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.     

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.     

Gender Differences and Correlated Factors of Heroin Use Among Heroin Users

Background: Gender differences in illicit drug use are becoming increasingly recognized. However, there are few studies concerning differences between male and female heroin users in China. Objectives: The study aimed to explore gender differences in terms of socio-demographic characteristics, drug-related behaviors, and treatment history among a heroin-using population in China. Methods: A cross-sectional study was conducted in four cities in December 2013. A total of 788 participants were recruited from several types of sites in each city: compulsory detoxification centers, methadone maintenance treatment clinics, and detention facilities. The data were collected via a self-administered questionnaire. Analysis of variance, chi-square test, and multivariate logistic regression analyses were conducted to examine gender differences in socio-demographic characteristics, drug-related behaviors, and treatment history. Results: Female heroin users were more likely to be unemployed, have more education, and use heroin with their spouse/companion (p <.05). Male heroin users were more likely to be in detention facilities and MMT clinics, and relapse when they felt hopeless (p <.05). Conclusions/Importance: Although there were some similarities between male and female heroin users, significant gender differences do exist in some aspects of socio-demographic characteristics and heroin use. The data provide evidence that interventions aimed at preventing the initiation of heroin use and reducing relapse should take gender into account.     

WHO协作研究项目-阿片类依赖的替代治疗和HIV/AIDS:泰国的研究结果

背景:静脉注射海洛因使用者中,HIV感染率上升已成为众多国家日益突出的严重问题.为海洛因依赖者提供美沙酮维持治疗可以降低与注射相关的HIV传播的危险.美沙酮维持治疗研究在工业化国家已经广泛开展,但在发展中国家/转型国家开展的研究较少.世界卫生组织(WHO)在包括泰国在内的发展中国家开展了多中心美沙酮维持治疗研究.目的:对曼谷大都市行政区(BMA)药物治疗门诊开展的阿片类替代治疗和HIV/AIDS的治疗过程和结果进行评估.方法:对BMA 4个门诊收治的118例参加美沙酮维持治疗者在治疗的两周内(基线调查)、3个月和6个月(随访)进行调查.调查的内容包括:药物使用情况、注射危险、身体和社会功能.在基线调查时采集了参加治疗者的血样本,对血清HIV和丙型肝炎情况进行分析.由独立评估人员在4个诊所进行了过程评估.他们对参加治疗者、工作人员和社区居民进行独立访谈,对项目的完成情况、实施情况及质量进行评估.结果:3个月、6个月的治疗保持率分别为:81% 和68%;平均海洛因使用的时间从基线调查前30 d的22 d降到6个月调查时的2 d;注射危险行为从基线调查时报告的38%降到6个月调查时的11%;使用其他药物的情况也有所减少,健康状况有所好转.过程评估显示,治疗的标准合适,病人、工作人员和社区居民对美沙酮维持治疗比较满意.结论:曼谷正在成功实施美沙酮维持治疗,结果使海洛因使用和注射危险行为明显减少.得出的结果支持在泰国和其他发展中国家/转型国家扩大美沙酮维持治疗项目.     

Injection opioid use as a predictor of treatment outcomes among methadone-maintained opioid-dependent patients

BackgroundInjection opioid use is associated with more severe health and psychosocial consequences relative to non-injection use, but few studies have examined whether injection use is associated with methadone maintenance treatment outcomes. The present study examined differential MMT outcomes among opioid injectors and non-injectors.MethodsData were extracted from the clinic charts of opioid-dependent MMT patients (N = 290; n = 115 injectors) enrolled in a university-affiliated, urban MMT clinic. Injection status was examined as a predictor of short- (3-month opioid, cocaine, benzodiazepine and cannabis urine drug screens) and long- (days retained in treatment) term MMT outcomes.ResultsBivariate analyses revealed injection users were less likely to be African American and to have completed high school, were more likely to have started heroin use before age 21, to report having hepatitis C, to report a baseline cocaine use disorder, and had higher methadone doses at 3-months into treatment. Injection status significantly predicted a greater proportion of cocaine-positive urine drug screens in the first 3 months of treatment, but did not significantly predict opioid, benzodiazepine or cannabis drug screens, or length of treatment retention.ConclusionThis is one of a handful of studies to examine injection status as a predictor of MMT outcomes. Injection status is associated with cocaine use early in treatment, which has implications for the focus of treatment.     

WHO协作研究项目—阿片类依赖的替代治疗和HIV/AIDS：泰国的研究结果

背景：静脉注射海洛因使用者中,HIV感染率上升已成为众多国家日益突出的严重问题。为海洛因依赖者提供美沙酮维持治疗可以降低与注射相关的HIV传播的危险。美沙酮维持治疗研究在工业化国家已经广泛开展,但在发展中国家/转型国家开展的研究较少。世界卫生组织（WHO）在包括泰国在内的发展中国家开展了多中心美沙酮维持治疗研究。目的：对曼谷大都市行政区（BMA）药物治疗门诊开展的阿片类替代治疗和HIV/AIDS的治疗过程和结果进行评估。方法：对BMA4个门诊收治的118例参加美沙酮维持治疗者在治疗的两周内（基线调查）、3个月和6个月（随访）进行调查。调查的内容包括：药物使用情况、注射危险、身体和社会功能。在基线调查时采集了参加治疗者的血样本,对血清HIV和丙型肝炎情况进行分析。由独立评估人员在4个诊所进行了过程评估。他们对参加治疗者、工作人员和社区居民进行独立访谈,对项目的完成情况、实施情况及质量进行评估。结果：3个月、6个月的治疗保持率分别为：81%和68%;平均海洛因使用的时间从基线调查前30d的22d降到6个月调查时的2d;注射危险行为从基线调查时报告的38%降到6个月调查时的11%;使用其他药物的情况也有所减少,健康状况有所好转。过程评估显示,治疗的标准合适,病人、工作人员和社区居民对美沙酮维持治疗比较满意。结论：曼谷正在成功实施美沙酮维持治疗,结果使海洛因使用和注射危险行为明显减少。得出的结果支持在泰国和其他发展中国家/转型国家扩大美沙酮维持治疗项目。     

Active Heroin Injectors' Perceptions and Use of Methadone Maintenance Treatment: Cynical Performance or Self-Prescribed Risk Reduction?

In addition to the numerous heroin users who voluntarily enter methadone treatment as a way to free themselves from illicit drug addiction and those ordered to do so by the courts, there are a large number of opioid users who enter methadone treatment with other objectives in mind. These include shorter-term goals that users do not necessarily equate with complete heroin abstinence. In this paper we report the results of a qualitative study designed to identify and describe the motivations active heroin users have for entering methadone treatment, and to suggest that many of these short-term methadone episodes may operate as self-prescribed attempts at risk reduction, and act as pilot tests for users considering or anticipating entering treatment to quit the use of illicit drugs. We argue that heroin users' motivations, perceptions about methadone, and the strategies they devise for adapting methadone treatment for their own needs should be recognized for their value in reducing the multiple risks associated with drug use.     

The Cedar Project: methadone maintenance treatment among young Aboriginal people who use opioids in two Canadian cities

Introduction and Aims. The Cedar Project is a community‐based study aiming to identify variables associated with ever being on methadone maintenance treatment (MMT) among young Aboriginal people using drugs and to discuss possible barriers to MMT in this population. Design and Methods. This is a prospective cohort study with recruitment by health‐care providers, outreach, and word of mouth in Vancouver and Prince George. Participants included 605 Aboriginal participants who were age 14–30 years, reported illicit drug use in the month prior to enrolment, and provided written informed consent. Variables associated with ever being on MMT were analysed through χ²‐testing and multivariate logistic regression, limited to people reporting opioid use (n = 397). Results. Less than half of participants reporting daily injection of opioids had ever been on MMT. In adjusted multivariate logistic regression analyses, older age [odds ratio (OR) 1.17; 95% confidence interval (CI) 1.08–1.28)]; female gender (OR 3.76; 95% CI 2.00–7.07); hepatitis C antibody positivity (OR 2.76; 95% CI 1.53–4.95); and daily opioid injection (OR 2.59; 95% CI 1.46–4.61) were positively associated with ever being on MMT. Weekly or more alcohol use (OR 0.43; 95% CI 0.21–0.87) was negatively associated with ever being on MMT. Discussion and Conclusion. MMT access by young Aboriginal people is low. The associations between MMT use and other variables need further study to steer efforts directed at recruitment into MMT. The removal of barriers to MMT and inclusion of young Aboriginal people in the development of treatment programs based on Indigenous values are urgently required to help Aboriginal people who use drugs.[Yang J, Oviedo‐Joekes E, Christian KWM, Li K, Louie M, Schechter M, Spittal P. The Cedar Project: Methadone maintenance treatment among young Aboriginal people who use opioids in two Canadian cities. Drug Alcohol Rev 2011;30:645–651]     

贵州美沙酮维持治疗受治者间隔服药特点的观察

目的:了解贵州省8家美沙酮维持治疗(MMT)门诊的受治者间隔服药特点。方法:采用队列研究设计,从2006年6月到2007年6月,对1003名贵州省8家MMT门诊受治者进行服药情况调查。结果:有87.1%、74.9%、60.6%和50.3%受治者分别有过连续3d、7d、15d和30d间隔不到门诊服药情况。结论:MMT受治者间隔服药现象十分普遍。     

Active heroin injectors' perceptions and use of methadone maintenance treatment: cynical performance or self-prescribed risk reduction?

In addition to the numerous heroin users who voluntarily enter methadone treatment as a way to free themselves from illicit drug addiction and those ordered to do so by the courts, there are a large number of opioid users who enter methadone treatment with other objectives in mind. These include shorter-term goals that users do not necessarily equate with complete heroin abstinence. In this paper we report the results of a qualitative study designed to identify and describe the motivations active heroin users have for entering methadone treatment, and to suggest that many of these short-term methadone episodes may operate as self-prescribed attempts at risk reduction, and act as pilot tests for users considering or anticipating entering treatment to quit the use of illicit drugs. We argue that heroin users' motivations, perceptions about methadone, and the strategies they devise for adapting methadone treatment for their own needs should be recognized for their value in reducing the multiple risks associated with drug use.     

Barriers associated with the treatment of hepatitis C virus infection among illicit drug users

BACKGROUND: Illicit drug users account for the majority of cases of HCV infection in the developed world, but few have received treatment. METHODS: We evaluated barriers to initiating HCV treatment -- including general treatment willingness -- and factors associated with these among HCV infected illicit drug users. Participants were recruited via convenience sampling from two community clinics in Canada. Individuals age >18 years with a history of illicit drug use completed interviewer-administered surveys. Those reporting positive HCV testing underwent additional questioning on willingness, uptake and barriers to treatment for HCV. RESULTS: Of 188 HCV positive illicit drug users, 16% (n=30) had received treatment for HCV. Factors associated with a decreased treatment uptake included current heroin use and HIV/HCV co-infection. Among those not having received therapy, 77% (117/153) indicated a willingness to receive HCV treatment. Factors associated with treatment willingness included not being infected with HIV, having not recently used drugs by injection and having reported physical health problems. Among those not having sought HCV treatment (n=107), the major reasons for not doing so were: lack of information about HCV or knowledge that treatment was available (23%), the absence of symptoms (20%) and the perceived side effects of treatment (14%). CONCLUSIONS: Among illicit drug users attending inner city clinics, we have observed a low uptake of HCV treatment, but a high willingness to receive therapy. An increased focus on improving education about the long-term consequences of HCV and the availability of effective treatment are important components for expanding HCV treatment among illicit drug users.     

Is inhalant use a risk factor for heroin and injection drug use among adolescents in the United States?

PURPOSE: We examined whether inhalant use was associated with heroin and injection drug use (IDU) among adolescents aged 12 to 17 in the United States. METHODS: Data were drawn from the 2002/2003 administrations of the National Survey on Drug Use and Health (NSDUH). We conducted logistic regression analyses to estimate associations of inhalant use with heroin use, heroin injection, and IDU, respectively, among adolescent drug users (N=8161). RESULTS: Approximately 30.9% of adolescents had ever used at least one illicit drug. More than one-fifth (22.2%) of adolescents were past-year or recent drug users. Among past-year adolescent drug users, 1.4% had progressed to heroin use and 1.2% reported IDU. Adolescents who had used inhalants and marijuana were 2.8 and 2.9 times as likely as adolescents who had used marijuana but not inhalants to report heroin use and any IDU, respectively. Adolescents who had used inhalants or other drugs but not marijuana were unlikely to use heroin. However, inhalant users, irrespective of their marijuana use histories, had greater odds of IDU than drug users who had not used inhalants. Adolescent drug users who were females, school dropouts, whites, or delinquents had significantly increased odds of heroin use and IDU. Cigarette smoking before the age of 15 was strongly associated with heroin use, and a history of foster care placement was associated with IDU. CONCLUSIONS: This national study of American adolescents identifies several subgroups of recent drug users, such as females, school dropouts, and youth who have used inhalants and marijuana, which have substantially increased odds of heroin use and IDU. Screening, prevention, and treatment interventions targeted to these groups might reduce medical and social complications of heroin use and IDU.     

Alcohol and cocaine use and abuse among opioid addicts engaged in a methadone maintenance treatment program

Alcohol and cocaine abuse result in unsatisfactory treatment outcomes for heroin and illicit opioid addicts engaged in Methadone Maintenance Treatment Programs (MMTPs). This study aims to clarify the impact of MMT, which focuses on cessation of opioid abuse and diminishing psychopathology to acceptable levels (stabilization) on alcohol and cocaine abuse. Of specific interest was whether reduction of polysubstance abuse and associated psychopathological complications diminished illicit opioid abuse and/or increased retention in treatment. Changes in cocaine and alcohol use that occurred in 53 heroin addicts who had been stabilized were monitored. A control group was composed of patients terminated from treatment due to noncompliance with treatment recommendations, poor attendance, or failure to have opioid abuse stabilized, within a year. The association of psychiatric severity with alcohol and cocaine abuse in these methadone maintained patients was assessed. Cessation of illicit opioid abuse and retention in treatment are positively correlated with decrease in alcohol and cocaine abuse and the absence of the psychosocial complications associated with such abuse.