Cost-effectiveness of center-based compulsory rehabilitation compared to community-based voluntary methadone maintenance treatment in Hai Phong City, Vietnam

Provider costs of treating opioid dependence with extended-release buprenorphine in Australia

INTRODUCTION

The costs of providing medication-assisted treatment for opioid dependence can determine its scale of provision. To provide estimates of the costs of extended-release buprenorphine (BUP-XR), we performed a bottom-up costing analysis of provider operational treatment costs.

METHODS

Data were collected in a single-arm open label trial of BUP-XR injections conducted in specialist public drug treatment services and primary care private practices in three Australian states (the CoLAB study). The unit costs of resources used for each activity were combined with quantities used at each participating facility to arrive at the average annual cost per client.

RESULTS

One hundred participants across the six health facility sites received monthly subcutaneous BUP-XR injections administered by a health-care practitioner. The average cost of providing 1 year of treatment per participant was $6656 ($6026-$8326). Screening cost (initial assessment and medical history) was $282 while monthly follow-up appointments cost $531 per client. The main cost driver was the monthly treatment costs accounting for 79% of the average annual client cost, with medication costs comprising 95% of this cost.

DISCUSSION AND CONCLUSION

With medication costs making up the largest proportion of treatment costs, treatment using BUP-XR has the potential to free up other health system resources, for example, staff time. The costs reported in this study can be used in an economic evaluation to estimate the net benefit or cost-effectiveness of BUP-XR especially when compared to other opioid agonist treatments.

"If they get out of drug rehab centers, they're on their own": Opportunities and challenges for people released from compulsory drug rehabilitation centers to communities in Vietnam

INTRODUCTION

Compulsory drug rehabilitation is a major governmental response to illicit drug use in Vietnam and other countries in Asia. Long-term compulsory rehabilitation is associated with negative health, social and economic outcomes. The transition to community-based services for people released from compulsory drug rehabilitation has been problematic not only in Vietnam. This study utilized the WHO Health System Building Blocks Framework to examine the opportunities and challenges for people with substance use disorders (SUD) who are released from compulsory drug rehabilitation back into the community.

METHODS

Between October 2021 and August 2022, we interviewed people with SUD who had recently returned from or were preparing to leave compulsory drug rehabilitation (n = 25), their family members (n = 20) and professionals working in the field of drug rehabilitation (n = 28) across three cities in Vietnam. Additionally, we conducted a review of policy documents to complement the interview data.

RESULTS

The study identified opportunities and challenges within Vietnam's drug rehabilitation system concerning leadership and governance, financing, workforce, information systems and service delivery for people with SUD. Key opportunities include a legal framework that emphasizes community-based support for people with SUD, a government-funded national network of lay social workers, and ongoing efforts to connect people to community-based services. We found significant challenges caused by the lack of clear instructions for implementing supportive policies, inadequate funding for community-based services, persisting stigma from providers towards people with SUD and unavailability of community-based drug treatment other than methadone.

CONCLUSION

Vietnam continues with compulsory drug rehabilitation yet endorses recovery-oriented policies to address substance use issues. Substantial challenges hinder the effective implementation of these policies. Our study recommends reinforcing existing policies and enhancing recovery-oriented community-based services by improving the quality of data collection, building capacity of lay social workers who facilitate linkages to services and expanding community-based drug treatment options.

Continuity of opioid substitution treatment between prison and community in Southeast Asia: A scoping review

BACKGROUND

Criminalisation of drug use and compulsory detention has largely characterised the Southeast Asia region's response to people who use drugs. Whilst access to and provision of healthcare for people living in prison are mandated by international human rights standards, many opioid dependent people living in prison continue to lack access to opioid substitution treatment (OST) during incarceration, and face uncertainties of continuity of care beyond the prison gate.

METHODS

A scoping review using Arksey and O'Malley's framework mapped what is currently known about the continuity of OST post-release in Southeast Asia, with a focus on the three countries (Indonesia, Malaysia, Vietnam) that provide OST in at least one prison. A multi-lingual systematic search (English, Malay, Indonesian, Vietnamese) on Medline, CINAHL, Scopus, Web of Science, PsycINFO and the Cochrane Library collected and reviewed extant relevant published empirical and grey literature including government reports between 2011 and 2021. Of the 365 records found, 18 were eligible for inclusion following removal of duplicates and application of exclusion criteria. These records were charted and thematically analysed.

RESULTS

Three main themes were generated: Facilitators of post release continuity of care, Barriers to post release continuity of care and Therapeutic considerations supporting post release continuity of care. When individual and structural gaps exist, disruptions to continuity of OST care post release are observed. Adequate methadone dosage of >80mg/day appears significantly associated with retention in post-release OST.

CONCLUSIONS

The review highlights the facilitators, barriers and therapeutic considerations of continuity of care of OST between prison and community for people living in prisons from Indonesia, Malaysia and Vietnam. Improving community services with family support are key to supporting continued OST adherence post release along with reducing societal stigma towards people who use drugs and those entering or leaving prison. Further efforts are warranted to ensure parity, quality and continuity of OST care post release.

A prospective, multisite implementation-efficacy trial of a collaborative prescriber-pharmacist model of care for Medication Assisted Treatment for Opioid Dependence: Protocol for the EPIC-MATOD study

BACKGROUND

Medication Assisted Treatment for Opioid Dependence (MATOD) is clinically effective and cost effective, yet a lack of MATOD prescribers in the community limits access to this treatment in Australia. These shortages are often greatest in regional and rural areas.

OBJECTIVE(S)

The Enhancing Pharmacist Involvement in Care (EPIC)-MATOD study will evaluate clinical and implementation outcomes among people with opioid dependence receiving MATOD through a collaborative pharmacist-prescriber model of care across multiple sites in a regional location (encompassing a mix of metropolitan and non-metropolitan areas) of Victoria, Australia.

METHODS AND ANALYSIS

The EPIC-MATOD study is a prospective, multisite, implementation trial of collaborative MATOD care. Pharmacists and prescribers will be recruited through the local network of opioid pharmacotherapy providers. Patients will be recruited through participating healthcare providers. After induction into the collaborative care model, patients and healthcare professionals will be followed up over 6- (patients) and 12-months (pharmacists and prescribers) in a hybrid implementation-efficacy study, with outcomes mapped to the RE-AIM framework. The primary clinical efficacy endpoint is patient retention in treatment at 26 weeks. The primary implementation outcome is treatment capacity, based on prescriber time required to provide treatment through collaborative care compared with traditional care. Secondary clinical endpoints include attendance for dosing and clinical reviews, substance use, mental and physical health and overall well-being. Implementation costs, acceptability, and provider engagement in collaborative care will be used as secondary implementation outcome indicators. Time and costs associated with collaborative care, and health service utilisation, will also be estimated.

PROJECT IMPACT

The study will provide important information on outcomes and acceptability of collaborative care for MATOD, as well as the cost and key considerations in delivering a collaborative model of care in Australia and other countries where similar treatment barriers exist.

Outcomes of a single-arm implementation trial of extended-release subcutaneous buprenorphine depot injections in people with opioid dependence

BACKGROUND

Opioid agonist treatment (OAT) is an effective intervention for opioid dependence. Extended-release buprenorphine injections (BUP-XR) may have additional potential benefits over sublingual buprenorphine. This single-arm trial evaluated outcomes among people receiving 48 weeks of BUP-XR in diverse community healthcare settings in Australia, permitting examination of outcomes when BUP-XR is delivered in standard practice.

METHODS

Participants were recruited from a network of specialist public drug treatment services, primary care and some private practices in three states. Following a minimum 7 days on 8-32 mg of sublingual buprenorphine (±naloxone), participants received monthly subcutaneous BUP-XR injections administered by a healthcare practitioner and completed monthly research interviews. The primary endpoint was retention in treatment at 48 weeks.

FINDINGS

Participants (n = 100) were 28% women, mean age 44 years with a long history of OAT (median 5.8 years); heroin was the most common opioid of concern (58%). Treatment retention at 24 and 48 weeks was 86% and 75%, respectively. Participants with past-month injecting drug use (OR 0.23; 95%CI: 0.09-0.61) or heroin use (OR 0.23; 95%CI: 0.08-0.65) at baseline had lower odds of being retained in treatment to 48 weeks. Reductions in multiple forms of extra-medical drug use were observed. Improvements in quality of life, participation in employment, and treatment satisfaction measures were also observed.

INTERPRETATION

This real-world implementation study of BUP-XR demonstrated high retention and treatment satisfaction. This study provides important additional data on the uptake and experience of clients, with relevance for policy makers, health service planners, administrators, and practitioners.

FUNDING

Indivior.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03809143.

A Quasi-Experimental Study on the Effectiveness of Compulsory and Voluntary Treatment Settings for 1,299 Drug Abusers in Hunan, China

Background: Although the type and structure of substance abuse treatment have changed, the overall approaches of drug rehabilitation in China has remained largely unchanged. Evidence of effectiveness for compulsory drug rehabilitation centers (CRCs) and voluntary drug rehabilitation centers (VRCs) remains mixed. The main objective of our study is to reveal the outcomes of CRCs and VRCs and examine the factors associated with relapse in these two centers. Methods: In this cross-sectional study, we recruited a total of 1,299 drug abusers in Hunan Province, 709 from CRCs and 590 from VRC, respectively. We used Pearson chi-squared test and t-test to examine the differences in demographics and drug-related characteristics. Binary logic regression was used to examine the relationship between important factors and relapse in CRCs and VRC. Results: Patients from CRCs and VRC significantly differed in age, sex, types of drug used, medical illness, education, occupation, mental illness, and marital status. After drug rehabilitation, both groups both had improved in occupation, family support, and social function (p < 0.05). In addition, employment and family support were significantly associated with a decreased risk of relapse (p < 0.05). Conclusion: This study revealed that compulsory rehabilitation is as effective as voluntary rehabilitation in (1) getting jobs and increasing monthly income, (2) having a good relationship with family, and (3) becoming more satisfied with their spared time. The components of these two settings were very different and may imply the necessity of these two approaches in China. In addition, employment and family support may prevent relapse.

Economic Evaluations of Pharmacologic Treatment for Opioid Use Disorder: A Systematic Literature Review

OBJECTIVE

The crisis of opioid use puts a strain on resources in the United States and worldwide. There are 3 US Food and Drug Administration-approved medications for treatment of opioid use disorder: methadone, buprenorphine, and injectable extended-release naltrexone (XR-NTX). The comparative effectiveness and cost vary considerably among these 3 medications. Economic evaluations provide evidence that help stakeholders efficiently allocate scarce resources. Our objective was to summarize recent health economic evidence of pharmacologic treatment of opioid use disorder interventions.

METHODS

We searched PubMed for peer-reviewed studies in English from August 2015 through December 2019 as an update to a 2015 review. We used the Drummond checklist to evaluate and categorize economic evaluation study quality. We summarized results by economic evaluation methodology and pharmacologic treatment modality.

RESULTS

We identified 105 articles as potentially relevant and included 21 (4 cost-offset studies and 17 cost-effectiveness/cost-benefit studies). We found strengthened evidence on buprenorphine and methadone, indicating that these treatments are economically advantageous compared with no pharmacotherapy, but found limited evidence on XR-NTX. Only half of the cost-effectiveness studies used a generic preference-based measure of effectiveness, limiting broad comparison across diseases/disorders. The disease/disorder-specific cost-effectiveness measures vary widely, suggesting a lack of consensus on the value of substance use disorder treatment.

CONCLUSION

We found studies that provide new evidence supporting the cost-effectiveness of buprenorphine compared with no pharmacotherapy. We found a lack of evidence supporting superior economic value for buprenorphine versus methadone, suggesting that both are attractive alternatives. Further economic research is needed on XR-NTX, as well as other emerging pharmacotherapies, treatment modalities, and dosage forms.

Detaining people who use drugs in Cambodia: A dual-track system

Reports focusing on drug detention centres in Cambodia have predominantly been concerned with documenting conditions and human rights abuses in the government centres, while highlighting the failure of the Royal Government of Cambodia (RGC) to adopt a human rights and public health-based approach to substance use issues. They have not focused as extensively on the underlying institutional, legal and regulatory reasons that help explain, though not justify, the RGC's law-enforcement-based approach to illicit substance use in Cambodia. Therefore, this policy analysis examines Cambodia's legal and regulatory set-up, in particular how the criminal provisions of the laws governing substance use combined with the administrative mechanisms in place shape the county's drug-related practices. This paper is based on a wide-ranging literature review of primary legislative and interpretive material; international human rights, public health and drug control instruments; research papers and international reports from multilateral agencies, international non-governmental organisations, civil society and academic experts. Qualitative interviews were also carried out with key international agency, national and international NGO officers. By examining the Law on the Control of Drugs (2012), the RGC's main law covering substance use, as well as relevant administrative provisions, it becomes apparent that there are two parallel systems in place for sending people to drug detention centres in Cambodia: one based on criminal law and the other through an 'alternative' administrative avenue. This division constitutes a structural fragmentation, or two 'parallel tracks', that provide law enforcement and other relevant RGC agencies with a wide sphere of discretion for how to address drug-related issues. The result is an enhanced risk of serious human rights violations for people who use drugs in Cambodia.

Quality of life as a predictor of time to heroin relapse among male residents following release from compulsory rehabilitation centres in Vietnam

INTRODUCTION AND AIMS

Quality of life (QOL) is a relevant and quantifiable outcome of drug dependence treatment. We assessed health-related QOL for people released from three centre-based compulsory treatment (CCT) centres in Vietnam, using the EQ-5D. The study aimed to examine the prognostic value of health-related QOL in relation to time to relapse to heroin use among the participants.

DESIGN AND METHODS

Two hundred and eight CCT participants with heroin dependence were interviewed at release, and at 3, 6 and 12 months post-release. Health-related QOL was measured with the EQ-5D. Kaplan-Meier survival models were fitted using Cox modelling to examine the rate, timing and prediction of the number of days to heroin relapse and to examine the predictability of the health-related QOL measures for days to relapse. Relapse was defined as first time of heroin use.

RESULTS

The study found a substantial relapse rate (85.6%) among participants within 12 months following release from CCT centres; the mean number of days to relapse was 57.7 (SD = 31.6). There was no statistically significant change over time in the mean values of health-related QOL (P = 0.11). While the total index score (across the five pre-specified EQ-5D domains) did not have a significant effect in predicting cumulative relapse, lower scores on the Visual Analogue Scale of the EQ-5D were significantly (P < 0.05) predictive of cumulative relapse, with adjusted hazard ratios for relapse of 0.987 (P = 0.013).

DISCUSSION AND CONCLUSIONS

EQ-5D Visual Analogue Scale score is a useful predictor of cumulative heroin relapse among participants released from CCT centres.

Open-label, multicentre, single-arm trial of monthly injections of depot buprenorphine in people with opioid dependence: protocol for the CoLAB study

INTRODUCTION

Opioid agonist treatment is effective for opioid dependence and newer extended-release buprenorphine (BUP-XR) injections represent a significant development. The Community Long-Acting Buprenorphine (CoLAB) study aims to evaluate client outcomes among people with opioid dependence receiving 48 weeks of BUP-XR treatment, and examines the implementation of BUP-XR in diverse community healthcare settings in Australia.

METHODS AND ANALYSIS

The CoLAB study is a prospective single-arm, multicentre, open-label trial of monthly BUP-XR injections in people with opioid dependence. Participants are being recruited from a network of general practitioner and specialist drug treatment services located in the states of New South Wales, Victoria and South Australia in Australia. Following a minimum 7 days on 8-32 mg of sublingual buprenorphine (±naloxone), participants will receive monthly subcutaneous BUP-XR injections administered by a healthcare practitioner at intervals of 28 days (-2/+14 days). The primary endpoint is participant retention in treatment at 48 weeks after treatment initiation. Secondary endpoints will evaluate dosing schedule variations, craving, withdrawal, substance use, health and well-being, and client-reported treatment experience. Qualitative and costing substudies will examine implementation barriers and facilitators at the client and provider level.

ETHICS AND DISSEMINATION

The study has received ethics approval from the St Vincent's Hospital Sydney Human Research Ethics Committee (Ref. HREC/18/SVH/221). The findings will be disseminated via publication in peer-reviewed journals, presentations at national and international scientific conferences, and in relevant community organisation publications and forums.

TRIAL REGISTRATION NUMBER

NCT03809143 PROTOCOL IDENTIFIER: CoLAB1801, V.4.0 dated 01 August 2019.

Perceptions of extended-release buprenorphine injections for opioid use disorder among people who regularly use opioids in Australia

AIMS

To examine perceptions of extended-release (XR) buprenorphine injections among people who regularly use opioids in Australia.

DESIGN

Cross-sectional survey prior to implementation. XR-buprenorphine was registered in Australia in November 2018.

SETTING

Sydney, Melbourne and Hobart. Participants A total of 402 people who regularly use opioids interviewed December 2017 to March 2018.

MEASUREMENTS

Primary outcome concerned the proportion of participants who believed XR-buprenorphine would be a good treatment option for them, preferred weekly versus monthly injections and perceived advantages/disadvantages of XR-buprenorphine. Independent variables concerned the demographic characteristics and features of current opioid agonist treatment (OAT; medication-type, dose, prescriber/dosing setting, unsupervised doses, out-of-pocket expenses and travel distance).

FINDINGS

Sixty-eight per cent [95% confidence interval (CI) = 63-73%] believed XR-buprenorphine was a good treatment option for them. They were more likely to report being younger [26-35 versus > 55 years; odds ratio (OR) = 3.16, 95% CI = 1.12-8.89; P = 0.029], being female (OR = 1.67, 95% CI = 1.04-2.69; P = 0.034), < 10 years school education (OR = 1.87, 95% CI = 1.12-3.12; P = 0.016) and past-month heroin (OR = 1.81, 95% CI = 1.15-2.85; P = 0.006) and methamphetamine use (OR = 1.90, 95% CI = 1.20-3.01; P = 0.006). Fifty-four per cent reported no preference for weekly versus monthly injections, 7% preferred weekly and 39% preferred monthly. Among OAT recipients (n = 255), believing XR-buprenorphine was a good treatment option was associated with shorter treatment episodes (1-2 versus ≥ 2 years; OR = 3.93, 95% CI = 1.26-12.22; P = 0.018), fewer unsupervised doses (≤ 8 doses past-month versus no take-aways; OR = 0.50; 95% CI = 0.27-0.93; P = 0.028) and longer travel distance (≥ 5 versus < 5 km; OR = 2.10, 95% CI = 1.20-3.65; P = 0.009). Sixty-nine per cent reported 'no problems or concerns' with potential differences in availability, flexibility and location of XR-buprenorphine.

CONCLUSIONS

Among regular opioid users in Australia, perceptions of extended-release buprenorphine as a good treatment option are associated with being female, recent illicit drug use and factors relating to the (in)convenience of current opioid agonist treatment.

Changes in Substance Abuse and HIV Risk Behaviors over 12-Month Methadone Maintenance Treatment among Vietnamese Patients in Mountainous Provinces

Methadone maintenance treatment (MMT) programs have been used worldwide to reduce the number of drug users and for HIV prevention; however, evidence of their effectiveness in mountainous areas is limited. This study aimed to identify changes in substance abuse and sexual practices among MMT patients after treatment in three Vietnamese mountainous provinces. A survey on risk behaviors was conducted among 300 drug users in six MMT clinics prior to and following one year of MMT. Cramér's effect size of changes was extrapolated to justify the magnitude of the intervention's effectiveness. A generalized estimation equation was used to find the factors associated with respondents' substance use and sexual risk behavior. While drug-related risk behaviors were significantly reduced, alcohol and sex-related behaviors remained risk factors for HIV in this group. Additionally, condom use was common among participants at both time points, but not among those having sex with sex workers. Socio-economic characteristics of ethnic, education, occupation, as well as drug use history influenced the possibility of engaging in drug use and/or sexual risk behavior following treatment. Further emphasis on managing these among MMT patients is required, potentially by providing integrated services including smoking and drinking counseling and condom use promotion in accordance with MMT.

Client and Provider Perspectives on Antiretroviral Treatment Uptake and Adherence Among People Who Inject Drugs in Indonesia, Ukraine and Vietnam: HPTN 074

HIV-infected people who inject drugs (PWID) have low uptake of HIV services, increasing the risk of transmission to uninfected injection or sexual partners and the likelihood of AIDS-related deaths. HPTN 074 is a vanguard study assessing the feasibility of an integrated intervention to facilitate treatment as prevention to PWID in Indonesia, Ukraine, and Vietnam. We describe barriers to and facilitators of ART uptake and adherence among PWID. We conducted in-depth interviews with 62 participants, including 25 providers and 37 PWID at baseline across all sites. All interviews were recorded, transcribed, translated into English and coded in NVivo for analysis. Matrices were developed to identify emergent themes and patterns. Overall, differences between provider and PWID perspectives were greater than differences in cross-site perspectives. Providers and PWID recognized clinic access, financial barriers, side effects, and lack of information about HIV testing and ART enrollment as barriers to ART. However, providers tended to emphasize individual level barriers to ART, such as lack of motivation due to drug use, whereas PWID highlighted health systems barriers, such as clinic hours and financial burden, fears, and side effects. Providers did not mention stigma as a barrier though their language reflected stereotypes about drug users. The differences between provider and PWID perspectives suggest a gap in providers' understanding of PWID. This misunderstanding has implications for patient-provider interactions that may affect PWID willingness to access care or adhere to ART. Lessons learned from this study will be important as countries with a significant HIV burden among PWID design and implement programs to engage HIV-infected PWID in care and treatment.

HIV knowledge and risk behaviors among drug users in three Vietnamese mountainous provinces

BACKGROUND

Globally, people who inject drugs are highly vulnerable to HIV transmission. Methadone maintenance treatment (MMT) programs are one of the most cost-effective mechanisms to substitute opioid use and improve the quality of life of patients. Since the coverage of MMT is still limited and even for those patients who are treated, improving their knowledge on HIV and maintaining healthy behaviors are key to maximizing the outcomes of HIV harm reduction programs. This study examined the knowledge on HIV, perceived risk and HIV testing among drug users accessing methadone maintenance services in three Vietnamese mountainous areas.

METHODS

A cross-sectional study of 300 people enrolling for MMT services in three provinces in Vietnam was conducted. The factors associated with the knowledge, attitudes, and practices of respondents about HIV/AIDS were exploited using multivariable logistic model.

RESULTS

Of the 300-people surveyed, 99% knew of HIV and 60.6% were identified as having good knowledge. While 75.2% identified that injecting drugs was a risk factor for HIV, 52.2% thought they were not at risk of HIV mainly as they did not share needles. 92.6% had undergone HIV testing with 17.4% being positive, a number which was significantly lower than Vietnam's national average for people who inject drugs. Age, ethnicity and education were associated with knowledge of HIV while ART treatment was linked to self-assessed HIV status.

CONCLUSIONS

This study sheds new light on the knowledge attitudes and practices of people who inject drugs, particularly males in mountainous areas of Vietnam regarding HIV prevention. Overall, knowledge was good with most conducting safe practices towards transmission. Enhanced education and targeting of minority groups could help in increasing the numbers receiving MMT and HIV services.

Methadone Maintenance Treatment Reduces the Vulnerability of Drug Users on HIV/AIDS in Vietnamese Remote Settings: Assessing the Changes in HIV Knowledge, Perceived Risk, and Testing Uptake after a 12-Month Follow-Up

Methadone Maintenance Treatment (MMT) program has been considered a medium through which human immunodeficiency virus (HIV) risks assessment and prevention on drug use/HIV-infected population can be effectively conducted. Studies concerning the implementation of such idea on patients in remote, under-developed areas, however, have been limited. Having the clinics established in three mountainous provinces of Vietnam, this study aimed to evaluate the changes in knowledge of HIV, perceived risk, and HIV testing uptake of the patients. A longitudinal study was conducted at six MMT clinics in three provinces with a pre- and post-assessments among 300 patients. Outcomes of interest were compared between baseline and after 12 months. The magnitude of changes was extrapolated. The proportion of participants reporting that their HIV knowledge was not good fell by 4.4% (61.3% at the baseline vs. 56.8% at 12 months). The significant improvement seen was in the knowledge that needle sharing was a mode of transmission (82.7% vs. 89.6%). Nevertheless, the majority of participants reportedly considered mosquitoes/insect and eating with the HIV-infected patient were the route of transmission at both time points (84.7% vs. 89.1%, 92.2% vs. 93.3%, respectively). This study found a limited improvement in HIV knowledge and testing uptake among MMT patients following a 12-month period. It also highlighted some shortcomings in the knowledge, attitudes and practices (KAP) of these patients, in particular, incorrect identification of HIV transmission routes, among patients both at program initiation and follow-up. The findings lent support to the argument for enhancing education and counseling efforts at MMT clinics regarding HIV, as well as for improving access to preventive and health care services through the integration of MMT/HIV services.

Strengthening advocacy efforts with empirical evidence: A case example of the conduct, uptake and utilisation of research in drug policy decision-making in Vietnam

During the last decade, international aid agencies and advocates have been working with Southeast Asian governments to move away from punitive responses towards people who use drugs to more public health, humane approaches. The lack of local scientific evidence about the effectiveness of different treatment approaches has made this advocacy work more challenging. This paper reflects on a generation of treatment research evidence and how it can assist advocacy efforts. The case example is the cost-effectiveness research, comparing centre-based compulsory treatment with community-based voluntary methadone maintenance treatment in Vietnam (2012-2015). Using our long-term and on-going connections with key Vietnamese decision-makers and government agencies, our collective experiences in drug policy advocacy and our unique insight into the working of government in Vietnam, we have used strategies to maximise opportunities for research to inform policy discussions. We have made an assessment here about the extent to which study findings have contributed to policy change in Vietnam and the challenges that impede progressive policy implementation. In doing this, we hope to make a contribution to the research evidence use literature.

Barriers to accessing and using health insurance cards among methadone maintenance treatment patients in northern Vietnam

Background

Methadone maintenance treatment (MMT) patients face unique costs associated with their healthcare expenditures. As such, it is important that these patients have access to health insurance (HI) to help them pay for both routine and unforeseen health services. In this study, we explored factors related to health insurance enrollment and utilization among MMT patients, to move Vietnam closer to universal coverage among this patient population.

Methods

A cross-sectional study was conducted with 1003 patients enrolled in MMT in five clinics in Hanoi and Nam Dinh provinces. Patients were asked a range of questions about their health, health expenditures, and health insurance access and utilization. We used multivariate logistic regressions to determine factors associated with health insurance access among participants.

Results

The majority of participants (nearly 80%) were not currently enrolled in health insurance at the time of the study. Participants from rural regions were significantly more likely than urban participants to report difficulty using HI. Family members of participants from rural regions were more likely to have overall poor service quality through health insurance compared with family members of participants from urban regions. Overall, 37% of participants endorsed a lack of information about HI, nearly 22% of participants reported difficulty accessing HI, 22% reported difficulty using HI, and more than 20% stated they had trouble paying for HI. Older, more highly educated, and employed participants were more likely to have an easier time accessing HI than their younger, less well educated, and unemployed counterparts. HIV-positive participants were more likely to have sufficient information about health insurance options.

Conclusions

Our study highlights the dearth of health insurance utilization among MMT patients in northern Vietnam. It also sheds light on factors associated with increased access to and utilization of health insurance among this underserved population. These results can help improve health insurance enrollment among MMT patients, a population that is at increased need of financial assistance in accessing health services.

The political and scientific challenges in evaluating compulsory drug treatment centers in Southeast Asia

Background

In Vietnam, like many countries in Southeast Asia, the commonly used approach of center-based compulsory drug treatment (CCT) has been criticized on human rights ground. Meanwhile, community-based voluntary methadone maintenance treatment (MMT) has been implemented for nearly a decade with promising results. Reform-minded leaders have been seeking empirical evidence of the costs and effectiveness associated with these two main treatment modalities. Conducting evaluations of these treatments, especially where randomization is not ethical, presents challenges. The aim of this paper is to discuss political challenges and methodological issues when conducting cost-effectiveness studies within the context of a non-democratic Southeast Asian country.

Methods

A retrospective analysis of the political and scientific challenges that were experienced in the study design, sample size determination, government approval and ethics approvals, participant recruitment, data collection, and determination of sources, and quantification of cost and effectiveness data was undertaken. As a consequence of the non-randomized design, analysis of patient characteristics for both treatment types was undertaken to identify the magnitude of baseline group differences. Concordance between self-reported heroin use and urine drug testing was undertaken to determine the reliability of self-report data in a politically challenging environment.

Results

We demonstrate that conducting research around compulsory treatment in a non-democratic society is feasible, yet it is politically challenging and requires navigation between science and politics. We also demonstrate that engagement with the government decision makers in the research conception, implementation, and dissemination of the results increases the likelihood of research evidence being considered for change in a contentious drug policy area.

Conclusions

Local empirical evidence on the comparative cost-effectiveness of CCT and MMT in a Southeast Asian setting is critical to consideration of more holistic, humane, and effective drug-dependence treatment approaches, but the garnering of such evidence is very challenging.