Corrected-QT intervals as related to methadone dose and serum level in methadone maintenance treatment (MMT) patients: a cross-sectional study

AIMS: To determine and evaluate QTc intervals in electrocardiograms (ECGs) of former heroin addicts, currently in methadone maintenance treatment (MMT), as previous reports suggest that methadone may prolong QTc intervals, thus possibly increasing the risk for Torsade de pointes (TdP). DESIGN: Cross-sectional study. SETTING: Between January 2003 and September 2004, patients on a steady dose of methadone for at least 2 weeks were studied. PARTICIPANTS: This study is a subset of 153 patients, of whom 151 patients participated in a study of high methadone doses and serum levels. A total of 138 patients in MMT for a minimum of 100 days up to 10.7 years, receiving 40-290 mg/day methadone dose, participated. MEASUREMENTS: Patients had an ECG at the time when blood was drawn for determination of serum methadone levels at around 24 hours after the last oral methadone dose. Corrected-QT intervals (QTc) were calculated using the Bazett formula. FINDINGS: Of 138 patients studied, 98 (71%) were male. Mean QTc interval was 418.3 +/- 32.8 milliseconds (ms). Mean methadone dose was 170.9 +/- 50.3 mg/day and mean serum methadone level was 708.2 +/- 363.1 ng/ml. Methadone dose and serum levels did not correlate with QTc. Three patients had QTc intervals above 500 ms ('prolonged'). After 2 +/- 0.4 years of follow-up, two patients died; they were two of three patients with very prolonged QTc. Causes of death were not attributed to cardiac origin. An additional 19 patients had QTc intervals of between 450 and 499 ms ('possibly prolonged'). None of these QTc > or = 450 ms patients had any cardiac problems. Methadone doses of all 22 patients were > 120 mg/day. CONCLUSIONS: Methadone maintenance is generally safe; however, the possible toxicity of high dose (> 120 mg/day) should be monitored for QTc.     

Misconceptions predict dropout and poor adherence prospectively among newly admitted first-time methadone maintenance treatment clients in Guangzhou, China

Aims To investigate the incidence of dropout and the prevalence of poor adherence among newly admitted first‐time clients of methadone maintenance treatment (MMT) clinics, and the associations between MMT‐related misconceptions and these two treatment outcomes. Design A cohort study (maximum follow‐up period = 17.6 months) was conducted. Setting Three of the nine MMT clinics in Guangzhou, China participated in the study. Participants The sample included 158 newly admitted first‐time MMT clients. Measurements Information collected included background characteristics, history of drug use, MMT‐related misconceptions, dropout during the entire study period and poor adherence within the first 6 months since admission to MMT. Findings Of all newly admitted MMT clients, 98.2% possessed at least one and 50.6% possessed all four types of MMT‐related misconception; 51.3% had dropped out before the completion of the study [95% confidence interval (CI): 43.5–59.1%] and 62% exhibited poor adherence within the first 6 months since admission (95% CI: 54.2–69.6%). Adjusting for significant background variables, the number of misconceived responses predicted significantly both dropout [hazard ratio (HR) = 3.80 for two to three misconceived items, HR = 7.13 for four misconceived items, with zero to one misconceived item being the reference] and poor adherence within the first 6 months [relative risk (RR) = 4.13 for two to three misconceived items; RR = 4.40 for four misconceived items, with zero to one misconceived item being the reference. Conclusions Among opiate addicts in China prescribed methadone maintenance therapy for the first time, misconceptions about this medication are prevalent and are associated with poor adherence to the medication regimen and a high a rate of dropout from the treatment programme.     

Estimating heroin epidemics with data of patients in methadone maintenance treatment, collected during a single treatment day

AIMS: Effects of differing drug policies are difficult to evaluate, because time trends in the spread of heroin use, the most problematic illicit drug world-wide, are unknown in almost all countries. We aimed to develop a simple method to estimate these dynamics with data that can be gathered from patients in substitution treatment within a single day. DESIGN: We tested the assumption that being in substitution treatment on any day depends solely upon individual time since onset of regular heroin use (following a 'general inclusion function'). We used data from the case register for substitution treatments in the canton of Zurich (1992--2004), comprising 9518 patients, to model a 'general inclusion function'. Applying this function, we calculated 30 incidence curves for heroin dependence, each with data of one of 30 randomly chosen treatment days between 1992 and 2004. FINDINGS: Incidence modelling led to 30 similar curves, and therefore our hypothesis was corroborated. Additionally, our approach also revealed a restricted access to substitution treatment in the early 1990s and a decline in demand due to the introduction of heroin-assisted treatment from 1994 onwards. CONCLUSIONS: In the canton of Zurich, the probability of being in substitution treatment can be described by a 'general inclusion function', and therefore dynamics of heroin epidemics can be estimated based on data of a single treatment day. Adaptation of our function to areas with a more restricted access to substitution treatment may permit these estimations also in other regions or countries. Thus, our approach facilitates the urgently needed assessment of the effects of different drug policies.     

Levo-alpha-acetylmethadol (LAAM) versus methadone maintenance: 1-year treatment retention, outcomes and status

AIMS: To compare levo-alpha-acetylmethadol (LAAM) and methadone maintenance (MM) on treatment retention, drug use during treatment and at follow-up, and abstinence. DESIGN: A two-group experimental design with patients assigned randomly (2:1) to receive fully subsidized LAAM or MM for 52 weeks. SETTING: A community clinic providing maintenance treatment in Los Angeles, California. PARTICIPANTS: A total of 315 treatment-seeking patients willing to be assigned randomly to treatment condition; 289 (91.7%) were interviewed at 52 weeks. INTERVENTION: LAAM or MM, plus ancillary services available to all patients. Medication dose varied according to clinical judgement. MEASUREMENTS: Treatment retention and status at 52-week follow-up, weekly clinical urinalysis, self-reported drug use and research urinalysis on samples collected at follow-up. FINDINGS: LAAM participants were more likely to complete the planned 52 weeks (57.4%) than MM participants (46.2%) and were less likely to be discharged for arrest/incarceration. LAAM produced fewer during treatment clinic opiate-positive samples (M = 48.8) than MM (M = 62.3). Further, 24.4% on LAAM compared to 11.8% on MM were able to sustain at least 12 weeks of abstinence during the last 24 weeks of treatment. Opiate use at follow-up was lowest (50.9%) among LAAM participants in maintenance treatment. No adverse events, cardiological or otherwise, were observed with LAAM administration. CONCLUSIONS: LAAM is an effective medication for the treatment of opiate dependence in community clinics with numerous behavioral and clinical advantages. LAAM is more effective than MM in promoting retention and extended reduction in and abstinence from opiate use while in treatment.     

美沙酮维持治疗期间患者继续滥用海洛因与冰毒及相关因素分析

目的了解在美沙酮维持治疗期间,患者偷用海洛因及冰毒等多药滥用情况,探索相关因素对患者滥用毒品的影响。方法随机抽取并检测参与治疗患者的尿样,记录结果,并结合门诊收集的患者基本信息和美沙酮治疗情况进行分析。结果被调查的179名患者中,39.1%(70/179)的患者在治疗期间仍然滥用毒品,其中16.2%(29/179)吸食海洛因,18.4%(33/179)服用冰毒,同时滥用海洛因和冰毒者占4.5%(8/179)。性别和服药是否规律是影响患者滥用毒品的因素。滥用海洛因者与滥用冰毒者之间不存在明显的差异。结论要关注美沙酮维持治疗患者的多种毒品滥用现象,警惕新型毒品的危害。     

Club drugs and alcohol abuse predicted dropout and poor adherence among methadone maintenance treatment patients in Guangzhou,China

Club drugs and alcohol abuse are prevalent among methadone maintenance treatment (MMT) patients. However, little is known about the association between these abuse and treatment outcomes among MMT patients. The aim of this study was to examine the prevalence of club drugs and alcohol abuse among MMT patients and to investigate the associations between these abuse and treatment outcomes – dropout and poor adherence. In this one-year cohort study conducting in Guangzhou, China, data including background characteristics, club drugs use in the last six months, alcohol use history and treatment-related information was collected. Cox regression analyses and log-binomial regression analyses were applied to identify the associations between these abuse and dropout and poor adherence, respectively. Thirty-seven participants (9.2%) admitted to the use of at least one type of club drugs in the last six months and 88 (21.9%) were identified as alcohol abusers. Of all participants, 21.0% had dropped out of treatment and 27.7% exhibited poor adherence during the study period. Adjusting for significant background variables, use of at least one type of club drugs [hazards ratio (HR)?=?1.90, 95% confidence interval (CI)?=?1.01–3.56] and use of methamphetamine in the last six months (HR?=?2.26, 95% CI?=?1.15–4.43) significantly predicted dropout. Frequency of having six or more drinks on one drinking occasion when drinking [relative risk (RR)?=?1.87, 95% CI?=?1.16–2.95] significantly predicted poor adherence. Our findings indicated that club drugs and alcohol abuse predicted dropout and poor adherence among MMT patients. Early identification and intervention for the abuse should be taken into consideration when developing interventions tailored to improve treatment outcomes among MMT patients.     

Slow‐release oral morphine for maintenance treatment of opioid addicts intolerant to methadone or with inadequate withdrawal suppression

Aims Evaluation of the efficacy, safety and acceptability of slow‐release oral morphine (SROM) in opioid addicts intolerant to methadone or with inadequate withdrawal suppression. Design Prospective, open, non‐comparative multi‐centre study. Setting Twelve out‐patient Centres for Prevention and Treatment of Drug Addiction in Slovenia. Participants Male and female opioid addicts (age >18 years) under methadone maintenance therapy requiring a change of treatment in order to continue more effectively with maintenance. Interventions Maintenance therapy with methadone was switched to once‐daily SROM. Measurements Efficacy evaluations were based on the reduction of side effects and on the degree of suppression of opiate craving, signs and symptoms of withdrawal. In addition, self‐reported somatic and psychic symptoms (SCL‐27) as well as World Health Organization quality of life‐related (WHO QOL) parameters were monitored. Findings Thirty‐nine subjects intolerant to methadone and 28 subjects showing inadequate withdrawal suppression under methadone ≥90 mg/day were included as two separate groups in the efficacy analyses. Treatment was switched easily from methadone to SROM on a 1 : 8 ratio. Four‐week SROM treatment resulted in significant reduction of side effects reported under methadone. Signs and symptoms of opioid withdrawal as well as craving for opiates were improved significantly in patients with inadequate response to methadone. Physical and psychological wellbeing improved significantly under SROM treatment. SROM was tolerated very well. Conclusions Maintenance treatment with SROM appears to be a clinically useful alternative treatment in subjects not tolerating methadone or with inadequate withdrawal suppression.     

综合强化干预措施提高美沙酮服用剂量效果分析

目的评估综合强化干预措施提高美沙酮维持治疗(MMT)病人美沙酮服用剂量的效果。方法选取MMT门诊60个,分层配对后,以门诊为单位随机分配到干预组或对照组,在干预组实施综合强化干预措施,对照组为常规防治工作。采用混合效应模型以及多因素Logistic回归分析,评价综合强化干预对提高美沙酮服用剂量的效果。结果共入组6 631人,干预组3 797人,对照组2 834人。干预组美沙酮日均服用剂量从(64.1±35.4)mg/d提高到(68.9±38.2)mg/d,对照组美沙酮日均服用剂量从(61.4±33.6)mg/d提高到(63.3±34.1)mg/d,在控制了社会人口学等因素后,混合效应模型分析结果表明,美沙酮日均服用剂量在两组间的差异有统计学意义(F=48.69,P<0.0001)。干预组和对照组美沙酮日均服用剂量提高者所占比例分别为58.8%和53.5%(χ2=34.78,P<0.0001)。多因素Logistic回归分析表明,综合强化干预是提高美沙酮日均服用剂量有意义的影响因素(OR=1.236,95%CI:1.119～1.364)。结论综合强化干预措施对提高美沙酮服用剂量有一定效果,但是提高幅度有限,需要进一步分析原因。     

Effects of a randomized contingency management intervention on opiate abstinence and retention in methadone maintenance treatment in China

Aims Methadone maintenance treatment has been made available in China in response to the rapid spread of human immunodeficiency virus (HIV), but high rates of dropout and relapse are problematic. The aim of this study was to apply and test if a contingency management (or motivational incentives) intervention can improve treatment retention and reduce drug use. Design Random assignment to usual care with (n = 160) or without (n = 159) incentives during a 12‐week trial. Incentives participants earned draws for a chance to win prizes on two separate tracks targeting opiate‐negative urine sample or consecutive attendance; the number of draws increased with continuous abstinence or attendance. Setting Community‐based methadone maintenance clinics in Shanghai and Kunming. Participants The sample was 23.8% female, mean age was 38, mean years of drug use was 9.4 and 57.8% had injected drugs in the past 30 days. Measurements Treatment retention and negative drug urine. Findings Relative to the treatment‐as‐usual (control) group, better retention was observed among the incentive group in Kunming (75% versus 44%), but no difference was found in Shanghai (90% versus 86%). Submission of negative urine samples was more common among the incentive group than the usual care (74% versus 68% in Shanghai, 27% versus 18% in Kunming), as was the longest duration of sustained abstinence (7.7 weeks versus 6.5 in Shanghai, 2.5 versus 1.6 in Kunming). The average total prize amount was 371 Yuan (or $55) per participant (527 for Shanghai versus 216 in Kunming). Conclusions Contingency management improves treatment retention and drug abstinence in methadone maintenance treatment clinics in China, although there can be considerable site differences in magnitude of effects.     

Drug abuse and responsible fathering: a comparative study of men enrolled in methadone maintenance treatment

AIM: Because very little is known about the parenting of drug-abusing men, this study was designed to document ways that drug abuse contributes to compromise of responsible fathering. DESIGN, SETTING, PARTICIPANTS: Generalized linear models and data representing different dimensions of responsible fathering were used to clarify ways that the fathering of 106 men receiving methadone maintenance treatment differed from that of 118 men living in the same community with no history of alcohol or drug abuse. MEASUREMENT: Men who enrolled in the study completed two structured interviews and a battery of five self-report measures selected to document current and historical dimensions of responsible fathering. FINDINGS: When the opioid-dependent fathers were compared to the other fathers, there were significant differences in: (i) economic resources to support family formation; (ii) patterns of pair-bonding; (iii) patterns of procreation; and (iv) parenting behavior. When fathering of the youngest biological child was examined, the opioid-dependent fathers confirmed few differences in historical dimensions of fathering, but they reported significant differences in current dimensions reflecting: (i) constricted personal definitions of the fathering role; (ii) poorer relationships with biological mothers; (iii) less frequent residence with the child; (iv) less frequent provision of financial support; (v) less involvement in positive parenting; (vi) poorer appraisal of self as a father; and (vii) less satisfaction as a father. CONCLUSIONS: The findings highlight ways that drug abuse contributes to compromise of responsible fathering, and they raise questions about ways that the drug abuse treatment system might better address parenting as a treatment issue for men.     

Depression,suicidal ideation,and related factors of methadone maintenance treatment users in Guangzhou,China

Mental health problems are prevalent among drug users. Methadone maintenance treatment (MMT) is an evidence-based effective treatment for drug addiction; however, there are few studies investigating depression, suicidal ideation, and their related factors among MMT users. In this cross-sectional study, 648 MMT users were recruited from six MMT clinics in Guangzhou, China. Data were collected through face-to-face interviews by trained interviewers. Of all participants, 270 (42.7%) exhibited probable depression (Depression Subscale of the Chinese short version of Depression, Anxiety, and Stress Scale (DASS-D), score?≥?10) and 99 (15.3%) reported having suicidal ideation in the last six months. After adjusting for significant socio-demographic characteristics, all studied variables, including drug use history, social support, family support for MMT use, and satisfaction toward MMT services were significantly associated with both probable depression and suicidal ideation in the last six months. Furthermore, depression fully mediated the associations between drug use history, satisfaction toward MMT services, and suicidal ideation. In the final multivariate models, probable depression was associated with social support (OR?=?0.88, 95% CI?=?0.83–0.93) and satisfaction toward MMT services provided by doctors (OR?=?0.59, 95% CI?=?0.40–0.86), while for suicidal ideation, social support (OR?=?0.85, 95% CI?=?0.78–0.92) and probable depression (OR?=?5.94, 95% CI?=?3.39–10.42) were significant. The findings suggest that there are unmet mental health needs among MMT users. For countries with limited resources of psychological services, mental health care toward MMT users should be implanted into current health care settings and incorporate components such as social support, family's understanding of MMT, and service satisfaction.     

Improving access to better care for people with knee and/or hip pain: service evaluation of allied health professional‐led primary care

Introduction

Chronic knee and hip pain is prevalent, impairing mobility, function and quality of life. Allied health professions (AHPs) are better trained and have more time than general practitioners in primary care to advise and support people to adopt healthier lifestyles (maintain healthy weight, increase physical activity) that reduce joint pain. We evaluated whether AHP‐led primary care delivering person‐centred, practical lifestyle coaching was a feasible, effective way to manage chronic knee and/or hip pain.

Methods

At initial assessment the ‘Joint Pain Advisor’ assessed pain, function, quality of life, physical activity, waist circumference and body mass, taught simple self‐management strategies and used behaviour change techniques (motivational interviewing, goal setting, action/coping planning) to alter participants' lifestyles. Participants were invited for 6‐week and 6‐month reviews, when the Advisor reassessed clinical outcomes, fed back progress and reinforced health messages. Feasibility and effectiveness of the service was evaluated using quantitative and qualitative methods.

Results

Uptake of the service was good: 498 people used the service. Between initial assessment and reviews, participants' pain, function, quality of life, weight, waist circumference and physical activity improved (p < 0.005). Service user satisfaction was high; they reported easier access to advice and support tailored to their needs that translated into clinical benefits and a more efficient pathway reducing unnecessary consultations and investigations. Relatively few people returned for a 6‐month review as they considered they had received sufficient advice.

Conclusions

AHP‐led care is a popular, effective, efficient and sustainable way to manage joint pain, without compromising safety or quality of care.