The role of the Chinese police in methadone maintenance therapy: A literature review

Association of random and observed urine drug screening with long-term retention in opioid treatment programs

BACKGROUND

In the US, opioid treatment providers (OTPs) have wide latitude to perform urine drug screening (UDS) and discharge clients for positive results. OTP clients have identified randomized and directly observed UDS as potentially stigmatizing, but little research has examined the association between UDS modality and retention in OTPs.

METHODS

This cross-sectional study uses the 2016-2017 NDATSS wave among OTPs that administered methadone. The exposure was a 4-level variable based on whether OTPs had a high percentage (≥ 90% of clients) who experienced randomized, observed, both, or neither modality of UDS. The outcome was the proportion of clients retained in treatment 1 year or longer (long-term retention). Analyses were conducted using fractional logit regression with survey weighting and presented as percentages and 95% confidence intervals. We also present how policies for involuntary clinic discharge modify these effects.

RESULTS

150 OTPs were eligible with a median of 310 clients. 40 (27%) OTPs did not highly utilize either randomized or observed UDS, 22 (15%) only highly utilized observed UDS, 42 (28%) only highly utilized randomized UDS and 46 (31%) utilized both practices on ≥ 90% of clients. Adjusted estimates for long-term retention ranged from 57.7% in OTPs that conducted both randomized and observed UDS on ≥ 90% of clients and 70.4% in OTPs that did not highly utilize these practices. Involuntary discharge may moderate this relationship.

CONCLUSION

Findings showed an association between high utilization of randomized and observed UDS and decreased long-term retention, suggesting that UDS modality may impact long-term OTP retention.

Negotiating SHI-FEI and shifei: Pursuing a Moralist Self in China's Community-Based Addiction Treatment Programs

Based on 16 months of fieldwork conducted at drug addiction treatment facilities in Yunnan, Southwest China, this article examines how Chinese drug users invent moralist selves during the frequent occurrences of shifei incidents. Shìfēi, meaning literally right/wrong, is a crucial concept in Chinese society with two contradictory meanings: (1) moral norms/judgment that ought to be discerned and followed (SHI-FEI); (2) "troubles" or "quarrels" that are often morally undesirable (shifei). By delving into a typical incident of shifei, this article analyzes the logic, motivation, and interpretations of the drug users and addiction treatment facility staff who are involved in the local moral world. It argues that for drug users, the relationship between SHI-FEI and shifei is not oppositional, as often assumed. Instead, both are valuable moral experiences and useful cultural means in response to users' moral demands and tensions. Negotiating SHI-FEI and shifei enables an ambiguous space in which drug users seek, claim, and practice their moralist selves. This article also argues that under various sociopolitical and moral constraints, drug users' moral selves are characterized by an inward focus on claims of morality and legitimacy. This inward focus reflects a process of moral involution. This study contributes to understandings of moral self-making in stigmatized situations.

The Emerging Role of Police in Facilitating Psychiatric Evaluation Since the 2013 Implementation of the First Chinese Mental Health Law

In 2013, China's first Mental Health Law (MHL) took effect, with the goal of better protecting patients' rights. Under the law the police, with appropriate training, rather than family members, employers or medical staff sent from a hospital, are the ones who bring persons in behavioral crises to medical facilities for psychiatric assessment for possible involuntary hospitalization. We examined the proportion and distinctive characteristics of persons brought to psychiatric emergency services (PES) by the police since the implementation of MHL. We used medical records to document demographic and clinical characteristics of all persons evaluated at the PES of the Guangzhou Psychiatric Hospital, the largest psychiatric hospital in China's fourth largest city, from April 2017 to August 2017. Bivariate and multivariate statistical analyses were performed to identify characteristics of patients brought to the PES by the police. Among 1515 PES visits, 166 (11.0%) were brought by the police as compared to virtually none in the years before the law took effect. Compared to non-police referrals, police referrals were associated with male gender, age greater than 30, more documented violent behavior, greater likelihood of having been restrained, and higher rates of hospital admission after assessment. Assessed risk of suicidality and diagnoses of substance use disorder were not significantly associated with police referral. A modest but increased and noteworthy proportion of patients evaluated at the PES after implementations of China's MHL were brought by the police, especially those with violent behavior requiring restraint and hospitalization resulting from mental illness.

Abstinence Following a Motivation-Skill-Desensitization-Mental Energy Intervention for Heroin Dependence: A Three-year Follow-up Result of a Randomized Controlled Trial

The high rate of relapse among heroin users remains a significant public concern in China. In the present study, we utilized a Motivation-Skill-Desensitization-Mental Energy (MSDE) intervention and evaluated its effects on abstinence and mental health. Eighty-nine male heroin users in a drug rehabilitation center were enrolled in the study. The participants in the MSDE intervention group (n=46) received MSDE intervention, which included motivational interviewing, coping skills training, eye movement desensitization and reprocessing, and mindfulness-based psychotherapy. The participants in the control group (n=43) received a series of lectures on skills training. A significant increase in Contemplation Ladder score (P<0.001) and decreases in scores on the Obsessive Compulsive Drug Use Scale (P<0.001), Beck Depression Inventory (P<0.001), and Aggression Questionnaire (P=0.033) were found immediately after intervention. Compared to the control group, the MSDE intervention group reported significantly higher abstinence rates (P=0.027) and retention rates (P<0.001) at follow-up. Overall, the MSDE intervention, which uses a combined strategy for relapse prevention, could be a promising approach for preventing relapse among heroin users in China.

Cross-country Comparison of Treatment Policies Facing the Drug Abuse in Five Selected Countries

BACKGROUND

Drug abuse is one of the main problems of human's life; thus communities have been thinking about the solution of this problem. The present study aimed to compare the general features of drug abuse treatment policies, war on drugs (WOD), and harm reduction (HR), in the selected countries.

METHODS

The present study was a comparative and desk research that sought to compare context, stewardship, financing, type of substance abuse treatment services, reasons of paradigm shift, and executive challenges of treatment policies in the selected countries (China, Malaysia, Germany, Netherland, and Iran). The necessary data for comparison of the countries were collected through valid databases, review of documents, and reports of international organizations.

FINDINGS

Context conditions were better in the HR countries. In most countries, the central government played a key role in the stewardship, financing, and service providing. In WOD countries, the presence of judicial structure was higher in the treatment of drug abuse. The policy-making approach was ideological in WOD countries, but evidence-based in HR countries.

CONCLUSION

It seems that performance of HR countries is better than WOD countries.

Strategies to control HIV and HCV in methadone maintenance treatment in Guangdong Province, China: a system dynamic modeling study

Background

Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections among methadone maintenance treatment (MMT) participants remain high. Optimized HIV and HCV prevention strategies for MMT clinics in resource-limited regions are urgently needed. This study aims to develop an MMT system dynamic model (SDM) to compare and optimize HIV and HCV control strategies in the MMT system.

Methods

We developed an MMT-SDM structure based on literature reviews. Model parameters were estimated from a cohort study, cross-sectional surveys and literature reviews. We further calibrated model outputs to historical data of HIV and HCV prevalence among MMT participants in 13 MMT clinics of Guangdong Province. Lastly, we simulated the impact of integrated interventions on HIV and HCV incidence among MMT participants using the MMT-SDM.

Results

The MMT-SDM comprises MMT clinics, MMT participants, detoxification centers, and HIV and HCV transmission, testing and treatment systems. We determined that condom promotion was the most effective way to reduce HIV infection (2013-2020: 2.86% to 1.76%) in MMT setting, followed by needle exchange program (2013-2020: 2.86% to 2.56%), psychological counseling (2013-2020: 2.86% to 2.71%) and contingency management (2013-2020: 2.86% to 2.72%). Health education had marginal impact on reducing HIV incidence among MMT participants (2013-2020:2.86% to 2.84%) from 2013 to 2020. By contrast, psychological counseling (2013-2020: 7.54% to 2.42%) and contingency management (2013-2020: 7.54% to 2.96%) had been shown to be the most effective interventions to reduce HCV incidence among MMT participants, followed by needle exchange program (2013-2020: 7.54% to 5.76%), health education (2013-2020: 7.54% to 6.35%), and condom promotion program (2013-2020: 7.54% to 6.40%). Notably, HCV treatment reduced HCV incidence by 0.32% (2013-2020: 7.54% to 7.22%).

Conclusions

In conclusion, we generated a valuable system dynamic model to analyze the Chinese MMT system and to guide the decision-making process to further improve this system. This study underscores the importance of promoting condom use in MMT clinics and integrating psychosocial interventions to reduce HIV and HCV infections in MMT clinics in China.

Electronic supplementary material

The online version of this article (10.1186/s13011-017-0140-3) contains supplementary material, which is available to authorized users.

HIV, prisoners, and human rights

Worldwide, a disproportionate burden of HIV, tuberculosis, and hepatitis is present among current and former prisoners. This problem results from laws, policies, and policing practices that unjustly and discriminatorily detain individuals and fail to ensure continuity of prevention, care, and treatment upon detention, throughout imprisonment, and upon release. These government actions, and the failure to ensure humane prison conditions, constitute violations of human rights to be free of discrimination and cruel and inhuman treatment, to due process of law, and to health. Although interventions to prevent and treat HIV, tuberculosis, hepatitis, and drug dependence have proven successful in prisons and are required by international law, they commonly are not available. Prison health services are often not governed by ministries responsible for national public health programmes, and prison officials are often unwilling to implement effective prevention measures such as needle exchange, condom distribution, and opioid substitution therapy in custodial settings, often based on mistaken ideas about their incompatibility with prison security. In nearly all countries, prisoners face stigma and social marginalisation upon release and frequently are unable to access health and social support services. Reforms in criminal law, policing practices, and justice systems to reduce imprisonment, reforms in the organisation and management of prisons and their health services, and greater investment of resources are needed.

Barriers to community-based drug dependence treatment: implications for police roles, collaborations and performance indicators

Introduction

Worldwide, people who use drugs (PWUD) are among the populations at highest risk for HIV infection. In China, PWUD are primarily sentenced to compulsory detainment centres, in which access to healthcare, including HIV treatment and prevention services, is limited or non-existent. In 2008, China's 2008 Anti-Drug Law encouraged the development and use of community-based drug dependence rehabilitation, yet there is limited evidence evaluating the efficacy and challenges of this model in China. In this study, we explore these challenges and describe how cooperation between law enforcement and health departments can meet the needs of PWUD.

Methods

In 2015, we conducted semi-structured, in-depth interviews with all four staff members and 16 clients of the Ping An Centre No. 1 for community-based drug treatment, three local police officers and three officials from the local Centre for Disease Control. Interviews explored obstacles in implementing community-based drug dependence treatment and efforts to resolve these difficulties. Transcripts were coded and analyzed with qualitative data analysis software (MAXQDA 11).

Results

We identified three challenges to community-based drug treatment at the Ping An Centre No. 1: (1) suboptimal coordination among parties involved, (2) a divergence in attitudes towards PWUD and harm reduction between law enforcement and health officials and (3) conflicting performance targets for police and health officials that undermine the shared goal of treatment. We also identified the take-home methadone maintenance treatment model at the Ping An Centre No. 1 as an example of an early successful collaboration between the police, the health department and PWUD.

Conclusions

To overcome barriers to effective community-based drug treatment, we recommend aligning the goals of law enforcement and public health agencies towards health-based performance indicators. Furthermore, tensions between PWUD and police need to be addressed and trust between them fostered, using community-based treatment centres as mediators. The preliminary success of the take-home methadone maintenance treatment pilot can serve as an example of how collaboration with the police and other government agencies can meet the needs of PWUD and contribute to the success of community-based treatment.

Evaluation of an implementation of methadone maintenance treatment in China

BACKGROUND

Methadone maintenance treatment (MMT) reduces the harms of opioid use disorder and is being rapidly scaled-up in China. This study evaluated the real-world implementation of MMT system in Wuhan, China.

METHODS

Data extracted from electronic medical records collected in 2010 on 8811 patients were used to compute for each patient indices of the prescribed and consumed daily methadone doses, an adherence index, dose adjustments following missed doses, the rates of opiate positive urine tests, self-reported drug use, injection drug use (IDU), and the duration of MMT exposure.

FINDINGS

The modal daily doses prescribed were 60 mg and above for 68.5% of patients. Adherence was variable: 51% of patients attended less than 60% and 26% attended 80-100% of their treatment days; and patients with long MMT exposure had significantly higher adherence rates than patients with short MMT exposure. The differences between doses dispensed immediately before and after the interruption in dosing days ranged from 0 to 7 mg, independently of the length of the interruption or the prescribed dosing level. The overall rate of opiate positive tests was 20%; 45% of patients had at least one opiate positive test; 29% reported past month drug use and 53% of them reported past month IDU. Adherence and MMT exposure duration correlated significantly with the proportion of opiate negative urine tests (r=0.355, p<0.001; r=0.351, p<0.001, respectively). Treatment for males and females was comparable.

CONCLUSIONS

Provision of safe methadone dosing after absences and improving daily attendance are identified as priority improvement areas.

From Abstinence to Relapse: A Preliminary Qualitative Study of Drug Users in a Compulsory Drug Rehabilitation Center in Changsha, China

Background

Relapse among abstinent drug users is normal. Several factors are related to relapse, but it remains unclear what individuals’ actual life circumstances are during periods of abstinence, and how these circumstances facilitate or prevent relapse.

Objective

To illuminate drug users’ experiences during abstinence periods and explore the real-life catalysts and inhibitors contributing to drug use relapse.

Method

Qualitative in-depth interviews were conducted with 20 drug users recruited from a compulsory isolated drug rehabilitation center in Changsha. The interviews were guided by open-ended questions on individuals’ experiences in drug use initiation, getting addicted, treatment history, social environment, abstinence, and relapse. Participants were also encouraged to share their own stories. Interviews were digitally recorded and fully transcribed. The data of 18 participants who reported abstinence experiences before admission were included in the analyses. The data were analyzed using a thematic analysis with inductive hand coding to derive themes.

Results

Most drug users were able to successfully abstain from drugs. During abstinence, their lives were congested with challenges, such as adverse socioeconomic conditions, poor family/social support, interpersonal conflicts, and stigma and discrimination, all of which kept them excluded from mainstream society. Furthermore, the police’s system of ID card registration, which identifies individuals as drug users, worsened already grave situations. Relapse triggers reported by the participants focused mainly on negative feelings, interpersonal conflicts, and stressful events. Craving was experienced but not perceived as a relapse trigger by most participants.

Conclusions

This study of in-depth interview with drug users found evidence of situations and environments they live during abstinence appear rather disadvantaged, making it extremely difficult for them to remain abstinent. Comprehensive programs on relapse prevention that acknowledge these disadvantages are implicated.

Prevalence of depressive symptoms and associated factors among people who inject drugs in China

BACKGROUND

People who inject drugs (PWID) have a high prevalence of mental health problems (e.g., depression) which compromise the effects of HIV prevention. We investigated the prevalence of depression and associated factors among PWID in Dazhou, China.

METHODS

Anonymous face-to-face interviews were administered to eligible participants by well-trained doctors. The Center of Epidemiological Studies Depression Scale (CES-D) was used to measure depression, using hierarchical linear regression models.

RESULTS

Among the 257 participants, 7.0%, 11.3%, and 75.1% were probable cases of mild (16 ≤ CES-D < 21), moderate (21 ≤ CES-D < 25), and severe (CES-D ≥ 25) depression, respectively. Hopefulness (standardized β = -0.34, p < 0.001) and emotional family support (β = -0.21, p < 0.001) were negatively associated, whereas severity of drug dependence (β = 0.12, p = 0.034) and unmet service needs (β = 0.20, p < 0.001) were positively associated, respectively, with CES-D scores. The adjusted analysis showed that resilience was negatively associated with CES-D, but it was not selected by the stepwise model containing hopefulness and emotional family support. Protective factors (i.e., hopefulness and emotional family support) and risk factors (i.e., severity of drug dependence and unmet service needs) remained significant in the same regression model.

CONCLUSION

Protective and risk factors were independently associated with depressive symptoms. Integrated interventions covering basic and psychosocial needs for PWID are warranted. Such interventions should strengthen emotional family support and cultivate positive factors such as hopefulness.