Patterns of service use and treatment involvement of methadone maintenance patients

Perceptions and Experiences of Methadone Maintenance Treatment: A Qualitative Descriptive Research Study

Over the past 10 years, there has been a consistent increase in opioid use, which has resulted in an increase in methadone maintenance treatment (MMT). With retention in MMT being a key factor, to understand the process of retention, it is important to better understand individual perceptions and experiences. Little research in Ottawa, Ontario, has addressed the perspective of MMT from people enrolled in MMT; therefore, nursing-based research was undertaken. The objective was to understand the process and experiences associated with MMT from the perspective of persons who are enrolled in treatment. Twelve participants were engaged in semistructured interviews. These participants described that, although MMT can positively affect the people who use such a treatment option, multiple barriers, including social perceptions, physical environment, and healthcare delivery practices, continue to affect MMT initiation and delivery.

Research Note — Review of Corrections-Based Therapy for Opiate-Dependent Patients: Implications for Buprenorphine Treatment among Correctional Populations

Inmates with a history of opiate dependence represent a substantial proportion of the correctional population in the United States. Opiate use has negative consequences for both the inmate and society, including increased recidivism rates, increased infectious disease prevalence, avoidable emergency room use, decreased access to primary care services, and overdose. While there have been great successes in community-based treatment of opiate dependence, these successes have not yet been achieved in correctional settings. This paper reviews the pharmacological treatment options for opiate-dependent inmates, along with potential application for community-to-correctional approaches. The recent approval by the Food and Drug Administration (FDA) of physician-prescribed buprenorphine and the new opportunities it presents to corrections-based treatment are also explored in depth. Successful implementation of such strategies is likely to result in desirable health and social outcomes for both the inmate and the community at large.

Factors associated with work and taking prescribed methadone or buprenorphine among Swedish opiate addicts

BACKGROUND/AIMS

Using national register data from 2002 to 2008, this exploratory study examines for opiate addicts (n=2638) whether there is an association between predisposing, enabling and need factors and working and taking methadone or buprenorphine prescribed by a physician for a year or more.

METHODS

Chi-square analyses and One-way ANOVA were used to determine significant relationships between the independent variables and the dependent variable. A binomial logistic regression model, with variables entered as a single block, measured statistical associations between the independent variables and the dichotomous dependent variable.

RESULTS

Men and those with greater number of years of education (7%) and those with children were 7.08 times more likely to be working and taking prescription methadone or buprenorphine. Those who had more inpatient drug treatment episodes (5%), those who had been charged with crime 3.23 times, and those who had used psychiatric medications were 8.43 times more likely to be working and to have taken prescription methadone or buprenorphine one year or more.

CONCLUSION

This study highlights that clients in treatment for opiate addiction who are working and have received methadone or buprenorphine treatment may have better treatment retention and be more integrated socially than their counterparts even though they have a higher level of problem severity and treatment needs.

Patterns, determinants and barriers of health and social service utilization among young urban crack users in Brazil

Background

Crack use is prevalent across the Americas, and specifically among marginalized urban street drug users in Brazil. Crack users commonly feature multiple physical and mental health problems, while low rates of and distinct barriers to help service use have been observed in these populations. This study examined profiles and determinants of social and health service utilization, and unmet service needs, in a two-city sample of young (18–24 years), marginalized crack users in Brazil.

Methods

N = 160 study participants were recruited by community-based methods from impoverished neighborhoods in the cities of Rio de Janeiro (n = 81) and Salvador (n = 79). A mixed methods protocol was used. Participants’ drug use, health, and social and health service utilization characteristics were assessed by an anonymous interviewer-administered questionnaire completed in a community setting; descriptive statistics on variables of interest were computed. Service needs and barriers were further assessed by way of several focus groups with the study population; narrative data were qualitatively analyzed. The study protocol was approved by institutional ethics review boards; data were collected between November 2010 and June 2011.

Results

The majority of the sample was male, without stable housing, and used other drugs (e.g., alcohol, marijuana). About half the sample reported physical and mental health problems, yet most had not received medical attention for these problems. Only small minorities had utilized locally available social or health services; utilization appeared to be influenced by sex, race and housing characteristics in both sites. Participants cited limited service resources, lack of needs-specific professional skills, bureaucratic barriers and stigma as obstacles to better service access. However, most respondents stated strong interest and need for general social, health and treatment services designed for the study population, for which various key features were emphasized as important.

Conclusions

The study contributes substantive evidence to current discussions about the development and utilization of health and treatment interventions for crack use in Brazil. Based on our data, crack users’ social, service needs are largely unmet; these gaps appear to partly root in systemic barriers of access to existing services, while improved targeted service offers for the target population seem to be needed also.

Effects of receiving additional off-site services on abstinence from illicit drug use among men on methadone: a longitudinal study

Health and psychosocial service needs that may be co-morbid with opioid addiction may impede the success of drug treatment among patients attending methadone maintenance treatment programs (MMTPs). This longitudinal panel study investigates whether receipt of services from one or more helping professionals outside of the MMTP confers a benefit for drug treatment outcomes among a random sample of male MMTP patients (N=356). Each participant was interviewed 3 times, with 6 months between each interview. Since this observational study did not employ random assignment, propensity score matching was employed to strengthen causal validity of effect estimates. Results support hypotheses that receiving additional off-site services has significant beneficial effects in increasing the likelihood of abstaining from cocaine, heroin, and any illicit drug use over both the ensuing 6- and 12-month time periods. These findings indicate that receipt of additional medical and/or psychosocial services enhances the efficacy of methadone treatment in increasing abstinence from illicit drug use.

Criminal Justice Involvement and Service Need among Men on Methadone who Have Perpetrated Intimate Partner Violence

Perpetrators of male-to-female intimate partner violence (IPV) may be likely to have multiple service needs, the extent of which may vary with respect to criminal justice involvement. The salience of the criminal justice system and the potential impact on service needs due to arrest and incarceration is underscored given the association between substance use and IPV. This study utilized a sample of men in methadone treatment who perpetrated male-to-female IPV in order to examine associations between criminal justice involvement and perceived additional service need(s). Results indicate that the likelihood of having a service need(s) significantly increased as time since most recent arrest or incarceration decreased. These findings highlight the need and potential benefit that can be derived from greater coordination amongst the criminal justice, IPV prevention, and drug treatment systems and service providers.

Client consensus on beliefs about abstinence: effects on substance abuse treatment outcomes

Organizational culture, as evinced by consensus regarding staff and client beliefs and values, has been shown to affect client engagement in residential substance abuse treatment. The present paper extends this work to treatment outcomes. Secondary analysis of data from a "Beliefs About Abstinence Scale," used in the Drug Abuse Treatment Outcomes Study (DATOS), was conducted for 76 programs, including outpatient methadone treatment, outpatient drug-free, short-term inpatient, and long-term residential programs. Findings show that higher levels of client consensus after 1 month of treatment were associated with less use of drugs and alcohol at 1-year follow-up, after controlling for the mean of the scale score, gender, age, client substance use at baseline and treatment modality. The implications of the results for substance abuse treatment are discussed.

Healthcare utilization of individuals with opiate use disorders: an analysis of integrated medicaid and state mental health/substance abuse agency data

Data from the Substance Abuse and Mental Health Services Administration’s Integrated Database (IDB) were used to examine the service use patterns of individuals with possible opiate use disorders in Washington State. Results indicate that regardless of Medicaid enrollment status, individuals who received mental health (MH) or substance abuse (SA) services only through state agencies received no inpatient substance abuse service. Furthermore, when compared with individuals who received at least one MH/SA service through Medicaid, those who received services only through the state agencies were less likely to have received any MH services and were more likely to have received residential SA services. This analysis highlights the importance of using integrated client data in providing a more comprehensive understanding of services to inform policy and raises significant questions about how regulatory requirements affecting different funding mechanisms might drive settings of care in ways not related to the care needed.

Improving health and social care relationships for harm reduction

This paper explores elements of the relationships that develop between people who use illicit drugs and people who provide services to them. It focuses on expectations people who use drugs and service providers have of health and social care relationships for harm reduction, as well as facilitators and barriers to effective and ineffective interactions, and to what governments might better do to help strengthen interactions. Prior to Canada's inaugural national harm reduction conference, informal discussion groups were organized to source local views regarding policy reform for harm reduction. One component of these discussion groups focused upon improving health and social care relationships for harm reduction. Community-based organizations providing services for harm minimisation were consulted to help develop themes and questions. Discussion groups conducted in French or English were held in 10 cities across Canada. Groups were audio-recorded, transcribed and thematically analysed. Disjuncture between understandings of the nature of health and social care relationships for harm reduction were found. Interpersonal and structural factors functioned both for and against the development of effective interactions. Differences in expectation sets held by illicit drug users and service providers may reflect the fluid experience of boundaries as a population on society's margins moves between harm-causing and harm-reducing behaviours and identities. The research described in this paper targeted those most directly involved in receiving, developing and delivering harm reduction programmes across a very diverse nation. It did so by including representatives of those most directly involved in utilizing and providing services within the research process itself. By incorporating a process that was community-based, user-driven, and which strived to be non-judgmental, the research was able to explore suggestions for improving health and social care relationships for harm reduction proffered by professionals actively providing services, as well as a variety of users, including some isolated or structurally excluded from service access by geography, illiteracy and/or street-involvement.

Health and social services accessed by a cohort of Canadian illicit opioid users outside of treatment

OBJECTIVE

To examine the use of social and health services by illicit opioid users outside of treatment in five Canadian cities ('OPICAN' cohort).

METHODS

677 eligible participants completed an interviewer-administered protocol and 584 supplied saliva samples for HIV and HCV antibody-testing. Chi-squared tests and multivariate analyses of variance (MANOVA) were carried out in order to determine the associations between use of services and specific factors. The explanatory variables of service utilization were determined with multiple regression analysis.

RESULTS

The average age of respondents was 35 years, 66% were male and 68% were Caucasian. Women and HIV-positive individuals were more likely to receive health care. Participants who had a history of injection drug use, but had not injected within the previous 30 days, visited doctors more regularly and had a higher uptake of community-based services. Those who reported mental health problems used services less frequently than others. Participants recruited in Vancouver had more visits to needle exchange programs and centres specifically for women. Toronto participants were more likely to use homeless shelters and had a higher uptake of other types of community-based services.

CONCLUSION

Our study found a high rate of physical and mental health problems in illicit untreated opioid users in Canada, including the transmission of infectious disease. The availability of services seems to be a predictor of use of services. Setting up, adapting and evaluating front-line services tailored to illicit opioid users outside of treatment should be a policy and program priority.

Methadone dosage and retention: an examination of the 60 mg/day threshold

A National Institutes of Health (NIH) expert panel has mentioned a daily methadone dose of at least 60 mg as a best practice in methadone maintenance. The focus of this research is to estimate the percentage of outpatient methadone clients receiving this level of methadone and examine the association between treatment retention and level of methadone dosage as recommended by the NIH expert panel. A sample of 428 methadone clients discharged from methadone treatment facilities from the Alcohol and Drug Services Study (ADSS) was used, representing 109,973 methadone clients nationally. It was estimated that more than two-thirds of methadone clients nationally were receiving below 60 mg/day. While controlling for a number of client and organizational variables, a daily methadone dose of 60 mg/day or above was found to be associated with longer retention in treatment. Exploring factors affecting the utilization of the recommended daily methadone dose remains an important issue in effective delivery of methadone treatment.

Mental health and substance abuse treatment utilization among individuals served by multiple public agencies in 3 states

Patterns of mental health (MH) and substance abuse (SA) treatment utilization among populations receiving services through multiple public programs are not well known. This study examines to what extent populations with MH and/or SA conditions utilize treatment services through Medicaid and State MH/SA Agencies. Data are from the Substance Abuse and Mental Health Services Administration Integrated Database, a multiyear file for 3 states combining Medicaid and State MH/SA Agency administrative data into a uniform database. Although populations with co-occurring conditions and those served by both Medicaid and State MH/SA Agencies have substantial contact with the public treatment system, a majority of the MH/SA populations examined here utilize few services over brief periods of time. Utilization is most limited among individuals with MH-only conditions and those served exclusively by Medicaid. While a lack of data on clinical outcomes prevents us from drawing conclusions about the effectiveness of MH/SA services, results of this analysis indicate that public programs in the states examined here do not provide services that are primarily utilized on a frequent or chronic basis.

Patient and program factors in obtaining supportive services in DATOS

This study examined patient and program factors that influenced the receipt of scheduled supportive services in the Drug Abuse Treatment Outcome Studies (DATOS). Patients (N = 2,932) in 21 long-term residential (LTR) programs, 27 outpatient methadone treatment (OMT), and 25 outpatient drug-free programs were interviewed at admission and at 3 months during treatment. A hierarchical regression analysis was used to examine the relationship between patient-level and program-level factors associated with receiving supportive services in seven categories (medical, psychological, family, legal, educational, vocational, and financial). LTR patients received more services on average than outpatients (especially OMT), but patients overall received few services in the first 3 months of treatment. The patient-level likelihood of receiving services was related to being female and to having higher problem severity at intake. At the program level, outpatient clientele with higher problem severity received more services if they entered a program whose other enrolled patients were less troubled on average.

Sociodemographic disparities in supplemental service utilization among male methadone patients

The high prevalence of health and psychosocial needs among methadone treatment patients has prompted efforts to supplement methadone treatment with additional services. Research has generally focused on linking supplemental service utilization to drug treatment outcomes, with fewer studies aimed at understanding supplemental service utilization itself. This study with randomly selected male methadone maintenance treatment program (MMTP) patients examined associations between sociodemographic factors and supplemental service utilization while controlling for need for services and treatment duration. Findings indicate that MMTP patients who are African American, Latino, uninsured, or have less education were less likely to report any supplemental service utilization. Hypotheses positing sociodemographic differences in regular vs. occasional service utilization were not supported. There is a need to improve access to supplemental services for minority and disadvantaged MMTP patients, and MMTPs may represent an important venue to address health disparities in general.

Trends in comprehensive service availability in outpatient drug abuse treatment

Comprehensive medical and psychosocial services are essential to quality addiction treatment, but their availability declined in the 1980s. To determine whether this downward trend in the availability of comprehensive services continued in the 1990s, we analyzed data from a national panel study of outpatient substance abuse treatment units in 1990, 1995, and 2000. Response rates were greater than 85%. Regarding the availability of comprehensive services, including physical examinations, routine medical care, mental health services, financial counseling and employment counseling, administrators reported whether any substance abuse treatment client received the service in the past year. With the exception of physical examinations, whose reported availability increased from 1990 to 1995, and financial counseling, whose reported availability decreased during the same time, the reported availability of comprehensive services changed little during the 1990s. These findings highlight the continuing need to monitor access to comprehensive services and other quality markers in addiction treatment over time.

A conceptual framework for transferring research to practice

Systematic evaluations of efforts to transfer research-based interventions and procedures into general practice at community drug treatment programs have been limited. However, practical experiences as well as results from studies of technology transfer and organizational behavior in related fields provide a basis for proposing a heuristic model of key factors that influence this process. The successful completion of four stages of activity typically involved in program change (exposure, adoption, implementation, and practice of new interventions) appears to be influenced by several organizational considerations (e.g., institutional readiness for change, resources, and climate) as well as staff attributes. Assessment instruments for measuring organizational functioning (based on ratings aggregated for staff and patients in a program) are introduced, along with preliminary evidence for their validity. A better conceptual understanding of the process of program change and common barriers that may be encountered is needed for effectively transferring research to practice.

Health care utilization among young adult injection drug users in Harlem, New York

PURPOSE

This cross-sectional study investigated the predictors for and patterns of health care utilization among young adult injection drug users (IDUs).

METHODS

The subjects were 206 IDUs, ages 18-29, who were street-recruited from Harlem, New York. Participants were interviewed about their drug use, health conditions, and use of services such as health care, needle exchange programs (NEPs), and drug treatment in the preceding 6 months. Data were analyzed using logistic regression.

RESULTS

Health insurance was associated with use of health care both among NEP users [AOR (adjusted odds ratio) 10.66] and non-NEP users (AOR 2.45). Use of health care was independently associated with drug treatment (AOR 2.58), being gay/bisexual (AOR 3.86), and negatively associated with injecting cocaine (AOR 0.56). Half the participants (49%) had used health care in the previous 6 months; 48% were uninsured. Many participants who did not use health services reported a condition that would have warranted medical care.

IMPLICATIONS

Health insurance was strongly associated with use of health care, particularly among those who attend NEPs. Young adult IDUs may benefit from increased efforts to help them arrange and maintain health insurance coverage, potentially at NEPs. NEPs may be connecting young IDUs with health insurance to medical care through referrals.

Linkage to medical services in the Drug Abuse Treatment Outcome Study

BACKGROUND

An episode of substance abuse treatment is an opportunity to link substance-abusing patients to medical care at a time when management of medical problems might stabilize recovery and long-term health. However, little is known about the ability of organizational linkage mechanisms to facilitate the delivery of medical care to this population.

OBJECTIVES

The goal of this study was to examine whether organizational linkage mechanisms facilitate medical service utilization in drug abuse treatment programs.

RESEARCH DESIGN

This was a prospective secondary analysis of the Drug Abuse Treatment Outcome Study, a national longitudinal study of drug abuse treatment programs and their patients from 1991 to 1993. Hierarchical linear models evaluated the effect of on-site delivery, formal and informal referral, case management emphasis, and transportation on the log-transformed number of medical visits at the 1-month in-treatment patient interview.

MEASURES

Program directors' surveys provided organizational information, including the linkage mechanism used to deliver medical care. Patients reported the number of medical visits during the first month of drug abuse treatment.

RESULTS

Exclusive on-site delivery increased medical utilization during the first month of drug abuse treatment (beta estimate, 0.22; standard error [SE], 0.06; P <0.001). Transportation services also increased 1-month medical utilization (beta estimate, 0.13; SE, 0.03; P <0.001).

CONCLUSIONS

Exclusive on-site delivery of medical services increased drug abuse treatment patients' utilization of medical services in the first month of treatment. Transportation assistance warrants strong policy consideration as a facilitator of medical service delivery. Future research should clarify whether program-level linkage to medical services improves the patient-level outcomes of drug abuse treatment.

Access to services in the substance abuse treatment system. Variations by facility characteristics

In view of the importance of type and intensity of services during substance abuse treatment, this chapter looks at treatment and support services that substance abuse clients have access to during treatment. Trends in services over recent years are described. Services available to clients in the current treatment system are reviewed. Several facility characteristics affecting access to services are examined. Different ways of defining access to services are discussed. Findings from the Alcohol and Drug Services Study are used to illustrate service patterns in the national substance abuse treatment system. Variations in service patterns by facility characteristics such as type of care, treatment setting, ownership, percent of facility dependence on public revenue, and level of affiliation are analyzed. The implication is that clients who enter into treatment at different types of facilities are likely to have access to certain types of services.

Conceptualizing and assessing treatment structure and process in community-based drug dependency treatment programs

Having established the effectiveness of drug dependency treatment, the next generation of research will necessitate a focus on treatment structure and process and the systems within which programs operate. As a foundation for a process conceptualization, we constructed a grounded theory definition of treatment consisting of core elements and related comprehensive services. We then presented the multilevel conceptual framework that guided the Drug Abuse Treatment Outcome Study (DATOS) treatment structure and process study design and instrumentation, anchored by supporting empirical literature. The framework emphasizes seven critical levels of process measurement that future research should consider in order to avoid potential spurious findings.

Services provided during methadone treatment. A gender comparison

Greater improvement in posttreatment outcomes has been shown in programs that tailor frequency and type of services to unique client needs. Using a sample of 635 clients (199 females and 436 males) admitted to three community-based methadone treatment programs, this study examined gender differences in services needed and provided during the first 3 months of treatment. Results revealed that compared to males, women entered treatment with more psychological symptoms and AIDS/HIV-risky behaviors; they also presented with less criminal activity, less alcohol use, and higher motivation. Counselors addressed psychological and crisis issues more frequently with women, and counseling strategies were more often directed toward developing problem-solving and communication skills. Counselors also made more medical referrals and reported having better rapport with females. Attention to employment issues and HIV/AIDS sexual-risk behaviors did not differ by gender, even though women had more needs in these areas.