Admissions to methadone maintenance: Comparisons between programs and implications for treatment

Male admissions to six methadone maintenance programs in three cities were interviewed. The characteristics of these patients in the seven Addiction Severity Index (ASI) scales-medical, employment/support, alcohol, drug, lelgal, family/socila and psychiatric—were described. The characterization of drug addicts was not found to be unidimensional. Though the admissions, as a group, had some positive characteristics (e.g., over 50% reported full time employment over the past three years), they also reported severe problems. For the 30 days prior to interview, heroin was the most commonly used drug, followed by cannabis, cocaine, and alcohol. Less than 10% had never been arrested and subjects reported engaging in crime on 6.4 of the past 30 days. The majority of these subjects had never married, but very few lived alone. The most common psychiatric symptoms reported were depression and anxiety. Characteristics were compared between programs and differences were found in race and age as well as two of the seven ASI areas. Thus, despite differences in demographics there was a great commonality in terms of the characteristics of adminissions to these programs. The implications of this for the behavioral problems related to drug abuse and for the development of treatments aimed at specific areas (such as measured by the ASI) were discussed.     

Methadone maintenance treatment may improve completion rates and delay opioid relapse for opioid dependent individuals under community corrections supervision

Aims

Several studies have demonstrated the importance of agonist therapies such as methadone and buprenorphine for preventing relapse for individuals being released from jail or prison to the community. No studies have examined the impact of methadone for increasing the completion of community supervision requirements and preventing opioid relapse for individuals under community corrections supervision. This observational study compared the community corrections completion rate and opioid relapse rate of individuals receiving methadone maintenance therapy (MMT) to individuals who did not.

Methods

Of the 2931 individuals enrolled under criminal justice supervision in the community, Treatment Accountability for Safer Communities (TASC), and who met criteria for opioid dependence, 329 (11%) individuals reported receiving MMT in the community.

Results

The majority of participants were White (79.8%) and male (63.5%), with a mean age of 31.33 years (SD = 9.18), and were under supervision for 10.4 months (SD = 9.1). MMT participants were less likely to fail out of supervision compared to individuals not in MMT (39.0% vs. 52.9%, p < 0.001), and had a lower rate of relapse (32.9%) and longer time to relapse (average days = 89.7, SD = 158.9) compared to the relapse rate (55.9%) and time to relapse (average days = 60.5, SD = 117.9) of those not on MMT.

Conclusions

While the observational nature of this study prevents causal inferences, these results suggest that utilization of MMT in community corrections may increase the likelihood of completing supervision requirements and delay time to opioid relapse. Providing agonist therapies to opioid dependent individuals under supervision appears to be a critical strategy in this important population.     

Endogenous opioid systems and alcohol addiction

 Alcohol exerts numerous pharmacological effects through its interaction with various neurotransmitters and neuromodulators. Among the latter, the endogenous opioids play a key role in the rewarding (addictive) properties of ethanol. Three types of opioid receptors (μ, δ and κ) represent the respective targets of the major opioid peptides (β-endorphin, enkephalins and dynorphins, respectively). The rewarding (reinforcing) properties of μ- and δ-receptor ligands are brought about by activation of the mesolimbic dopamine system which ascends from the ventral tegmentum of the midbrain (VTA) to rostral structures; of these, the nucleus accumbens (NAC) is of particular importance in drug addiction. In contrast, dysphoria results from activation of κ-receptors. The neurochemical manifestations of these opposing effects are, respectively, increases and decreases in dopamine release in the NAC. Several lines of evidence indicate that alcohol interferes with endogenous opioid mechanisms which are closely linked with dopamine transmission in the mesolimbic pathway. The view that condensation products of dopamine and alcohol-derived aldehyde (tetrahydroisoquinolines) play a role remains controversial. There is, however, much information on the direct (acute and chronic) effects of alcohol on the binding properties of opioid receptors, as well as modulation of opioid peptide synthesis and secretion (e.g. a suggested increase in β-endorphin release). In view of the reinforcing properties of alcohol, it is relevant to consider behavioural studies involving alcohol self-administration in rodents and primates. Low doses of morphine have been found to increase, and higher doses of the opiate to decrease, alcohol consumption. Conversely, opioid antagonists such as naloxone and naltrexone (which bind to non-selectively opioid receptors) have been shown to decrease alcohol consumption under various experimental conditions. Similar results have been reported when selective μ- or δ-receptor antagonists are administered. Results obtained in genetic models of high preference for alcohol also support the view that alcohol intake depends on the activity of the endogenous opioid reward system and that alcohol consumption may serve to compensate for inherent deficits in this system. One hypothetical model proposes that reward results from activation of μ-opioid receptors in the VTA and/or δ-receptors in the NAC; both these nuclei are targets of endogenous β-endorphin. It is suggested that alcohol interferes with this reward pathway either directly or indirectly. The available experimental data accord well with those obtained from clinical studies in which opioid antagonists have been used to prevent relapse in alcoholics. Conceptual considerations concerning communalities between various forms of addictions are also discussed in this review. Received: 12 June 1996 / Final version: 30 August 1996     

Consumer and treatment provider perspectives on reducing barriers to opioid substitution treatment and improving treatment attractiveness

In New Zealand approximately 4600 people receive opioid substitution treatment (OST) for opioid dependence, primarily methadone maintenance treatment. This study explored ways in which OST could be improved, given the significant waiting times for treatment. Two parallel surveys were conducted: 1) peer interviews with 85 regular daily or almost daily opioid drug users (51.8% receiving OST, 18.8% not currently receiving OST, and 29.4% never received OST) and; 2) a census of all 18 specialist OST service providers. When asked how OST might be improved, the four categories most commonly cited by the opioid users were 'better treatment by staff', 'more flexibility', 'better takeaway arrangements', and 'decreased waiting time'. Both opioid users and specialist services rated 'restricted takeaways' and 'having to go on a waiting list' in the top three perceived barriers to OST. Almost all services reported significant resource issues and barriers to the transfer of stable clients from specialist services to continuing treatment in primary care. The findings from this study indicate how OST can be made more accessible and attractive and thus achieve better uptake and retention.     

The effect of methadone maintenance treatment on alcohol consumption: a systematic review

There is a high prevalence of alcohol use, abuse, and dependence in methadone maintenance treatment (MMT) programs. There have been reports that this may be a result of entry into methadone maintenance. Through a systematic review, this article attempts to determine whether alcohol consumption is affected during the course (from prior to treatment initiation to once on maintenance) of MMT. A literature search for publications addressing the issue of alcohol use while on MMT was conducted. Of 15 heterogeneous clinical studies that met inclusion criteria, three studies supported an increase in alcohol use, three supported a decrease in alcohol use, and nine supported no change in alcohol use. The studies varied in their methodology and in their definition of problematic alcohol use. This review found that alcohol use, although often problematic in methadone-using patients, likely does not change upon entering MMT. We recommend routine screening and treatment for problematic alcohol use in patients on MMT.     

Patterns of prescription opioid abuse and comorbidity in an aging treatment population

Very little is known about the impact of age and gender on drug abuse treatment needs. To examine this, we recruited 2,573 opioid-dependent patients, aged from 18 to 75 years, entering treatment across the country from 2008 to 2010 to complete a self-administered survey examining drug use histories and the extent of comorbid psychiatric and physical disorders. Moderate to very severe pain and psychiatric disorders, including polysubstance abuse, were present in a significant fraction of 18- to 24-year-olds, but their severity grew exponentially as a function of age: 75% of those older than 45 years had debilitating pain and psychiatric problems. Women had more pain than men and much worse psychiatric issues in all age groups. Our results indicate that a “one-size-fits-all” approach to prevention, intervention, and treatment of opioid abuse that ignores the shifting needs of opioid-abusing men and women as they age is destined to fail.     

Predictors of methadone maintenance treatment utilization in a multisite cohort of illicit opioid users (OPICAN)

Although methadone maintenance treatment (MMT) has been a primary treatment response to illicit opioid use in Canada for decades, analytical treatment data are scarce. Using data from the multisite OPICAN cohort of illicit opioid and other drug users repeatedly assessed between 2002 (baseline) and 2005 (last follow-up [FU]), we (1) longitudinally examined characteristics associated with MMT uptake between baseline and FU and (2) cross-sectionally compared drug use patterns between cohort participants in MMT (n = 133) and those not in MMT (n = 400) at the last FU through bivariate and multivariate analyses (stepwise logistic regression). Significant baseline predictors of MMT uptake emerging in the logistic regression model included injection drug, heroin, as well as alcohol use, housing status, and Quebec City as a site. Furthermore, lower prevalence levels of opioid (e.g., morphine and OxyContin) and nonopioid (e.g., cocaine and crack) drug use as well as lower frequency of heroin use days were observed among MMT users. This study highlights potential factors relevant for improved MMT uptake and illustrates possible reductions of drug use related to MMT.     

Self-perceived problem with alcohol use among opioid substitution treatment clients

Background and aim

Excessive alcohol use increases mortality and morbidity among opioid substitution therapy (OST) clients. Regular attendance for OST dosing presents key opportunities for screening and treatment. However, individuals' perception of their alcohol consumption as problematic or otherwise may impact their willingness to change. This study examines patterns of alcohol consumption among OST clients, perceptions of their own use and correlates of excess consumption.

Methods

Confidential, structured interviews were conducted with 264 clients of two Sydney OST clinics. Alcohol consumption was assessed using the Alcohol Use Disorders Identification Test (AUDIT); and illicit drug dependence with the Severity of Dependence Scale.

Results

Forty-one percent of the participants scored ≥ 8 on the AUDIT (‘AUDIT-positive’), indicating excessive alcohol use. The higher a participant's AUDIT score, the more likely they were to demonstrate insight into the potential problems associated with their drinking (linear trend, p < 0.01). However, only half of AUDIT-positive participants believed they drank too much and/or had a problem with alcohol. One-third had discussed their drinking with OST staff, and a similar proportion reported a history of alcohol treatment. AUDIT-positive participants were more likely than others to be classified as dependent on an illicit drug in the last six months (AOR = 1.76, 95% CI:1.00–3.09), report a history of alcohol treatment (AOR = 5.70, 95% CI:2.83–11.48) and believe it is safe to drink 4 + standard drinks in one session (AOR = 5.30, 95% CI:2.79–10.06).

Conclusions

OST clients with AUDIT scores ≥ 8 appear to underestimate the risks associated with their alcohol consumption. Regular assessments of alcohol use and targeted brief alcohol interventions may improve health outcomes among OST clients.     

Patterns of heroin, cocaine, and alcohol abuse during long-term methadone maintenance treatment

Individuals' use of heroin, cocaine, and alcohol during long-term methadone maintenance treatment (MMT) was studied. Prospectively collected data from 103 heroin-addicted individuals who were consecutively admitted for MMT and remained 2 years in treatment were evaluated. The patients were assessed every 6 months with a standardized interview. Three longitudinal patterns of drug abuse were identified. A proportion of patients abstained fully from their particular drug use (26% from heroin, 39% from cocaine, and 19% from alcohol); a proportion (39%, 32%, and 47%, respectively) switched between periods of abuse and nonuse of these drugs; and chronic drug users (34%, 28%, and 33%, respectively) continued use, including periods of daily abuse throughout MMT. Different therapeutic interventions may be needed in patients with different longitudinal patterns of additional substance use during MMT.     

海洛因成瘾者美沙酮维持治疗的疗效评估

目的:评估美沙酮维持治疗(MMT)试点工作的疗效.方法:采用社区美沙酮药物维持治疗随访观察表、问卷调查表、相关人员个别访谈等形式,调查分析美沙酮维持治疗的效果.结果:参加美沙酮维持治疗后,安全套的使用率明显提高,艾滋病/性病(STD)的发病率下降,违法犯罪率降低,就业率增加,部分恢复了美沙酮维持治疗者的社会功能.结论:美沙酮维持治疗能降低传播HIV/AIDS的高危行为,减少非法毒品的使用,降低违法犯罪率,可有效预防艾滋病/性病在海洛因成瘾者中的传播和蔓延.     

盐酸纳洛酮在阿片类或乙醇类中毒患者中的临床应用及效果观察

目的：探究与分析盐酸纳洛酮在阿片类或乙醇类中毒患者中的临床应用及效果。方法选取我院2012年12月至2014年12月收治的84例急性酒精中毒患者,采取随机数字表法分为对照1组与实验1组,各42例,比较两组酒精中毒症状消失时间、起效时间以及治疗有效率;同时选取我院2012年12月至2014年12月收治的60例阿片类药物吗啡过量使用导致中毒的患者,采取随机数字表法分为对照2组与实验2组,各30例,比较两组吗啡中毒症状消失时间、起效时间以及治疗有效率。结果对照1组的起效时间为（40.29±18.22）min,实验1组为（21.33±9.25）min,组间差异有统计学意义（t=3.98, P＜0.05）;对照1组症状消失时间为（80.29±28.32）min,实验1组为（40.33±14.23）min,组间差异有统计学意义（t=3.54,P＜0.05）。对照1组治疗总有效率为85.7%,实验1组为100.0%,实验1组有总效率比对照1组明显提高,组间差异有统计学意义（χ2=5.49,P＜0.05）。对照2组治疗总有效率为66.7%,实验2组为100.0%,实验2组总有效率比对照2组明显提高,组间差异有统计学意义（χ2=4.69, P＜0.05）。结论盐酸纳洛酮治疗急性酒精中毒或阿片类药物中毒,可有效控制中毒症状、缩短起效时间,有利于机体功能的恢复。     

ALDH5A1 variability in opioid dependent patients could influence response to methadone treatment

Methadone maintenance treatment is the most widely-used therapy in opioid dependence, but some patients relapse or drop out from treatment. We genotyped a genetic variant in the succinic semialdehyde dehydrogenase enzyme gene, ALDH5A1, and found that subjects carrying the T variant allele have a higher risk to be nonresponders to methadone treatment (OR=3.16; 95% CI [1.48–6.73], P=0.0024). This could be due to a reduction in the ALDH5A1 enzyme activity, that would increase endogenous gamma-hydroxbutyric acid (GHB) and gamma-aminobutyric acid (GABA) levels and therefore, inducing symptoms such as sedation and impaired pschomotor performance. These neuropsychological effects related with the reduction in enzyme activity could be responsible for a higher propensity to relapse in these genetically predisposed patients.     

Willingness to pay for opioid agonist treatment among opioid dependent people who inject drugs in Ukraine

BackgroundIn the context of decreasing external and limited Ukrainian governmental funding for opioid agonist treatments (OAT) for opioid dependent people who inject drugs in Ukraine, information on sustainable financial models is needed.MethodsData on 855 opioid dependent people who inject drugs (PWID) were drawn from a cross-sectional nationwide survey of 1613 PWID. They comprised 434 participants who were receiving OAT and 421 who were on OAT in the past or have never been on OAT and were interested in receiving the treatment. Multivariate logistic regression was used to examine factors associated with willingness-to-pay (WTP) for OAT, stratified by OAT experience. Variation in the price which respondents were willing to pay for OAT and its effect on their monthly income among PWID with different OAT experience were assessed as a continuous variable using one-way ANOVA and Kruskal–Wallis test.ResultsOverall, 378 (44%) expressed WTP for OAT. Factors independently associated with WTP differed by OAT experience. Among those using OAT, independent predictors of WTP included: city (Dnipro – aOR = 1.9; 95%CI = 1.1–4.8 and Lviv – (aOR = 2.2; 95%CI = 1.1–4.8) compared to those elsewhere in Ukraine), higher income (aOR = 1.8; 95%CI = 1.2–2.7) and receiving psychosocial counseling (aOR = 1.8; 95%CI = 1.2–2.7). Among those who had previously been on OAT, positive attitude towards OAT (aOR = 1.3; 95%CI = 1.1–1.6) and family support of OAT (aOR = 2.5; 95%CI = 1.1–5.7) were independently associated with WTP. Among PWID who had never been on OAT, being male (aOR = 2.2; 95%CI = 1.1–4.2), younger age (aOR = 1.9; 95%CI = 1.2–3.2), higher income (aOR = 2.0; 95%CI = 1.2–3.4) and previous unsuccessful attempts to enter OAT (aOR = 2.3; 95%CI = 1.1–4.7) were independently associated with WTP. PWID were willing to commit a large percentage of their monthly income for OAT, which, however, varied significantly based on OAT experience: current OAT: 37% of monthly income, previous OAT: 53%, and never OAT: 60% (p-value = 0.0009).ConclusionsWTP for OAT was substantial among PWID in Ukraine, supporting the implementation of self-pay or co-payment programs. Such strategies, however, must remain affordable, provide better access to OAT, and consider specific needs of PWID.     

Knowledge and stigma regarding methadone maintenance treatment among personnel of methadone maintenance treatment and non-methadone maintenance treatment addiction facilities in Israel

Stigma attached to methadone maintenance treatment is very common. The objective of the current article is to evaluate the presence of stigma and its relation to the extent of knowledge about methadone maintenance treatment. The authors conducted a survey among methadone maintenance treatment and non-methadone maintenance treatment addiction therapists from different treatment centers in Israel, including methadone maintenance treatment clinics (Ministry of Health) and non-methadone maintenance treatment addiction facilities (Ministry of Social Services), using an anonymous questionnaire about methadone maintenance treatment stigma and knowledge. There were 63 therapists from methadone maintenance treatment clinics (63%) and 46 therapists from the social services department (SSD) non-methadone maintenance treatment addiction facilities (9.2%) who responded. Methadone maintenance treatment versus social services department personnel were older (42.7 ± 12.8 versus 37.5 ± 8.2 years; p = 0.03), with fewer females (48 versus 75%; p = 0.006), and 50% were social workers compared to 100% social workers in the SSD group (p < 0.0005). Stigma score was lower among methadone maintenance treatment personnel compared to the social services department personnel (3 ± 2.5 versus 5.0 ± 3.5; p = 0.0001), while the knowledge score about methadone maintenance treatment was higher among the methadone maintenance treatment personnel (10.3 ± 2.9 versus 7.7 ± 2.8; p < 0.0005). The difference in both the stigma and knowledge scores remained significant after controlling for age, gender, and profession. There was a negative correlation between the stigma and knowledge scores among both the methadone maintenance treatment (R = –0.5, p < 0.0005) and the social services department personnel (R = –0.33, p = 0.03). These results revealed a significant correlation between the presence of stigma and the extent of education and knowledge about methadone maintenance treatment, with ignorance and stigma against methadone maintenance treatment being more pronounced among social services department personnel. An educational intervention, especially among social services department personnel, may benefit people who use opioids and improve the overall quality of treatment for opioid addiction in Israel.     

Factors associated with dropout among patients in opioid maintenance treatment (OMT) and predictors of re-entry. A national registry-based study

Background

Retention in treatment is often highlighted as one of the key indicators of success in opioid maintenance treatment (OMT).

Aims

To identify factors associated with long-term retention in opioid maintenance treatment and to analyse predictors of subsequent treatment episodes.

Methods

Treatment retention and re-entry were examined for a national cohort of patients admitted to OMT in Norway in the period 1997–2003. Multivariate Cox regression models were used to investigate factors associated with treatment dropout 18 months after treatment entry.

Results

The 18 month retention rate among patients admitted to OMT in Norway (n = 2431) was 65.8% (n = 1599). Dropout from OMT within 18 months was associated with younger age (HR 0.97 [0.96–0.98]), high levels of general pre-treatment criminal offences (HR 1.66 [1.32–2.09]) and having drug-related offences during the 30 days prior to dropout (HR 1.80 [1.36–2.38]). Of the patients who dropped out (n = 832), 42.7% (n = 355) were re-engaged in subsequent treatment episodes. Pre-treatment criminal offences were associated with increased odds for treatment re-entry, whereas being younger and having drug-related offences during the first OMT episode were associated with lower odds for re-engagement in OMT. Gender was not associated with treatment dropout and re-entry.

Conclusion

High levels of pre-treatment criminal offences and drug offences during the 30 days prior to dropout were associated with treatment dropout. Efforts to increase support services to these patients may contribute to higher rates of retention in OMT.     

Methadone treatment improves tuberculosis treatment among hospitalized opioid dependent patients in Ukraine

BackgroundUkraine's volatile syndemics of tuberculosis (TB) and HIV among people who inject drugs (PWIDs) introduces numerous treatment challenges for each condition, including high mortality and development of multi-drug resistant TB (MDR-TB).MethodsA prospective, non-randomized 90-day observational study was conducted in six Ukrainian TB treatment sites to assess the effectiveness of integrating methadone maintenance (MMT) with TB treatment using: (1) 90-day TB treatment retention; (2) time to treatment discontinuation; (3) TB medication adherence; and (4) subject disposition, including mortality. Of the 110 participants enrolled, 57 received MMT and 53 did not (non-MMT).ResultsAll of the primary outcomes were significantly better in MMT versus non-MMT groups, including 90-day TB treatment completion (89.5% versus 73.6%; p = 0.031), time to TB treatment discontinuation (p = 0.039) and TB medication adherence (97.1% versus 86.2%; p < 0.001) after controlling for death. The major reasons for treatment non-completion in the non-MMT group included death (N = 3), administrative discharge from the clinic (N = 5), loss to follow-up (N = 2), and arrest (N = 4). Overall, 90-day mortality was high (8.2%). After controlling for covariates differing between the two groups at baseline, the only independent predictor of completing 90 days of TB treatment was receipt of MMT in an integrated treatment setting (AOR = 3.05; 95% CI 1.08–8.66).ConclusionsMMT integrated into inpatient TB treatment significantly improves retention in TB treatment and TB medication adherence among PWIDs. These findings call for policy change to increase the number of MMT sites in TB facilities and make MMT a low-threshold treatment option for opioid dependence in Ukraine.     

Substance,structure and stigma: Parents in the UK accounting for opioid substitution therapy during the antenatal and postnatal periods

BackgroundParenting and pregnancy in the context of drug use is a contentious topic, high on the policy agenda. Providing effective support to parents who are opioid dependent, through early intervention, access to drug treatment and parenting skills training, is a priority. However, little is known about opioid dependent parents’ experiences and understanding of parenting support during the antenatal and postnatal periods. This paper focuses on the position and impact of opioid substitution therapy (OST) in the accounts of parents who were expecting, or who had recently had, a baby in the UK.MethodsSemi-structured qualitative interviews were held with a purposive sample of 19 opioid dependent service users (14 female, 5 male). Longitudinal data was collected across the antenatal and postnatal (up to 1 year) periods, with participants interviewed up to three times. Forty-five interviews were analysed thematically, using a constant comparison method, underpinned by a sociologically informed narrative approach.ResultsParticipants’ accounts of drug treatment were clearly oriented towards demonstrating that they were doing ‘the best thing’ for their baby. For some, OST was framed as a route to what was seen as a ‘normal’ family life; for others, OST was a barrier to such normality. Challenges related to: the physiological effects of opioid dependence; structural constraints associated with treatment regimes; and the impact of negative societal views about drug-using parents.ConclusionParents’ accounts of OST can be seen as a response to socio-cultural ideals of a ‘good’, drug-free parent. Reflecting the liminal position parents engaged in OST found themselves in, their narratives entailed reconciling their status as a ‘drug-using parent’ with a view of an ‘ideal parent’ who was abstinent.