Effects of urine testing frequency on outcome in a methadone take-home contingency program

A Systematic Review of Treatment Maintenance Strategies in Token Economies: Implications for Contingency Management

Contingency management (CM) interventions are based on operant principles and are effective in promoting health behaviors. Despite their success, a common criticism of CM is that its effects to not persist after the intervention is withdrawn. Many CM studies evaluate posttreatment effects, but few investigate procedures for promoting maintenance. Token economy interventions and CM interventions are procedurally and conceptually similar. The token economy literature includes many studies in which procedures for promoting postintervention maintenance are evaluated. A systematic literature review was conducted to synthesize the literature on treatment maintenance in token economies. Search procedures yielded 697 articles, and application of inclusion/exclusion criteria resulted in 37 articles for review. The most successful strategy is to combine procedures. In most cases, thinning or fading was combined with programmed transfer of control via social reinforcement or self-management. Social reinforcement and self-monitoring procedures appear to be especially important, and were included in 70% of studies involving combined approaches. Thus, our primary recommendation is to incorporate multiple maintenance strategies, at least one of which should facilitate transfer of control of the target behavior to other reinforcers. In addition, graded removal of the intervention, which has also been evaluated to a limited extent in CM, is a reasonable candidate for further development and evaluation. Direct comparisons of maintenance procedures are lacking, and should be considered a research priority in both domains. Researchers and clinicians interested in either type of intervention will likely benefit from ongoing attention to developments in both areas.

Evaluating the association between urine drug screening frequency and retention in opioid agonist treatment in Ontario, Canada: a retrospective cohort study

OBJECTIVE

The objective of this study was to evaluate how urine drug screening (UDS) frequency is associated with retention in opioid agonist treatment (OAT).

METHODS

Data for this retrospective cohort study of 55 921 adults in OAT in Ontario, Canada, were derived from administrative sources between 1 January 2011 and 31 December 2015. All patient information was linked anonymously across databases using encrypted health card numbers. Descriptive statistics were calculated for comparing UDS frequency groups using standardised differences (d) where d less than 10% indicated a statistically significant difference. A logistic regression model was then used to calculate ORs adjusting for baseline covariates, including sex, age, location of residence, income quintile, mental disorders, HIV status and deep tissue infections.

RESULTS

Over 70% of the cohort had four or more UDS tests per month (weekly or more UDS). Significant associations were observed between UDS frequency and 1-year treatment retention in OAT biweekly (adjusted OR (aOR)=3.20, 95% CI 2.75 to 3.75); weekly UDS (aOR=6.86, 95% CI 5.88 to 8.00) and more than weekly (aOR=8.03, 95% CI 6.87 to 9.38) using the monthly or less groups as the reference.

CONCLUSION

This study identified an association between weekly UDS and 1-year treatment retention in OAT. There is an active discussion within Canada about the utility of UDS. The lack of evidence for the impact of UDS on retention has left it open to some to argue they simply provide a barrier to patient engagement. Therefore, it is timely of this study to demonstrate that more frequent urine testing is not associated with a reduction in treatment retention.

Understanding opportunities and challenges with telemedicine-delivered buprenorphine during the COVID-19 pandemic

INTRODUCTION

Opioid use disorder (OUD) is a debilitating illness that remains a serious public health issue in the United States. Use of telemedicine to deliver medications for the treatment of OUD (MOUD) was limited until the confluence of the COVID-19 and opioid addiction epidemics in spring 2020. Starting in spring 2020, the Department of Veterans Health Affairs (VHA) transitioned from in-person to mostly telemedicine-delivered OUD care to reduce COVID-19 transmission among veterans and providers. To gain a nuanced understanding of provider perspectives on MOUD care delivery using telemedicine, we conducted semi-structured interviews with VHA providers who were using telehealth to deliver MOUD care.

METHODS

We conducted semi-structed Zoom interviews with VA clinicians at nine VA Medical Centers (VAMCs) in eight states. Potential study participants were identified as providers who were involved in referrals and provision of buprenorphine treatment for chronic pain and opioid addiction. Audio-recordings of all interviews were transcribed and entered into Atlas. Ti qualitative analysis software. The study team analyzed the transcripts for major themes related to tele-prescribing practices for buprenorphine.

RESULTS

Twenty-three VA providers participated in the study, representing 32% of all providers invited to participate in the study. The research team identified the following four themes: (1) COVID-19 spurred a seismic shift in OUD treatment; (2) Video calls provided a rare window into veterans' lives; (3) Providers experienced numerous challenges to virtual visits; and (4) Providers wrestled with paternalism and trust.

CONCLUSIONS

The pandemic accelerated the movement toward harm reduction approaches. Prior to the pandemic, stringent requirements existed for patients receiving MOUD care. Providers in this study reflected on the need for these requirements (e.g., in-person visits, toxicology screens) and how reducing this monitoring implied more trust in patients' autonomous decisions. Providers' observation that videoconferencing offered them a window into patients' lives may offer some ways to improve rapport, and research should explore how best to incorporate the additional information conveyed in virtual visits.

Lacking evidence for the association between frequent urine drug screening and health outcomes of persons on opioid agonist therapy

BACKGROUND

Opioid agonist therapy (OAT) is a first-line treatment for opioid use disorder (OUD); however, the efficacy and role of urine drug screening (UDS) in OAT has received little research attention. Prior evidence suggests that UDS frequency reflects philosophy and practice context rather than differences in patient characteristics or clinical need. Therefore, we reviewed the literature on the effect of and recommendations for the frequency of UDS on health outcomes for persons with OUD who receive OAT.

METHODS

We searched Medline and EMBASE for articles published from 1995-2017. Search results underwent double, independent review with discrepancies resolved through discussion with a third reviewer, when necessary. Additional articles were identified through snowball searching, hand searching (Google Scholar), and expert consultation. The Cochrane tool was used to assess risk of bias.

RESULTS

Of the 60 potentially eligible articles reviewed, only one three-arm randomized open-label trial, comparing weekly and monthly UDS testing with take-home OAT doses, met our inclusion criteria.

CONCLUSIONS

Our review identified an urgent gap in research evidence underpinning an area of clinical importance and that is routinely reported by patients as an area of concern.

Opiate agonist treatment to improve health of individuals with opioid use disorder in Lebanon

BACKGROUND

Opioid agonist therapy has been widely used to reduce harms among individuals with opioid use disorder but its effectiveness has not been evaluated in the Middle East North African (MENA) region. This study aims to evaluate the effectiveness of a program using opioid agonist therapy in combination with psychosocial support on improving psychological and social well-being, reducing arrest, and reducing risky behavior in individuals with opioid use disorder in Lebanon.

METHODS

A one-group pre-test post-test design study was performed at SKOUN Lebanese Addiction Centre between January 2013 and December 2014. Eighty-six out of 181 patients agreed to participate and completed the 3-month assessment and 38 concluded the 12-month assessment. Psychological (depression and anxiety, quality of life), substance dependence/abuse, behavioral (injecting behavior, sharing needles and paraphernalia), and social outcomes were evaluated at baseline, 3, and 12 months post-treatment.

RESULTS

Remarkable statistical significance improvements were observed 3 months after treatment in most outcome variables including quality of life, anxiety, substance dependence, overdose, employment, and injecting behavior. Improvements were sustained 12 months after treatment.

CONCLUSION

Results support expanding the access to opioid agonist therapy in other MENA countries to treat substance dependence and reduce harms among individuals with opioid use disorder.

Contingency Management interventions for non-prescribed drug use during treatment for opiate addiction: A systematic review and meta-analysis

BACKGROUND AND AIMS

Use of non-prescribed drugs during treatment for opiate addiction reduces treatment success, creating a need for effective interventions. This review aimed to assess the efficacy of contingency management, a behavioural treatment that uses rewards to encourage desired behaviours, for treating non-prescribed drug use during opiate addiction treatment.

METHODS

A systematic search of the databases Embase, PsychInfo, PsychArticles and Medline from inception to March 2015 was performed. Random effects meta-analysis tested the use of contingency management to treat the use of drugs during opiate addiction treatment, using either longest duration of abstinence (LDA) or percentage of negative samples (PNS). Random effects moderator analyses were performed for six potential moderators: drug targeted for intervention, decade in which the study was carried out, study quality, intervention duration, type of reinforcer, and form of opiate treatment.

RESULTS

The search returned 3860 papers; 22 studies met inclusion criteria and were meta-analysed. Follow-up data was only available for three studies, so all analyses used end of treatment data. Contingency management performed significantly better than control in reducing drug use measured using LDA (d=0.57, 95% CI: 0.42-0.72) or PNS (d=0.41) (95% CI: 0.28-0.54). This was true for all drugs other than opiates. The only significant moderator was drug targeted (LDA: Q=10.75, p=0.03).

CONCLUSION

Contingency management appears to be efficacious for treating most drug use during treatment for opiate addiction. Further research is required to ascertain the full effects of moderating variables, and longer term effects.

The ABCs of incentive-based treatment in health care: a behavior analytic framework to inform research and practice

Behavior plays an important role in health promotion. Exercise, smoking cessation, medication adherence, and other healthy behavior can help prevent, or even treat, some diseases. Consequently, interventions that promote healthy behavior have become increasingly common in health care settings. Many of these interventions award incentives contingent upon preventive health-related behavior. Incentive-based interventions vary considerably along several dimensions, including who is targeted in the intervention, which behavior is targeted, and what type of incentive is used. More research on the quantitative and qualitative features of many of these variables is still needed to inform treatment. However, extensive literature on basic and applied behavior analytic research is currently available to help guide the study and practice of incentive-based treatment in health care. In this integrated review, we discuss how behavior analytic research and theory can help treatment providers design and implement incentive-based interventions that promote healthy behavior.

Take home maintenance medication in opiate dependence

BACKGROUND

Opiate-dependent patients can be given several days' worth of maintenance medication to take home. We studied whether the patients chosen to receive take home maintenance medication met the criteria that were published in the guidelines of the German Medical Association. These include, among other things: abstinence from additional consumption of heath-endangering substances, psychosocial reintegration, completion of the switch from illegal narcotics to the substitute maintenance medication, and clinical stabilization.

METHODS

In this study, data were obtained by questionnaire over the period from May to October 2011 from patients of all 20 psychiatric hospitals and all 110 physicians' practices with licenses to provide opiate maintenance medication in Berlin, Germany.

RESULTS

986 (19.9%) of the 5032 patients taking opiate medication answered the study questionnaire; 956 gave information about the frequency with which they received medication. 365 of these 956 patients (38.2%) reported having received take home medication. Among them, 197 (56.0%) said that they additionally consumed health-endangering substances, compared to 388 (69.9%) of those who received maintenance medication every day (p<0.0001). Lower rates of additional consumption among recipients of take home maintenance medication were also found for each of the substances heroin, cocaine, and benzodiazepines (p<0.0001 for each). Patients receiving take home medication more commonly indicated that they were employed and tended to have been in the maintenance program longer than patients receiving maintenance medication every day (p<0.0001 for each question). Clinical stabilization, i.e., improvement of mental and physical health, was reported in equal measure by patients who were and were not receiving take home medication.

CONCLUSION

The patient questionnaire reveals that most patients receiving take home maintenance medication meet the criteria specified in the guidelines of the German Medical Association.

Methadone dose, take home status, and hospital admission among methadone maintenance patients

OBJECTIVES

Among patients receiving methadone maintenance treatment (MMT) for opioid dependence, receipt of unobserved dosing privileges (take homes) and adequate doses (ie, ≥ 80 mg) are each associated with improved addiction treatment outcomes, but the association with acute care hospitalization is unknown. We studied whether take-home dosing and adequate doses (ie, ≥80 mg) were associated with decreased hospital admission among patients in an MMT.

METHODS

We reviewed daily electronic medical records of patients enrolled in one MMT program to determine receipt of take-home doses, methadone dose 80 mg or more, and hospital admission date. Nonlinear mixed-effects logistic regression models were used to evaluate whether take-home doses or dose 80 mg or more on a given day were associated with hospital admission on the subsequent day. Covariates in adjusted models included age, sex, race/ethnicity, human immunodeficiency virus status, medical illness, mental illness, and polysubstance use at program admission.

RESULTS

Subjects (n = 138) had the following characteristics: mean age 43 years; 52% female; 17% human immunodeficiency virus-infected; 32% medical illness; 40% mental illness; and 52% polysubstance use. During a mean follow-up of 20 months, 42 patients (30%) accounted for 80 hospitalizations. Receipt of take homes was associated with significantly lower odds of a hospital admission (adjusted odds ratio [AOR] = 0.26; 95% confidence interval [CI], 0.11-0.62), whereas methadone dose 80 mg or more was not (AOR = 1.01; 95% CI, 0.56-1.83).

CONCLUSIONS

Among MMT patients, receipt of take homes, but not dose of methadone, was associated with decreased hospital admission. Take-home status may reflect not only patients' improved addiction outcomes but also reduced health care utilization.

The effectiveness of matrix interventions in improving methadone treatment

BACKGROUND

The treatment of opioid dependence disorder is one of the major problems in medical centers around the world. Although MMT has been the major treatment in last few years in Iran, the existence of relapse before and after detoxification is still high. Methadone treatment has had a very low percentage of complete success.

OBJECTIVES

To evaluate the effectiveness of matrix group interventions in improving methadone treatment in the addicted was the main goal of this research.

MATERIALS AND METHODS

In a semi - experimental design, 24 male patients on the qualification cutoff score for the questionnaire survey (score less than 19 in depression test, and less than 21 in anxiety test) and the diagnosis of opioid dependence according to (DSM - IV) were substituted in two experimental and control groups randomly. At the beginning of the study, after the treatment period and in the follow-up phase (three months after the end of treatment), participants were evaluated by Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI) and the Anger Questionnaire (AQ), control group with no psychological treatment only took methadone. Data were analyzed using covariance analysis, chi square and Repeated Measures Analysis of Variance.

RESULTS

Results showed that the effect of matrix group interventions on reducing relapse (P < 0.05), increasing the maintenance of treatment (P < 0.01), increasing the treatment compliance, reducing anger, anxiety and depression and methadone dose is more effective than methadone treatment (P < 0.05).

CONCLUSIONS

It seems matrix group interventions increase the effectiveness of methadone treatment by reducing the relapse prevention, the dose of methadone and remaining in treatment.

Efficacy of disulfiram and Twelve Step Facilitation in cocaine-dependent individuals maintained on methadone: a randomized placebo-controlled trial

BACKGROUND

Cocaine use remains a major problem within methadone maintenance programs. Disulfiram's efficacy in reducing cocaine use has been demonstrated in several trials, but its relative efficacy among individuals who use versus abstain from alcohol remains unclear. Treatment approaches which seek to enhance substance users' involvement in self-help activities (Twelve Step Facilitation, TSF) have been associated with better outcomes among alcohol and cocaine users, but have rarely been evaluated among methadone-maintained cocaine-opioid users.

METHODS

We conducted a randomized, placebo-controlled, double blind (for medication condition), factorial (2×2) trial with 4 treatment conditions: Disulfiram plus TSF, disulfiram plus standard counseling only, placebo plus TSF, and placebo plus standard counseling in the context of a community-based methadone maintenance program. Participants (N=112) received either disulfiram (250 mg/d) or placebo in conjunction with daily methadone maintenance.

RESULTS

Assignment to TSF was associated with less cocaine use throughout treatment and a higher number of cocaine-negative urines. While there were no significant main effects of disulfiram versus placebo, individuals without an alcohol use disorder demonstrated greater reductions in cocaine use over time when assigned to disulfiram.

CONCLUSIONS

TSF appears feasible in this methadone maintenance program and was associated with modest reductions in cocaine use, an often intractable problem in this setting. Support for the efficacy of disulfiram was weaker, as it appeared effective only for those without a current alcohol use disorder for this sample.

The impact of community pharmacy dispensing fees on the introduction of buprenorphine-naloxone in Australia

INTRODUCTION AND AIMS

The introduction of buprenorphine - naloxone in Australia in April 2006 has permitted the revision of takeaway policies in many states and has introduced the possibility of unsupervised treatment. This study explored the implications of the introduction of buprenorphine - naloxone in terms of cost to patients through a survey of pharmacists' intended pricing practices. The aim of the research was to examine the intentions of pharmacists in relation to fees for buprenorphine - naloxone and study the potential implications to patients when compared with the existing fee structure for methadone and for buprenorphine alone.

DESIGN AND METHODS

A self-complete questionnaire was mailed to every community pharmacy in New South Wales (NSW) (n = 593) dispensing methadone or buprenorphine to people with opioid dependence. A response rate of 68.6% (n = 407) was achieved after three mailouts.

RESULTS

The majority of pharmacies charged a flat weekly fee for methadone (92.2%; mean = $31.90) and buprenorphine (74.8%; mean = $31.00). The mean intended fees for buprenorphine - naloxone according to different dosing and takeaway regimens ranged from $19.19 per week for no supervised doses and fortnightly takeaways to a $30.88 per week flat fee. There appeared to be little variation in fee structure irrespective of the takeaway regimen, until reaching the 2 weeks' unsupervised dose regimen.

DISCUSSION AND CONCLUSIONS

This study highlights the importance of the early dissemination of unambiguous information regarding the introduction of a new medication, especially where supervised dispensing through community pharmacies is essential to the provision of treatment. The potential impact upon the successful rollout of a new treatment paradigm that was developed to benefit stable patients in the community may be jeopardised when such processes are not followed.

Behavioral drug and HIV risk reduction counseling (BDRC) with abstinence-contingent take-home buprenorphine: a pilot randomized clinical trial

This pilot randomized clinical trial evaluated whether the efficacy of office-based buprenorphine maintenance treatment (BMT), provided with limited counseling or oversight of medication adherence is improved by the addition of individual drug counseling and abstinence-contingent take-home doses of buprenorphine. After a 2-week buprenorphine and stabilization period, heroin dependent individuals (n=24) in Muar, Malaysia were randomly assigned to Standard Services BMT (physician administered advice and support, and weekly, non-contingent medication pick-up) or Enhanced Services (nurse-delivered manual-guided behavioral drug and HIV risk reduction counseling (BDRC) and abstinence-contingent take-home buprenorphine (ACB), 7 day supply maximum). Outcomes included retention, proportion of opioid-negative urine tests, self-reported drug use, and self-reported HIV risk behaviors. 12/12 (100%) of Enhanced Services and 11/12 (92%) of Standard Services participants completed the entire protocol. The proportion of opioid-negative urine tests increased significantly over time for both groups (p<0.001), and the reductions were significantly greater in the Enhanced Services group (p<0.05); Enhanced Services group achieved higher overall proportions of opiate negative urine toxicology tests (87% vs. 69%, p=0.04) and longer periods of consecutive abstinence from opiates (10.3 weeks vs. 7.8 weeks, p=0.154). Both groups significantly reduced HIV risk behaviors during treatment (p<0.05), but the difference between Enhanced and Standard Services (26% vs. 17% reductions from the baseline levels, respectively) was not statistically significant (p=0.9). Manual-guided behavioral drug and HIV risk reduction counseling and abstinence-contingent take-home buprenorphine appear promising for adding to the efficacy of office-based BMT provided with limited drug counseling and medication oversight.

A 12-month controlled trial of methadone medical maintenance integrated into an adaptive treatment model

Methadone medical maintenance (MMM) reduces the reporting schedule for stable and well-functioning methadone maintenance patients to once a month, with counseling provided by medical staff. We report on the 12-month outcomes of 92 highly stable methadone maintenance patients randomly assigned to one of three study conditions: routine care, MMM at the methadone maintenance program, and MMM at a physician's office. Methadone medical maintenance patients received a 28-day supply of methadone, whereas routine care patients received five or six take-home methadone doses each week. All patients performed a medication recall once a month and submitted two urine samples each month. An adaptive stepped-care system of treatment intensification was used for patients who failed recall or who had drug-positive urine specimens. Seventy-seven patients completed the 12-month study period. Dropout was caused primarily by problems with handling methadone and disliking the recall frequency. There were low rates of drug use or failed medication recall. Treatment satisfaction was high in all groups, but the MMM patients initiated more new employment or family/social activities than did routine care patients over the study period. The stepped-care approach was well tolerated and matched patients to an appropriate step of service within a continuum of treatment intensity.

Comparative study of the effectiveness of slow-release morphine and methadone for opioid maintenance therapy

AIMS

Slow-release morphine may represent a much-needed new pharmacological treatment for opioid dependence.

DESIGN

In a 14-week randomized, double-blind, double-dummy, cross-over study oral slow-release morphine was compared with methadone as a treatment for opioid dependency. During two study periods, each consisting of a 1-week titration and a 6-week fixed-dose treatment phase, medication was administered daily under supervised conditions.

SETTING

The study was carried out at the Addiction Clinic, Department of Psychiatry, Medical University Vienna.

PARTICIPANTS

Sixty-four subjects (56 males, eight females) with opioid dependence participated in the trial.

MEASUREMENTS

Efficacy was evaluated on the basis of retention, use of illicit substances based on urinalysis, extent of drug cravings, withdrawal symptoms and general wellbeing. Safety was assessed on the basis of adverse events and clinical and physical examination. Demographic and baseline characteristics were assessed using the European Addiction Severity Index.

FINDINGS

Fifty-five patients (86%) completed the study, with a mean methadone dose of 85 mg and a mean slow-release morphine dose of 680 mg. No significant differences in retention or use of illicit substances (opioids, benzodiazepines, cocaine) were observed, irrespective of treatment group or medication. However, patients receiving slow-release morphine had significantly lower depression (P < 0.001) and anxiety scores (P = 0.008) and fewer physical complaints (P < 0.001).

CONCLUSIONS

Oral slow-release morphine is as effective as methadone in the treatment of opioid dependency, with comparable safety and tolerability and a greater benefit on patient wellbeing. Greater pharmaceutical diversity represents a modern development in mainstream medicine. Slow-release morphine might represent a future treatment option that will improve long-term outcomes for this target group.

The relationship between take-away methadone policies and methadone diversion

The development of policies in relation to unsupervised doses of methadone (take-away doses) should be based upon the best available evidence. There are both risks and benefits associated with take-away doses. This study aimed to explore the relationship between take-away policies and one measure of harm: methadone injection rates. Six different states in Australia were compared in relation to their methadone take-away policy and rates of methadone injection within their population of injecting drug users. At a simplistic level, those states with restrictive and less flexible take-away policies tended to have the lowest reported prevalence of methadone injection. However, this does not fully explain variability in methadone injecting. There were also considerable differences between those states with similar take-away policies. Variables which appear to impact upon methadone injecting rates include: take-away policies, drug preference, drug availability, treatment availability and degree of treatment penetration. Consideration of the benefits, rather than merely the harms, of various take-away policy options may provide an evidence-based platform for take-away policy development.

Urine labeling with orally applied marker substances in drug substitution therapy

The compliance of 581 drug addicts attending six methadone substitution outpatient clinics was determined over a period of 18 months. Urine from these patients was labeled following oral administration of low molecular weight polyethylene glycols as marker substances. These substances were measured in approx. 5800 urine samples. A protocol for applying marker substances and ways to prevent substitution of urine samples were evaluated. Normal values for marker substances in urine were determined. The results suggest that this labeling procedure is a new diagnostictool to prevent manipulation of urine samples by drug addicts receiving substitution therapy.