Drug treatment on demand--not

A trial of implementation facilitation to increase timely admission to methadone treatment

BACKGROUND

During the ongoing opioid epidemic, some Opioid Treatment Programs (OTPs) are unable to admit program applicants in a timely fashion. Interim methadone (IM) treatment (without routine counseling) is an effective approach to overcome this challenge when counseling capacity is inadequate to permit admissions within 14 days of request. It requires both federal and state approval and has been rarely utilized since its incorporation into the federal OTP regulations in 1993.

METHODS

We evaluated the impact of Implementation Facilitation (IF) on OTPs providing timely admission to methadone treatment (i.e., within 14 days of request), adopting IM, and changing admissions procedures. IF included data collection on admission processes and an external facilitator who engaged OTP leadership, Local Champions through site visits, remote academic detailing, and feedback. Local Champions and State Opioid Treatment Authorities (SOTAs) participated in learning collaboratives. Using a modified stepped wedge design, six OTPs in four US states on the east and west coasts were randomly assigned to one of two clusters that staggered the timing of IF receipt. Study Phases included: Pre-Implementation, IF, and Sustainability. OTPs submitted data on treatment requests and admissions for 28 months (N = 3108 requests for treatment).

RESULTS

Although none of the OTPs adopted IM, all six developed policies and procedures to enable its use. Some OTPs streamlined admissions processes prior to study launch and during the IF intervention. OTPs reduced admission delays over time, although there was substantial site heterogeneity. The IF Phase for the early cluster coincided with the onset of COVID-19, complicating the study. Rates of timely admission within 14 days of request were 56.2 % (Pre-Implementation), 55.8 % (IF), and 78.8 % (Sustainability). Compared to the Pre-Implementation Phase, the odds of timely admission were not significantly different during the IF Phase but significantly higher during the Sustainability Phase (OR = 2.35 [95 % CI = 1.34, 4.12]; p = 0.003).

CONCLUSIONS

Committing to study participation and IF activities may have prompted some OTPs to change practices that improved timely admission. Attributing changes to IF should be done with caution considering study limitations. Data collection for the study spanned the COVID-19 pandemic, which complicates interpretation.

TRIAL REGISTRATION

Clinicaltrials.gov registration # NCT04188977.

Treatment-seeking behaviour among people with opioid use disorder in the high-income countries: A systematic review and meta-analysis

Objectives

To determine treatment seeking behaviour in those with opioid use disorder (OUD) in the high-income countries.

Methods

Five databases were searched in November 2019 for quantitative studies that reported OUD treatment seeking behaviour. Data analysis involved determining an overall pooled proportion estimate of treatment seeking behaviour for the two base groups, lifetime treatment and past 12-month or less treatment using the IVhet effect model. Subgroup analysis included heroin OUD, prescription OUD and general OUD. The sensitivity analysis included removal of outliers, separating adults and adolescents and the metaXL sensitivity analysis (studies are excluded if outside the pooled proportion confidence interval of the base case). Systematic review Prospero database registration number [CRD42020159531].

Results

There were 13 quantitative studies included in the systematic review, with all studies being from the United States of America (USA). IVhet models showed that 40% (95% CI: 23%, 58%) and 21% (95% CI: 16%, 26%) sought treatment in their lifetime and past 12 months respectively. Sub-group analysis found that lifetime treatment seeking for prescription OUD, 29% (95% CI: 27%, 31%), was less than for heroin plus combined OUD, 54% (95% CI: 26%, 82%). Most of the pooled results had high heterogeneity statistics except for results of lifetime treatment seeking for prescription OUD and past 12-month treatment seeking for prescription OUD.

Conclusion

All included studies in this meta-analysis were from the USA and indicate modest levels of treatment seeking for those with OUD. In particular, this review found that in the USA one in five people with OUD sought OUD treatment in the previous 12 months and two in five people with OUD sought OUD treatment in their lifetime. Further research is urgently required to explore the barriers and facilitators that can improve this low treatment seeking in those with OUD.

Barriers to accessing opioid substitution treatment for opioid use disorder: A systematic review from the client perspective

OBJECTIVES

To update the existing evidence to identify specific barriers to initiation of opioid substitution therapy (OST) for those with opioid use disorder (OUD).

METHODS

The review follows Preferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) guidelines. Six databases were initially searched in November 2019, with the search updated on 11 November 2020, for qualitative or quantitative studies reporting the barriers to initiating OST from the client with OUD perspective. Thematic analysis of the barriers to OST was undertaken to determine barrier themes and subthemes.

RESULTS

There were 37 studies included in the review; 18 were qualitative, 15 were quantitative and four were mixed methods. The barrier themes identified were stigma and fear, regulatory, logistical, attitudinal and social factors. Within these barrier themes 19 barrier subthemes were identified. The most reported OST barrier subthemes were negative treatment perceptions, cost, stigma and lack of flexibility.

CONCLUSION

This review discusses important barriers to OST and examines reported barriers from the client perspective. OST guidelines and programs would benefit by introducing programs that reduce stigma, increase treatment knowledge and health literacy, reduce treatment costs, increase treatment flexibility and allow for easier treatment access.

Motivations for Diverted Buprenorphine Use in a Multisite Qualitative Study

Drawing on a multisite sample of 40 persons who sell, share, or use diverted buprenorphine to manage opioid use disorder, in this study we describe why individuals seek to obtain buprenorphine outside of formal treatment contexts, and between-site variation regarding their motives and means. Findings indicate that both the provision and purchase of diverted buprenorphine support user-defined risk minimization strategies to avoid withdrawal, reduce heroin use, and satiate opioid cravings in periods of lowered tolerance. We also found that a subset of the sample used buprenorphine recreationally, and that it functioned to extend or augment illicit drug use careers. Implications of the findings are discussed in light of federal and state drug control and treatment policies.

Waiting Time as a Barrier to Treatment Entry: Perceptions of Substance Users

Many substance users report that they experience multiple barriers that produce significant challenges to linking with treatment services. Being on a waiting list is frequently mentioned as a barrier, leading some people to give up on treatment and to continue using, while prompting others to view sobriety during the waiting period as proof they do not need treatment. This ethnographic study examines the views that 52 substance users have of the waiting time before treatment and the strategies they created to overcome it. Understanding how substance users react to waiting time itself and in relation to other barriers can lead to services that are effective in encouraging treatment linkage.

Meyer A, Hruska B, Ochalek T, Rose G, Badger GJ, Brooklyn JR, Heil SH, Higgins ST, Moore BA, Schwartz RP. Bridging waitlist delays with interim buprenorphine treatment: initial feasibility

Despite the effectiveness of agonist maintenance for opioid dependence, individuals can remain on waitlists for months, during which they are at significant risk for morbidity and mortality. Interim dosing, consisting of daily medication without counseling, can reduce these risks. In this pilot study, we examined the initial feasibility of a novel technology-assisted interim buprenorphine treatment for waitlisted opioid-dependent adults. Following buprenorphine induction during Week 1, participants (n=10) visited the clinic at Weeks 2, 4, 6, 8, 10 and 12 to ingest their medication under staff observation, provide a urine specimen and receive their remaining doses via a computerized Med-O-Wheel Secure device. They also received daily monitoring via an Interactive Voice Response (IVR) platform, as well as random call-backs for urinalysis and medication adherence checks. The primary outcome was percent of participants negative for illicit opioids at each 2-week visit, with secondary outcomes of past-month drug use, adherence and acceptability. Participants achieved high levels of illicit opioid abstinence, with 90% abstinent at the Week 2 and 4 visits and 60% at Week 12. Significant reductions were observed in self-reported past-month illicit opioid use (p<.001), opioid withdrawal (p<.001), opioid craving (p<.001) and ASI Drug composite score (p=.008). Finally, adherence with buprenorphine administration (99%), daily IVR calls (97%) and random call-backs (82%) was high. Interim buprenorphine treatment shows promise for reducing patient and societal risks during delays to conventional treatment. A larger-scale, randomized clinical trial is underway to more rigorously examine the efficacy of this treatment approach.

Interim treatment: Bridging delays to opioid treatment access

OBJECTIVE

Despite the undisputed effectiveness of agonist maintenance for opioid dependence, individuals can remain on waitlists for months, during which they are at significant risk for morbidity and mortality. To mitigate these risks, the Food and Drug Administration in 1993 approved interim treatment, involving daily medication+emergency counseling only, when only a waitlist is otherwise available. We review the published research in the 20years since the approval of interim opioid treatment.

METHODS

A literature search was conducted to identify all randomized trials evaluating the efficacy of interim treatment for opioid-dependent patients awaiting comprehensive treatment.

RESULTS

Interim opioid treatment has been evaluated in four controlled trials to date. In three, interim treatment was compared to waitlist or placebo control conditions and produced greater outcomes on measures of illicit opioid use, retention, criminality, and likelihood of entry into comprehensive treatment. In the fourth, interim treatment was compared to standard methadone maintenance and produced comparable outcomes in illicit opioid use, retention, and criminal activity.

CONCLUSIONS

Interim treatment significantly reduces patient and societal risks when conventional treatment is unavailable. Further research is needed to examine the generality of these findings, further enhance outcomes, and identify the patient characteristics which predict treatment response.

Heroin Use, HIV-Risk, and Criminal Behavior in Baltimore: Findings from Clinical Research

This article reviews research conducted in Baltimore over the past 15 years, examining the following: (1) What factors differentiate heroin-addicted individuals who enter methadone treatment from those who do not? (2) How difficult is gaining access to methadone treatment? (3) What are effective ways to overcome barriers to treatment entry? (4) Why do so many methadone patients drop out of treatment prematurely? (5) What are the added benefits of counseling when coupled with methadone or buprenorphine treatment? (6) Does increasing access to treatment have an impact on overdose deaths? Specific recommendations are made for policymakers concerned with addressing heroin addiction.

Inability to access addiction treatment and risk of HIV infection among injection drug users recruited from a supervised injection facility

BACKGROUND

Treatment for drug addiction is effective in reducing the harms of injection drug use, including infection with HIV and/or hepatitis C. We sought to examine the prevalence and correlates of being unable to access addiction treatment in a representative sample of injection drug users randomly recruited from a supervised injection facility.

METHODS

Using generalized estimating equations, we determined the prevalence and factors associated with being unable to access addiction treatment.

RESULTS

Between 1 July 2004 and 30 June 2006, 889 individuals completed at least one interview and were included in this analysis. At each interview, approximately 20% of respondents reported trying but being unable to access any type of drug or alcohol treatment in the previous 6 months. Being unable to access treatment was independently associated with recent incarceration, daily use of heroin and borrowing used syringes. In a secondary question, the majority of individuals reported waiting lists were the reason for being unable to access treatment.

CONCLUSION

Given the independent association between inability to access addiction treatment and elevated HIV risk behavior, these results suggest expanding addiction treatment may contribute significantly to HIV prevention efforts in this population.

Women and drug addiction: a historical perspective

The history of women and addiction in America extends back more than 150 years. Although the true epidemiology of women and addiction has always been difficult to determine, the spectrum of female addicts extends well beyond those women who make sensationalistic headlines by "abandoning" or "battering" their children. Historically, female addiction has been largely the result of inappropriate overmedication practices by physicians and pharmacists, media manipulation, or individuals own attempts to cope with social or occupational barriers preventing equality and self-fulfillment. From the mid-nineteenth century, uneasy tolerance, social ostracism, vilification, persecution, and legal prosecution have grudgingly, but not completely, given way to more humane treatment opportunities in the setting of more enlightened comprehensive care.

Dropout from interim methadone and subsequent comprehensive methadone maintenance

BACKGROUND: Methadone maintenance in the U.S. is delivered primarily through specialized clinics that provide psychosocial services together with medication. Interim methadone (IM) is an evidence-based approach to increase access by providing methadone without counseling for individuals waiting for admission to comprehensive treatment. Little is known about the role of patient characteristics in predicting outcomes in the IM service pathway (IM with comprehensive methadone treatment following IM). METHODS: This study examined the relationship between patient motivation and dropout among patients in the IM service pathway (n=183). Participants were assessed with the Addiction Severity Index, the Texas Christian University Motivation Scales, and study-specific instruments at baseline, 4 month follow-up or admission to comprehensive treatment (whichever occurred first), and 6 months thereafter. Multinomial logistic regression was used for the analysis, controlling for demographics, route of administration, cocaine use, criminal justice history, and treatment history. RESULTS: Of the total sample, 62% were retained throughout the IM service pathway, 20% left IM, and 18% left subsequent comprehensive treatment. Motivation did not predict dropout from either IM or comprehensive treatment following IM. Unexpectedly, neither did any of the other explanatory variables included in the model. CONCLUSIONS: Most patients remained in the IM service pathway. The patient characteristics examined are not associated with discontinuation of IM or subsequent comprehensive methadone treatment. SCIENTIFIC SIGNIFICANCE: The findings that most patients were retained in the IM service pathway, and that no subgroup experienced higher probability of dropout, bolster the public health potential of IM as a service strategy.

Scaling-up interim methadone maintenance: treatment for 1,000 heroin-addicted individuals

The objectives of this study were to determine the following: (a) the feasibility of expanding interim methadone treatment (IM), (b) the impact of IM on heroin and cocaine use, and (c) the effect of charging a modest fee for IM. Six clinics provided daily methadone plus emergency counseling only (IM) to heroin-addicted individuals on a waiting list for treatment. IM was provided for up to 120 days before transfer to regular methadone treatment. Drug testing was conducted at admission to IM and at transfer to methadone treatment program (MTP). Half the patients were charged $10/week for IM. Logistic regression analysis was used to determine the effect of fee status and other variables on transfer. Of 1,000 patients enrolled in IM, 762 patients (76.2%) were admitted to a regular MTP. For those who transferred (n = 762), opioid-positive tests decreased from 89.6% to 38.4%; cocaine, from 49.9% to 44.9% from admission to transfer. Logistic regression analysis indicated that fee status at baseline was not significantly associated with transfer. When limited public resources create waiting lists, IM can allow additional patients to sharply reduce heroin use while waiting for admission to MTP.

Access to drug and alcohol treatment among a cohort of street-involved youth

BACKGROUND

A number of options for treatment are available to young drug users, but little is known about the youth who actually attempt to access such services. Here we identify characteristics of a cohort of street-involved youth and highlight commonly encountered barriers.

METHODS

From September 2005 to July 2007, data were collected from the At-Risk Youth Study (ARYS), a prospective cohort of 529 drug users aged 14-26 living in Vancouver, Canada. Participants who attempted to access any addiction services in the 6 months prior to enrollment were compared in univariate analyses and multiple logistic regression modeling of socio-demographic and drug-related factors.

RESULTS

Factors positively associated with attempting to access services included Aboriginal ethnicity (adjusted odds ratio [AOR]=1.66 [1.05-2.62]), high school education (AOR=1.66 [1.09-2.55]), mental illness (AOR=2.25 [1.50-3.38]), non-injection crack use (AOR=2.93 [1.76-4.89]), and spending >$50 on drugs per day (AOR=2.13 [1.41-3.22]). Among those who experienced difficulty-accessing services, the most commonly identified barrier was excessively long waiting lists. In a subgroup analysis comparing those who tried to access services but were unsuccessful to those who were successful, risk factors positively associated with failure included drug bingeing (odds ratio [OR]=2.86 [1.22-6.76]) and homelessness (OR=3.86 [1.11-13.4]).

CONCLUSIONS

In light of accumulating evidence that drug use among street youth is associated with risky health-related behaviors, improving access to treatment and other addiction services should remain an important public health priority.

Access to drug abuse treatment under Treatment on Demand policy in San Francisco

OBJECTIVES

We evaluated whether implementation of Treatment on Demand (TOD) policy in San Francisco was associated with improved access to drug abuse treatment.

METHODS

Data came from San Francisco's treatment program waiting list over 4 years spanning the implementation of TOD policy. Access measures were monthly applicants waiting and days waited by treatment admissions. Quantitative analyses with 69 treatment facilities contrasted those receiving vs. not receiving TOD funds. Qualitative data came from interviews with facility administrators.

RESULTS

There was a small statistically significant decline in monthly waiting lists in the number of people waiting for treatment during the study period. The days waited by those admitted to treatment, however, significantly increased in TOD-funded facilities. Facilities used varied criteria for completing the access measures, which limit the utility of the measures.

CONCLUSIONS

Access to treatment improved slightly with implementation of TOD policy.

Individual and system influences on waiting time for substance abuse treatment

Waiting time is a contemporary reality of many drug abuse treatment programs, resulting in substantial problems for substance users and society. Individual and system factors that influence waiting time are diverse and may vary at different points in the treatment continuum. This study assessed waiting time preceding clinical assessment at a centralized intake unit and during the period after the assessment but before treatment entry. The present study included 577 substance abusers who were enrolled in a large clinical trial of two brief treatment interventions in a midsize metropolitan area in Ohio. Bivariate analyses identified individual and system factors that influenced preassessment and postassessment waiting time, as well as total wait to treatment services. Multivariate analyses demonstrated that longer wait time for an assessment is influenced by being court referred, less belief in having a substance abuse problem, and less desire for change. A shorter wait to actually enter treatment is predicted by having a case manager, being more ready for treatment, and having less severe employment and alcohol problems. The different influences present during the two waiting periods suggest that assessment and treatment programs need to implement system changes and entry enhancement interventions that are specific to the needs of substance abusers at each waiting period.

Pathways of Substance Users Linking (Or Not) With Treatment

This qualitative paper describes different pathways substance users experience as they decide whether to link to treatment or not after being assessed in a centralized intake unit in a Midwestern city. The narratives of 16 participants who did not link with treatment were compared with the narratives of 20 participants who did. Narratives from both groups described similar themes that were experienced differently. Nonlinkers were characterized by pretreatment abstinence, a negative experience with previous treatment, little previous engagement in a treatment career, and meaningful social support coming from AA. Linkers were more likely to continue using drugs before treatment entry, yet they described more readiness for treatment and were more engaged in a treatment career. The treatment careers approach provides a broader framework for understanding linkage versus nonlinkage to treatment.

Predictors of the degree of drug treatment coverage for injection drug users in 94 metropolitan areas in the United States of America

AIMS

A prior study concluded that drug treatment coverage, defined as the percentage of injection drug users in drug treatment, varied from 1 percent to 39 percent (median 9 percent) in 96 metropolitan statistical areas (MSAs) in the United States. Here, we determine which metropolitan area characteristics are associated with drug treatment coverage.

METHODS

We conducted secondary analysis of official data, including the number of injection drug users in treatment and other variables, for 94 large US MSAs. We estimated the number of injection drug users in these metropolitan areas using previously described methods. We used lagged cross-sectional analyses where the independent variables, chosen on the basis of a Theory of Community Action, preceded the dependent variable (drug treatment coverage) in time. Predictors were determined using ordinary least squares multiple regression and confirmed with robust regression.

RESULTS

Independent predictors of higher drug treatment coverage for injectors were: presence of organisations that support treatment (unstandardized beta=1.64; 95 percent CI .59 to 2.69); education expenditures per capita in the MSA (unstandardized beta=.12; 95 percent CI -.34 to 2.69); lower percentage of drug users in treatment who are non-injection drug users (unstandardized beta=-0.18; 95 percent CI -0.24 to -0.12); higher percentage of the population who are non-Hispanic White (unstandardized beta=.14; 95 percent CI .08 to .20); lower per capita long-term debt of governments in the metropolitan area (unstandardized beta=-0.93; 95 percent CI -1.51 to -0.35).

CONCLUSIONS

In conditions of scarce treatment coverage for drug injectors, an indicator of epidemiologic need (the per capita extent of AIDS among injection drug users) does not predict treatment coverage, and competition for treatment slots by non-injectors may reduce injectors' access to treatment. Metropolitan finances limit treatment coverage. Political variables (racial structures, the presence of organisations that support drug treatment, and budget priorities) may be important determinants of treatment coverage for injectors. Although confidence in these results would be higher if we had used a longitudinal design, these results suggest that further research and action that address structural, political, and other barriers to treatment expansion are sorely needed.

Sociodemographic disparities in access to addiction treatment among a cohort of Vancouver injection drug users

Vancouver's explosive HIV epidemic among injection drug users (IDUs) has received international attention due to the presence of a large needle exchange program. The role of addiction treatment has not been evaluated in this setting. We evaluated factors associated with use of addiction treatment among a prospective cohort of Vancouver IDUs. Addiction treatment was negatively associated with Aboriginal ethnicity and unstable housing, both of which have been associated with HIV infection in previous studies. These findings demonstrate low levels of addiction treatment among Vancouver IDUs and suggest that programs may need to be targeted towards specific populations with poor access.

Inability to Access Addiction Treatment and Risk of HIV Infection Among Injection Drug Users

It was recently found that 94% of the nearly $500 million allocated annually to Canada's illicit drug strategy has been spent on enforcement-based interventions. As a result, lack of funds for addiction treatment has meant demand for substance abuse treatment among illicit drug users has exceeded availability. This study evaluated whether injection drug users (IDUs) who reported being unable to access addiction treatment were at elevated risk of HIV infection. A prospective analysis was done of factors associated with syringe borrowing by baseline HIV-negative IDUs among participants enrolled in the Vancouver Injecting Drug Users Study (VIDUS). Since serial measures for each individual were available, variables potentially associated with syringe borrowing were evaluated using generalized estimating equations (GEEs) with logit link for binary outcomes. Overall, 1157 HIV-negative IDUs were enrolled into the VIDUS cohort between May 1996 and May 2002. Unsuccessful attempts to access addiction treatment were associated with reporting syringe borrowing during follow-up in both univariate (odds ratio 1.72; 95% CI 1.47-2.00; P<0.001) and in multivariate GEE analyses (adjusted odds ratio 1.29; 95% CI 1.09-1.53; P=0.003). Inability to access addiction treatment was independently associated with syringe borrowing among HIV-negative IDUs at risk for HIV infection. These findings suggest that the limited provision of addiction treatment may result in a major missed opportunity to reduce HIV transmission behavior among IDUs and that the expansion of addiction treatment services has major potential to reduce the substantial human and fiscal costs of HIV infection.

Accessibility of addiction treatment: results from a national survey of outpatient substance abuse treatment organizations

OBJECTIVES

This study examined organization-level characteristics associated with the accessibility of outpatient addiction treatment.

METHODS

Program directors and clinical supervisors from a nationally representative panel of outpatient substance abuse treatment units in the United States were surveyed in 1990, 1995, and 2000. Accessibility was measured from clinical supervisors' reports of whether the treatment organization provided "treatment on demand" (an average wait time of 48 hours or less for treatment entry), and of whether the program turned away any patients.

RESULTS

In multivariable logistic models, provision of "treatment on demand" increased two-fold from 1990 to 2000 (OR, 1.95; 95 percent CI, 1.5 to 2.6), while reports of turning patients away decreased nonsignificantly. Private for-profit units were twice as likely to provide "treatment on demand" (OR, 2.2; 95 percent CI, 1.3 to 3.6), but seven times more likely to turn patients away (OR, 7.4; 95 percent CI, 3.2 to 17.5) than public programs. Conversely, units that served more indigent populations were less likely to provide "treatment on demand" or to turn patients away. Methadone maintenance programs were also less likely to offer "treatment on demand" (OR, .65; 95 percent CI, .42 to .99), but more likely to turn patients away (OR, 2.4; 95 percent CI, 1.4 to 4.3).

CONCLUSIONS

Although the provision of timely addiction treatment appears to have increased throughout the 1990s, accessibility problems persist in programs that care for indigent patients and in methadone maintenance programs.

A brief telephone intervention targeting treatment engagement from a substance abuse program wait list

This study compares three brief participant-initiated telephone interventions aimed at enhancing treatment engagement of individuals on a substance abuse treatment wait list. Policies requiring that wait list members call at least every other week in order to remain eligible for treatment remained in place for the standard and enhanced conditions but not for the voluntary condition. The standard condition was a minimal intervention, providing information on the program. The enhanced condition focused on client motivation for treatment and recovery. If individuals in the voluntary condition called, they were provided information about current wait list number and approximate remaining wait time. The rate of treatment engagement was the same among treatment conditions. The best predictor of engagement was the number of calls placed to the program while waiting. Treatment condition was a positive predictor of call frequency; presence of a comorbid psychiatric diagnosis was a negative predictor. The article also discusses future directions.

A placebo-controlled study of high dose buprenorphine in opiate dependents waiting for medication-assisted rehabilitation in Oslo, Norway

AIMS

To evaluate whether buprenorphine. even without additional control and psychosocial treatment and support, alleviates the problems faced by patients waiting for medication assisted rehabilitation (MAR).

DESIGN

A randomized, double-blind, 12-week study of Subutex versus placebo without additional support as an interim therapy.

PARTICIPANTS

One hundred and six patients, 70 males and 36 females, waiting for MAR in Oslo. The average age was 38 years with an average history of heroin use of 20 years. Fifty-five patients were assigned to buprenorphine and 51 to a placebo.

INTERVENTION

Subutex or placebo sublingual tablets were given under supervision in a daily dose of 16 mg with the exception of a double dose on Saturday and no dose on Sunday.

MEASUREMENT

Retention, compliance, self-reported drug-abuse, wellbeing and mental health.

FINDINGS

The average number of days of participation was significantly higher in the buprenorphine group, 42 (median: 29) compared to 14 (median: 11) for the placebo group (P < 0.001). The retention of patients after 12 weeks was 16 patients in the buprenorphine group and one patient in the placebo group. The buprenorphine group had a larger decrease in reported opioid use (p < 0.001) and in reported use of other drugs, tablets and alcohol abuse (p < 0.01). The group also showed a stronger increase in wellbeing (p < 0.01) and life satisfaction (p < 0.05). None of the participants died.

CONCLUSION

The patients waiting for MAR benefited significantly from the buprenorphine as an interim therapy according to retention, self-reported use of drugs and wellbeing. However, the patients had difficulties in remaining in treatment over time without psychosocial support.

Administrative, clinical, and ethical issues surrounding the use of waiting lists in the delivery of mental health services

The waiting list is commonly used in the delivery of mental health services. Despite their prevalence, their design and management are generally not standardized; rather, they take place on an ad hoc basis as a response to undesirable circumstances. The formulation and management of a waiting list initially appear to be simple, straightforward, and benign. However, on close examination, waiting lists are complicated, and implementation involves pervasive costs and benefits. This article delineates the costs and benefits involved in the use of waiting lists. It outlines administrative, clinical, and ethical issues intrinsic in the use of waiting lists and provides recommendations aimed at assisting in their design and management. While recommendations encompassing the range of possible unique situations are impractical, guidelines for consideration of important variables are provided.

Canadian illicit opiate users' views on methadone and other opiate prescription treatment: an exploratory qualitative study

Although methadone treatment has been available in North America for decades, only a small proportion of opiate addicts (some 25% of estimated opiate users in Canada) are receiving methadone treatment. Many users have tried methadone treatment, often multiple times, but leave treatment prematurely. Others would not consider it as a worthwhile treatment option for themselves. This exploratory study examines regular opiate users' attitudes towards and experiences with methadone treatment in Canada, primarily setting out to determine what makes methadone an unsuccessful or even an undesirable treatment option for considerably large groups of opiate users. This empirical effort to explore the limitations of existing methadone treatment comes at an appropriate time, when alternative forms of opiate pharmacotherapy treatment are being proposed in Canada as complementary modes of intervention that hope to address the shortcomings of methadone treatment. The rationale for this study were feasibility questions and development efforts for a clinical trial in North America evaluating the effectiveness of using injectable opioids (heroin, dilaudid) in attracting and engaging treatment-resistant opiate users into treatment. Data for this exploratory qualitative study was collected in 1999 through a series of focus groups involving 47 treatment-experienced and treatment-naive opiate users in Vancouver, Montreal, and Toronto, with the objective of identifying key themes and issues on the described topic as a basis for further systematic research.

Report of the Council on Scientific Affairs: methadone maintenance and needle-exchange programs to reduce the medical and public health consequences of drug abuse

Extensive evaluation studies show that methadone maintenance therapy (MMT) reduces heroin use and associated problems in a cost-effective manner, without negative public health impact. MMT is limited by inadequate funding and understanding of relevant research, extensive regulation, and limits on the freedom of physicians to provide methadone in a variety of medical settings. Broad-based medical, public health, and scientific support exists for expansion of MMT with greater emphasis on consistency and quality, and provision of ancillary services. Programs for the exchange, free distribution, and legal pharmacy sale of needles and syringes reduce injection drug use and prevent the spread of bloodborne pathogens; drug abuse treatment and other services are important components. Neither strategy increases existing drug use nor leads to drug use initiation. The scientific literature supports assertions that drug abuse issues should be treated primarily as medical and public health rather than criminal justice issues. The effectiveness of both strategies warrants increased support for services, easing of federal and state restrictions governing their availability, and advocacy in their support.

Optimal investment in a portfolio of HIV prevention programs

OBJECTIVES

In this article, the authors determine the optimal allocation of HIV prevention funds and investigate the impact of different allocation methods on health outcomes.

METHODS

The authors present a resource allocation model that can be used to determine the allocation of HIV prevention funds that maximizes quality-adjusted life years (or life years) gained or HIV infections averted in a population over a specified time horizon. They apply the model to determine the allocation of a limited budget among 3 types of HIV prevention programs in a population of injection drug users and nonusers: needle exchange programs, methadone maintenance treatment, and condom availability programs. For each prevention program, the authors estimate a production function that relates the amount invested to the associated change in risky behavior.

RESULTS

The authors determine the optimal allocation of funds for both objective functions for a high-prevalence population and a low-prevalence population. They also consider the allocation of funds under several common rules of thumb that are used to allocate HIV prevention resources. It is shown that simpler allocation methods (e.g., allocation based on HIV incidence or notions of equity among population groups) may lead to alloctions that do not yield the maximum health benefit.

CONCLUSIONS

The optimal allocation of HIV prevention funds in a population depends on HIV prevalence and incidence, the objective function, the production functions for the prevention programs, and other factors. Consideration of cost, equity, and social and political norms may be important when allocating HIV prevention funds. The model presented in this article can help decision makers determine the health consequences of different allocations of funds.

Drug treatment experiences: rural and urban comparisons

This study sought to investigate treatment-seeking behaviors among drug users in rural populations and how they compare to their urban counterparts. Data for this analysis were drawn from the Miami and Immokalee sites of the National Institute on Drug Abuse's Cooperative Agreement Program for AIDS outreach/intervention research study targeting high-risk out-of-treatment injection drug users and crack smokers. Findings indicate that Miami subjects were 2.57 times more likely to have been in drug treatment compared to their rural counterparts. This differential may be explained in terms of the availability, accessibility, and acceptability of health care services.

Accessing Drug-Abuse Treatment: Perceptions of Out-of-Treatment Injectors

The Presidential Commission on the Human Immunodeficiency Virus Epidemic (1988) developed a 10-year plan in 1987 that recommended: “Expanded drug abuse treatment programs sufficient to admit all IV drug users who desired services and, until that occurred, short-term detoxification and low-dose methadone for those on waiting lists.” This study presents data collected from a sample of 2,613 out-of-treatment and non-incarcerated injection drug users in 21 U.S. cities to examine their drug-treatment access during the past year. Analyses on injectors who tried but were unable to enter treatment revealed that program-based reasons (e.g., no room, too costly, or stringent admission criteria) are the most commonly given barriers to drug treatment (72%). However, a notable number of injectors (20%) also reported that individual-based reasons are important for not accessing drug treatment. Injectors giving program- and individual-based reasons for not entering treatment are profiled using logistic regression.

Injecting drug users who want treatment

This study examined characteristics of injecting drug users (IDUs) who want treatment and the features that differentiate them from IDUs who do not want treatment. Data were collected as part of a community-based HIV prevention project in San Antonio, Texas. Interviews were administered to 1,100 IDUs between February 1993 and May 1995. Interview topics included sociodemographics, drug use history, current drug use, treatment history, injection-related HIV risk behavior, sexual behavior, and previous contact related to HIV prevention. Multiple logistic regression analysis identified four factors independently associated with wanting treatment in the multivariate model. These were: (1) 30 or more injections per month; (2) being eligible for methadone maintenance; (3) 2 or more previous treatment admissions; and (4) being recruited after the first year of the project. Implications of these findings are discussed.

Defunding the Poor: The Impact of Lost access to Subsidized Methadone Maintenance Treatment on Women Injection Drug Users

Qualitative data from women defunded from a subsidized methadone maintenance treatment (MMT) program were analyzed to determine the impact of defunding on the women and their dependents. Women attested to the efficacy of MMT in creating a stable environment in which their illicit drug use was eliminated or controlled; they were able to decrease their participation in illicit activities and pursue further employment and educational goals. When defunding occurred women employed a variety of strategies including family borrowing, welfare funds, and illicit activities to remain on private MMT programs. The result of these payment strategies was often a premature detoxification from MMT due to unpaid clinic bills. Many women returned to heroin use to alleviate withdrawal symptoms from methadone detoxification. This return to heroin use was also accompanied by increased illicit activities. Defunded women reported severe emotional and financial destabilization as a result of lost access to subsidized methadone maintenance treatment.

What happens when a demonstration project ends. Consequences for a clinic and its clients

The Los Angeles Enhanced Methadone Maintenance Project was a 5-year research demonstration project funded by the National Institute on Drug Abuse with the goal of reducing high-risk behavior for human immunodeficiency virus (HIV) among heroin users. A clinic was established for the purposes of the study and 500 clients with high-risk profiles were recruited into treatment. Follow-up assessments demonstrated that clients had reduced their drug use, criminal behavior, and HIV-risk behaviors after entering treatment. At the end of the project clients were given the option of continuing treatment at the clinic on a fee-for-service basis, transferring to another treatment provider, or undergoing detoxification. Clients who were eligible for Medicaid were likely to continue receiving methadone treatment, but those without Medicaid funding were not. The implications of terminating treatment among a high-risk population recruited into a research demonstration project are discussed.