Willingness to pay for drug rehabilitation: implications for cost recovery

OBJECTIVES: This study estimates the value that clients place on methadone maintenance and how this value varies with the effectiveness of treatment and availability of case management. We provide the first estimate of the price elasticity of the demand for drug treatment. METHODS: We interviewed 241 heroin users who had been referred to, but had not yet entered, methadone maintenance treatment in Baltimore, Maryland. We asked each subject to state a preference among three hypothetical treatment programs that varied across three domains: weekly fee paid by the client out-of-pocket ($5-$100), presence/absence of case management, and time spent heroin-free (3-24 months). Each subject was asked to complete 18 orthogonal comparisons. Subsequently each subject was asked if they likely would enroll in their preferred choice among the set of three. We computed the expected willingness to pay (WTP) as the probability of enrollment times the fee considered in each choice considered from a multivariate logistic model that controlled for product attributes. We also estimated the price elasticity of demand. RESULTS: The median expected fee subjects were willing to pay for a program that offered 3 months of heroin-free time was $7.30 per week, rising to $17.11 per week for programs that offered 24 months of heroin-free time. The availability of case management increased median WTP by $5.64 per week. The price elasticity was -0.39 (S.E. 0.042). CONCLUSIONS: Clients will pay more for higher rates of treatment success and for the presence of case management. Clients are willing to pay for drug treatment but the median willingness to pay falls short of the estimated program costs of $82 per week. Thus a combined approach of user fees and subsidization may be the optimal financing strategy for the drug treatment system.     

Tobacco use and quit attempts among methadone maintenance clients

OBJECTIVES: This study examined tobacco use prevalence, types of tobacco used, interest in quitting, and prior quit attempts among persons in methadone maintenance treatment. METHODS: Counselors collected surveys from 84% (550 of 655) of all clients in a 4-county metropolitan area. RESULTS: Most clients (77%) smoked cigarettes. Of the 59 former tobacco users, only 6 reported using a cessation pharmacotherapy to quit. Three quarters of the current smokers had attempted to quit at least once, with an average of 5 attempts. Most smokers (80%) were "somewhat" or "very" interested in quitting. CONCLUSIONS: The quit ratio among methadone maintenance treatment clients was 12%, compared with 50% nationwide. To reduce morbidity and mortality, cessation interventions must be developed and disseminated.     

Couple-friendly services in a metropolitan sexually transmitted disease clinic: views of clients and providers.

CONTEXT: Clients making clinic visits related to reproductive health might benefit from participation with their partner. There is little information available, however, on whether either clients themselves or clinic staff would feel comfortable with such a possibility. METHODS: The Multnomah County Health Department Sexually Transmitted Disease Clinic in Portland, Oregon, conducted a survey of 237 new clients in June 1994 to assess clients' and providers' responses to the idea of offering couple visits. RESULTS: Twenty-six percent of female clients and 16% of male clients were accompanied by their partner on their visit to the clinic. Eighty-seven percent of all clients favored the clinic's offering couple visits, 5% opposed the concept and 8% were undecided. Fifty-four percent would have wanted their partner to be with them during their present visit if this choice had been offered, and 62% would want their partner to join them in follow-up couple visits if this were recommended by their provider. Seventy-one percent had already discussed with their partner the reason for their immediate clinic visit, and 88% expected to discuss the visit with their partner afterward. Attitudes toward couple services were similar for male and female clients and did not vary by race or ethnicity. For more than one-fifth of clients, clinic staff reported that they would not recommend couple visits; however, many of these clients reported that they would prefer being accompanied by their partner. CONCLUSIONS: Appropriately designed couple-friendly options are likely to be generally accepted and moderately utilized by clients of varying backgrounds. Clinic staff may be more reluctant to involve clients' partners than the clients are themselves, however.     

The influence of client-provider relationships on teenage women's subsequent use of contraception.

This paper describes the relationships of selected dimensions of nurse-client interaction in county health department family planning clinics to the subsequent contraceptive use of the clinic's unmarried teenage clients. The subjects for the study are the clients and professional staff of 78 clinics: 2,900 eligible clients making their first contraceptive visit and 338 clinic staff nurses. Results of interviews demonstrate that client and staff expectations and interactions are significant predictors of adherence to a contraceptive regimen; under circumstances where clients anticipate, and staff employ, authoritative guidance in helping the clients to select a contraceptive method, clinic mean levels of contraceptive use are substantially increased. Overall, 40 per cent of clinic variation in contraceptive compliance is explained by the interaction dimensions and other aspects of clinic organization addressed in this paper. Implications of these results for the structuring of family planning clinic programs directed toward teenage women are briefly considered.     

Barriers to the dissemination of four harm reduction strategies: a survey of addiction treatment providers in Ontario

A sample of service providers at addictions agencies' in Ontario were interviewed by telephone to assess attitudes toward, anticipated internal and external barriers to implementing, and expected benefits of four harm reduction strategies: needle exchange, moderate drinking goals, methadone treatment, and provision of free condoms to clients. Respondents were also asked to define harm reduction, list its most important elements, and describe what they find most troubling and most appealing about harm reduction. Attitudes toward harm reduction in general and the services provided at each agency were also assessed. Results indicated that the service providers surveyed had positive attitudes toward each of the four harm reduction strategies and harm reduction in general, and the majority of respondents were aware of the benefits associated with each strategy. Almost all of the agencies surveyed allowed for moderate drinking outcomes in the treatment of alcohol problems, and most agencies provided free condoms to clients. In terms of barriers, anticipated negative community reaction to needle exchange, methadone treatment, and free condoms was a major concern for the majority of respondents. Lack of staff, of funding, or anticipated staff resistance were also cited as potential barriers to introducing these strategies. In the case of methadone maintenance, the unavailability of a qualified physician was listed as the primary constraint. Implications for future efforts directed at encouraging the adoption of these strategies and suggestions for future research are discussed.     

Abstinence at Successful Discharge in Publicly Funded Addiction Health Services

Abstinence at successful discharge in substance use disorder treatment is important to reducing relapse rates and increasing long-term recovery from substance use disorders. However, few studies have examined abstinence as an essential component of successful discharge. This study examined rates and correlates of reported abstinence (nonuse of drugs 30 days prior to successful discharge) among clients attending publicly funded treatment in Los Angeles County, California. Finding show that only 36% of clients who were successfully discharged reported abstinence. Black clients were less likely than non-Hispanic Whites to report abstinence at successful discharge. Clients in methadone treatment programs were less likely than outpatient clients to report abstinence, whereas clients referred to treatment through the legal system (Proposition 36) were more likely to report abstinence compared to self-referred clients. Findings underscore the importance of systematic assessment of abstinence in determining successful discharge and provide a basis for further examination of strategies to improve abstinence and reduce relapse.     

The impact of organization of family planning clinics on waiting time.

Mathematical simulations and structured observations were used to assess factors in family planning clinic procedures responsible for long waiting times for clients. Principal causes of unnecessarily long waiting times in selected clinics of a Mexican program included: inflexibilty of client's routes within the clinic and of staff functions, late arrival of staff, patterns of client arrival times, and the proportion of clients seen by the doctor.     

Accessibility of and client satisfaction with dental services in Melbourne

Abstract: Public dental clinics play an important role in delivering dental services to Australian adults on low incomes. Our objective was to compare the accessibility of and client satisfaction with the two main types of public dental service providers in Victoria and with private practice services. Clients attending the Royal Dental Hospital of Melbourne, Northcote Community Health Centre and private practices in Melbourne were surveyed. The hospital's clients faced the greatest ecological and organisational obstacles, while private clients faced the greatest financial and desirability obstacles. Community centre clients faced fewer ecological and organisational obstacles than hospital clients, with the exception of long waiting times. Private practice clients were more satisfied overall, and had better continuity of care. Private practice clients were more satisfied with access, availability and convenience than community centre clients, who in turn were more satisfied than hospital clients. There was no distinction between private practice and hospital clients on satisfaction with 'pain and treatment', but community centre clients were less satisfied. There was no significant difference between client group evaluations of interaction with the dentist. Regardless of the effects of the Commonwealth Dental Health Program, distinctions between various service types and public clinic types are likely to remain, because of their different settings. The contrast between a central hospital and a community health centre, in terms of the ecological and organisational obstacles to care, points to the advantages of putting dental services close to the communities they serve.     

贵州省美沙酮维持治疗受治者保持治疗状况及其影响因素

目的 了解美沙酮维持治疗(MMT)的受治者保持治疗率及其影响因素.方法 采用队列研究设计,于2006年6-10月在贵州省8家MMT门诊选择1003名自愿参加调查、新进入MMT项目的 海洛因成瘾者,以面对面访谈方式对影响MMT受治者保持治疗的因素进行问卷调查,并随访其保持治疗的情况至2007年6月.用Kaplan.Meier方法计算保持治疗率,Cox比例风险回归分析影响受治者保持治疗的因素.结果 对MMT受治者的随访共持续14个月,受治者平均保持治疗时间为10个月,第6、12个月时的保持治疗率分别为68.8%、57.4%.受治者在不同MMT门诊、每日服用的美沙酮剂量和对MMT的认识是影响保持治疗的主要因素随着受治者每日服用美沙酮剂量的增加,其退出治疗的风险降低,剂量每增加25 mg,退出治疗的风险降低20%(风险比HR=0.80,P＜0.01).进入MMT时认为需要终生服用美沙酮的受治者比认为以后可以戒断美沙酮的受治者退出治疗的风险低(HR=0.66,P＜0.05).结论 贵州省MMT受治者治疗12个月时只有近一半仍保持治疗;不同的MMT门诊、每日服用美沙酮剂量和对MMT的认识是影响保持治疗的主要因素.     

Assessing the spatial distribution of methadone clinic clients and their access to treatment

Using Geographic Information System (GIS), the spatial distribution of methadone clinic clients and their utilization of a treatment service in Hong Kong was analysed. A majority (93.7%) of the 63 methadone users recruited were residing in the same district, of which 84.1% spent not more than 15 minutes for traveling. Walking (55.6%) was the commonest transport mode followed by cycling (30.2%). There was no distance decay effect on traveling time, but an association between distance and transport selection could be demonstrated. The residence locations displayed a compact distribution, merging with the general population without any evidence of clustering. Though the distribution of methadone users could have been shaped by the location of clinic, it can also be concluded that methadone clinics at convenient locations are needed if maintenance is a key determinant of service effectiveness.     

Measuring program performance in methadone treatment using in-treatment outcomes: An illustration

Quality measurement and quality assurance in substance abuse treatment have, over the past few years, become a major policy issue. In addition, there is interest in the degree to which client outcomes can play a role in measuring treatment program performance. This article discusses the movement toward outcome-based performance measureemnt in substance abuse treatment. Examples of the products that such a performance measurement system might produce are provided. Why outcomes must be case-mix adjusted is discussed. In addition, using data from 18 methadone programs and more than 2,000 methadone clients from the Treatemnt Outcome Prospective Study, an illustration of case-mix-adjusted performance measurement is provided.     

Improving the quality of child health services: participatory action by providers.

OBJECTIVE: To test a quality improvement approach called COPE (Client-Oriented, Provider-Efficient services), for use in strengthening health systems and supporting Integrated Management of Child Health (IMCI) efforts. DESIGN: Pre- and post-intervention observations of client/provider interactions, facility audits, staff and client surveys, and focus groups to evaluate differences between eight COPE intervention and eight matched non-intervention facilities after a 15-month intervention in 2001. SETTING: Primary care clinics in Guinea and Kenya. STUDY PARTICIPANTS: Health care providers and child caregivers. INTERVENTIONS: Over 15 months, the intervention supported four COPE exercises at each intervention site, supported supervisor training in quality management, and organized minimal training in topics selected by site staff as areas where training was needed. MAIN OUTCOME MEASURES: Differences in staff's and child caregiver's knowledge, attitudes, and practices; differences in the quality of services provided. RESULTS: On almost every quality indicator (over 65 indicators), whether reported by staff, observed by evaluators, or reported by clients, the intervention sites performed statistically significantly better than control sites. INTERVENTION: sites were cleaner and more pleasant, with more respect and information for clients, and more privacy. Staff had better personal communication skills, better diagnostic skills, and prescribing practices and gave better home care instructions to carers. Clients in intervention sites were more informed and more satisfied, and their children had better immunization coverage than those in control sites. CONCLUSION: COPE is a simple process, yet our study confirms that it can have a very dramatic effect on the quality of services. This study demonstrated how all areas of quality can be addressed by empowering health care providers to take action by using COPE. We suggest that COPE can complement Integrated Management of Childhood Illness (IMCI) training and can help to achieve better health for children.     

Incidence and prevalence of hepatitis C among clients of a Brisbane methadone clinic: factors influencing hepatitis C serostatus

Abstract: The objective of this study was to describe the incidence and prevalence of hepatitis C infection among clients of a methadone program in Queensland. The clinical notes of clients receiving methadone for treatment of opiate dependence who first registered at the clinic after 1989 were perused for information about their serological status for hepatitis C and hepatitis B infections during a six–week period in 1994. We followed hepatitis C negative clients until August–September 1995. At study entry, 69 per cent of the clients were recorded as being hepatitis C positive. Of those who were negative, the seroconversion rate was 11 per 100 person–years. The high incidence and prevalence of hepatitis C among methadone clients emphasises the need for effective early intervention strategies to prevent the transmission of hepatitis C among injecting drug users.     

Correlates of retention on the South Australian Methadone Program 1981–91

Objectives: To investigate correlates of retention on the South Australian Methadone Program during 1981–91.
Design: Retrospective study of a non-stratified random sample of 229 HIV-negative clients who received methadone between January 1981 and June 1991. Data were collected from clinical records of the 229 HIV-negative clients and also from the 40 clients known to be infected with HIV during the decade.
Results: Being HIV positive, receiving larger maximum doses of methadone, receiving methadone from a private pharmacy and enrolling later in the decade were all associated with longer retention times on the program.
Conclusions: This study supports the findings of previous studies, that maximum dose of methadone is crucial to retention in methadone programs, But even allowing for maximum dose, obtaining methadone from a private pharmacy was also strongly associated with retention on the program. The more 'humane' clinic policy later in the decade is likely to have increased retention and reduced illicit drug use also.     

Policy implementation of methadone maintenance treatment and HIV infection: evidence from Hubei province,China

To view methadone maintenance treatment (MMT) globally, it is necessary to accumulate data on MMT policy implementation under different health service systems. The aim of the current study is to provide empirical evidence about policy implementation of MMT and HIV infection control, as well as recommendations for improvement of MMT in the future. Based on China’s national policy framework of MMT, policy implementation of MMT in Hubei province has two objectives: 1) to create linkages between health and public security, and 2) to provide integrated services for management of drug abusers. From 2007 to 2011, following the establishment of MMT clinics that provide methadone as well as HIV prevention services, the proportion of HIV infection among drug abusers decreased relatively quickly (12.12%?→?5.77%?→?5.19%?→?2.39%?→?2.04%). However, high drop-out rate and poor information management have been identified as particular problems which now need to be addressed. Furthermore, client drop-out from MMT programs may reflect social issues the clients encounter, and consequently, sustainable MMT development requires incorporation of social measures that help MMT clients return to society without discrimination, especially through family cooperation and employment opportunities.     

贵州省美沙酮维持治疗门诊海洛因成瘾者偷吸海洛因现状及其影响因素

目的 调查贵州省美沙酮维持治疗门诊海洛因成瘾者偷吸海洛因的情况及其影响因素.方法 从贵州省的8个美沙酮门诊招募了1003名新人组的海洛因成瘾者,进行14个月随访.在随访期间对每个招募的海洛因成瘾者在不同的时间进行尿检.将美沙酮门诊、性别、婚姻情况、工作情况、民族、宗教信仰、使用海洛因的方法、是否强制戒毒过、年龄、美沙酮日平均服药剂量、受教育时间和使用毒品的年限作为自变量代入广义估计方程(GEE)进行分析.结果 1003名海洛因成瘾者平均年龄为(33.3±6.1)岁,平均使用毒品的时间为(8.0±4.0)年,平均日美沙酮剂量为(38.0±16.6)mg.1003名海洛因成瘾者中女性成瘾者占26.0%;15.5%离异;35.8%有全职工作.在治疗不足10个月的海洛因成瘾者中尿检阳性率在30%左右,治疗超过10个月后尿检阳性率开始下降.美沙酮门诊、美沙酮日平均剂量(RR=0.98,P=0.003)、维持治疗时间(RR=0.95,P=0.029)和受教育时间(RR=0.94,P=0.014)是影响海洛因成瘾者偷吸海洛因的因素.结论 在贵州省的8个美沙酮门诊受治者中偷吸海洛因现象比较普遍,应考虑提高美沙酮剂量和维持治疗时间以减少患者偷吸海洛因的情况.     

Socio-spatial stigmatization and the contested space of addiction treatment: Remapping strategies of opposition to the disorder of drugs

In recent years, the Not-In-My-Back-Yard (NIMBY) phenomenon has become increasingly prevalent with regard to harm reduction sites, addiction treatment facilities and their clients. Drawing from a case study of community conflict generated by the relocation of a methadone clinic into a rapidly gentrifying neighbourhood in downtown Toronto, Canada, this article offers a unique analysis of oppositional strategies regarding the perceived (socio-spatial) ‘disorder of drugs’. Based on interviews with local residents and business owners this article suggests the existence of three interrelated oppositional strategies, shifting from a recourse to urban planning policy, to a critique of methadone maintenance treatment (MMT) practice, to explicit forms of socio-spatial stigmatization that posited the body of the (methadone) ‘addict’ as abject agent of infection and the clinic as a site of contagion. Exploring the dialectical, socio-spatial interplay between the body of the addict and the social body of the city, this article demonstrates the unique aspects of opposition to the physically, ideologically and discursively contested space of addiction treatment. Representations of the methadone clinic, its clients and the larger space of the neighbourhood, this paper suggests, served to situate addiction as a ‘pathology (out) of place’ and recast the city itself as a site of safe/supervised consumption.     

Childhood sexual abuse, post-traumatic stress disorder, and use of heroin among female clients in Israeli methadone maintenance treatment programs (MMTPS)

This study investigated association between post-traumatic stress disorder (PTSD) and a 1-year follow-up heroin use among female clients in methadone clinics in Israel. Participants were 104 Israeli female clients from four methadone clinics (Mean age = 39.09, SD = 8.61) who reported victimization to childhood sexual abuse. We tested traces in urine of these female clients for heroin a year preceding and a year following the assessment of their PTSD. Results show that 54.2% reported symptoms that accedes the DSM-IV criteria for PTSD. We found that among childhood victimized women PTSD is associated with more frequent use of heroin at a 1-year follow-up even after controlling for duration of the stay at the clinic, background, other traumatic experiences and heroin use a year prior the assessment of their PTSD. This study shows the potential long-run negative consequences of childhood sexual abuse. Not only are these sexually abused women trapped into drug dependence and addiction, they cannot break the vicious cycle of continuing the use of illicit drugs even when treated for their addiction. One major practice implication is that treatment for PTSD proven efficacious will be provided in the methadone and other drug treatment services.