Detection of illicit opioid and cocaine use in methadone maintenance treatment.

Urine toxicology is the gold standard for estimating the prevalence of illicit drug use in methadone maintenance treatment (MMT). The frequency of urine testing may be crucial for establishing accurate use rates. Infrequent testing may lead programs to undercount active drug users and to target interventions too narrowly. This study compared results from frequent testing (twice per week) versus less frequent testing of 166 patients at four MMT programs. As part of a research study, all patients were tested by research staff for opioid and cocaine use twice per week on a fixed schedule for 10 weeks. During the same period, the four MMT programs tested the patients according to their standard protocols, approximately weekly (one program) or every 3-4 weeks (three programs). The research tests identified approximately 50% more illicit opioid users and 70% more cocaine users than the less frequent program tests. Patients who were drug positive according to the research tests but drug negative according to the program tests tended to be infrequent users. The data suggest that standard urine testing practices in MMT programs may result in underestimates of the prevalence of opioid and cocaine use. More frequent testing, even for time-limited periods, should produce more accurate depictions of drug use prevalence and help indicate the direction of interventions.     

Alcohol use in methadone maintenance clinics

A study was undertaken to determine the frequency of alcohol use and the amount consumed by methadone maintenance patients. In four clinics of the Beth Israel Medical Center Methadone Maintenance Treatment Program, every fifth patient from an alphabetical clinic list was selected for interview. Among the 101 patients who were interviewed, mean alcohol consumption was 1.2 ounces per day. Among those who drank, there was a continuum in terms of amount consumed. Forty-three percent had totally abstained from alcohol during the prior 3 months, and an additional 30% drank one or less ounces per day. Independently obtained staff rankings generally approximated interview results, and thus supported the reliability of the interview. Since staff rankings for participants and nonparticipants in the interview were similar, it appears that those who participated were typical of the group selected for study.     

Serum levels of methadone in maintenance clients who persist in illicit drug use

This study examined pharmacological factors contributing to persisting drug abuse by methadone maintenance clients. Three groups of clients, drawn from one treatment programme, were studied: persistent heroin users, persistent benzodiazepine users, and control subjects who were not using illicit drugs in addition to methadone. Persistent abusers mostly had high trough serum methadone levels, and their ongoing drug use appears to reflect a preference for a different drug effect rather than inadequate methadone dose. Several clients did have the expectation that methadone should prevent them from using other drugs; such expectations may diminish the effectiveness of treatment.     

Optional versus mandatory psychotherapy in methadone maintenance

Treatment outcomes of 23 methadone maintenance patients who were offered optional psychotherapy were compared with those of 31 methadone maintenance patients who received mandatory psychotherapy. There were no statistically significant differences in pretreatment characteristics between the optional group and the mandatory group. Patients in the optional group received less than half as many hours of therapy as patients in the mandatory group. Differences between the two groups in retention, employment, illicit drug use, and arrests were nonsignificant during a 1-year study period. The findings were compatible with those of most previous studies of the effectiveness of psychotherapy in methadone maintenance, which suggest that outcomes with or without psychotherapy do not differ significantly.     

Infrequent illicit methadone use among stimulant-using patients in methadone maintenance treatment programs: a national drug abuse treatment clinical trials network study

We sought to determine the prevalence, patterns, and correlates of past-month illicit methadone use and history of regular illicit use among stimulant-using methadone maintenance treatment patients. We obtained self-reported information on illicit methadone use from 383 participants recruited from six community-based methadone maintenance programs. Overall, 1.6% of participants reported illicit use in the past month, and 4.7% reported a history of regular use. Younger age and history of outpatient psychological treatment were associated with increased odds of past-month illicit use. Illicit methadone use among patients in maintenance programs is infrequent; however, a number of factors may increase risk of illicit use.     

Measuring outcome in cocaine clinical trials: a comparison of sweat patches with urine toxicology and participant self-report

Aims To evaluate the advantages of using a sweat patch (PharmCheck?) for detecting cocaine abuse in cocaine‐dependent patients participating in a clinical trial. The utility of the sweat patch was assessed from the following perspectives: the reliability and validity of quantitative sweat patch results, the possible degradation of cocaine to benzoylecgonine (BE) as a function of the length of time that a patch is worn, the completeness of the dataset yielded by thrice‐weekly urine toxicology compared with thrice‐weekly and weekly sweat patches, and the relative costs associated with sweat patch versus urine measures. Design Data were collected during a 10‐week out‐patient clinical trial in which participants wore two sweat patches, one applied every visit and one applied weekly. Urine samples were collected thrice weekly, as were self‐reports of substance use. Setting A multi‐site clinical trial conducted in Boston, Cincinnati and New York, USA. Participants Twenty‐seven participants with comorbid diagnoses of cocaine dependence and adult attention deficit disorder completed the study. Measurements Sweat patch and urine samples were analyzed by standard methods for cocaine and cocaine metabolites. Findings Quantitative sweat patch measures had good reliability in that the correlation between the weekly and per‐visit patches was 0.96 (P < 0.0001). The concurrent validity, as judged by the correlation between quantitative urine BE levels and either weekly (0.76, P < 0.0001) or per‐visit (0.73, P < 0.0001) cocaine sweat patch levels was reasonable. The correlation between the self‐report of cocaine use and these same two patches, however, was lower (0.40, P < 0.05 and 0.30, P < 0.05, respectively). The results revealed no significant degradation of cocaine to BE associated with wearing the patch for a longer time. Finally, the per‐visit patch provided cocaine use data on 80.5% of all study days (a total of 70), while urine toxicology and the weekly patch provided 77.4% and 76.1%, respectively. Conclusions The present findings suggest that the PharmCheck? patch might be an attractive alternative to urine toxicology for use as an outcome measure in cocaine clinical trials.     

Illicit drug use and injection practices among drug users on methadone and buprenorphine maintenance treatment in France

Aims To evaluate the associations between methadone and high‐dose buprenorphine maintenance treatment and illicit drug use and injection among drug users in France. Design A cross‐sectional study. Data were gathered using a questionnaire administered containing closed‐ended questions. Setting Drug dependence clinics (DDC) and general practitioners’ (GPs) offices in three French cities. Participants Drug users undergoing maintenance treatment with methadone (n = 197) and buprenorphine (n = 142). Measurements Interviews covered the use of illicit drugs (heroin, cocaine or crack) and injection practices (illicit drugs and/or substitution drugs) during the last month, current treatment modalities, socio‐demographic and health characteristics. Bivariate analysis and multivariate logistic regressions were conducted. Findings Overall, 35.4% of respondents (34.5% in the methadone group, 36.6% in the buprenorphine group, P= 0.69) had used at least one illicit drug, 25.7% reported having injected drugs and 15.3% had injected the substitution drug. Injection was more common among buprenorphine‐maintained individuals (40.1%) than among users on methadone (15.2%) (P < 0.01). Multivariate analyses indicate that the type of substitution drug (buprenorphine versus methadone) was not associated with illicit drug use (OR = 1.1; 95% CI = 0.7–1.8). In the buprenorphine group, injection was related independently to social situation, as measured by housing (unstable versus stable housing, OR = 4.3; 95% CI = 1.6–11.5), but this was not the case in the methadone group. The risk of injection increased with buprenorphine dosage (high/low dosage OR = 6.2; 95% CI = 2.0–19.7), but this association was not observed in the methadone group. Conclusion Further studies comparing the benefits of these two types of treatment should be carried out, taking outcomes such as physical health, mental health and social functioning into consideration.     

The consequences of a change in formulation of methadone prescribed in a drug clinic

Methadone mixture DTP (Img in 1 ml) is a safe non-injectable alternative to methadone tablets (5mg). It also allows for a more gradual detoxification from opiate dependence. For these reasons it was decided to ‘rationalise’ our prescribing so that methadone in mixture form only would be dispensed. At the beginning of 1989, 66 opiate-dependent patients were receiving methadone tablets, 61 the methadone mixture. We report the consequences of instituting a policy change which was clearly very unpopular with patients. Of the 66 patients receiving methadone tablets prior to the change to mixture, 53 were represcribed tablets by the end of the 3-month follow-up period. In many cases this was because of an intense resistance to the change over, physical complications of methadone mixture occurred in very few. We were able to observe a decline in social stability and an increased use of non-prescribed drugs in some patients who changed to methadone mixture. More far-reaching consequences of the change included an increase in chemist break-ins, an increase in the street value of methadone tablets and greater hostility and threatening behaviour towards staff. These changes reflect psychological rather than pharacological or pharmacokinetic effects.     

美沙酮维持治疗社区拓展服药点的定性调查

目的了解美沙酮维持治疗社区拓展服药点的运转情况。方法对调查地区美沙酮维持治疗社区拓展服药点正在服药的在治病人、40名家属、20名门诊医生进行个人深入访谈。结果 40名在治病人平均年龄36.7岁,文化程度以小学和初中为主,多为首次参加美沙酮维持治疗,接受美沙酮维持治疗平均为18.3个月。从居住地到达拓展服药点的距离和费用可以接受,拓展服药点提供了较为方便的服务,便于家属和工作人员了解在治病人的情况。门诊医生主动将服药者的家庭纳入了门诊的干预活动之中。在治病人家属认为拓展服药点的开诊为病人提供了更多方便。结论美沙酮维持治疗社区拓展服药点在交通不方便地区是可行的,有利于提高在治病人的依从性。     

Is on-site urine testing of therapeutic value in a methadone treatment program?

Patients in a methadone maintenance clinic were randomly assigned to two groups: one to have urine tests on-site (by the EMIT system) with immediate feedback of results to patients and staff; the other to have urine specimens sent away to an offsite laboratory for testing by thin-layer chromatography. Although other advantages might justify the adoption of on-site testing in methadone programs, the method appeared to have little or no therapeutic advantage over customary off-site testing. There were negligibly small differences between the groups with respect to illicit drug use.     

Providing HIV counseling and testing services in methadone maintenance programs

Counseling about AIDS and optional confidential testing for antibody to HIV-1 have been available in state-supported methadone maintenance programs in Connecticut since 1 January 1987. In the first 2 years of the program, 2118 people received pre-test counseling. Overall, 1521 people agreed to anti-HIV-1-antibody testing and 1010 received post-test counseling. Other than the pre- and post-test counseling sessions, a total of 1600 HIV counseling sessions were conducted. This is the first statewide program for providing HIV counseling and testing in methadone maintenance programs in the United States. Our experience suggests that the prevention of both drug use and HIV-1 transmission can be integrated in drug treatment centers.     

Buprenorphine versus methadone maintenance therapy: a randomized double-blind trial with 405 opioid-dependent patients

Aims To assess the efficacy of buprenorphine compared with methadone maintenance therapy for opioid dependence in a large sample using a flexible dosing regime and the marketed buprenorphine tablet. Design Patients were randomized to receive buprenorphine or methadone over a 13‐week treatment period in a double‐blind, double‐dummy trial. Setting Three methadone clinics in Australia. Participants Four hundred and five opioid‐dependent patients seeking treatment. Intervention Patients received buprenorphine or methadone as indicated clinically using a flexible dosage regime. During weeks 1–6, patients were dosed daily. From weeks 7–13, buprenorphine patients received double their week 6 dose on alternate days. Measurements Retention in treatment, and illicit opioid use as determined by urinalysis. Self‐reported drug use, psychological functioning, HIV‐risk behaviour, general health and subjective ratings were secondary outcomes. Findings Intention‐to‐treat analyses revealed no significant difference in completion rates at 13 weeks. Methadone was superior to buprenorphine in time to termination over the 13‐week period (Wald χ² = 4.371, df = 1, P = 0.037), but not separately for the single‐day or alternate‐day dosing phases. There were no significant between‐group differences in morphine‐positive urines, or in self‐reported heroin or other illicit drug use. The majority (85%) of the buprenorphine patients transferred to alternate‐day dosing were maintained in alternate‐day dosing. Conclusions Buprenorphine did not differ from methadone in its ability to suppress heroin use, but retained approximately 10% fewer patients. This poorer retention was due possibly to too‐slow induction onto buprenorphine. For the majority of patients, buprenorphine can be administered on alternate days.     

Buprenorphine versus methadone maintenance treatment in an ambulant setting: a health-related quality of life assessment

Background To compare the effects on quality of life (QOL) of oral methadone with sublingual buprenorphine. Methods We performed an open‐label, non‐randomized, two‐site (methadone–buprenorphine) study. During 6 months we assessed the quality of life status of 53 opioid‐dependent patients admitted to a methadone or buprenorphine maintenance programme using the German version (Berlin Quality of Life Profile) of the Lancashire Quality of Life Profile. Physical symptoms were measured using the Opioid Withdrawal Scale. Five hundred and thirty urine screening tests were carried out randomly to detect additional consumption. Results Sixty‐seven opioid‐dependent subjects (38 on methadone and 29 on buprenorphine) were enrolled in the study, and 53 completed it (30 subjects treated with buprenorphine and 23 subjects with racemic methadone). The subjects were comparable on all baseline measures. At the first follow‐up (week 8), the buprenorphine‐maintained group showed significantly less additional consumption of opioids (P = 0.013) compared with the methadone group. Patients retained in the buprenorphine or methadone programme (week 24) showed no significant differences in all quality of life scores. At the end of the study period, the buprenorphine‐maintained group showed significantly less additional consumption of opioids (P = 0.001) and cocaine (P = 0.018) compared with the methadone group. The outcome measures for withdrawal symptoms after 24 weeks of treatment with buprenorphine showed slight advantages in stomach cramps, fatigue or tiredness, feelings of coldness and heart pounding. Conclusions These results suggest that buprenorphine treatment is as effective as methadone regarding effects on quality of life and withdrawal symptoms. Buprenorphine has the potential to reduce the harm caused by drug abuse. Further research is needed to determine if buprenorphine is more effective than methadone in particular subgroups of patients.     

Tuberculosis chemoprophylaxis using a liquid isoniazid-methadone admixture for drug users in methadone maintenance

Background. Tuberculosis is common in drug users, although compliance with therapy may be difficult in this population. Objective. To evaluate an approach to enhancing compliance with tuberculosis chemoprophylaxis in drug users enrolled on methadone maintenance utilizing an isoniazid (INH)-methadone admixture. Design. A prospective cohort study. Setting. A drug treatment program in New Haven, Connecticut, USA. Patients. Opioid-dependent drug users enrolled in methadone maintenance. Intervention. Liquid isoniazid was mixed into subjects' daily dose of methadone. Vitamin B6 was given to subjects for self-administration. Measurements and main results. Number of eligible subjects, reasons for not starting therapy, number starting therapy, proportion completing therapy and median duration of INH therapy were calculated. Thirty-nine subjects were eligible for INH chemoprophylaxis: 34 (87%) received INH mixed directly in their methadone and five (13%) had their INH consumption supervised by a nurse. Among these subjects, 72% (28/39) completed therapy. Among the 11 subjects who discontinued INH, discharge from the methadone maintenance program was the most common reason-73% (8/11). Thus, among the 31 subjects who were not discharged from methadone maintenance, 90% (28/31) successfully completed INH prophylaxis. The median duration of therapy was 182 days. Conclusions. Tuberculosis chemoprophylaxis using a liquid isoniazid-methadone admixture appears to be an effective approach to enhancing compliance with this therapy in methadone-maintained drug users.     

Cost-effectiveness of methadone maintenance treatment for HIV-positive drug users in Vietnam

Methadone maintenance treatment (MMT) is efficacious in reducing drug use that may improve HIV/AIDS care and treatment outcomes. This study evaluated the incremental cost-effectiveness of MMT for HIV-positive drug users from the perspective of health service providers. A sample of 370 HIV-positive drug users (age: mean ± SD: 29.5 ± 5.9 years; 95.7% male) taking MMT in multi-sites was assessed at baseline, three, six and nine months. Costs of MMT services were analyzed and converted to the year 2009. Quality-adjusted life years (QALYs) were modeled from changes in health-related quality of life of patients using the modified World Health Organization Quality of Life - Brief Version (WHOQOL-BREF). Inverse probability-of-treatment weights, constructed using propensity score of non-responses, were applied to adjust for potential confounding. Over nine months, MMT substantially improved QALYs of HIV/AIDS patients (0.076 QALY [0.066-0.084]). The increments in QALY were large and stabilized in those patients taking antiretroviral treatment and abstinent to drug use. For one QALY gained, the MMT program would cost US$3745.3, approximately 3.2 times Vietnam GDP per capita in 2009. The cost-effectiveness of MMT intervention was robust against HIV advanced status or co-morbidity, e.g., TB treatment, but it might not be cost-effective for those patients who continued to use drug. Findings of this study indicate that providing MMT for HIV-positive drug users is a cost-effective intervention in Vietnam. Integrating MMT to HIV/AIDS care and treatment services would be beneficial in injection-driven HIV epidemics.     

Buprenorphine versus methadone maintenance for the treatment of opioid dependence

Aims. To evaluate the effectiveness of buprenorphine compared with methadone maintenance therapy in opiate addicts over a treatment period of 24 weeks. Design. Subjects were randomized to receive either buprenorphine or methadone in an open, comparative study. Setting. Subjects were recruited and treated at the drug addiction outpatient clinic at the University of Vienna. Participants. Sixty subjects (19 females and 41 males) who met DSM-IV criteria for opioid dependence and were seeking treatment. Intervention. Subjects received either sublingual buprenorphine (2-mg or 8-mg tablets; maximum daily dose 8 mg) or oral methadone (racemic D -/+ L-methadone; maximum daily dose 80 mg). A stable dose was maintained following the 6-day induction phase. Measurement. Assessment of treatment retention and illicit substance use (opiates, cocaine and benzodiazepines) was made by urinalysis. Findings. The retention rate was significantly better in the methadone maintained group (p< 0.05) but subjects completing the study in the buprenorphine group had significantly lower rates of illicit opiate consumption (p = 0.04). Conclusion. The results support the superiority of methadone with respect to retention rate. However, they also confirm previous reports of buprenorphine use as an alternative in maintenance therapy for opiate addiction, suggesting that a specific subgroup may be benefiting from buprenorphine. This is the first comparative trial to use sublingual buprenorphine tablets: previously published comparison studies refer to 30% solutions of buprenorphine in alcohol.