterns may further increase such dysfunctional coping. In contrast, regular physical activity may have the power to counteract such dysfunctional coping. Given this background, the aim of the present study was to combine categories of circadian rhythms as a proxy of normative sleep patterns and categories of physical activity patterns, and to associate these categories with aggressive behavior, non-suicidal self-injury and suicidal behavior among a larger sample of adolescents and young adults, aged 15 to 34 years. Method: A total of 2991 (55.6% females) individuals aged 15 to 34 years of the so-called Ravansar non-communicable disease cohort study (RaNCD) took part in this study. Participants completed self-rating questionnaires covering circadian-related sleep patterns, regular physical activity, socio demographic information and dimensions of aggression, non-suicidal self-injury and suicidal behavior. Results: In a first step, both sleep patterns (circadian rhythm disorder: yes vs. no) and physical activity patterns (high vs. low) were dichotomized. Next, participants were assigned to one of four prototypical clusters: No circadian sleep disorders and high physical activity (“Hi-SleepHi-PA”); no circadian sleep disorders and low physical activity (“Hi-Sleep-Lo-PA”); circadian sleep disorders and high physical activity (“Lo-Sleep-Hi-PA”); circadian sleep disorders and low physical activity (“Lo-Sleep-Lo-PA”). Projecting these four clusters on dimensions of aggressive behavior, non suicidal self-injury and suicidal behavior, the following findings were observed: Participants of the “Hi-Sleep-Hi-PA” reported the lowest scores for aggressive behavior, self-injury and suicidal behavior, compared to participants of the “Lo-Sleep-Lo-PA” cluster. No differences for aggressive behavior, self-injury and suicidal behavior were observed among participants of the “Hi-Sleep-Lo-PA” and the “Lo-Sleep-Hi-PA” clusters. Conclusions: It appeared that the combination of favorable circadian sleep patterns and high physical activity patterns was associated with lower aggressive behavior, lower self-injury and suicidal behavior as proxies of favorable psychological functioning. In contrast, persons reporting high circadian sleep disorders and low physical activity patterns appeared to demand particular attention and counseling for both their lifestyle issues (sleep and physical activity) and their dysfunctional coping strategies.
Hosein Rafiemanesh, Afarin Rahimi-Movaghar, Behrang Shadloo, Yasna Rostam-Abadi, Saharnaz Nedjat & Kamran Yazdan
Background: Comorbid alcohol and illicit drug use disorder is relatively prevalent . We aimed to assess the prevalence, pattern, and associated factors of alcohol use disorder among treatment-seeking individuals with drug use disorders in Iran. Methods This was a cross-sectional study, conducted on 387 male patients from residential drug treatment centers in Tehran, Iran. The alcohol module from the Composite International Diagnostic Interview (CIDI 2.1) was used to assess alcohol use disorder.Logistic regression analyses were used to assess the determinants . Results The main drug of use was opioids, stimulants, and both among 78.0%, 32.3%, and 10.3% of the participants, respectively. The lifetime prevalence of alcohol dependence, harmful use, and hazardous use were 50.6%, 18.3%, and 22.0%, respectively. The past 12-month prevalence was 17.1% for alcohol dependence, 23.0% for harmful use, and 14.7% for hazardous use. Multivariable regression analysis showed that alcohol use by friends (OR = 3.8) and use of stimulants as the main drug (OR = 1.9) were significantly associated with alcohol use disorder. Conclusion The prevalence of alcohol use disorder was relatively high among males who used drugs. It seems comorbid alcohol and illicit drug use disorder is of utter importance and has been neglected in Iran.
Ardavan Mohammad Aghaei, Jaleh Gholami, Arshiya Sangchooli, Yasna Rostam-Abadi, Sogol Olamazadeh, Maryam Ardeshir, Shahab Baheshmat, Behrang Shadloo, Mahshid Taj, Khalid Saeed, Afarin Rahimi-Movaghar
Abstract
Background: Considerable disease burden is attributed to injecting drug use (IDU). This regional systematic review and meta-analysis aimed to assess the prevalence of IDU and the characteristics of people who inject drugs in the 22 countries of the WHO Eastern Mediterranean region.Methods: We conducted a systematic review and meta-analysis on the prevalence of IDU, estimation of the population size of people who inject drugs, the characteristics of people who inject drugs, commonly injected drugs, the prevalence of HIV, hepatitis C virus, and hepatitis B virus in people who inject drugs, and opioid agonist treatment and needle and syringe programme services. We searched PubMed, Web of Science, Scopus, Embase, and the Index Medicus for the Eastern Mediterranean Region for documents published between Jan 1, 2010, and April 17, 2022, with no language restrictions. We also searched government reports, civil society information, and UN websites and databases for grey literature published between Jan 1, 2010, and April 17, 2022. Documents were eligible if they reported or estimated an indicator of interest, or reported enough data to permit calculation of the indicator. We extracted data from the eligible documents and calculated national and regional estimates. Findings: We identified 38 283 documents and included 201 documents in the systematic review. A total of 115 documents were included for the four outcomes for which meta-analyses were performed. The number of people who inject drugs was estimated as 864 597 (95% CI 641 909-1 205 255), amounting to a prevalence of 20•0 per 10 000 adults (95% CI 14•9-27•9) in the region. Among people who inject drugs, the prevalence of HIV was estimated as 19•22% (95% CI 12•86-26•36), hepatitis C virus as 44•82% (29•32-61•16), and hepatitis B virus as 2•66% (0•84-7•26). Countries varied greatly regarding the variables of interest and the availability of relevant data. Nine countries provided needle and syringe programme services and seven countries provided opioid agonist treatment services, mostly with very low, low, or unclear coverage. Interpretation: The prevalence of IDU in the Eastern Mediterranean region is lower than the global mean, particularly among women. The HIV infection rate is higher than the global mean, and the hepatitis C virus infection rate is lower than the global mean. Harm-reduction services are underdeveloped. Data collection on IDU and provision of services need improvement in the region.
Development and Psychometric Evaluation of a DSM-V-Based Social Networking Site Use Disorder Test: The SNS-DT-10
Arshiya Sangchooli 1, Marziyeh Hamzehzadeh 1, Hosein Rafiemanesh 2, Kamyar Ghani 1, Rabert Farnam 1, Afarin Rahimi-Movaghar 1
Abstract
While the problematic use of Social Networking Sites (SNS) has been observed in some individuals, few validated and widely accepted measures are available to assess and screen for problematic use. This is an attempt at adapting the Diagnostic and Statistical Manual of Mental Disorders-based Internet Gaming Disorder Test-10 (IGDT-10) measure to assess SNS use disorder and problematic SNS use in the form of the SNS use disorder Test-10 (SNS-DT-10) questionnaire, and assessing its validity and reliability. The study was conducted in three phases: First, the IGDT-10 questionnaire was translated and adapted to assess SNS use disorder, and content validity was assessed. Then, a sample of 126 students from the Tehran University of Medical Sciences was used to determine internal consistency and construct validity using confirmatory factor analysis. Finally, retest data from 87 participants were used to estimate test-retest reliability. Item content validity indices were above .80 and scale content validity indices surpassed .83. The root mean square error of approximation for the 1-factor model was .04 and the comparative fit and Tucker-Lewis fit indices were .97 and .96, respectively, indicating appropriate construct validity. The intra-class correlation coefficient of the number of positive criteria for SNS use disorder was .81 and the Kappa coefficients for SNS use disorder and problematic SNS use were .85 and .57. Cronbach's alpha was .79 for the entire questionnaire. Overall, the SNS-DT-10 questionnaire has appropriate content and construct validity, internal consistency, and test-retest reliability. Further validation of this questionnaire in larger and more diverse samples and comparison with professional clinical diagnostic interviews are warranted.
Keywords: internet/gaming addiction; tests/questionnaires; translated questionnaires; validity of assessment.