Pathways to ‘recovery’ and social reintegration: The experiences of long-term clients of methadone maintenance treatment in an Irish drug treatment setting

IntroductionThis paper examines the experiences of long-term clients of methadone maintenance treatment (MMT) in one area of Dublin in the context of a recent emphasis on rehabilitation and recovery in Irish drug policy.MethodsIn-depth qualitative interviews were conducted with 25 long-term clients of methadone maintenance treatment (MMT). All participants had first enrolled in methadone treatment at least ten years prior to participating in the research and a majority (n = 16) had first accessed MMT more than 20 years previously.ResultsWhile acknowledging several beneficial aspects of methadone treatment, research participants saw themselves as passive recipients of a clinical regime that offered no opportunity to exercise agency in relation to their ongoing treatment. Rather than perceiving themselves as progressing along a pathway to recovery, the treatment experience was depicted in terms of stasis or confinement. Neither did participants report any progress in attaining the kind of social reintegration that is commonly presented as a key aspect of addiction recovery and which, in the Irish context, is a central plank of drug policy discourse.DiscussionThe findings highlight a disconnect between policies that ostensibly aim to promote social reintegration and recovery and the experiences of individuals who are long-term clients of MMT. Irish policy aspirations of facilitating opiate-dependent clients to progress along a pathway to recovery are difficult, if not impossible, to realise given the marginal status of addiction services within the health system and the difficulties involved in securing ongoing cooperation from other public service sectors.     

Pilot randomised controlled trial of community pharmacy administration of buprenorphine versus methadone

Objectives The established regime for opiate substitute prescribing for drug misusers is daily methadone administered under supervision in community pharmacies. Buprenorphine has recently been introduced as an alternative. However there is a lack of evidence of the effectiveness of buprenorphine maintenance therapy (BMT) in the UK treatment setting. This study aimed to assess methods for a randomised controlled trial (RCT) and the feasibility of pharmacy‐based supervised self‐administration (SSA) of buprenorphine compared to methadone. Setting Specialist substance misuse service, general practices and community pharmacies in Aberdeen, Scotland. Method The design was a pilot RCT. Opiate‐dependent drug misusers, newly referred for maintenance treatment were randomised to receive BMT or methadone maintenance therapy (MMT). Clients and pharmacists were interviewed at baseline and at the end of a 12‐week intervention period. Clients completed the quality of life measure EQ‐5D. Pharmacy activities were timed. Key findings Twenty‐one opiate‐dependent clients were recruited (BMT = 11, MMT = 10). Recruitment levels improved as the trial progressed. Clients' treatment preferences were evident. Withdrawals occurred early with BMT. Clients found SSA of buprenorphine acceptable, but found daily administration more manageable than three times weekly. Pharmacists found the dispensing of buprenorphine to be an acceptable role, but felt less certain of ensuring against diversion with buprenorphine than they were with methadone. Pharmacy activities associated with buprenorphine took longer than those associated with methadone (mean = 7 min 25 s versus mean = 3 min 27 s, respectively). Conclusion Recruitment to a trial comparing MMT to BMT for opiate‐dependent clients within a UK treatment setting is feasible. Clients and pharmacists found buprenorphine acceptable.     

Excessive alcohol consumption and drinking expectations among clients in methadone maintenance.

Excessive alcohol consumption and related problems are common among clients in methadone maintenance treatment (MMT), yet relatively little is known about the psychological and social determinants of alcohol-related attitudes and behaviors during treatment. This study reports on the prevalence of alcohol dependence, patterns of alcohol consumption and preliminary findings about clients' beliefs that they will change their drinking behavior in the future. Data were gathered from personal interviews with 66 clients attending a MMT program in South London (some 80.5% of the eligible caseload). Forty-one percent of the overall sample met DSM-IV criteria for alcohol dependence in the past 12 months. Among clients who reported drinking in the past month (n = 50), 54% were classified as dependent, and these clients reported consuming an average of 23.5 UK standard units of absolute alcohol (188g/6.58 ounces) on a typical drinking day in the past month. Exploratory analyses suggested that expectations to change drinking behavior were predicted by subjective norms (social pressures), perceived functions of alcohol use, past drinking levels and current dose of methadone. Clinicians engaged in alcohol problems assessment and counseling during MMT could usefully examine these influences to strengthen treatment provision.     

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.     

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.     

德国的阿片类依赖替代治疗(英文)

经过漫长而激烈的争论,德国于1987年首次引进了美沙酮维持治疗。最初,由于入治标准严格,接受治疗的人数很少,但自1990年后接受治疗的人数迅速上升,到2005年底已有61 000人。在德国每位全科医生只要完成了成瘾医学的培训都允许为阿片类成瘾病人开具替代治疗药物。目前德国有2700个全科医生在为阿片类药物成瘾病人开具处方。每位参加维持治疗的病人需接受社会心理治疗。研究结果和实践经验表明,病人从美沙酮维持治疗中获得了实质性的好处,他们的身心健康得到了改善。美沙酮维持治疗的留治率高(65% -85%),对HIV和肝炎的评估和坚持治疗十分重要;在促进病人回归社会方面也是极其重要的因素;在降低药物相关伤害方面如:减少共患疾病、死亡和预防感染性疾病具有重要的作用。有10%的人在长期的治疗过程中戒掉了毒品。虽然丁丙诺啡正在显示其重要性,但是美沙酮仍是主要的替代药物。在农村,参加美沙酮维持治疗仍是难题。虽然一致认为工作是治疗的正性因素,但对病人来说就业机会很少。德国监狱的替代治疗采用不同的准入和治疗模式。准入治疗不协调,参加治疗的人数很少。无论如何,在德国替代治疗在为药物使用者提供的卫生医疗系统中发挥了重要作用。     

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.     

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.     

Pharmacists' provision of methadone to intoxicated clients in community pharmacies, Victoria, Australia

This paper concerns pharmacists dispensing methadone to intoxicated clients, drawing on both questionnaire and focus-group data from a 1996 evaluation of the community-based methadone programme in Victoria, Australia. The questionnaire was sent to registered community methadone pharmacies in Victoria (N = 188). The response rate was 84% and 148 questionnaires were analysed. Pharmacists were asked how they would respond to clients who presented intoxicated for their methadone dose. Results indicated that 32% of pharmacists said that they would provide a client who presented intoxicated with his or her usual methadone dose. The analyses suggested that pharmacists who were male and those pharmacists whose number of methadone clients exceeded 10 were more likely to dispense methadone to an intoxicated client than female pharmacists and those pharmacists with less than 10 clients. Pharmacists who would withhold the methadone dose were more likely to inform the client's prescribing doctor at the time (74%) than pharmacists who would provide the usual or modified dose (41%). In order to understand the social processes underlying provision of methadone to intoxicated clients this theme was later taken up in a focus group with pharmacists. Reasons given by pharmacists to explain the dispensing of methadone to intoxicated clients were: insufficient communication between prescribers and pharmacists; a down playing of the pharmacological dangers; personal beliefs and values; a fear of retribution from the client if thedose was refused; difficulty in recognizing intoxication; lack of education and training. The results raise concerns about the basis on which pharmacists make decisions about providing methadone to intoxicated clients. [Koutroulis GY, Kutin JJ, Ugoni AM, Odgers P, Muhleisen P, Ezard N, Lintzeris N, Stowe A, Lanagan A. Pharmacists' provision of methadone to intoxicated clients in community pharmacies, Victoria, Australia. Drug Alcohol Rev 2000;19:299-308]     

What factors affect medication‐storage practice among patients on methadone maintenance treatment?

Objectives Medication storage in patients' homes is an important safety issue. Safe storage of methadone oral solution is of particular concern. Previous studies have suggested that only about half of patients store methadone appropriately. The aims of this study were to describe medication‐storage practice in a sample of patients receiving methadone maintenance treatment (MMT), and to identify factors associated with safe storage. Methods The setting was a primary health care centre in Edinburgh, Scotland. One hundred and four consecutive patients on MMT completed a self‐administered questionnaire covering medication‐storage practice, together with clinical and demographic variables. Storage of medication was classified as ‘acceptable’ if medication was out of sight and out of reach of children, and ‘optimal’ if it was also kept in a secure container. Key findings Percentages (95% confidence intervals) for acceptable and optimal storage were as follows: methadone 80% (71–86%) and 33% (24‐12%); other prescribed medication 69% (59–78%) and 27% (19–37%); purchased medication 64% (50–76%) and 28% (17–42%). Safe storage of methadone was more common in patients taking higher doses of methadone (P = 0.004 for acceptable storage, and P = 0.012 for optimal storage), and in those with children in the house (P = 0.007 and 0.061). Safe storage of prescribed and purchased medication was strongly associated with safe storage of methadone (P < 0.01 in both cases). Conclusions Medication‐storage practice was better than in previous surveys of patients on MMT. This may reflect the high profile given to safety issues for children of drug‐using parents in Scotland, as well as local initiatives. Some aspects of prescribing and dispensing practice could be improved further.     

What factors affect medication‐storage practice among patients on methadone maintenance treatment?

Objectives Medication storage in patients' homes is an important safety issue. Safe storage of methadone oral solution is of particular concern. Previous studies have suggested that only about half of patients store methadone appropriately. The aims of this study were to describe medication‐storage practice in a sample of patients receiving methadone maintenance treatment (MMT), and to identify factors associated with safe storage. Methods The setting was a primary health care centre in Edinburgh, Scotland. One hundred and four consecutive patients on MMT completed a self‐administered questionnaire covering medication‐storage practice, together with clinical and demographic variables. Storage of medication was classified as ‘acceptable’ if medication was out of sight and out of reach of children, and ‘optimal’ if it was also kept in a secure container. Key findings Percentages (95% confidence intervals) for acceptable and optimal storage were as follows: methadone 80% (71–86%) and 33% (24‐12%); other prescribed medication 69% (59–78%) and 27% (19–37%); purchased medication 64% (50–76%) and 28% (17–42%). Safe storage of methadone was more common in patients taking higher doses of methadone (P = 0.004 for acceptable storage, and P = 0.012 for optimal storage), and in those with children in the house (P = 0.007 and 0.061). Safe storage of prescribed and purchased medication was strongly associated with safe storage of methadone (P < 0.01 in both cases). Conclusions Medication‐storage practice was better than in previous surveys of patients on MMT. This may reflect the high profile given to safety issues for children of drug‐using parents in Scotland, as well as local initiatives. Some aspects of prescribing and dispensing practice could be improved further.     

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.     

An evaluation of community methadone services in Victoria, Australia: results of a client survey

One hundred and ninety-five metropolitan clients enrolled in the community-based methadone programme in Victoria, Australia were surveyed in order to evaluate client perspectives of methadone treatment delivered from primary health care settings. Results indicated that the average daily methadone dose was 41 mg, ranging from 7 mg to 140 mg. The majority of clients were satisfied with the programme and the services delivered by dispensing pharmacies and prescribing doctors. Most clients were found to have reduced their heroin use and criminal activity since commencing methadone. A number of concerns about the programme were identified, however, including the high proportion of weekly income spent on methadone-related activities and a high use of tranquillizers by clients on higher methadone doses. In general the community-based methadone programme was found to be an acceptable methadone of service delivery to metropolitan clients in Victoria, Australia.     

美沙酮门诊受治者甲基苯丙胺连续性尿检调查

目的:通过连续性尿检调查,了解美沙酮门诊受治者甲基苯丙胺滥用情况及影响因素。方法:对云南省7个美沙酮门诊在治海洛因成瘾人员149例进行甲基苯丙胺连续性尿检及问卷调查,将结果进行2χ检验。结果:18次尿检中甲基苯丙胺阳性次数为10次及以上的占22.2%,1至9次的占20.1%。阳性次数较高的危险因素有:瑞丽门诊、男性、傣族、已婚或同居、初中及以下文化程度,农民,未了解或接受过针具交换、机会性感染治疗、抗病毒治疗及母婴阻断治疗服务。结论:美沙酮门诊受治者甲基苯丙胺滥用现象比较普遍,滥用频率较高,应利用美沙酮门诊的平台加强多药滥用及艾滋病综合防治干预。     

Symptom complaints of patients prescribed either oral methadone or injectable heroin

Many methadone patients and untreated heroin users have an ambivalent attitude toward methadone maintenance. This may be a result of the widespread belief that methadone produces various side effects not found with heroin. This study compared the symptom complaints of patients on oral methadone maintenance (MMT) with those of patients prescribed injectable heroin (IHT). A convenience sample of 117 (63 MMT, 54 IHT) patients was recruited from two maintenance clinics. With the use of a self-completion questionnaire, patients were interviewed about a range of symptoms they had experienced and which, in their view, were due to maintenance substance immediately after the last 10 opioid administrations, during the previous week and previous year. The complaints of the two groups overlapped considerably with only few significant differences; these appeared related to the route of administration. IHT patients reported a larger number of complications experienced immediately after administration than MMT patients (p = .007). From the patients' view, methadone does not produce many more or side effects very different from heroin and thus seems at least as tolerable as heroin for maintenance treatment.     

Addiction treatment-related employment barriers: The impact of methadone maintenance

Employment is commonly upheld as an important outcome of addiction treatment. To explore this attribution, we assessed whether treatment enrollment predicts employment initiation among participants enrolled in a community-recruited Canadian cohort of people who inject drugs (IDU; N = 1,579). Survival analysis initially found no association between addiction treatment enrollment and employment initiation. However, when methadone maintenance therapy (MMT) was separated from other treatment modalities, non-MMT treatment positively predicted employment transitions, whereas MMT was negatively associated with employment initiation. Subanalyses examining transitions into temporary, informal, and under-the-table income generation echo these results. Findings suggest that individual factors impacting employment transitions may systematically apply to MMT clients and that, in this setting, the impact of treatment on employment outcomes is contingent on treatment type and design. Treatment-specific differences underscore the need to expand low-threshold MMT, explore MMT alternatives, and evaluate the impact of treatment design on the social and economic activity of IDU.     

美沙酮维持治疗180天的效果评价

目的:对贵州省8家美沙酮维持治疗(MMT)门诊的受治者180 d的治疗效果进行评价。方法:采用队列研究设计。2006年6月-2007年3月,在贵州省8家MMT门诊,选择自愿参加调查、新接受社区MMT的海洛因成瘾者1003名,用第5版成瘾严重性指数量表中文版(ASI-C),通过面对面访谈的方式,测量受治者进入MMT时的成瘾严重性指数作为基线资料,对治疗满180 d的受治者进行随访调查,评价治疗效果。结果:受治者经过180 d的MMT,ASI-C的7项维度评分,除酒精成瘾维度外,其他6项维度的评分明显低于基线评分(P<0.01),MMT受治者的海洛因成瘾、教育就业、家庭社会、违法犯罪和精神心理状态明显改善。结论:自愿接受美沙酮维持治疗可减少海洛因成瘾者毒品使用、改善身心健康、促进就业和减少违法犯罪行为。