Client and counselor attitudes toward the use of medications for treatment of opioid dependence

Attitudes, perceived social norms, and intentions were assessed for 376 counselors and 1,083 clients from outpatient, methadone, and residential drug treatment programs regarding four medications used to treat opiate dependence: methadone, buprenorphine, clonidine, and ibogaine. Attitudes, social norms, and intentions to use varied by treatment modality. Methadone clients and counselors had more positive attitudes toward the use of methadone, whereas their counterparts in residential and outpatient settings had neutral or negative assessments. Across modalities, attitudes, perceived social norms, and intentions toward the use of buprenorphine were relatively neutral. Assessments of clonidine and ibogaine were negative for clients and counselors in all settings. Social normative influences were dominant across settings and medications in determining counselor and client intentions to use medications, suggesting that perceptions about beliefs of peers may play a critical role in use of medications to treat opiate dependence.     

Predictive factors for treatment retention in methadone programs in Indonesia

This article presents the results of a 6-month prospective cohort study of methadone maintenance treatment (MMT) in Indonesia. The study aimed to investigate the predictor variables of retention in MMT in Indonesia. The duration of treatment (in days) was the main outcome of the study. For the study, program, client, social network, and accessibility factors were investigated as potential predictors of retention. The study analyzed the relative weight of each factor in predicting treatment retention. The sample consisted of 178 clients drawn from three participating clinics: Rumah Sakit Ketergantungan Obat and Tanjung Priok in Jakarta and Sanglah in Bali. The 3- and 6-month retention rates were 74.2% and 61.3%, respectively. These rates are comparable with previous studies conducted in developed countries. A survival analysis using a robust estimation for the Cox PH regression found that the strongest predictors of retention were methadone dose followed by an interaction between take-home dose and the experience of the clinic providing this treatment. Other significant predictor variables included age, perceived clinic accessibility, and client's belief in the program. The study concludes that MMT cannot solely rely on the pharmacology for retention but should also promote informed access to take-home doses.     

Injection drug users' experience with and attitudes toward methadone clinics in Denver, CO

Clients' perceptions and attitudes toward methadone treatment programs are frequently overlooked in substance abuse research. Given the importance of methadone maintenance as a harm-reduction strategy and clients' concerns about treatment, it is essential to understand perceptions and attitudes toward existing programs. Using data from the 2009 National HIV Behavioral Surveillance system with injection drug users in Denver, CO, we evaluated participants' experiences with methadone clinics and examined predictive factors associated with ever being a client of a methadone clinic. Costs of services, perceptions of staff not caring about the client, and attitudes toward the counseling services seemed to be the major barriers to program retention. Besides heroin use, previous attempt at self-detoxification and being infected with hepatitis C were the strongest predictors of ever being on methadone treatment. Addressing the barriers to program retention and encouraging treatment engagement are essential to embracing methadone maintenance as a harm-reduction strategy for injection drug users.     

Factors predicting retention in treatment: 10-year experience of a methadone maintenance treatment (MMT) clinic in Israel

The aims were to identify predictors of treatment retention in an Israeli methadone maintenance treatment (MMT) clinic, and to compare the findings to other international settings. We prospectively studied 492 patients admitted since 1993 through 10 years to an Israeli MMT clinic associated with a university-affiliated tertiary care medical center. Analyses (Kaplan Meier and Cox regression) included methadone dose and urinalysis results (for methadone, cocaine, opiates, benzodiazepines, THC, amphetamines) of each patient in the first month and after 1 year in treatment (or during the last month if the stay was >3 months and <1 year) and patients' characteristics (modified ASI). The 1-year retention rate was 74.4%; 65.8% stopped opiate abuse after 1 year in treatment. On admission, 13.6% of patients had used cocaine: there was a net decrease of 61.6% after 1 year. Factors predicting prolonged retention in MMT treatment (Cox regression) were daily methadone dose of 100mg or greater, negative urine for opiates after 1 year, and being a parent on admission. We conclude that our good outcome results (high rate of retention after 1 year (74.4%), high proportion of opiate abuse cessation (65.8%), and net reduction in cocaine abuse, similar to normal standards in other MMT clinics elsewhere in the world, justify the expansion of the MMT clinic network in Israel in order to make treatment available to all those who need it. A protocol favoring higher methadone dosage as appropriate is recommended.     

Structural-level factors affecting implementation of the methadone maintenance therapy program in China

This study identifies structural-level factors influencing methadone maintenance therapy (MMT) program implementation in China. Twenty-eight service providers and 560 randomly selected clients from 28 MMT clinics in the study area underwent face-to-face interviews. Number of clients, retention rate, coverage, and structural-level factors were collected from a survey of service providers. Individual-level factors and self-reported illicit drug use information were obtained from clients. Urine specimens were collected from the client participants to test for heroin use. Clinics affiliated with the local Centers for Disease Control and Prevention (CDC) had more clients, higher retention rates, and broader coverage than those not affiliated with the CDC. Longer operating hours, incentive for compliant clients, and comprehensive services were positively associated with client recruitment and coverage. Comprehensive services and incentives for compliant clients were negatively associated with concurrent illicit drug use. Comprehensive services should be incorporated into the MMT program. Extended operating hours and incentives for compliant clients should be implemented.     

分阶段综合个体心理干预对 MMT 受治者效果分析

目的：研究分阶段综合个体心理干预在美沙酮维持治疗中的效果。方法：将100例海洛因依赖者分为美沙酮个体心理干预组（研究组）和美沙酮维持治疗组（对照组）,比较组间治疗保持率、治疗12个月后抑郁自评量表、焦虑自评量表、家庭支持量表的差异。结果：分阶段综合个体心理干预技术能够提高美沙酮维持治疗受治者治疗保持率,治疗12个月后两组对比抑郁、焦虑、家庭支持量表评分均值有统计学差异（P〈0.05）。结论：个体心理干预能通过坚定海洛因成瘾者的戒毒愿望与信心,改善不良情绪,使患者在家庭关系方面都得到改善,帮助海洛因成瘾者彻底戒毒,真正回归社会。     

Counseling issues in methadone maintenance treatment.

This article reviews some of the issues and dilemmas faced by methadone maintenance treatment (MMT) programs counselors. The context in which MMT occurs sets the tone and constraints within which clinicians must find ways to be effective; negative attitudes and tensions with regulatory agencies have a strong impact. Coexisting disorders, particularly depression and thought disorders, are discussed and special medication considerations are noted. Counselor collaboration on medical issues, and dosing policies and practices are explored, as well as the clinical approach to tapering off methadone. The article examines helpful clinical strategies when clients continue to use heroin or other drugs, and explores psychological issues that frequently occur, women's issues, and problems that may arise when patients have human immunodeficiency virus-spectrum disease. It also reconsiders the role of family therapy. Several innovative and promising psychoeducational approaches are described and the potential integration of MMT with 12-Step programs is addressed. Recommendations are offered for training and supervision.     

Correlates of methadone client retention: a prospective cohort study in Guizhou province, China

BackgroundMethadone client retention levels and treatment doses of patients vary widely in methadone clinics across China. Because methadone clinics have been available in China only recently, this study explored the relationship between methadone dosage and client retention in methadone maintenance programmes in Guizhou province.MethodsThe study used a prospective cohort study design. Injecting and non-injecting heroin-using clients who had been treated for no more than two and half months in one of eight methadone maintenance treatment clinics in Guizhou province were recruited into the cohort, beginning on 3 June 2006 and followed up until 1 June 2007. A total of 1003 participants were enrolled. Face-to-face interviews were conducted to collect baseline information, and clients’ daily doses were recorded.ResultsThe 14-month retention rate was 56.2%. Controlling for other covariates in the multivariate Cox model, a higher methadone dose was found to predict higher client retention. Retention was also associated with intention to remain in treatment for life and the clinic attended.ConclusionClients need to receive an adequate methadone dose to assure continued retention. Patients who expect to be treated for life have higher retention rates than patients who anticipate only short-term treatment. Key factors associated with successful clinics in China need to be elucidated.     

An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research

AIM: To summarize the major findings of the five Cochrane reviews on substitution maintenance treatments for opioid dependence. METHODS: We conducted a narrative and quantitative summary of systematic review findings. There were 52 studies included in the original reviews (12,075 participants, range 577-5894): methadone maintenance treatment (MMT) was compared with methadone detoxification treatment (MDT), no treatment, different dosages of MMT, buprenorphine maintenance treatment (BMT), heroin maintenance treatment (HMT), and l-alpha-acetylmethadol (LAAM) maintenance treatment (LMT). MEASUREMENTS: Outcomes considered were retention in treatment, use of heroin and other drugs during treatment, mortality, criminal activity, and quality of life. FINDINGS: Retention in treatment: MMT is more effective than MDT, no treatment, BMT, LMT, and heroin plus methadone. MMT proved to be less effective than injected heroin alone. High doses of methadone are more effective than medium and low doses. Use of heroin: MMT is more effective than waiting list, less effective than LAAM, and not different from injected heroin. No significant results were available for mortality and criminal activity. CONCLUSIONS: These findings confirm that MMT at appropriate doses is the most effective in retaining patients in treatment and suppressing heroin use but show weak evidence of effectiveness toward other relevant outcomes. Future clinical trials should collect data on a broad range of health outcomes and recruit participants from heterogeneous practice settings and social contexts to increase generalizability of results.     

A qualitative inquiry into methadone maintenance treatment for opioid-dependent prisoners in Tehran,Iran

BackgroundThis study aimed to investigate the context in which methadone maintenance treatment (MMT) is provided for opioid-dependent prisoners, and to identify barriers against further scale-up of MMT in Ghezel Hesar prison in Tehran.MethodsThis was a cross-sectional qualitative study using field observations, focus group discussions, and individual interviews. In total, 30 prisoners and 15 prison staff and health policymakers participated in this study in November 2006.ResultsThe rate of drug injecting in the prison unit was unanimously reported to have decreased drastically since introducing the MMT program. In addition to the health benefits to MMT recipients, interview data indicates that MMT has had positive effects on socio-economic status of prisoners’ families. Nevertheless, several impediments to the provision of MMT services and to its further expansion were also identified, including staff shortages, some degree of methadone diversion, widespread concerns over the possible side effects of methadone, and the stigma attached to methadone treatment.ConclusionMMT constitutes one of the main components of the Iran Prison Organization's comprehensive HIV prevention package and is becoming increasingly accessible to opioid-dependent prisoners in Iran. Our findings indicate that the MMT program in Ghezel Hesar prison has been helpful for many opioid-dependent prisoners to reduce their risk of drug-related harm and to ease social and financial burden over their families. Meanwhile, existing barriers against provision of MMT should be properly addressed before further scale up of the program.     

海洛因成瘾者社区美沙酮维持治疗脱失和保持的定性研究

目的:了解四川省西昌市海洛因成瘾者社区美沙酮维持治疗脱失和保持情况及其影响因素。方法:2005年12月-2006年1月,从四川省西昌市美沙酮维持治疗社区中分别选取87名参加维持治疗的吸毒者和50名相关社区人员进行美沙酮维持治疗脱失和保持情况及影响因素的个人深入访谈。结果:西昌市参加社区美沙酮维持治疗的吸毒者脱失的主要原因是因偷吸而被强制戒毒和外出;保持的主要影响因素是参加治疗的吸毒者主动与吸毒伙伴减少来往和积极工作。社区对美沙酮的主要影响因素是美沙酮维持治疗的知晓和了解程度低、对参加治疗的吸毒者仍存在偏见。结论:应对美沙酮维持治疗的参加者开展干预服务提高保持率,同时加大社区宣传减少社会偏见。     

Effectiveness of Therapies for Heroin Addiction in Retaining Patients in Treatment: Results From the VEdeTTE Study

Treatment is effective in reducing heroin use and clinical and social problems among heroin addicts. The effectiveness is related to the duration of treatment. “VEdeTTE” is an Italian longitudinal study funded by the Ministry of Health to evaluate the effectiveness of treatments provided by the National Health Services. The study involved 115 drug treatment centers and 10,454 heroin users. Clinical and personal information were collected at intake through a structured interview. Treatments were recorded using a standardized form. Survival analysis and Cox Proportional Hazard model were used to evaluate treatment retention. Five thousand four hundred and fifty-seven patients who started a treatment in the 18 months of the study were included in the analysis: 43.2% received methadone maintenance therapy (MMT), 10.5% therapeutic community, and 46.3% abstinence-oriented therapy (AOT). The likelihood of remaining in treatment was 0.5 at 179 days. The median daily dose of methadone was 37 mg. Psychotherapy was provided in 7.6% of patients receiving methadone and 4.9% of those in therapeutic community. Type of therapy was the strongest predictor of retention, with AOT showing the lowest retention. In MMT patients, retention improved according to dose. Living alone, psychiatric comorbidity and cocaine use increased the risk of dropout. Psychotherapy associated halved the risk of dropout.     

德国的阿片类依赖替代治疗(英文)

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

美沙酮门诊患者尼古丁依赖检测量表中文版的信效度研究

目的獉獉:研究中文版尼古丁依赖检测量表(FTND)在吸烟美沙酮维持治疗(MMT)门诊患者中使用的信效度。方法獉獉:在深圳市三家MMT门诊选取217位吸烟MMT门诊患者自评完成一般情况问卷、FTND量表和Russell吸烟原因问卷(RRSQ);间隔2周后对其中60名患者进行FTND量表重测;采用信度分析、相关分析和因子分析评价量表的信效度。结果獉獉:FTND量表的Cronbachα系数为0.638,两周重测信度系数为0.797(P<0.01);FTND量表总分与RRSQ依赖分和每日吸烟量的校标关联效度系数分别为0.404和0.637(P均<0.01);因子分析提取了两个公因子,累积解释总变异的55.039%。结论獉獉:中文版FTND量表在吸烟MMT患者中具有较好的重测信度、校标关联效度和结构效度,但其内部一致性未达心理测量学要求,需要进一步修订。     

湖南北湖区开展美沙酮维持治疗社会经济学评价

目的:分析吸毒者参加美沙酮维持治疗前后的社会经济效益以及社会、心理、功能的恢复情况,为制订应对措施和进一步推广美沙酮维持治疗提供依据。方法:现场问卷调查和定性访谈。结果:吸毒人员在参加美沙酮维持治疗后,海洛因的使用率减少、就诊维持率相比较高,违法犯罪、就业学习情况、家庭社会关系及心理状态等方面的情况与参加治疗前相比都有所改善。结论:美沙酮维持治疗有助于吸毒人员恢复家庭、社会等功能,萎缩毒品市场,维护社会治安,提高社会经济效益,是值得推广的有效方法。     

影响美沙酮维持治疗依从性及相关因素的定性研究

目的:了解北京市社区美沙酮维持治疗(methadone maintenance treatment,MMT)脱失和保持的影响因素。方法:根据课题设计,于2007年12月-2008年9月,在北京市社区药物维持治疗门诊选择29名服药人员,对每位服药人员单独进行深入访谈,归纳总结服药人员脱失和保持的影响因素。结果:脱失的主要影响因素是:服药人员对美沙酮药物本身或/和MMT普遍存在不正确认知、服药期间偷吸毒品、缺乏必要的社会心理干预、个别服药人员缴费困难、存在服药不够便利的问题和公安部门的配合仍需提高等;有利于保持的因素是:家人支持、给药剂量合适、门诊工作人员的服务态度积极等。结论:加大MMT政策和相关知识的宣传力度,对MMT服药人员积极开展社会心理干预活动,针对北京市美沙酮维持治疗的薄弱环节采取有针对性的防治措施,降低脱失率。     

What is low threshold methadone maintenance treatment?

BackgroundLow threshold methadone maintenance (MMT) was developed for clients who do not have abstinence as a treatment goal. We explored how MMT programs in Canada defined low threshold and the challenges they faced.MethodsUsing semi-structured interviews, we collected data from clients (n = 46), nurses/counsellors (n = 15) and physicians (n = 9) at three low threshold MMT programs. All participants were asked to define low threshold MMT and describe how it was implemented in practice. Interviews were taped, transcribed, verified and analysed using an iterative thematic coding technique.ResultsLow threshold MMT was defined by an explicit rejection of abstinence from opiates and other drugs as an over-arching treatment goal. In the absence of guidelines defining a set of practices as low threshold, programs implemented practices they believed would reduce barriers to admission and help retention. There was not always agreement between professional groups or across the programs regarding these practices. For physicians, there was a tension between accepting poly-drug use during treatment as a means to improve retention, with an obligation to do more good than harm for their patients. Missed prescribing appointments generated few to severe consequences and revealed differential focus on reducing barriers versus encouraging client ‘ownership’ of treatment. Differences of opinion regarding appropriate urine drug testing practices revealed power dynamics between medical and non-medical staff.ConclusionOur findings show that there are potentially more ways to reduce barriers to MMT than those presented in the current literature. Our findings are important given the growing number of people with opiate dependence across the world and calls to increase access to MMT. To fully develop the low threshold model, it will be important to evaluate what policies and practices can achieve the goals of reducing barriers to admission and improving retention in treatment.     

Stigma towards people who use drugs: A case vignette study in methadone maintenance treatment clinics in China

BackgroundDrug use stigma among service providers has been recognized as a barrier to improving the accessibility and outcomes of addiction treatment. This study examined the stigmatizing attitudes towards people who use drugs (PWUD) among service providers in methadone maintenance treatment (MMT) clinics in China and its associated factors.MethodsThe cross-sectional study used the baseline data of a randomized intervention trial conducted in China, and the data were collected from January 2012 to August 2013. A total of 418 MMT service providers were included in the study. Stigma towards PWUD was measured via a 10-item scale embedded in two case vignettes (PWUD and non-PWUD). The Wilcoxon signed-rank test was performed to evaluate the vignette difference for each item of the scale. The linear mixed model was used to identify the adjusted association between drug use stigma and other interested variables including demographics, professional background, and MMT knowledge of the service providers.ResultsThe Wilcoxon signed-rank tests showed that the participants had a higher level of stigmatizing attitudes towards PWUD than non-PWUD (p-value<0.001 for all items of the stigma scale). The linear mixed model identified that the reception of national MMT training was associated with a lower degree of drug use stigma (estimate=−1.79; 95% CI: −3.13, −0.45; p-value = 0.009).ConclusionThe findings of the study provide evidence of the existence of drug use stigma among MMT providers in China. The expansion of national-level training and the development of stigma reduction interventions are needed to address this issue.     

Cox模型预测云南省美沙酮维持治疗早期脱失的风险因素分析

目的：云南省美沙酮维持治疗早期脱失相关因素分析。方法：用队列研究的方法观察2009年3月1日至8月31日期间,218例第一次入组美沙酮门诊的调查对象,并随访到2010年2月28日。美沙酮剂量的记录来自于门诊的数据库。利用Cox回归模型进行数据分析。结果：在第1、2个阶段美沙酮剂量和脱失之间没有关系,而在3个月后高剂量组（〉60mg）脱失的可能性较小。脱失还与汉族（HR=1．86,95％CI：1．65—3．26）、到达门诊时间超过30分钟（HR=1．63,95％CI：1．07—2．49）及与药物滥用者住在一起（HR=2．71,95％CI：1．55-4．74）有关。结论：病人早期脱失和民族、门诊可及性、和药物滥用者居住在一起以及美沙酮的剂量有关。推荐使用更高剂量的美沙酮可能对美沙酮维持治疗更有用。     

Trends in methadone maintenance treatment participation,retention, and compliance to dosing guidelines in British Columbia,Canada: 1996–2006

Aspects of methadone maintenance treatment (MMT) delivery, particularly daily dosing practices, are associated with longer retention in treatment. Our objective was to identify trends in compliance to MMT dosing guidelines at the population level in British Columbia, Canada, from 1996 to 2006. Analysis of a provincial drug dispensation database identified 31,724 MMT episodes initiated during the study period. The number of patients in treatment increased from 2,827 in 1996 to 9,601 in 2006. Long-term retention (>36 months) was achieved in 20%–25% of all episodes. Compliance to minimally effective dose guidelines, which is independently associated with retention, fell from 2001 to 2006. Accordingly, this decline was mirrored by 12-month retention figures, which fell from 45.9% in 2001 to 40.5% in 2005. Our evaluation has both highlighted the successes of the British Columbia Methadone program and identified aspects that may be improved to ensure safety and maximize the benefits of MMT.