Integrating antiretroviral therapy in methadone maintenance therapy clinics: Service provider perceptions

BackgroundUsing methadone maintenance therapy (MMT) clinics to deliver antiretroviral therapy (ART) is an effective strategy to promote treatment initiation and adherence for HIV-positive drug users. This paper describes the implementation barriers perceived by service providers for an intervention pilot designed to integrate ART services in MMT clinics.MethodsThe study was conducted in six MMT clinics in Sichuan province, China. Two service providers selected from each of the six clinics underwent training in administering ART. The trained providers delivered ART-related services in their clinics. A focus group was conducted among the service providers to assess their experiences and perceived challenges in delivering integrated services.ResultsBarriers at policy, institutional, provider, and client levels were identified. Policy level barriers included household registration restrictions and a lack of insurance coverage for testing expenses. Inefficient coordination between treatment sites and MMT clinics was an obstacle at the institutional level. Insufficient training and added workload were barriers at the provider level. Finally, conflict with daily dosing habits was identified as the primary reason that clients did not accept ART.ConclusionAlthough integrating ART into MMT clinics is beneficial, multilevel barriers to implementation need to be addressed. This study documents the need for treatment transferability and insurance coverage, protection of client confidentiality, proper provider training, coordination with treatment sites, and individualized ART service for MMT clients.     

Client Acceptability for Integrating Antiretroviral Therapy in Methadone Maintenance Therapy Clinics in Sichuan,China

Background: Using methadone maintenance therapy (MMT) clinics to deliver antiretroviral therapy (ART) has proven to be effective for promoting treatment initiation and adherence in drug users living with HIV. Objectives: The objective of this study was to investigate the HIV-positive client acceptability of integrated ART services and to identify the reasons for and factors associated with service acceptability. Methods: A total of 86 HIV-positive MMT clients were recruited from 12 MMT clinics in Sichuan Province, China. They participated in a cross-sectional survey that queried their willingness to receive seven different types of MMT-based ART services. The reasons for their willingness/unwillingness to accept these services were documented. The association between service acceptability and background characteristics was examined. Results: The most accepted integrated services were ART-related counseling (75.6%) and referral (73.2%). Concerns regarding the provider's lack of ART expertise and confidentiality issues were common barriers for the acceptance of MMT-based ART services. A trust relationship with MMT providers was a reason for service acceptance. Service acceptability was associated with a poorer perceived health status. Conclusions/Importance: ART-related services, based on the client perspective, can be delivered at MMT clinics. However, service provider training and the protection of confidentiality must be strengthened for the effective implementation of integrated service delivery.     

The risk environments of people who use drugs accessing two harm reduction centers in Tehran,Iran: A qualitative study

BackgroundIran has developed the most robust harm reduction infrastructure in the Middle East, marked by availability of low threshold methadone maintenance treatment (MMT), needle and syringe program (NSPs), and condom distribution services. However, little is known about the socially situated risk factors that make harm reduction clients—specifically those enrolled in MMT—vulnerable to relapse or continued illicit drug use. In this study, we sought to understand the “risk environment” of clients enrolled in harm reduction services in Tehran, Iran.MethodsThrough observation and in-depth interviews with 22 drop-in-center clients and 8 staff members from July to August 2017, we explored the risk environments of clients of two drop in centers (DICs) in Tehran. All interviews were transcribed, coded and analyzed using a qualitative thematic analysis.ResultsWe found that compulsory drug treatment programs, social stigma, police encounters, and difficulties in obtaining governmental identification documents, among other factors, contribute to social marginalization of DIC clients.ConclusionMany interviewed DIC clients continued to use illicit substances (particularly methamphetamine) despite having access to methadone treatment. This study underscores the panoply of social and structural barriers that DIC clients face while attempting to engage in treatment and harm reduction services. Following the “risk environment” framework, it is essential to identify the structural factors shaping individual behaviors that perpetuate experiences of social marginalization and poor health outcomes in this population.     

Predicting treatment retention with a brief "Opinions About Methadone" scale

It is important to identify social conditions, program factors, and client characteristics that predict retention because time in substance abuse treatment is associated with improved health, mood, and social functioning. Treatment dropouts also are at high risk for serious harms, including relapse. Most opioid-dependent persons require long-term stabilization in methadone maintenance treatment (MMT) to normalize brain function and control withdrawal symptoms. The purpose of this study was to determine whether a client characteristic, namely, attitude toward methadone, was related to retention. Analysis of 14 opinion statements about methadone identified a reliable five-item scale with factorial validity. This scale (Opinions About Methadone; OAM-5) also predicted retention in MMT. Of 338 clients followed for one year after MMT enrollment, 48% dropped out of treatment; those who were more likely to remain had more favorable opinions. A supplementary qualitative study with MMT counselors demonstrated face validity for the OAM-5; counselors found the items easy to interpret and relevant to client attitudes towards MMT. The findings suggest that it would be worthwhile for MMT staff to assess client attitudes at intake, using the OAM-5. This would help them to identify and intervene promptly with those in greatest need of support for remaining in treatment.     

Preliminary analysis of the Northern Territory's illicit drug court diversion program highlights the need to examine lower program completion rates for indigenous clients

Introduction and Aims. Court drug diversion programs are now available in all jurisdictions in Australia, but there is increasing evidence that such programs have differing success rates for certain client populations, including indigenous clients. This study investigates client characteristics, program completion rates and factors associated with retention, for all 484 clients admitted to the Northern Territory's Court Referral and Evaluation for Drug Intervention and Treatment 12 week illicit drug pre‐sentence court diversion program between July 2003 and December 2008. Design and Method. Client data were collected by court clinicians as part of the face‐to‐face assessment interview and treatment outcomes were recorded. Results. Multivariate logistic regression analysis showed that indigenous clients were significantly less likely to complete their treatment than non‐indigenous clients, as were clients who were younger, male, had an educational level of Year 10 or less, were unemployed, had a previous custodial order and used drugs other than cannabis. Discussion and Conclusions. The lower program completion rates for indigenous clients are consistent with findings from other Australian studies and highlight the need to further explore and address factors contributing to this result.[Rysavy P, Cunningham T, O'Reilly‐Martinez R. Preliminary analysis of the Northern Territory's illicit drug court diversion program highlights the need to examine lower program completion rates for indigenous clients. Drug Alcohol Rev 2011;30:671–676]     

Challenges in providing services in methadone maintenance therapy clinics in China: Service providers’ perceptions

BackgroundThe Methadone Maintenance Therapy (MMT) program has been initiated in China since 2004. As of the end of November, 2008, 558 MMT clinics had been established countrywide. The objective of this study was to elucidate the difficulties and challenges as perceived by service providers working in MMT clinics.MethodsOne service provider from each of the 28 MMT study clinics in Zhejiang and Jiangxi Provinces of China participated in a face-to-face in-depth interview for about 1–2 h to describe their perceptions of working in MMT clinics. Qualitative data were analysed using ATLAS.ti. The grounded theory was used to guide the data analysis.ResultsParticipants identified major problems in providing services in MMT clinics including lack of resources, professional training, and institutional support. Difficulties in pursuit of career, concern for personal safety, low income, heavy working load, and poor opinion of MMT by Chinese society often contributed to greater stress and burnout among the service providers.ConclusionThe MMT programs in China desperately need additional resource allocation and institutional support for the current and perhaps future expansion of the programs. The service providers are in urgent need of professional training to improve the quality of care they can offer MMT clients.     

Deficit models and divergent philosophies: Service providers' perspectives on barriers and incentives to drug treatment

Aims: To ascertain service providers' views on barriers and incentives to illicit drug users accessing or remaining in treatment.

Methods: Interviews with service providers in Australia were conducted.

Results: Two main themes were explored. Service providers suggested that the perception of a person seeking treatment was strongly associated with the image of that person as deficient, defective or lacking, and that this could impede treatment. Service providers also suggested that differing treatment philosophies and their related treatment goals were at the core of many barriers to treatment. We argue that it is important to find a balance between a model of treatment which works and is responsive to clients' needs while also avoiding the potential for feeding stigma of those who seek treatment for drug dependence.

Conclusion: Our results suggest that knowledge and understanding of treatment philosophies are important for people seeking treatment so that clients can find services that match their needs and treatment goals.     

Predictive factors for treatment retention in methadone programs in Indonesia

This article presents the results of a 6-month prospective cohort study of methadone maintenance treatment (MMT) in Indonesia. The study aimed to investigate the predictor variables of retention in MMT in Indonesia. The duration of treatment (in days) was the main outcome of the study. For the study, program, client, social network, and accessibility factors were investigated as potential predictors of retention. The study analyzed the relative weight of each factor in predicting treatment retention. The sample consisted of 178 clients drawn from three participating clinics: Rumah Sakit Ketergantungan Obat and Tanjung Priok in Jakarta and Sanglah in Bali. The 3- and 6-month retention rates were 74.2% and 61.3%, respectively. These rates are comparable with previous studies conducted in developed countries. A survival analysis using a robust estimation for the Cox PH regression found that the strongest predictors of retention were methadone dose followed by an interaction between take-home dose and the experience of the clinic providing this treatment. Other significant predictor variables included age, perceived clinic accessibility, and client's belief in the program. The study concludes that MMT cannot solely rely on the pharmacology for retention but should also promote informed access to take-home doses.     

Unmet need for recommended preventive health services among clients of California syringe exchange programs: implications for quality improvement

BACKGROUND: Comprehensive preventive services are recommended for injection drug users (IDU), including screening tests, vaccinations, risk reduction counseling, and sterile syringes. Syringe exchange programs (SEP) may facilitate receipt of preventive services by IDUs, but whether SEP clients receive recommended preventive care is not known. We examined use of recommended preventive services by clients of 23 SEPs throughout California. METHODS: Five hundred and sixty SEP clients were recruited from 23 SEPs throughout California between March and September 2003. Receipt of 10 recommended preventive services and source of care (SEP versus non-SEP providers) was ascertained from client interviews. RESULTS: On average, SEP clients received only 13% of recommended preventive services and 49% of clients received none of the recommended services. Of services that were received, 76% were received from SEPs. In multivariate analysis, use of drug treatment and more frequent SEP visits were associated with receipt of recommended preventive services by clients. CONCLUSIONS: SEPs are often the only source of preventive care for their IDU clients. Still, SEP clients fail to receive most recommended preventive services. Interventions to increase use of preventive services and improve the quality of preventive care received by IDUs, such as increased access to drug treatment and SEPs, are needed.     

Comparative Cocaine Abuse Treatment Strategies:

The current investigation explores the clinical utility in providing a series of enhanced clinical services to a sample of 303 cocaine-abusing clients (primarily crack smokers) relative to a standard group therapy treatment program. In addition to examining the comparative impact of six varying psychosocial treatment approaches for cocaine abuse on client retention and treatment exposure rates, an additional emphasis has been to examine the ability of fixed and dynamic client variables in predicting client outcome in this regard. No fixed (e.g., sex, income, marital status, income level, or employment status) or dynamic (e.g., recent alcohol use, antisocial personality disorder diagnoses, or motivational variables) client characteristics were useful in predicting client client retention or treatment exposure rates. Program characteristics, however, or the frequency, intensity, and/or type of treatment services offered, were related to client retention and treatment exposure. Treatment exposure and retention were significantly enhanced by providing clients with more frequent and intensive group therapy, or by adding individual treatment services to a standard group therapy treatment regimen. With a population such as cocaine abusers, who typically have an extremely high treatment dropout rate, an obvious strategy is to focus efforts on engaging and retaining clients in treatment, and maximizing levels of treatment exposure. The current findings suffest that one successful approach towards enhancing psychosocial treatments for cocaine abuse is to increase the frequency, intensity, and/or types of treatment services offered.     

Medicaid Coverage,Methadone Maintenance,and Felony Arrests: Outcomes of Opiate Treatment in Two States

ABSTRACT

A modest number of clinics in Oregon and Washington provide MMT maintenance treatment (MMT) services. More than 10,000 clients in each state were followed for 3 years after an initial admission for opiate use between 1993 and 2000. Medicaid clients in both states had far greater access to MMT than their non-Medicaid counterparts, controlling for differences in client characteristics using propensity scores. Months in MMT were associated with much lower arrest rates than time not in treatment, but unexpectedly this was only true for clients participating in MMT for many months. Despite differences in the treatment systems for opiate addiction in these two states observed in previous studies, the current findings generalized across both states.     

A qualitative study exploring the reason for low dosage of methadone prescribed in the MMT clinics in China

Objectives

Dosage of methadone maintenance therapy (MMT) is an important factor influencing retention in methadone treatment. MMT clients in China received lower dosages of methadone compared with those provided in other countries. The objective of this study is to elucidate the reason for the low methadone dosage prescribed in MMT clinics in China.

Methods

Twenty-eight service providers were recruited from the MMT clinics in Zhejiang and Jiangxi Provinces, China. Qualitative in-depth interviews were conducted to ascertain the procedure for prescribing methadone in the MMT clinics.

Results

The average dosage prescribed in the 28 clinics was 35 mg/person/day. Four major themes resulting in low dosage of methadone were identified: (1) the service providers fear the liability resulting from large doses of methadone in combination with other substances which might result in overdose fatalities, (2) lack of understanding of harm reduction which resulted in low acceptance of the long term maintenance treatment approach, (3) break-down in communication between clients and service providers about dosage adjustment, and (4) dosage reduction is perceived by most service providers as an effective way to treat the side-effects associated with MMT.

Conclusions

The findings of the study highlighted the necessity to formulate clear guidelines concerning individualized dosage management and to improve training among service providers’ in MMT clinics in China.     

Linking women to health and wellness: Street Outreach takes a population health approach

In a small city (population 86,000) situated in the Interior Health Authority, one of six health authorities in British Columbia, Canada, a local Public Health Street Outreach program was challenged with addressing the increasing complexities of individuals and families affected by substance use, poverty, mental illness, human immunodeficiency virus (HIV), hepatitis C virus (HCV), and homelessness. The individual health service delivery model currently used to provide care in the community, limited and impeded prevention and health promotion activities by nurses working with these populations. Changing to a client centred population health approach instead of the individual service approach gave Street Outreach nurses greater flexibility so that they were able to more effectively engage with clients, families, and other service providers regarding health related issues. The strategies that were developed to use a client centered population health approach entailed: (1) a compilation of health and related information of a specific client group (vulnerable, disenfranchised women); (2) a community based health conference for the specific client group and (3) resource development and knowledge translation to increase the education and awareness of health and social services providers as well as the community at large. All strategies were developed with particular attention to the World Health Organization (WHO) health determinants. Implementation of these strategies resulted in the building of capacity within the specific target group and their families, other health and service providers and the community at large.     

Participation and retention in drug abuse treatment services research

We examined potential bias in treatment effectiveness research by studying client characteristics associated with initial participation and subsequent retention in research assessments among clients in substance abuse treatment receiving case management. Six hundred thirty-four residential and 429 outpatient clients were invited to participate. Participants were randomly assigned to one of four conditions. Logistic regression examined the relation between client characteristics and initial participation and retention in follow-up assessments. Females and clients with significant others were more likely to participate and remain in the study. Older persons and criminal justice-referred clients were less likely to participate. Older clients and urban outpatient clients were more likely, and criminal justice-referred clients were less likely, to be retained. Two case management conditions were associated with decreased retention. Client characteristics are important factors in participation and retention in treatment services research. Further, client characteristics may bias estimates of effectiveness generally, or for specific populations.     

Encouraging smoking cessation among disadvantaged groups: a qualitative study of the financial aspects of cessation

Introduction and Aims. This study aimed to explore perceptions about financial aspects of smoking cessation among a group of disadvantaged welfare agency clients and their carers. Design and Methods. Qualitative focus groups and in‐depth interviews were supplemented with participant exit surveys about preferred smoking cessation strategies. Each discussion was audiotaped, transcribed and analysed using a thematic analysis. The setting was six non‐government community welfare service organisations operating in New South Wales, Australia. Eleven social services offered by these organisations participated. Thirty two clients participated in six client focus groups, 35 staff participated in six staff focus groups and eight manager telephone interviews were conducted. Results. Clients indicated that the cost of nicotine replacement therapy was a barrier to its use and that financial incentives were acceptable. Of the 16 possible strategies listed in the exit survey, the three selected as the most preferred by clients incorporated financial or non‐financial assistance. By contrast, staff and managers selected financial and non‐financial incentives as the least preferred and least feasible strategies. Discussion and Conclusions. The study found high acceptance of incentives as a smoking cessation strategy among a disadvantaged group of non‐government welfare service clients. The comparatively low level of desirability and feasibility from the perspective of service staff and managers suggests implementation of such an approach within the community service setting requires careful further testing.[Bonevski B, Bryant J, Paul C. Encouraging smoking cessation among disadvantaged groups: A qualitative study of the financial aspects of cessation. Drug Alcohol Rev 2011;30:411–418]     

Interaction Effects of Client and Treatment Program Characteristics on Retention: An Exploratory Analysis Using Hierarchical Linear Models

This paper applied a hierarchical linear modeling approach to explore the interaction effects of treatment program and client characteristics on client retention in treatment for drug users. Program characteristics included services provision, funding sources, and staff-client gender congruence, and client characteristics included gender, age at admission, and drug use level prior to admission. The same model was applied separately to three modalities: residential, methadone maintenance, and outpatient drug-free programs. Data were obtained from 59 treatment programs and 3,764 of their clients who had discharge records. The most noteworthy significant interaction effect detected was program's funding source and client's gender on treatment retention in the outpatient drug-free modality. for example, female clients remained less time in the programs that accepted only public funding than in the programs that accepted both public and private funding. Male clients remained in the treatment an average of 25.3 fewer days than female clients in drug-free programs that only accepted public fund, but stayed about the same time as females if the programs received mixed funding.     

Patterns of Abstinence or Continued Drug Use Among Methadone Maintenance Patients and Their Relation to Treatment Retention

The efficacy and effectiveness of methadone maintenance treatment (MMT) in the medical management of opioid addiction has been well-established, but treatment outcomes are compromised by the continued use of licit and illicit drugs during MMT. The present study examined the relationship between in-treatment illicit drug use and retention and dropout of 604 MMT patients in Washington, D.C. Sixty-eight percent of patients did not test positive for an unprescribed drug during the study period. Of patients who tested positive for an illicit drug during the baseline period, 55% tested positive for cocaine, 44% for opiates, 23% for THC, 20% for benzodiazepines, 7% for PCP, and 4% for amphetamines. Those testing positive were three times more likely to leave treatment than those who did not test positive. Testing positive for one drug doubled the rate of attrition; testing positive for multiple drugs quadrupled the risk of attrition. Non-prescribed opioid or benzodiazepine use was a predictor of MMT dropout, but prescribed opioid or benzodiazepine use was not. Continued illicit drug use poses significant risk for subsequent premature termination of MMT. Assertive clinical management of continued illicit drug use could provide mechanisms to enhance MMT retention and long-term recovery outcomes.     

Injection frequency mediates health service use among persons with a history of drug injection

Drug injectors are known to have high rates of hospital and emergency room (ER) use. We hypothesized that out-of-treatment injection drug users (IDUs) have higher rates of health service use than methadone-maintained persons, and that heroin injection frequency mediates health service use among drug injectors (IDUs). HIV-negative individuals with a history of drug injection were recruited from a needle exchange program (NEP) and a methadone maintenance treatment program (MMT) in Providence, RI. ER visits, outpatient visits, and hospitalizations in the last 6 months were the dependent variables with number of heroin injections the hypothesized mediator variable. The 472 participants were predominately male (60.6%) and white (82%) with a mean age of 37. NEP clients were more likely than MMT clients to visit an ER (39.2% vs. 29.8%; P=0.03). NEP participants were somewhat more likely to report a hospital admission (16.0% vs. 10.6%; P=0.08). Relative to non-injecting MMT participants, the odds of visiting an ER were 1.80 and 1.67 times higher for subjects recruited through NEP and actively injecting MMT participants, respectively. Additionally, subjects recruited through NEP (OR=2.2) and actively injecting MMT participants (OR=2.3) were over twice as likely to report a hospital admission than non-injecting MMT participants. Each increase of one heroin injection per day increased the expected odds of injection-related infection by a factor of 1.92. NEP clients are more likely to have ER visits and hospitalizations than methadone clients. We describe a pathway by which injection frequency influences health service use.     

Spanish language proficiency among providers and Latino clients' engagement in substance abuse treatment

Quality of care, such as provision of services in Spanish, is a common factor believed to improve treatment engagement among Spanish-speaking Latinos in health care. However, there is little evidence that Spanish language proficiency among providers increases treatment access and retention in publicly funded substance abuse treatment. We analyzed client and program data collected in 2010–2011 from publicly funded treatment programs in Los Angeles County, California. An analytic sample of 1903 Latino clients nested within 40 treatment programs located in minority communities was analyzed using multilevel negative binomial regressions on days to initiate and spent in treatment. As hypothesized, Spanish language proficiency was negatively associated with client wait time and positively associated with retention in treatment, after controlling for individual and program characteristics. The path analysis models showed that Spanish language proficiency played a mediating role between professional accreditation and client wait time and retention. These preliminary findings provide an evidentiary base for the role of providers' Spanish language proficiency and Latino engagement in treatment for a population at high risk of treatment dropout. Implications related to health care reform legislation, which seeks to enhance linguistically competent care, are discussed.     

Enhancing treatment access: Evaluation of an Australian Web‐based alcohol and drug counselling initiative

Introduction and Aims. The provision of counselling and other health interventions over the Internet is an emerging treatment modality. In 2007, an evaluation of the first Australian pilot Web‐based alcohol and other drug (AOD) counselling initiative, known as CounsellingOnline, was completed. This paper explores whether CounsellingOnline enhanced AOD service accessibility for clients. Design and Methods. Service utilisation data (n = 2004) and client survey data (n = 277) were collected and analysed to evaluate service responses, service impact, client characteristics and client satisfaction. Comparative client data were obtained from a state‐wide conventional counselling dataset (Alcohol and Drug Information System; n = 19 283) and a statewide telephone counselling database (DirectLine; n = 59 863). Results. Service responses, such as fast counsellor connection speed, low client attrition and anonymous login, contributed to good service accessibility. CounsellingOnline clients differed from conventional and telephone counselling clients, representing much higher proportions of young, employed and female clients. Notably, the majority of CounsellingOnline sessions occurred outside standard business hours. Discussion and Conclusions. CounsellingOnline has showed enhanced AOD service accessibility through its service responsiveness, high level of after‐hours service utilisation, and appeal to a client group that differs from those seen in conventional and telephone AOD counselling services. The capacity of Web‐based services such as CounsellingOnline to enhance service accessibility is significant, particularly for clients whose access to conventional treatment services is limited.[Swan AJ, Tyssen EG. Enhancing treatment access: Evaluation of an Australian Web‐based alcohol and drug counselling initiative. Drug Alcohol Rev 2009;28:48–53]