Patterns of Abstinence or Continued Drug Use Among Methadone Maintenance Patients and Their Relation to Treatment Retention

The efficacy and effectiveness of methadone maintenance treatment (MMT) in the medical management of opioid addiction has been well-established, but treatment outcomes are compromised by the continued use of licit and illicit drugs during MMT. The present study examined the relationship between in-treatment illicit drug use and retention and dropout of 604 MMT patients in Washington, D.C. Sixty-eight percent of patients did not test positive for an unprescribed drug during the study period. Of patients who tested positive for an illicit drug during the baseline period, 55% tested positive for cocaine, 44% for opiates, 23% for THC, 20% for benzodiazepines, 7% for PCP, and 4% for amphetamines. Those testing positive were three times more likely to leave treatment than those who did not test positive. Testing positive for one drug doubled the rate of attrition; testing positive for multiple drugs quadrupled the risk of attrition. Non-prescribed opioid or benzodiazepine use was a predictor of MMT dropout, but prescribed opioid or benzodiazepine use was not. Continued illicit drug use poses significant risk for subsequent premature termination of MMT. Assertive clinical management of continued illicit drug use could provide mechanisms to enhance MMT retention and long-term recovery outcomes.     

Predictors of methadone maintenance treatment utilization in a multisite cohort of illicit opioid users (OPICAN)

Although methadone maintenance treatment (MMT) has been a primary treatment response to illicit opioid use in Canada for decades, analytical treatment data are scarce. Using data from the multisite OPICAN cohort of illicit opioid and other drug users repeatedly assessed between 2002 (baseline) and 2005 (last follow-up [FU]), we (1) longitudinally examined characteristics associated with MMT uptake between baseline and FU and (2) cross-sectionally compared drug use patterns between cohort participants in MMT (n = 133) and those not in MMT (n = 400) at the last FU through bivariate and multivariate analyses (stepwise logistic regression). Significant baseline predictors of MMT uptake emerging in the logistic regression model included injection drug, heroin, as well as alcohol use, housing status, and Quebec City as a site. Furthermore, lower prevalence levels of opioid (e.g., morphine and OxyContin) and nonopioid (e.g., cocaine and crack) drug use as well as lower frequency of heroin use days were observed among MMT users. This study highlights potential factors relevant for improved MMT uptake and illustrates possible reductions of drug use related to MMT.     

Unintended impacts of regulatory changes to British Columbia Methadone Maintenance Program on addiction and HIV-related outcomes: An interrupted time series analysis

BackgroundIn February 2014, several regulatory reforms were introduced to the methadone maintenance treatment (MMT) program in British Columbia, Canada, including a switch to a ten-times more concentrated methadone formulation and restrictions in pharmacy delivery services. We evaluated possible unintended effects of these changes on illicit drug use patterns and HIV treatment outcomes among HIV-positive opioid users.MethodsData was drawn from ACCESS, a prospective community-recruited cohort of HIV-positive people who use illicit drugs in Vancouver, Canada. Interrupted Time Series Analyses were used to evaluate impacts of the policy change on monthly rates of MMT enrolment, illicit heroin injection, antiretroviral therapy (ART) adherence, and HIV viral suppression among HIV-positive opioid users between November 2012 and May 2015.ResultsA total of 331 HIV-positive opioid users were included. The MMT policy change led to a significant immediate 11.5% increase in heroin injection, and 15.9% drop in optimal ART adherence. A gradual increase in the prevalence of MMT enrolment after the policy change was also documented (0.9% per month). No changes in viral suppression rates were observed.ConclusionWe observed immediate increases in illicit heroin injection and decreases in ART adherence in the wake of regulatory changes to the local MMT program. These findings underscore the need to consider potential unintended effects of altering health programmes for vulnerable populations, the need to develop appropriate mitigation strategies, as well as to involve all relevant stakeholders in the planning and implementations of new policies.     

Feasibility of buprenorphine and methadone maintenance programmes among users of home made opioids in Ukraine

BackgroundOpioid substitution therapy (OST) in the Ukraine was not provided until 2004. Methadone maintenance therapy only became available in May 2008. Injecting drug users in Ukraine are predominantly injecting self-made opioid solution (‘Shirka’). A feasibility study on buprenorphine and methadone maintenance treatment was conducted in 2008.MethodsA total of 331 opioid dependent patients were given buprenorphine (n = 191) or methadone (n = 140) as a substitute, and a survey of substance use, HIV transmission risks, and legal and social status was conducted at baseline and at six months follow-up.ResultsIllegal substance use, illegal activities, incomes and HIV related transmission risks were highly reduced, whereas employment rates and psychiatric problems improved. Retention was comparatively high among the patients in buprenorphine (84.8%) and in methadone maintenance treatment (85.0%) after six months of treatment.ConclusionThese data show the successful implementation of OST in the Ukraine among drug users who were predominantly injectors of self-made opioid solutions. Continuing scale-up of OST in the Ukraine is therefore both feasible and highly recommended.     

The impact of ongoing illicit drug use on methadone adherence in illicit drug users receiving treatment for HIV in a directly observed therapy program

INTRODUCTION: Studies evaluating the effectiveness of opioid agonist therapy programs typically evaluate drug abstinence or treatment retention as their primary outcomes. However, in many circumstances (e.g. directly observed therapy (DOT) programs within methadone maintenance programs), methadone adherence is an extremely relevant clinical outcome. We sought to evaluate the impact of ongoing illicit drug use on methadone adherence within a DOT program for the treatment of HIV-infection. METHODS: Patients were enrolled in a DOT program, where methadone and HIV medication are co-administered by a community pharmacist. Drug use (amphetamines, benzodiazepines, cocaine, and opiates) was assessed by repeated urinalysis results. Methadone adherence was calculated as the fraction of days methadone was administered. RESULTS: Ongoing drug use, and poly-substance use was common, with only 4 of 60 patients abstaining from all illicit drug use. Overall methadone adherence was 84.5%. Amphetamine use (without benzodiazepine and cocaine use), benzodiazepine use (without amphetamines) and higher methadone doses were associated with higher methadone adherence. When patients used benzodiazepines or cocaine, any positive effect associated with amphetamine use was negated. In addition, opiate use was associated with decreased methadone adherence. DISCUSSION: The effect of many illicit drugs on methadone adherence may differ from reports using other treatment outcomes.     

A Randomized,Controlled Trial of the Efficacy of an Interoceptive Exposure-Based CBT for Treatment-Refractory Outpatients with Opioid Dependence

Many patients diagnosed with opioid dependence do not adequately respond to pharmacologic, psychosocial, or combination treatment, highlighting the importance of novel treatment strategies for this population. The current study examined the efficacy of a novel behavioral treatment focusing on internal cues for drug use (Cognitive Behavioral Therapy for Interoceptive Cues; CBT-IC) relative to an active comparison condition, Individual Drug Counseling (IDC), when added to methadone maintenance treatment (MMT) among those who had not responded to MMT. Participants (N=78) were randomly assigned to receive 15 sessions of CBT-IC or IDC as an adjunct to ongoing MMT and counseling. Oral toxicology screens were the primary outcome. Results indicated no treatment differences between CBT-IC and IDC and a small, significant reduction of self-reported drug use, but no change on toxicology screens. Tests of potential moderators, including sex, anxiety sensitivity, and coping motives for drug use, did not yield significant interactions. Among opioid-dependent outpatients who have not responded to MMT and counseling, the addition of IDC or CBT-IC did not result in additive outcome benefits. These results highlight the need for more potent treatment strategies for opioid dependence, particularly among those who do not fully respond to frontline treatment.     

Non-prescribed use of opioid substitution medication: Patterns and trends in sub-populations of opioid users in Germany

BackgroundNon-prescribed use of opioid substitution medication (NPU) appears to represent a relevant source of opioids among European drug users. Little is known about the prevalence of NPU in Germany and possible differences between subgroups of opioid users. The present study examines NPU and other drug use patterns among drug consumption room (DCR) clients, opioid substituted DCR clients, and patients recruited in opioid substitution treatment (OST) practices.MethodsCross-sectional data was collected in 2011 from 842 opioid users in 10 DCRs and 12 OST practices across 11 German cities. Structured interviews comprised indicators for socio-demographics, health status, drug use, motives for NPU, and the availability and price of illicit substitution medication. Group differences were examined with one-way ANOVAs, chi-square tests, or t-tests, and factors for NPU were included in a multivariate model. Over-time comparisons were performed with similar data collected in 2008.ResultsLifetime, 30-day and 24-h NPU prevalence for the total sample was 76.5%, 21.9%, and 9.3%, respectively, with methadone being the most frequently used substance. NPU, poly-drug use and injection drug use were more common among DCR clients, especially among DCR clients not in OST. The three groups featured distinct socio-demographic characteristics, with substituted patients being more socially integrated, while few differences in health parameters emerged. Motives for NPU were mostly related to potential shortcomings of OST, such as insufficient dosages, difficulties with transportation, and lack of access. NPU prevalence was found to be higher than in 2008, while injection rate of substitution medication was similarly low. Main factors associated with NPU were not being in OST, past 24-h use of other drugs, and younger age.ConclusionAlthough diverted methadone or buprenorphine are rarely used as main drugs, NPU is prevalent among opioid users, particularly among DCR clients not in OST. OST reduces NPU if opioid users’ needs are met.     

Concurrent validity of cocaine and sedative dependence diagnoses in opioid-dependent outpatients

The present study evaluated the relationship between diagnoses of cocaine and sedative dependence and drug use early in treatment among opioid-dependent patients in methadone substitution therapy. New admissions (n = 138) were assessed via the Structured Clinical Interview for the DSM III-R (SCID) for presence of Axis I and Axis II disorders and followed for five weeks on standard methadone maintenance. Patients submitted urines three times per week tested for opioids, cocaine, and benzodiazepines. Patients diagnosed with current cocaine dependence (n = 90) submitted a higher proportion of cocaine-positive urines (M = 0.84) than patients diagnosed with past cocaine dependence (n = 32; M =0.28) and those diagnosed with no cocaine use disorder (n = 14; M = 0.12), P < 0.001. Current cocaine dependence diagnosis accounted for 52% of the cocaine use variance. Patients exhibiting current sedative dependence (n = 25) submitted a higher proportion of benzodiazepine-positive urines (M = 0.60) than patients with past sedative dependence (n = 44; M = 0.20) and those with no sedative use disorder (n = 60; M = 0.05), P < 0.001. Current sedative dependence diagnosis accounted for 37% of the benzodiazepine use variance. Lifetime major depression (12%) and antisocial personality disorder (39%) were the most common nonsubstance use comorbid diagnoses. Axis I nonsubstance use disorder was associated with benzodiazepine use, while Axis II disorder was associated with both benzodiazepine and cocaine use early in treatment (P < 0.05). These data demonstrate the concurrent validity of DSM-III-R cocaine and benzodiazepine use diagnoses, and support the potentially important relationship between drug use and other psychiatric disorders.     

Persistence of attentional bias toward alcohol-related stimuli in intoxicated social drinkers

This study examined the dose-related efficacy of disulfiram for treating cocaine dependence in methadone-stabilized cocaine dependent participants.DesignOne hundred and sixty-one cocaine- and opioid-dependent volunteers were entered into a 14-week, double blind, randomized, placebo-controlled clinical trial at two sites.MethodsParticipants were stabilized on methadone during weeks 1–2 and received disulfiram at 0, 62.5, 125 or 250 mg/day during weeks 3–14. All participants also received weekly cognitive behavioral therapy. Thrice-weekly urine samples and weekly self-reported drug use assessments were obtained.ResultsBaseline subject characteristics, retention and drug use did not differ across groups. Outcome analyses were performed on those who participated beyond week 2. Opioid-positive urine samples and self-reported opioid use did not differ by treatment group. The prevalence of alcohol use was low prior to and during the trial and did not differ by treatment group. Cocaine-positive urines increased over time in the 62.5 and 125 mg disulfiram groups and decreased over time in the 250 mg disulfiram and placebo groups (p < 0.0001). Self-reported cocaine use increased in the 125 mg disulfiram group relative to the other three treatment groups (p = 0.04).ConclusionsDisulfiram may be contraindicated for cocaine dependence at doses <250 mg/day. Whether disulfiram at higher doses is efficacious in reducing cocaine use in dually cocaine and opioid dependent individuals needs to be determined.     

Injection and non-injection drug use and infectious disease in Baltimore City: Differences by race

PurposeThe current study examines differences in the prevalence of biologically-confirmed hepatitis C virus (HCV), HIV, and coinfection between Black and White adult cocaine/heroin users across three drug use subgroups identified in previous research (Harrell et al., 2012): non-injection smoking crack/nasal heroin users, heroin injectors, and polydrug injectors.Results59% of the 482 participants in the study were male. Significant race differences emerged between drug use subgroup memberships. Non-injection smoking crack/nasal heroin users were predominantly Black (75%), while heroin injectors and polydrug injectors were predominantly White (69% and 72%, respectively). Polydrug injectors accounted for nearly three quarters of the HCV positive diagnoses in Whites. Though HIV disease status, stratified by race, did not differ significantly between drug use subgroups, the non-injection smoking crack/nasal heroin subgroup contained over half of the HIV positive diagnoses in the sample and was predominantly Black. Despite much lower rates of injection, Blacks (8%) had a higher prevalence of coinfection than Whites (3%; X² (2) = 6.18, p = .015).ConclusionsThe current findings are consistent with trends in the recent HIV transmission statistics where sexual activity has overtaken injection drug use as a HIV risk factor. The current findings also provide further support to the notion of injection drug use as an exceedingly high-risk behavior for HCV and coinfection, specifically those who are polysubstance injectors.     

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.     

Variables associated with perceived sleep disorders in methadone maintenance treatment (MMT) patients

To characterize sleep disorders in methadone maintenance treatment (MMT) patients, we evaluated sleep quality of 101 non-selective patients from our MMT clinic in Israel between July, 2003 and July, 2004 by using the self-report questionnaire Pittsburgh Sleep Quality Index (PSQI). Patients' urine tests were analyzed for methadone metabolite, opiates, benzodiazepine, cocaine, cannabis and amphetamines. Their urine results for drug abuse throughout the months prior to filling in the questionnaire and their maintenance methadone doses were recorded. Drug abuse was defined by at least one positive urine test. Methadone serum levels were available in 55 patients, assessed by Gas Chromatography Mass Spectroscopy. The patients' self-reported chronic pain questionnaires and their diagnosed psychiatric disorders were analyzed. Out of the 101 study patients, 78.2% were male, 52.5% had psychiatric disorders, 46.5% reported having chronic pain and 46.5% had positive urine for benzodiazepine. The mean daily methadone dose was 157+/-52.9 mg. The mean PSQI score was 9+/-4.8 (75.2% had scores >5 indicating "poor sleepers"). PSQI scores were higher in patients with positive urine for benzodiazepine, chronic pain and psychiatric disorders and they correlated with years of opiate abuse before admission to MMT, and with the methadone dose (r=0.48, p<0.0005). The latter two also correlated with each other. The PSQI was not correlated with duration in MMT, gender, age, abuse of opiates, cannabis or cocaine. We concluded that sleep disorders should be evaluated and treated among MMT patients, particularly in those with psychiatric disorders, benzodiazepine abuse, chronic pain and high methadone dose.     

Patterns of cocaine and opioid co-use and polyroutes of administration among street-based cocaine users in Montréal,Canada

BackgroundEffective public health programs aimed at problematic cocaine users are challenged by the fact that they can have complex patterns of drug use with respect to polysubstance use and routes of drug administration. This study was carried out to explore the presence of subgroups of cocaine users on the basis of their concurrent use of opioids and their routes of cocaine and opioid administration, and to determine if subgroups could be differentiated in terms of sociodemographic factors and risk behaviours.MethodsRegular cocaine users (≥1 per week) were recruited in low-threshold services located in the Montréal downtown area. The following variables were examined: demographic characteristics, types of drug used, routes of drug administration, and condom use with occasional or commercial sexual partners. Latent class analysis and multinomial logistic regression modeling were carried out.Results886 cocaine users were recruited (83.5% male: mean age 35.38 years). A 5-class model was identified: (1) “cocaine smokers” (CSs) (n = 161; membership probability (MP) = 0.183); (2) “cocaine smokers/sniffers” (CSSs) (n = 201; MP = 0.218); (3) “cocaine injectors” (CIs) (n = 207; MP = 0.231); (4) “cocaine-opioid injectors” (COIs) (n = 277; MP = 0.291); (5) “cocaine-opioid polyroute users” (COPs) (n = 40; MP = 0.077). Compared with COIs, other subtypes were significantly different in terms of either age, duration of cocaine use, ethnic background, homelessness, polydrug use or condom use.ConclusionThe heterogeneity of consumption patterns supports the importance of offering an array of interventions aimed at problematic cocaine users. These should include the provision of clean injecting and smoking material, the promotion of safe sexual behaviours and the prevention of initiation to drug injection. In the absence of specific treatment, cocaine users should have access to primary health care services and addiction treatment based on innovative behavioural and pharmacological approaches.     

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.     

Family history influence on drug abuse severity and treatment outcome

Influence of parental alcohol/substance abuse on methadone maintenance therapy (MMT) outcome was examined in 164 DSM-III-R opioid dependent adults with no other current DSM Axis I disorder. Family history positive patients had more DSM-III-R opioid dependence symptoms and were more likely to be classified as severely dependent. However, when placed on identical daily doses of methadone (50 mg), they had lower rates of illicit opioid use but higher rates of cocaine use than family history negative patients. Both effects remained significant after adjusting for gender and race. These results suggest that common genetic factors may underlie both susceptibility to heroin dependence and response to therapeutic methadone treatment.