Implementation of a clinic policy of client-regulated methadone dosing

Assessing predictors of adequate individual buprenorphine maintenance dosage for the treatment of opioid use disorder: Listening to the patient

OBJECTIVE

Dose optimization plays a key role in determining clinical outcomes in patients on opioid agonist treatment (OAT). The objective of this study was to identify the variables independently associated with buprenorphine/naloxone (B/N) dose adequacy in patients with opiate use disorder (OUD).

METHOD

Cross-sectional study of a convenience sample of patients with OUD treated with B/N (n = 315) in four regions in Spain. The Opiate Dosage Adequacy Scale (ODAS) was used to determine B/N dose adequacy. The ODAS evaluate the six components of the "dose adequacy" construct, as follows: continued use of heroin; narcotic blockade or crossed tolerance; objective opioid withdrawal symptoms (OWS); subjective OWS; craving for heroin; and overmedication. A binomial logistic regression analysis was performed to identify the variables associated with the condition "ODAS Adequate B/N dose". Participants completed a battery of instruments to assess sociodemographic, substance use, clinical, and treatment variables.

RESULTS

The B/N dose was considered adequate in 231 of the 315 participants (73.3 %). Two variables, satisfaction with B/N as a medication (OR=5.764, 95 % CI=2.211-15.030) and patient-perceived participation in B/N dose decisions (OR=1.790, 95 % CI=1221-2623), were independently, significantly, and positively associated with the "ODAS Adequate B/N dose" condition. While the severity of heroin dependence was significantly associated with buprenorphine dose adequacy in the bivariate analyses, significance was lost in the full regression model.

CONCLUSION

Satisfaction with B/N as a medication and patient-perceived involvement in the dose decision are associated with clinician-assessed dose adequacy. In the context of good clinical practice, it is important to take into account both of these variables to individualize the prescribed dose through a shared decision-making process.

Treatment options and shared decision-making in the treatment of opioid use disorder: A scoping review

BACKGROUND

Shared decision-making (SDM) is an approach to clinical decision-making that includes patients' values and preferences during health-related decisions. Previous research suggests that SDM may be beneficial in the treatment of substance use disorders; however, the impact of SDM in the treatment of opioid use disorder (OUD) remains unclear.

OBJECTIVES

To identify relevant peer-reviewed literature related to SDM in the treatment of adults with OUD, and to summarize the main findings according to patient outcomes.

METHODS

The research team conducted a scoping review. The team searched five electronic health databases from database inception until September 2019 using MeSH and keywords related to SDM. The team included only peer-reviewed studies where adults (≥18 years) with OUD were provided a choice and/or allowed input into their treatment plan. Two independent reviewers screened, extracted, and assessed the quality of included studies.

RESULTS

Fourteen studies (n = 1748 participants) met inclusion criteria, including seven randomized controlled trials, three non-randomized controlled trials, two observational studies, and one qualitative study. Treatment options included: patient regulated methadone dosing vs. fixed dosing (n = 4 studies), optional vs. mandatory counseling (n = 4 studies), home vs. office buprenorphine inductions (n = 2 studies), and inpatient vs. outpatient treatment (n = 1 study). None of the studies measured SDM with a validated instrument. Seven of 14 studies reported at least one improved patient outcome.

CONCLUSIONS

The review found few studies that explored whether providing treatment options and/or encouraging participation in decision-making are beneficial for adults with OUD. Preliminary evidence suggests that SDM may be promising for this population. However, the field needs more research on person-centered care and SDM.

Patient perception of methadone dose adequacy in methadone maintenance treatment: The role of perceived participation in dosage decisions

OBJECTIVE

In clinical practice, methadone maintenance treatment (MMT) entails tailoring the methadone dose to the patient's specific needs, thereby individualizing treatment. The aim of this study was to identify the independent factors that may significantly explain methadone dose adequacy from the patient's perspective.

METHOD

Secondary analysis of data collected in a treatment satisfaction survey carried out among a representative sample of MMT patients (n=122) from the region of La Rioja (Spain). As part of the original study protocol, participants completed a comprehensive battery to assess satisfaction with MMT, psychological distress, opinion of methadone as a medication, participation in dosage decisions, and perception of dose adequacy.

RESULTS

Multivariate binary logistic regression showed that the only variable independently associated with the likelihood of a patient perceiving methadone dose as inadequate was the variable perceived-participation in methadone dosage decisions (OR=0.538, 95% CI=0.349-0.828).

CONCLUSION

Patient participation in methadone dosage decisions was predictive of perceived adequacy of methadone dose beyond the contribution of other socio-demographic, clinical, and MMT variables.

PRACTICE IMPLICATIONS

Patient participation in methadone dosage decision-making is valuable for developing a genuinely patient-centred MMT.

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.

Buprenorphine Use: The International Experience

The confluence of the heroin injection epidemic and the human immunodeficiency virus (HIV) infection epidemic has increased the call for expanded access to effective treatments for both conditions. Buprenorphine and methadone are now listed on the World Health Organization's Model Essential Drugs List. In France, which has the most extensive experience, buprenorphine has been associated with a dramatic decrease in deaths due to overdose, and buprenorphine diversion appears to be associated with inadequate dosage, social vulnerability, and prescriptions from multiple providers. Other treatment models (in the United States, Australia, Germany, and Italy) and buprenorphine use in specific populations are also reviewed in the present article. In countries experiencing a dual epidemic of heroin use and HIV infection, such as former states of the Soviet Union and other eastern European and Asian countries, access to buprenorphine and methadone may be one potential tool for reducing the spread of HIV infection among injection drug users and for better engaging them in medical care.

Patient perspectives on methadone maintenance treatment in the Valencia Region: dose adjustment, participation in dosage regulation, and satisfaction with treatment

Desired adjustment of methadone dose, perceived participation in dosage regulation, and satisfaction with methadone treatment centres were assessed in a sample of opioid-dependent patients from the Valencia Region (eastern Spain). An independent interviewer asked 278 consecutively arriving patients to answer the survey, and 165 (59.4%) completed it. Adjustment of methadone dose was assessed with a -10 to +10 visual analogue scale (VAS-MD); participation in methadone dose regulation, with specific questions; and patient satisfaction, with the Verona Service Satisfaction Scale for methadone treatment (VSSS-MT). The methadone dose (mg/d) prescribed by physicians was (mean+/-S.D.) 68.0+/-30.4. Participants scored -1.0+/-4.7 on the VAS-MD, indicating a significant downward desired adjustment of methadone dose (95% CI of -1.73 to -0.30). Of the patients surveyed, approximately one-third were, overall, content with their participation in methadone dose regulation. Overall, participants felt slightly satisfied (VSSS-MT=3.5+/-0.6) with the centres. Patients treated with a methadone dose of < 60 mg/d felt more satisfied than those treated with 60-100 mg/d. Information about dose changes was the only continuous methadone dose variable related with satisfaction that was found in a multiple regression analysis, which accounted for only 2.0% of the variance in VSSS-MT overall scores. In conclusion, patients' opinions on methadone dose and patient satisfaction are only very weakly related when methadone treatment is implemented as in the Valencia Region.

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.

Does retention matter? Treatment duration and improvement in drug use

AIM

This study examines whether there is a minimum threshold, continuous or non-linear relationship between the duration of addiction treatment and improvements in drug use.

DESIGN

Longitudinal cohort study of 62 drug treatment units and 4005 clients in the US National Treatment Improvement Evaluation Study, fielded from 1993 to 1995.

SUBJECTS

Baseline and 1-year follow-up interviews with clients in methadone maintenance, out-patient non-methadone, short-term residential and long-term residential treatment programs.

MEASURES

Improvement in drug use is the difference between the client-reported peak frequency of drug use (in days per month) in the year prior to the baseline interview minus the peak frequency in the year after discharge. Primary drug, and overall use of the major illicit drugs (heroin, cocaine powder, crack cocaine, and marijuana) are considered separately.

RESULTS

Controlling for multiple factors, treatment duration had a positive linear relationship with primary drug use improvement among methadone clients and an inverted-U-shaped relationship with overall and primary drug use improvements among out-patient and long-term residential clients. Improvement with longer duration is greatest for long-term residential clients.

CONCLUSIONS

Contrary to previous arguments for a sharp retention threshold for onset of treatment effects, we find smooth curves relating treatment duration to drug use improvements in methadone maintenance, out-patient non-methadone and long-term residential modalities. These relationships are effectively linear for durations typically observed in single treatment episodes, but unusually long retention in out-patient non-methadone and long-term residential units appear steadily less predictive of improvement.

Sensitivity to acute methadone dose changes in maintenance patients

This study assessed whether methadone patients can identify acute dose changes in their maintenance dose, and explored the relationships between self-reported drug effects and real or perceived dose changes. Four times each week patients (N = 10) unpredictably received either 80%, 90%, 100%, 110% or 120% of their usual daily dose (50-100 mg). Approximately 24 hr later they indicated which dose they had received on the previous day, and rated the previous day's dose in terms of good effects, bad effects, and change in medication taste. Correct estimation of the doses received was always at the levels expected by chance alone. Furthermore, this sample of patients could not detect dose-related changes in medication taste. However, self-reports of good effects were significantly higher when patients believed that they had received a dose increment, and ratings of bad effects were higher when patients believed that they had received a dose decrement.