Attitudes and beliefs towards methadone maintenance treatment among Australian prison health staff

INTRODUCTION AND AIMS: Justice Health NSW has one of the most extensive prison-based methadone programmes in the world. We examine prison health staff attitudes towards methadone treatment and compare these with community methadone staff. DESIGN AND METHODS: A cross-sectional survey of 202 staff employed by Justice Health New South Wales was undertaken in 2003. Results. The mean scores on the various sub-scales were: abstinence-orientation (AO) 2.9 (95% CI 2.8 - 3.0); disapproval of drug use (DDU) 3.3 (95% CI 3.2 - 3.4); knowledge (Know) 2.7 (95% CI 2.4 - 2.9); and toxicity 4.6 (95% CI 4.2 - 5.0). Both the AO and DDU score were correlated negatively with the Know score (r = -0.37 and r = -0.13, respectively). Prison health staff had higher AO (2.9 vs. 2.6, p < 0.001) and DDU (3.3 vs. 2.6, p < 0.001) scores, and lower Know (2.7 vs. 7.0, p < 0.001) scores than methadone staff working in the Australian community. They were more knowledgeable than US community methadone staff about the toxicity of methadone (4.6 vs. 0.0, p < 0.001). DISCUSSION AND CONCLUSIONS: This is the first survey to examine prison health staff attitudes to methadone treatment. Correctional health staff tend to be more abstinence-orientated, more likely to disapprove of drug use, and less knowledgeable about the risks and benefits of methadone than Australian community methadone staff. The findings have important implications for training health staff working in the prison environment with regard to client retention on methadone treatment.     

Hydromorphone polymer implant A potential alternative to methadone maintenance

Although methadone maintenance remains the best available treatment for opioid addiction, the need for daily oral dosing limits the effectiveness of methadone as opioid substitution therapy. Limitations of methadone maintenance include the administrative costs and burdensome time commitment associated with daily clinic visits, the danger of illicit diversion and accidental overdose associated with oral dosing, the low rate of treatment retention, and inadequate treatment capacity. A new opioid delivery device awaiting approval for clinical use may overcome some of these limitations. The device, a buttonsize polymer containing hydromorphone, releases near constant levels of opioid when implanted subcutaneously. Because of its location and duration of effect, the polymer may eliminate the need for daily clinic visits, reduce the costs and time constraints of treatment, reduce the risk of illicit diversion, provide an incentive for compliance with initial methadone maintenance treatment, and increase treatment capacity and retention.     

The effectiveness of methadone maintenance treatment: an overview

This paper reviews the evidence for the effectiveness of methadone maintenance as used in the treatment of opioid dependence. Findings from randomized controlled trials and observational studies suggest that methadone maintenance reduces heroin use, crime, injection-related risk behaviours and premature mortality among people dependent on opioids. The research further suggests that two aspects of treatment are important in ensuring this effectiveness. Methadone treatment is more effective when higher doses (>50 mg) are employed and, overall, the evidence suggests that a treatment goal of successful maintenance on methadone rather than total abstinence is appropriate. The importance of ancillary services in treatment outcome is less clear and is the subject of current research and debate.     

Barriers to, and incentives for, the transfer of opioid-dependent people on methadone maintenance treatment from secondary care to primary health care

Aim. To explore barriers to, and incentives for, clients on methadone-maintenance treatment (MMT) in Auckland, New Zealand to transfer from secondary care to general practitioner (GP) care. Design. Surveys (with free text response sections) of MMT secondary care staff, stabilised clinic clients, authorised GPs and GP patients. Results. High response rates from secondary care staff (77%) and GPs (74%). Barriers to stable clients' transfer included financial cost and attitudes of secondary care staff and clients. Incentives for patient transfer included confidentiality, a holistic approach to their care, continuity of care, increased patient control, convenience and avoidance of contact with other opioid-dependent people. Distrust in the quality of care provided by authorised GPs was a major barrier for some secondary care staff and their clients, despite prerequisite training for authorisation. In contrast, patients rated primary better than secondary care with none stating a likelihood to return to the secondary service within 6 months. Conclusions. Progression from secondary to primary care should be incorporated in MMT planning from the outset, with secondary services staff reassured about the quality of primary care. An integrated transition period and exploration of funding options to assist transfer from largely publicly funded secondary to largely privately funded primary care are also recommended. [Sheridan J, Goodyear-Smith F, Butler R, Wheeler A, Gohns A. Barriers to, and incentives for, the transfer of opioid-dependent people on methadone maintenance treatment from secondary care to primary health care. Drug Alcohol Rev 2008;27:178-184]     

The use of plasma levels to optimize methadone maintenance treatment

The question of the optimal methadone dose during maintenance therapy is controversial. For both philosophical and practical reasons, therapeutic drug monitoring has not been generally used. Some therapists prescribe low doses of methadone more for psychological than pharmacological reasons. This study examines, in 104 methadone patients, the relation between self-rating, observer-rating, urine tests, HIV-1 serostatus, daily methadone doses and plasma levels of methadone. No differences were found between HIV-1 infected and seronegative patients in these respects. The optimal methadone plasma level as judged by self- and observer-rating was more than 150 ng/ml. For oral methadone, the best results are obtained in patients receiving more than 90 mg daily. We found a significant relationship between methadone dose and plasma levels, also in patients who also used illicit drugs. We conclude that therapeutic drug monitoring should become routine in methadone treatment to achieve optimum results, especially in patients who complain of withdrawal symptoms and continue high-risk behaviour.     

Characteristics of methadone maintenance treatment patients prescribed opioid analgesics

ABSTRACT

Background: Opioid analgesic use and disorders have dramatically increased among the general American population and those receiving methadone maintenance treatment (MMT). Most research among MMT patients focuses on opioid analgesics misuse or disorders; few studies focus on MMT patients prescribed opioid analgesics. We describe demographic, clinical, and substance use characteristics of MMT patients prescribed opioid analgesics and compare them with MMT patients not prescribed opioid analgesics. Methods: We conducted a cross-sectional secondary data analysis using screening interviews from a parent study. From 2012 to 2015, we recruited adults from 3 MMT Bronx clinics. Questionnaire data included patterns of opioid analgesic use, substance use, comorbid illnesses, and demographic characteristics. Our main dependent variable was patients' report of currently taking prescribed opioid analgesics. To compare characteristics between MMT patients prescribed and not prescribed opioid analgesics, we conducted chi-square tests, t tests, and Mann-Whitney U tests. Results: Of 611 MMT patients, most reported chronic pain (62.0%), hepatitis C virus (HCV) infection (52.1%), and current use of illicit substances (64.2%). Of the 29.8% who reported currently taking prescribed opioid analgesics, most misused their opioid analgesics (57.5%). Patients prescribed (versus not prescribed) opioid analgesics were more likely to report human immunodeficiency virus (HIV) infection (adjusted odds ratio [aOR] = 1.6, 95% confidence interval [CI]: 1.1–2.3) and chronic pain (aOR = 7.6, 95% CI: 4.6–12.6). Conclusion: Among MMT patients primarily in 3 Bronx clinics, nearly one third reported taking prescribed opioid analgesics. Compared with patients not prescribed opioid analgesics, those prescribed opioid analgesics were more likely to report chronic pain and HIV infection. However, between these patients, there was no difference in illicit substance use. These findings highlight the complexity of addressing chronic pain in MMT patients.     

Antisocial personality disorder, HIV risk behavior and retention in methadone maintenance therapy

In a sample of 55 consecutive methadone maintenance admissions to our clinic, 42% were diagnosed with antisocial personality disorder (ASPD) using the National Institute of Mental Health Diagnostic Interview Schedule NIMH DIS. Individuals with ASPD exhibited greater risk for HIV infection as defined by more sexual contacts, needle use and equipment sharing. Data at 1 year follow-up were obtained on this group of patients. The objective was to compare the ASPD and non-ASPD groups with regards to demographics, drug abuse history, outcome and retention in treatment. There were no significant differences between the groups on any demographic or treatment outcome variables. Survival analysis indicated that there were no group differences in treatment retention. In conclusion, although there were no differences in treatment outcome between ASPD and non-ASPD groups it is possible that ASPD patients who drop out of treatment will be at higher risk for contracting and spreading HIV within the IV drug using population. These data also suggest that in this population the diagnosis of ASPD using primarily behavioral traits as measured in the NIMH-DIS-III, has little utility in predicting treatment outcome.     

The relationship between take-away methadone policies and methadone diversion

The development of policies in relation to unsupervised doses of methadone (take-away doses) should be based upon the best available evidence. There are both risks and benefits associated with take-away doses. This study aimed to explore the relationship between take-away policies and one measure of harm: methadone injection rates. Six different states in Australia were compared in relation to their methadone take-away policy and rates of methadone injection within their population of injecting drug users. At a simplistic level, those states with restrictive and less flexible take-away policies tended to have the lowest reported prevalence of methadone injection. However, this does not fully explain variability in methadone injecting. There were also considerable differences between those states with similar take-away policies. Variables which appear to impact upon methadone injecting rates include: take-away policies, drug preference, drug availability, treatment availability and degree of treatment penetration. Consideration of the benefits, rather than merely the harms, of various take-away policy options may provide an evidence-based platform for take-away policy development. [Ritter A, Di Natale R. The relationship between take-away methadone policies and methadone diversion. Drug Alcohol Rev 2005;24:347 - 352]     

Management of acute pain in methadone maintenance therapy in-patients

Methadone maintained treatment (MMT) patients may be given less opioid analgesia for acute pain than the general patient, due to requests for analgesia being misinterpreted as craving for drugs. Pain studies have showed that MMT patients have hyperalgesic responses and that cross-tolerance to opioids may be present, suggesting that they may need more analgesia than the non-MMT patient. This study compares the pain management of MMT patients and controls during an acute hospital stay. It is a retrospective study of MMT in-patients and controls matched for medical condition, age and gender, comparing the analgesia given and pain stated in hospital notes. Patients with a chronic pain condition were excluded. MMT patients and controls did not differ in relation to median morphine dose received or average number of pain reports per day, and only a small proportion of both groups engaged in drug-seeking behaviour. Behavioural problems were significantly more common among MMT patients (39% versus 5%, p < 0.001). The fact that the opioid doses were not significantly different between subjects and controls seems to contradict the experimental evidence that patients on methadone tend to be hyperalgesic. Alternatively, MMT patients may be hyperalgesic, and statistically equal levels of opioid analgesia given to both groups may indicate an effective under-treatment of pain in the hyperalgesic MMT group. Inadequate analgesia may contribute to both behavioural problems and premature discharge. Resolving these uncertainties will require prospective studies.     

A comparison of private and public methadone maintenance patients

A study was undertaken to examine claims that unsuitable individuals were being admitted into private methadone maintenance programs in New South Wales in late 1985, early 1986. A comparison was made of interview data collected by an independent team of researchers from 457 private and 91 public patients. Exhaustive attempts were made to identify individuals who failed current official admission criteria. While there were statistically and clinically significant differences between private and public methadone patients, there was no evidence that unsuitable individuals were being admitted into maintenance. The data and a review of the literature suggest that the rapid expansion of private sector methadone programs allowed suitable individuals more immediate and more equitable access to maintenance treatment.     

Pharmacokinetics of methadone during maintenance treatment: Adaptive changes during the induction phase

Summary Deuterated methadone (M-d₃0) and GC-MS were used to study the pharmacokinetics of methadone (M) during the induction stage of methadone maintenance treatment (MMT). A pulse dose of M-d₃ was given on Days 1 and 25 of two dosage regimens, one with a continuous 30 mg dose (n=6), and the other with 30 mg for 10 days, followed by 60 mg as the maintenance dose (n=6). Plasma and urinary levels of M and M-d₃ were measured throughout and plasma half-lives, oral bioavailabilities and volumes of distribution were calculated from the data of Days 1–2 and 24–26. The oral bioavailability of a methadone solution was found to be between 81 and 95%; elimination half-life in the -phase varied between 19 and 58 h; the volume of distribution was 4.1±0.65 l/kg; and total body clearance of M was 54–195 ml/min and its renal clearance 3.4–34 ml/min. A consistent finding was a lower urinary pH and increased renal clearance during the first days of MMT as compared with after one month. In 4/12 of the patients dispositional tolerance was developed to methadone during the first month of treatment. The shorter elimination half-lives in those patients probably caused unacceptably high fluctuation in the body content of M during the 24 h dosage interval, and may have interfered therefore, with its therapeutic effectiveness     

盐酸美沙酮口服液在中国美沙酮维持治疗患者体内药动学特征

目的建立盐酸美沙酮（MTD）人体内血药浓度的测定方法 ,并对口服MTD口服液后的美沙酮维持治疗患者（MMTPs）体内的药动学过程进行研究。方法采用Agilent ZORBAX SB-C₁₈（250mm×4.6 mm,5μm）色谱柱,以乙腈-磷酸盐缓冲液（pH 2.5）=32:68（V/V）为流动相,流速1.50 mL·min^-1,检测波长206 nm,盐酸苯海索为内标,对血浆中的MTD浓度进行检测。8名MMTPs口服MTD口服液80 mg,分别于服药前和服药后1、2、3、4、6、8、12、24 h采集血样,测定血浆中MTD的浓度,并采用3P97药动学软件对试验数据进行处理,计算有关药动学参数。结果在0.10～10.00 mg·L^-1内,MTD与内标峰面积的比值与浓度之间呈良好的线性关系（r=0.999 6）。日内及日间精密度（RSD）和回收率均符合要求。MTD药-时曲线经拟合符合二室模型,主要参数:ρ_max（623.13 4-231.06）μg·L^-1;t_max为（2.764±1.13）h;AUC_0→24h为（9 569.56±3 294.88）μg·h·L^-1;AUC_0→∞为（21 522.61±10 825.36）μg·h·L^*（-1）;t_1/2为（23.95±13.61）h。结论本试验建立的检测人血浆中MTD含量的HPLC法,适用性强,重复性好,操作简单,快速准确,成本低廉,可用于MTD药动学的研究;MTD药动学特征和参数在个体间存在较大差异,临床治疗中应实施个体化治疗方案。     

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.     

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.     

Controlled use of heroin in patients on methadone maintenance treatment

The efficacy of methadone maintenance treatment was evaluated on 93 patients after 10 years of therapy. On the basis of therapeutic compliance, patients were divided into three groups: (a) 40 Total-Agreement subjects on weekly take-home methadone; (b) 28 Partial-Agreement subjects, who regularly attended the clinic daily but presented episodic positive urinalysis; (c) 25 No- Agreement patients, who were absent from the clinic more than twice a monthand had a high rate of urinalysis positive for morphine. Statistical analysis, based on social adjustment improvement and criminality rate decrease, divided the 93 patients into 2 distinct categories. The first category, characterized by high social adjustment and low criminality score, included the Total- and Partial- agreement groups. The second, characterized by significantly lower social adjustment and higher criminality score, included all No-Agreement patients. This suggests that methadone treatment was able to dissociate heroin use from low social functioning. It was concluded that, in a condition of adequate compliance the episodic use of heroin is of no harm to patients on methadone maintenance therapy, that is, methadone maintenance treatment permits a controlled use of heroin.     

Problem drinking in relation to treatment outcome among opiate addicts in methadone maintenance treatment

This study analyzed indicators of alcohol-related problems in opiate addicts before, during, and after leaving methadone maintenance treatment (MMT), in relation to illicit drug use and retention in treatment. The study was based on 204 patients, admitted to MMT for the first time between 1 January 1995 and 31 July 2000, and followed until 31 December 2000. Three measures were used to indicate alcohol use and alcohol-related problems; records of hospital care with an alcohol-related diagnosis, any treatment with alcohol-sensitizing drugs (disulfiram or calcium carbimide) during MMT, and results of the 5-hydroxytryptophol to 5-hydroxyindoleacetic acid ratio (5HTOL/5HIAA) in urine, a sensitive biomarker for recent drinking. Use of illicit drugs was determined by routine urine drug testing. About one third of the patients (n = 69) had a lifetime prevalence of hospital treatment for an alcohol-related diagnosis, 45 of whom had been hospitalized (mean 4.2 stays) prior to the start of MMT. There was a significant association (p<0.05) between the number of alcohol-related diagnoses prior to treatment and a positive 5HTOL/5HIAA test during MMT. The alcohol indicators first became positive on average 1.6 years after admission to treatment, compared with after about 4 months for illicit drugs. Use of cannabis or benzodiazepines was significantly associated with alcohol use. Female methadone patients with indications of alcohol-related problems relapsed more often into illicit drug use than did women without such indications (3.9 vs. 2.5 relapse periods/year; p<0.005), whereas no significant association was found for men. The results of the present study indicate that drinking problems among patients undergoing MMT is associated with an increased risk of relapse into illicit drug use and with discharge from treatment. Concurrent treatment of alcohol-related problems, including systematic monitoring of alcohol use, therefore should be recommended to reduce the risk for relapse into illicit drug use and improve overall treatment outcome in MMT.     

Predictors of early dropout in methadone maintenance treatment program in Yunnan province,China

Introduction and Aim. The aim of this study is to identify the predictors of early dropout of patients in methadone maintenance treatment (MMT) clinics in Yunnan province, China. Methods. A cohort study was conducted on 218 patients starting treatment in five MMT clinics between 1 March 2008 and 31 August, with follow up to 28 February 2009. Patients were interviewed using a semistructured questionnaire covering socio‐demographic characteristics and drug abuse history. Attendance at clinic and daily dose were abstracted from the clinic records. The mean average daily dose per patient in each period was compared across three periods, 0–1, >1–3 and >3–6 months, using analysis of variance and random‐intercept mixed linear regression modelling. Cox regression model with time‐varying average daily dose within each period was performed to identify factors predicting dropout in the MMT program. Results. Cumulative probability of retention at 1, 3 and 6 months was 94%, 75% and 57%, respectively. There was no relationship between dose and probability of dropout in periods 1 and 2. However, after 3 months higher average daily dose (>60 mg) was associated with lower probability of dropout. Dropout was more likely among the Han ethnic group [hazard ratio (HR) = 1.86, 95% confidence interval (CI): 1.65–3.26], in those who had to spend over 30 min to visit the clinic (HR = 1.63, 95% CI: 1.07–2.49) and in those living with other drug users (HR = 2.71, 95% CI: 1.55–4.74). Discussion and Conclusion. Patients' early dropout was related to ethnicity, clinic accessibility, living with drug users and methadone dose. A higher methadone dose as appropriate for maintenance treatment is recommended.[Che Y, Assanangkornchai S, Mcneil E, Chongsuvivatwong V, Li J, Geater A, You J. Predictors of early dropout in methadone maintenance treatment program in Yunnan province, China. Drug Alcohol Rev 2010]     

Risk factors for weight gain during methadone maintenance treatment

ABSTRACT

Background: Weight gain was reported during methadone maintenance treatment (MMT). However, its relation to eating habits and specific risk factors, including methadone dose or serum level, was limited. The aims of this study were to characterize risk factors for weight gain and to study current eating habits, food preferences, and nutrition knowledge. Methods: Patients with available measures of weight and height (body mass index [BMI]) at admission to MMT and at follow-up, when methadone serum levels were determined (after 1 year or when stabilized) (N = 114), were studied (using the Addiction Severity Index [ASI], drugs in urine, methadone doses, and serum levels). In addition, 109 current patients with available earlier (5.8 ± 2.6 years earlier) BMI completed eating behavior rating and nutrition knowledge questionnaires, and their current and earlier BMI were compared. Results: The BMI of 114 newly admitted patients increased from 22.5 ± 3.8 to 24.4 ± 4.3 (P < .0005). Once stabilized on methadone, BMI increased further (24.3 ± 4.5 to 25.6 ± 5.0; P < .0005; n = 74), with no change in methadone doses (125.6 ± 32.5 to 128.0 ± 34.1; F = 1.4, P = .2) or serum levels (495.6 ± 263.7 to 539.8 ± 306.2; F = 1.3, P = .2). Repeated-measures analyses revealed that BMI elevation was higher among 45 hepatitis C virus seronegative and 46 non–benzodiazepine-abusing on-admission patients. Those who scored lower on knowledge about healthy diet and showed a higher sweet-foods preference had a higher BMI. Conclusion: BMI increased over time, but independent of methadone dosage and blood levels. As expected, worse diet habits and a desire for sweet foods are related to higher BMI. Paradoxically, healthier status (i.e., hepatitis C seronegative, no benzodiazepine abuse) at admission is predictive of greater weight gain during MMT. Education about nutrition habits is recommended.