The effectiveness of methadone maintenance treatment: an overview

Is pain empathy associated with pain indices and trauma history? A comparison between patients receiving methadone maintenance treatment and healthy controls

BACKGROUND

To study whether pain empathy and theory of mind (ToM) are related to pain indices and trauma experience, we studied opioid users receiving methadone maintenance treatment (MMT), a population with a history of traumas and a high prevalence of chronic pain.

METHODS

MMT patients (n = 53), substance abuse-free, with no impaired cognition (Montreal Cognitive Assessment (MoCA) ≥24), were compared to healthy controls (HC) matched by age and gender (n = 66). All participants were assessed using Reading the Mind in the Eyes (RMET) for ToM, empathy (Interpersonal Reactivity Index [IRI], Empathy Quotient Scale for Adults [EQ60]), and Pain Empathy [PE task]). An algometer was used for pain pressure threshold, and supra-pain threshold was rated using a visual analog scale (VAS). Catastrophizing, McGill pain, Negative life events (NLE), and MoCA questionnaires were administered. Substance abuse was tested in the urine of MMT patients and self-reported by HC.

RESULTS

MMT, compared to HC, were less educated with more NLE and a lower RMET (logistic regression). Groups had comparable empathy and pain indices, except for higher supra-threshold VAS rating and catastrophizing in univariate analyses. Pain empathy (PE) correlated with NLE in HC, and in MMT, with catastrophizing, which correlated with NLE, perceived stress, and pain intensity. Higher empathy was observed in 18 participants with a history of sexual abuse (83.3 % belong to the MMT group).

CONCLUSIONS

Pain Empathy was found to be associated with personal suffering experience in both groups, as reflected by correlations with NLE in HC and with catastrophizing, which correlates with NLE, stress, and pain intensity, in MMT.

Opioid, methamphetamine, and polysubstance use: perinatal outcomes for the mother and infant

The escalation in opioid pain relief (OPR) medications, heroin and fentanyl, has led to an increased use during pregnancy and a public health crisis. Methamphetamine use in women of childbearing age has now eclipsed the use of cocaine and other stimulants globally. Recent reports have shown increases in methamphetamine are selective to opioid use, particularly in rural regions in the US. This report compares the extent of our knowledge of the perinatal outcomes of OPRs, heroin, fentanyl, two long-acting substances used in the treatment of opioid use disorders (buprenorphine and methadone), and methamphetamine. The methodological limitations of the current research are examined, and two important initiatives that will address these limitations are reviewed. Current knowledge of the perinatal effects of short-acting opioids, OPRs, heroin, and fentanyl, is scarce. Most of what we know about the perinatal effects of opioids comes from research on the long-acting opioid agonist drugs used in the treatment of OUDs, methadone and buprenorphine. Both have better perinatal outcomes for the mother and newborn than heroin, but the uptake of these opioid substitution programs is poor (<50%). Current research on perinatal outcomes of methamphetamine is limited to retrospective epidemiological studies, chart reviews, one study from a treatment center in Hawaii, and the US and NZ cross-cultural infant Development, Environment And Lifestyle IDEAL studies. Characteristics of pregnant individuals in both opioid and MA studies were associated with poor maternal health, higher rates of mental illness, trauma, and poverty. Infant outcomes that differed between opioid and MA exposure included variations in neurobehavior at birth which could complicate the diagnosis and treatment of neonatal opioid withdrawal (NOWs). Given the complexity of OUDs in pregnant individuals and the increasing co-use of these opioids with MA, large studies are needed. These studies need to address the many confounders to perinatal outcomes and employ neurodevelopmental markers at birth that can help predict long-term neurodevelopmental outcomes. Two US initiatives that can provide critical research and treatment answers to this public health crisis are the US Environmental influences on Child Health Outcomes (ECHO) program and the Medication for Opioid Use Disorder During Pregnancy Network (MAT-LINK).

Harmful effects of opioid use in pregnancy: A scientific review commissioned by the European Board and College of obstetrics and gynaecology (EBCOG)

Caring for pregnant women who have a recreational opioid use disorder is a common clinical challenge in modern obstetric care. These are an elusive population who often have multiple social issues that complicate their pregnancy management. Comprehensive and supportive maternal care can motivate these mothers to change her lifestyle. Multidisciplinary non-judgemental approach with appropriate medication and management, can result in good pregnancy outcomes for mother and her baby.

Identifying relative strength of methadone versus health and social services in comprehensive substance use disorder treatment using a variance decomposition approach

BACKGROUND

The purpose of this study is to identify the relative strengths of association of medication and health and social services in comprehensive substance use disorder (SUD) treatment.

OBJECTIVES

The study uses a novel variance decomposition method to assess the relative strength of association of six active ingredients of comprehensive SUD treatment: methadone medication, access services, SUD counseling, matched service ratio, client-provider relationship, and treatment duration.

METHODS

The study uses data from the National Treatment Improvement Evaluation Study (1992-1997), a dataset with an unusual number of services and service strategies measured. The data include 3012 clients from 45 SUD treatment programs. Linear mixed models are used to assess the relation of service variables to the outcome of posttreatment substance use. Variance decomposition methods are used to assess the relative importance of the ingredients in the treatment model.

RESULTS

Along with a random intercept and background variables, receipt of methadone accounted for the greatest relative strength of association at 35.4%, compared with 23.8% for treatment duration, 15.4% for client-provider relationship, and 11.2% for matched service ratio. Access and SUD counseling accounted for modest strengths of association at 1% and 3% each.

CONCLUSION

Findings indicate somewhat greater strength of association of methadone compared with other services and service strategies and overall, reinforce the importance of both medication and services and service strategies in the design and development of effective models of service delivery.

SIGNIFICANCE

This study, among the first to evaluate the relative importance of specific services and service strategies of comprehensive SUD treatment, provides insights relevant to the development of effective models of service delivery.

Gender Differences in Patterns and Correlates of Continued Substance Use among Patients in Methadone Maintenance Treatment

Continued substance use is common during opioid use disorder (OUD) treatment. There are still inconsistencies in how continued substance use and concurrent patterns of substance use among patients with OUD varies by gender. There is still more to learn regarding how factors associated with continued and concurrent use might differ for men and women in methadone maintenance treatment (MMT). Methods: This cross-sectional study examined predictors of concurrent substance use subgroups among patients receiving MMT. The sample included 341 (n = 161 women) MMT patients aged 18 and older from opioid treatment programs in Southern New England and the Pacific Northwest. Patients completed a survey assessing sociodemographic and clinical characteristics including past-month substance use. Latent class analyses were conducted by gender to identify groups based on substance use and determine predictors of those classes. Results: Three-class solutions were the optimal fit for both men and women. For both genders, the first subgroup was characterized as Unlikely Users (59.8% women, 52.8% men). Classes 2 and 3 among women were Cannabis/Opioid Users (23.7%) and Stimulant/Opioid Users (13.0%). Among men, Classes 2 and 3 consisted of Alcohol/Cannabis Users (21.9%) and Cannabis/Stimulant/Opioid Users (25.3%). Ever using Suboxone (buprenorphine/naloxone) and depression/anxiety symptoms were significantly linked to substance use group among women, whereas homelessness and employment status were significantly associated with substance use group among men. Conclusions: This study furthers understanding of gender differences in factors associated with continued substance use and distinctive patterns of concurrent substance use that may guide tailored treatments among patients MMT.

Stigmatization among methadone maintenance treatment patients in mountainous areas in northern Vietnam

Background

Stigma and discrimination may adversely affect the benefits of methadone maintenance treatment (MMT) for drug users, especially in disadvantaged settings. This study assessed stigma and discrimination against MMT patients in the mountainous and rural areas in Vietnam and explored their associated factors to inform implementation strategies.

Methods

We interviewed 241 MMT patients in two clinics: one in Tuyen Quang Province’s inner city and the other in Son Duong District, to assess stigma and discrimination that patients perceived and experienced. Socioeconomic status, health behaviors, health status, and history of drug abuse were examined. Multivariate linear and logistic regression models were used to explore factors associated with stigma and discrimination.

Results

The majority of respondents reported experiencing stigma and discrimination including blame/judgment (95.1%), shame (95.1%), disclosure (71.4%), and the fear of human immunodeficiency virus (HIV) transmission by others (74.1%). Unemployed patients were more likely to experience discrimination (Coef = −1.18, 95% CI = −1.87; −0.89). Those who were taking an antiretroviral were more likely to disclose their health status (Coef = 2.27, 95% CI = 0.6; 3.94). In addition, a higher likelihood of being blamed/judged and shamed was associated with those who suffered from anxiety/depression (Coef = 1.59, 95% CI = 0.24; 2.93 and Coef = 1.07, 95% CI = 0.36; 1.79, respectively).

Conclusions

MMT patients in these mountainous areas perceived high levels of stigma and discrimination which were associated with mental health disorders, unemployment, and HIV infection. These findings highlighted the importance of reducing drug use and HIV-related stigma against high-risk populations. Besides, psychosocial and familial supports, as well as job referrals, also play crucial roles in terms of promoting quality of life among MMT patients.

Methadone Maintenance Treatment Promotes Referral and Uptake of HIV Testing and Counselling Services amongst Drug Users and Their Partners

Background

Methadone maintenance treatment (MMT) reduces HIV risk behaviors and improves access to HIV-related services among drug users. In this study, we assessed the uptake and willingness of MMT patients to refer HIV testing and counseling (HTC) service to their sexual partners and relatives.

Methods

Health status, HIV-related risk behaviors, and HTC uptake and referrals of 1,016 MMT patients in Hanoi and Nam Dinh were investigated. Willingness to pay (WTP) for HTC was elicited using a contingent valuation technique. Interval and logistic regression models were employed to determine associated factors.

Results

Most of the patients (94.2%) had received HTC, 6.6 times on average. The proportion of respondents willing to refer their partners, their relatives and to be voluntary peer educators was 45.7%, 35.3%, and 33.3%, respectively. Attending MMT integrated with HTC was a facilitative factor for HTC uptake, greater WTP, and volunteering as peer educators. Older age, higher education and income, and HIV positive status were positively related to willingness to refer partners or relatives, while having health problems (mobility, usual care, pain/discomfort) was associated with lower likelihood of referring others or being a volunteer. Over 90% patients were willing to pay an average of US $17.9 for HTC service.

Conclusion

The results highlighted the potential role of MMT patients as referrers to HTC and voluntary peer educators. Integrating HIV testing with MMT services and applying users’ fee are potential strategies to mobilize resources and encourage HIV testing among MMT patients and their partners.

Heroin craving and its correlations with clinical outcome indicators in people with heroin dependence receiving methadone maintenance treatment

BACKGROUND

Craving for substance use has been added as one of the diagnostic criteria of substance use disorders in DSM-5. However, further research is necessary to examine and expand the clinical potential of craving in the assessment and treatment for heroin users. This study aimed to examine the psychometrics of the Desire for Drug Questionnaire-Chinese Mandarin version (DDQ-CM) and its clinical utility of assessing craving for heroin measured among heroin users with methadone maintenance treatment (MMT).

METHOD

Self-reported craving for heroin use was measured on the DDQ-CM and visual analog scale among 314 intravenous heroin users receiving MMT. Self-reported heroin dependence, attitude toward heroin use, readiness to change heroin use, and depression were collected.

RESULTS

The results found that although the original three-factor model was acceptable for applying the DDQ-CM for heroin users with MMT, only the concurrent validity of the subscales of Desire and Intention and Negative Reinforcement was supported but not that of Control. Meanwhile, the levels of craving on the subscales of Desire and Intention and of Negative Reinforcement on the DDQ-CM were positively associated with the levels of heroin dependence, positive and negative attitudes toward heroin use, and depression, but negatively associated with readiness to change heroin use.

CONCLUSIONS

This study supported the application of the subscales of Desire and Intention and Negative Reinforcement on the DDQ-CM to measure heroin craving in Taiwanese-Chinese heroin users and supported the clinical implication of craving in heroin users with MMT.

Incarcerated intravenous heroin users: predictors of post-release utilization of methadone maintenance treatment

Incarcerated intravenous heroin users have more problematic patterns of heroin use, but are less likely to access methadone maintenance treatment by their own initiative than heroin users in the community. The present study examined predictors for receiving methadone maintenance treatment post-release among incarcerated intravenous heroin users within a 24-month period. This cohort study recruited 315 incarcerated intravenous heroin users detained in 4 prisons in southern Taiwan and followed up within the 24-month period post-release. Cox proportional hazards regression analysis was applied to determine the predictive effects of sociodemographic and drug-use characteristics, attitude toward methadone maintenance treatment, human immunodeficiency virus serostatus, perceived family support, and depression for access to methadone maintenance treatment after release. There were 295 (93.7%) incarcerated intravenous heroin users released that entered the follow-up phase of the study. During the 24-month follow-up period, 50.8% of them received methadone maintenance treatment. After controlling for the effects of the detainment period before and after recruitment by Cox proportional hazards regression analysis, incarcerated intravenous heroin users who had positive human immunodeficiency virus serostatus (HR = 2.85, 95% CI = 1.80-4.52, p < .001) and had ever received methadone maintenance treatment before committal (HR = 1.94, 95% CI = 1.23-3.05, p < .01) were more likely to enter methadone maintenance treatment within the 24-month follow-up period. Positive human immunodeficiency virus serostatus with fully subsidized treatment and previous methadone maintenance treatment experiences predicted access of methadone maintenance treatment post-release. Strategies for getting familiar with methadone maintenance treatment during detainment, including providing methadone maintenance treatment prior to release and lowering the economic burden of receiving treatment, may facilitate entry of methadone maintenance treatment for incarcerated intravenous heroin users.

Preference of methadone maintenance patients for the integrative and decentralized service delivery models in Vietnam

BACKGROUND

Integrating and decentralizing services are essential to increase the accessibility and provide comprehensive care for methadone patients. Moreover, they assure the sustainability of a HIV/AIDS prevention program by reducing the implementation cost. This study aimed to measure the preference of patients enrolling in a MMT program for integrated and decentralized MMT clinics and then further examine related factors.

METHODS

A cross-sectional study was conducted among 510 patients receiving methadone at 3 clinics in Hanoi. Structured questionnaires were used to collect data about the preference for integrated and decentralized MMT services. Covariates including socio-economic status; health-related quality of life (using EQ-5D-5 L instrument) and HIV status; history of drug use along with MMT treatment; and exposure to the discrimination within family and community were also investigated. Multivariate logistic regression with polynomial fractions was used to identify the determinants of preference for integrative and decentralized models.

RESULTS

Of 510 patients enrolled, 66.7 and 60.8 % preferred integrated and decentralized models, respectively. The main reason for preferring the integrative model was the convenience of use of various services (53.2 %), while more privacy (43.5 %) was the primary reason to select stand-alone model. People preferred the decentralized model primarily because of travel cost reduction (95.0 %), while the main reason for not selecting the model was increased privacy (7.7 %). After adjusting for covariates, factors influencing the preference for integrative model were poor socioeconomic status, anxiety/depression, history of drug rehabilitation, and ever disclosed health status; while exposure to community discrimination inversely associated with this preference. In addition, people who were self-employed, had a longer duration of MMT, and use current MMT with comprehensive HIV services were less likely to select decentralized model.

CONCLUSION

In conclusion, the study confirmed the high preference of MMT patients for the integrative and decentralized MMT service delivery models. The convenience of healthcare services utilization and reduction of geographical barriers were the main reasons to use those models within drug use populations in Vietnam. Countering community stigma and encouraging communication between patients and their societies needed to be considered when implementing those models.

Mortality Risk Among Heroin Abusers: Clients and Non-clients of Public Treatment Centers for Drug Addiction

In Europe, the prevalence of problematic heroin consumption is declining but, in spite of the constant rise in the number of treated patients, many of them do not turn to a public treatment center (PTC) for their drug addiction. The aim of this study is to study the mortality risk separately for heroin abusers PTC clients and non-PTC clients (i.e., those never treated at a PTC).

METHODS

Cohort study on 959 subjects resident in the metropolitan area of Bologna who went to a health service (i.e., hospital, emergency unit) or to a PTC following problems due to heroin abuse for the first time between 01/01/2004 and 31/12/2009. Standardized mortality ratios (SMRs) were calculated, and regression analysis using the Poisson method was used.

RESULTS

Elevated and statistically significant SMRs were found in both genders, irrespective of the contact facility, being higher for PTC clients. Among non-PTC clients 28% of deaths overall were from AIDS or infectious diseases (6% PTC clients), 17% from opiate overdose (6% PTC clients) and 14% from violent causes (6% PTC clients). Multivariate analysis showed a higher mortality risk for patients who used both heroin and cocaine and for concomitant abuse of benzodiazepines.

CONCLUSIONS

The characteristics of patients never before treated for addiction prompts a reflection on the presence of a hidden group of patients who are hard to reach, who have a high mortality risk and who turn to health care treatment facilities only in the event of an emergency.

Improving psychosocial health and employment outcomes for individuals receiving methadone treatment: a realist synthesis of what makes interventions work

BACKGROUND

For over 50 years, methadone has been prescribed to opioid-dependent individuals as a pharmacological approach for alleviating the symptoms of opioid withdrawal. However, individuals prescribed methadone sometimes require additional interventions (e.g., counseling) to further improve their health. This study undertook a realist synthesis of evaluations of interventions aimed at improving the psychosocial and employment outcomes of individuals on methadone treatment, to determine what interventions work (or not) and why.

METHODS

The realist synthesis method was utilized because it uncovers the processes (or mechanisms) that lead to particular outcomes, and the contexts within which this occurs. A comprehensive search process resulted in 31 articles for review. Data were extracted from the articles, and placed in four templates to assist with analysis. Data analysis was an iterative process and involved comparing and contrasting data within and across each template, and cross checking with original articles to determine key patterns in the data.

RESULTS

For individuals on methadone, engagement with an intervention appears to be important for improved psychosocial and/or employment outcomes. The engagement process involves attendance at interventions as well as an investment in what is offered. Three intervention contexts (often in some combination) support the engagement process: a) client-centered contexts (or those where clients' psychosocial and/or employment needs/issues/skills are recognized and/or addressed); b) contexts which address clients' socio-economic conditions and needs; and, c) contexts where there are positive client-counselor and/or peer relationships. There is some evidence that sometimes ongoing engagement is necessary to maintain positive outcomes. There is also some evidence that complete abstinence from drugs (e.g., cocaine, heroin) is not necessary for engagement.

CONCLUSIONS

It is important to consider how the contexts of interventions might elicit and/or support clients' engagement. Further research is needed to explore how an individual's background (e.g., involvement with different interventions over an extended period) may influence engagement. Long-term engagement may be necessary to sustain some positive outcomes although how long is unclear and requires further research. Engagement can occur without complete abstinence from such drugs as cocaine or heroin, but additional research is required as engagement may be influenced by the extent and type of drug use.

Public opinion of drug treatment policy: exploring the public's attitudes, knowledge, experience and willingness to pay for drug treatment strategies

BACKGROUND

Research evidence is strong for opiate replacement treatment (ORT). However, public opinion (attitudes) can be at odds with evidence. This study explored the relationships between, attitudes, knowledge of drugs and a range of socio-demographic variables that potentially influence attitude. This is relevant in the current policy arena in which a major shift from harm reduction to, rehabilitation is underway.

METHODS

A cross sectional postal questionnaire survey in Scotland was conducted where the drug, treatment strategy has changed from harm-reduction to recovery-based. A random sample (N=3000), of the general public, >18 years, and on the electoral register was used. The questionnaire was largely structured with tick box format but included two open questions for qualitative responses. Valuation was measured using the economic willingness-to-pay (WTP) method.

RESULTS

The response rate was 38.1% (1067/2803). Less than 10% had personal experience of drug, misuse but 16.7% had experience of drug misuse via a friend/acquaintance. Regression modelling revealed more positive attitudes towards drug users in those with personal experience of drug misuse, (p<0.001), better knowledge of drugs (p=0.001) and higher income (those earning >£50,000 per, annum compared to <£15K; p=0.01). Over half of respondents were not willing to pay anything for drug treatment indicating they did not value these treatments at all. Respondents were willing-to-pay most for community rehabilitation and least for methadone maintenance treatment. Qualitative analysis of open responses indicated many strong negative attitudes, doubts over the efficacy of methadone and consideration of addiction as self-inflicted. There was ambivalence with respondents weighing up negative feelings towards treatment against societal benefit.

CONCLUSIONS

There is a gap between public attitudes and evidence regarding drug treatment. Findings suggest a way forward might be to develop and evaluate treatment that integrates ORT with a community rehabilitative approach. Evaluation of public engagement/education to improve knowledge of drug treatment effectiveness is recommended.

Sexual dysfunction improved in heroin-dependent men after methadone maintenance treatment in Tianjin, China

Objective

To investigate whether methadone maintenance treatment (MMT) is correlated with sexual dysfunction in heroin-dependent men and to determine the prevalence and risk factors of sexual dysfunction among men on MMT.

Methods

The study included a retrospective survey and a cross-sectional survey which contained interviews of 293 men who are currently engaged in MMT. The results of the two surveys were compared. For a subset of 43 participants, radioimmunoassay was additionally conducted using retrospective and prospective blood samples to test the levels of plasma testosterone and luteinizing hormone. Other study evaluations were the International Index of Erectile Function (IIEF-15), and Self-rating Depression Scale.

Results

Sexual dysfunction in all five IIEF-15 domains (erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction) was strongly associated with long-term use of heroin. A decrease in the severity of sexual dysfunction was associated with MMT initiation. Erectile dysfunction, lack of sexual desire, inability to orgasm, and lack of intercourse satisfaction were significantly correlated with increasing age of the participants. Methadone dose and duration of methadone treatment were not found to be associated with sexual dysfunction. The level of plasma testosterone significantly declined during methadone treatment, but results from multivariate analysis indicated low levels of testosterone were not the main cause of sexual dysfunction. No correlation between reported depression status and sexual function was found.

Conclusions

While high levels of sexual dysfunction were reported by heroin-dependent men in our study before and after MMT initiation, MMT appears to be correlated with improved sexual function in the population of the study.

Changes in quality of life (WHOQOL-BREF) and addiction severity index (ASI) among participants in opioid substitution treatment (OST) in low and middle income countries: an international systematic review

BACKGROUND

Opioid substitution treatment (OST) can increase quality of life (WHOQOL-BREF) and reduce addiction severity index (ASI) scores among participants over time. OST program participants have noted that improvement in quality of life is one of the most important variables to their reduction in drug use. However, there is little systematic understanding of WHOQOL-BREF and ASI domain changes among OST participants in low and middle-income countries (LMIC).

METHODS

Utilizing PRISMA guidelines we conducted a systematic literature search to identify OST program studies documenting changes in WHOQOL-BREF or ASI domains for participants in buprenorphine or methadone programs in LMIC. Standardized mean differences for baseline and follow-up domain scores were compared along with relationships between domain scores, OST dosage, and length of follow-up.

RESULTS

There were 13 OST program studies with 1801 participants from five countries eligible for inclusion in the review. Overall, statistically significant changes were noted in all four WHOQOL-BREF domain and four of the seven ASI domain scores (drug, psychological, legal, and family) documented in studies. Dosage of pharmacologic medication and length of follow-up did not affect changes in domain scores.

CONCLUSION

WHOQOL-BREF and ASI domain scoring is a useful tool in measuring overall quality of life and levels of addiction among OST participants. Coupled with measurements of blood-borne infection, drug use, relapse, and overdose, WHOQOL-BREF and ASI represent equally important tools for evaluating the effects of OST over time and should be further developed as integrated tools in the evaluation of participants in LMIC.

The prevalence of sexual dysfunction among male patients on methadone and buprenorphine treatments: a meta-analysis study

INTRODUCTION

For many years, methadone has been recognized as an effective maintenance treatment for opioid dependence. However, of the many adverse events reported, sexual dysfunction is one of the most common side effects.

AIM

We conducted a meta-analysis to evaluate the prevalence of sexual dysfunction among male patients on methadone and buprenorphine treatments.

METHODS

Relevant studies published from inception until December 2012 were identified by searching PubMed, OVID, and Embase. Studies were selected using prior defined criteria. Heterogeneity, publication bias, and odds ratio were assessed thoroughly.

MAIN OUTCOME MEASURES

To examine the prevalence and odds ratio of sexual dysfunctions among the methadone and buprenorphine groups.

RESULTS

A total of 1,570 participants from 16 eligible studies were identified in this meta-analysis. The studies provided prevalence estimates for sexual dysfunction among methadone users with a meta-analytical pooled prevalence of 52% (95% confidence interval [CI], 0.39-0.65). Only four studies compared sexual dysfunction between the two groups, with a significantly higher combined odds ratio in the methadone group (OR = 4.01, 95% CI, 1.52-10.55, P = 0.0049).

CONCLUSIONS

Evidence showed that the prevalence of sexual dysfunction was higher among the users of methadone compared with buprenorphine. Patients with sexual difficulty while on methadone treatment were advised to switch to buprenorphine.

Trends and predictors in methadone maintenance treatment dropout in Shanghai, China: 2005-2011

BACKGROUND

The methadone maintenance treatment (MMT) program has been implemented in Shanghai since 2005. This study aims to portray the trend of MMT dropout and identify predictive factors that may influence dropout in Shanghai MMT clinics, which could assist in the intervention strategy development.

METHODS

A retrospective evaluation was used in the Shanghai component of the National MMT data management system between January 1, 2005 and December 31, 2011. The Cox model for recurrence events was employed to estimate hazard ratio (HR) predicting dropout during the follow-up period.

RESULTS

Of all 6169 participants, 63% dropped out of the program at least once (ranging from 0 to 10 times), and 74% of them did not return by the end of this study. The average monthly incidence rate of dropout was 4.4% with a range from 0 to 9.3%. Adjusted analyses demonstrated that the individuals with methadone tapering didn't have a greater probability of dropping out compared to those with stable dosage (HR = 1.07, 95% CI: 0.90-1.27). However, there was a higher dropout rate among younger individuals (<30 years vs. ≥50 years old; HR = 1.41, 95% CI: 1.16-1.71), among those who were less educated (HR = 1.48, 95% CI: 1.17-1.87), among those who shared needles with others (HR = 1.29, 95% CI: 1.06-1.58), among those whose urine tested positive for opiates (HR = 1.69, 95% CI: 1.51-1.89), and among those who had a low average methadone dose at the initial stable stage of treatment (≤35 mg/day vs. >65 mg/day; HR = 1.39, 95% CI: 1.19-1.63).

CONCLUSIONS

Shanghai has been facing the challenge of keeping a high MMT retention rate. Increasing the use of methadone tapering after a stable treatment stage with sufficient dosage could be attempted in the MMT program, as well as considering comprehensive interventions among specific populations, such as young, poorly educated, opiate-positive and needle sharing individuals.

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.

Predictors for dropping-out from methadone maintenance therapy programs among heroin users in southern Taiwan

This study examined the methadone maintenance therapy (MMT) retention rates of heroin users in Taiwan and the predictors for dropout in the 18-month period after starting MMT. We consecutively recruited 368 intravenous heroin users receiving MMT in 2007-2008 and applied Cox proportional hazards regression analysis to determine the predictive effect of pre- and in-treatment variables on early discontinuation of MMT. The retention rate at 18 months was 32.3%. High heroin expenses, more severe harm caused by heroin use, perceived lower family support, and lower methadone dosage at 3 months after starting MMT increased the risk of dropout in the follow-up period.

Addiction treatment-related employment barriers: the impact of methadone maintenance

Employment is commonly upheld as an important outcome of addiction treatment. To explore this attribution, we assessed whether treatment enrollment predicts employment initiation among participants enrolled in a community-recruited Canadian cohort of people who inject drugs (IDU; N = 1,579). Survival analysis initially found no association between addiction treatment enrollment and employment initiation. However, when methadone maintenance therapy (MMT) was separated from other treatment modalities, non-MMT treatment positively predicted employment transitions, whereas MMT was negatively associated with employment initiation. Subanalyses examining transitions into temporary, informal, and under-the-table income generation echo these results. Findings suggest that individual factors impacting employment transitions may systematically apply to MMT clients and that, in this setting, the impact of treatment on employment outcomes is contingent on treatment type and design. Treatment-specific differences underscore the need to expand low-threshold MMT, explore MMT alternatives, and evaluate the impact of treatment design on the social and economic activity of IDU.

Naltrexone extended-release injection: an option for the management of opioid abuse

The United States Food and Drug Administration (FDA) approved naltrexone, a synthetic competitive antagonist at opioid receptors, in oral form in 1984 for use in the management of opioid abuse and addiction. Because naltrexone and its major metabolite, 6-β-naltrexone, are both competitive antagonists at opioid receptors - and thereby inhibit opioid agonist-induced effects including those desired by abusers - it was hypothesized that once maintained on naltrex-one, opioid-induced desirable effects would be diminished to the point that relapse to illicit use would decline because it was no longer rewarding. However, good medication compliance is a requisite for such a strategy to be effective and a systematic review of oral naltrexone concluded that this method of treatment was not superior for any outcomes measured (ie, retention, abstinence, or side effects) to placebo, psychotherapy, benzodiazepines, or buprenorphine treatment. In addition, the retention rate on oral naltrexone was very low (less than 30%). Recently, the FDA approved an extended-release formulation (intramuscular depot injection) of naltrexone for prevention of relapse to opioid dependence following opioid detoxification and to be used along with counseling and social support. Since it needs to be administered only monthly, as opposed to the daily administration required for the oral formulation, naltrexone injection has the potential for increasing adherence and retention rates. Concerns include liver damage at high doses (oral formulation) and possible opioid overdose if an attempt is made to surmount receptor antagonism by taking higher doses of an opioid agonist or if opioid receptors become "sensitized" under long-term antagonism. The focus of the present review is the current information regarding the safety and efficacy of naltrexone extended-release therapy.

Meta-analysis of drug-related deaths soon after release from prison

AIMS

The transition from prison back into the community is particularly hazardous for drug-using offenders whose tolerance for heroin has been reduced by imprisonment. Studies have indicated an increased risk of drug-related death soon after release from prison, particularly in the first 2 weeks. For precise, up-to-date understanding of these risks, a meta-analysis was conducted on the risk of drug-related death in weeks 1 + 2 and 3 + 4 compared with later 2-week periods in the first 12 weeks after release from prison.

METHODS

English-language studies were identified that followed up adult prisoners for mortality from time of index release for at least 12 weeks. Six studies from six prison systems met the inclusion criteria and relevant data were extracted independently.

RESULTS

These studies contributed a total of 69 093 person-years and 1033 deaths in the first 12 weeks after release, of which 612 were drug-related. A three- to eightfold increased risk of drug-related death was found when comparing weeks 1 + 2 with weeks 3-12, with notable heterogeneity between countries: United Kingdom, 7.5 (95% CI: 5.7-9.9); Australia, 4.0 (95% CI: 3.4-4.8); Washington State, USA, 8.4 (95% CI: 5.0-14.2) and New Mexico State, USA, 3.1 (95% CI: 1.3-7.1). Comparing weeks 3 + 4 with weeks 5-12, the pooled relative risk was: 1.7 (95% CI: 1.3-2.2).

CONCLUSIONS

These findings confirm that there is an increased risk of drug-related death during the first 2 weeks after release from prison and that the risk remains elevated up to at least the fourth week.

Problems experienced by community pharmacists delivering opioid substitution treatment in New South Wales and Victoria, Australia

AIMS

To explore service provision and the range of problems that New South Wales (NSW) and Victoria (VIC) community pharmacists providing opioid substitution treatment (OST) have experienced with clients and prescribers.

DESIGN

ross-sectional postal survey.

SETTING

All community pharmacies providing OST in NSW (n = 593) and VIC (n = 393), Australia.

PARTICIPANTS

Completed questionnaires were received from 669 pharmacists (68% response rate).

MEASUREMENTS

The questionnaire addressed pharmacy characteristics, recent problems experienced with clients including refusal to dose, provision of credit for dispensing fees, termination of treatment, responses of pharmacists to problems experienced with clients, as well as problems experienced with OST prescribers.

FINDINGS

In the preceding month, 41% of pharmacists had refused to dose a client for any reason, due most commonly to expired prescriptions (29%), or > or issed doses (23%). Terminating a client's treatment in the past month was reported among 14% of respondents, due most commonly to inappropriate behaviour and missed doses. Treatment termination was reported by a significantly higher proportion of pharmacists in VIC (P < 0.001). Treatment termination in last month was predicted having more clients (P < 0.001), the provision of buprenorphine treatment (P = 0.008), having a separate dosing area (P = 0.021), and being a female pharmacist (P = 0.013). Past month refusal to dose was predicted by the pharmacy being in VIC (P < 0.001) and having more clients (P < 0.001). Problems experienced most commonly in the past month with prescribers were difficulty contacting prescriber (21%) and provision of takeaway doses to clients considered unstable by the pharmacist (19%) (higher in VIC: both P < 0.001).

CONCLUSIONS

This study highlights the range of problems experienced by community pharmacists in the delivery of OST and the consequences for people in treatment. Particular attention should be focused upon considering number of clients per pharmacy and improving professional communication between pharmacists and prescribers.

Harm reduction in Australia: has it worked? A review

The literature is reviewed with a view to determining what evidence exists for the success of Australia's policy of harm minimization in relation to drug use. While there are relatively few examples of strategies which can unequivocally be said to have succeeded, there are many more for which the evidence is suggestive. While there has been a considerable mushrooming of research since the advent of the National Campaign on Drug Abuse, it would appear that little of this has measured the extent to which harm has been reduced. The National Drug Strategy would benefit from more policy-orientated research which measures drug-related harm if it is to be, as claimed, research driven.

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.

The effects of maternally administered methadone, buprenorphine and naltrexone on offspring: review of human and animal data

Most women using heroin are of reproductive age with major risks for their infants. We review clinical and experimental data on fetal, neonatal and postnatal complications associated with methadone, the current "gold standard", and compare these with more recent, but limited, data on developmental effects of buprenorphine, and naltrexone. Methadone is a micro-opioid receptor agonist and is commonly recommended for treatment of opioid dependence during pregnancy. However, it has undesired outcomes including neonatal abstinence syndrome (NAS). Animal studies also indicate detrimental effects on growth, behaviour, neuroanatomy and biochemistry, and increased perinatal mortality. Buprenorphine is a partial micro-opioid receptor agonist and a kappa-opioid receptor antagonist. Clinical observations suggest that buprenorphine during pregnancy is similar to methadone on developmental measures but is potentially superior in reducing the incidence and prognosis of NAS. However, small animal studies demonstrate that low doses of buprenorphine during pregnancy and lactation lead to changes in offspring behaviour, neuroanatomy and biochemistry. Naltrexone is a non-selective opioid receptor antagonist. Although data are limited, humans treated with oral or sustained-release implantable naltrexone suggest outcomes potentially superior to those with methadone or buprenorphine. However, animal studies using oral or injectable naltrexone have shown developmental changes following exposure during pregnancy and lactation, raising concerns about its use in humans. Animal studies using chronic exposure, equivalent to clinical depot formulations, are required to evaluate safety. While each treatment is likely to have maternal advantages and disadvantages, studies are urgently required to determine which is optimal for offspring in the short and long term.

Safety and efficacy of oral slow release morphine for maintenance treatment in heroin addicts: a 6-month open noncomparative study

This open-label, noncomparative, single-center trial evaluated the safety and efficacy of once-daily treatment with slow release oral morphine (SROM) capsules for the maintenance treatment of 20 outpatients with heroin dependency over 6 months at the National Institute for Addictions in Sofia, Bulgaria. Doses were individually titrated up to a mean daily maintenance dose of 760 mg (range 440-1,200 mg). SROM was effective in significantly reducing the signs and symptoms of opioid withdrawal and craving for heroin, with stabilization generally evident within two weeks. Nineteen patients completed 6 months of treatment and illicit opioid use was virtually eliminated. One patient withdrew voluntarily at 22 weeks. Validated questionnaires and tests indicated improvements in patients' well-being from baseline assessments. These included significant improvements with regard to suicidal depression (85%), anxiety and dysphoria (66%), general illness (58%), social dysfunction (54%), sense of hopelessness (34%), attention (25%), and self-reported typical depressive (27%) and disease-related (11%) symptoms. No deaths, serious adverse events, or withdrawals due to adverse events occurred. Five episodes of constipation and one episode of sweating (all nonserious and of mild or moderate severity) were reported. Vital signs were unaffected by SROM and no weight change was evident over the study period. The observations made in this study indicate a promising role for once-daily treatment with SROM in the clinical management of heroin dependency.

Methadone Maintenance and Male Sexual Dysfunction

PURPOSE

This study reports the prevalence and types of sexual dysfunction in a sample of men on methadone maintenance for opioid dependence, and describes factors which may contribute to sexual dysfunction.

METHODS

92 opioid-dependent men were recruited from a methadone maintenance clinic and completed two questionnaires, a research interview and laboratory measures.

RESULTS

Fourteen percent reported some sexual dysfunction. Erectile dysfunction (r = 0.24, p = 0.020), libido dysfunction (r = 0.30, p = 0.003), and global dysfunction (r = 0.26, p = 0.013) increased with increasing age of the patient. Methadone dose showed a significant direct correlation with increased orgasm dysfunction, both before and after adjusting for duration of treatment (p = 0.012). None of the sexual dysfunction subscales or global dysfunction were associated with plasma testosterone or plasma prolactin levels.

CONCLUSIONS

The rate of global sexual dysfunction in methadonetreated men is similar to general population studies and should be evaluated using general population guidelines. Orgasm dysfunction is a special case and may respond to methadone dose reduction.

Users' experiences of heroin and methadone treatment

The present study, conducted in 2003, Melbourne, Australia, examined and compared how different personal and social resources related to participants' use of both heroin and methadone, as well as their experiences of stigma and program regulation, and their evaluation of methadone treatment. In-depth interviews were conducted with 10 participants (five men, five women) aged between 25 and 42. Participants who had diverse personal and social circumstances were purposefully sought. Findings showed that users with "non-addict" or "functional" self-concepts had more resources and supportive social relationships that assisted them to develop realistic treatment expectations, avoid the stigma associated with methadone, and focus on the benefits of the treatment. Conversely, "conflicted" users with limited resources, few social connections, and negative self-concept saw methadone as an addiction, and as a highly stigmatizing and disempowering intervention. Social policies that differentiate users and address ways of improving users' personal and social resources are now needed.

Slow-release oral morphine versus methadone: a crossover comparison of patient outcomes and acceptability as maintenance pharmacotherapies for opioid dependence

AIMS

To evaluate slow-release oral morphine (SROM) as an alternative maintenance pharmacotherapy to methadone for treatment of opioid dependence.

DESIGN

Open-label crossover study.

SETTING

Out-patient methadone maintenance programme.

PARTICIPANTS

Eighteen methadone maintenance patients. Intervention Participants were transferred from methadone to SROM (once-daily Kapanol trade mark ) for approximately 6 weeks before resuming methadone maintenance.

MEASUREMENTS

Patient outcomes were assessed (1) during the transition between medications (dose requirements, withdrawal severity) and (2) after at least 4 weeks on a stable dose of each drug (treatment preference, patient ratings of treatment efficacy and acceptability, drug use, health, depression and sleep).

FINDINGS

Transfer from methadone to SROM was associated with relatively mild withdrawal for the first 5 days; the final mean SROM : methadone dose ratio was 4.6 : 1. Compared to methadone, SROM was associated with improved social functioning, weight loss, fewer and less troublesome side-effects, greater drug liking, reduced heroin craving, an enhanced sense of feeling 'normal' and similar outcomes for unsanctioned drug use, depression and health. The majority of subjects preferred SROM (78%) over methadone (22%).

CONCLUSIONS

These findings provide justification for further evaluation of SROM as a maintenance pharmacotherapy for opioid dependence.

Suicidal behavior in a young offender population

Young offenders have numerous problems, including increased psychopathology, housing, and psycho-social stresses and increased rates of substance abuse. The current study investigated the contribution that substance use might make to a particularly vulnerable group of young people. Of the 300 young people approached for the study, 23.7% reported a prior suicide attempt. For this group, the most significant predictors of a prior suicide attempt were negative affect, prior exposure to violence, and housing stress. Life-time substance-use variables were most predictive of the number of suicide attempts a young person might make. Self-reported lethality (the expectation that on the last attempt the young person expected to die) was not strongly predicted by any variable. The research identifies the important role that dynamic risk factors (such as mood, substance use, and psychosocial stressors) play in increasing the risk of self-harm for young offenders, and raises the need to provide for more comprehensive discharge planning and support in order to manage these needs.

The long-term outcomes of drug use by methadone maintenance patients

The aim of the study is to predict long-term outcomes of methadone maintenance (MM), other than continued heroin use, on the basis of drug use occurring early in MM treatment. In previous research, the weak association of initial drug use during MM with measures of rehabilitation status may be due to the use of measures that do not differentiate trends in different types of drug use. In the present study, 222 patients who completed 6 months of MM were assessed at program intake, evaluated for opiates and cocaine in the first 6 months of treatment, and given a follow-up assessment 2 years after treatment entry. The intake status of the patients was assessed using the Addiction Severity Index. Opiate and cocaine use during the first 6 months of MM was assessed by urine toxicology. Outcomes were assessed using a structured interview and official criminal records at follow-up. Cluster analysis of urine toxicologies during treatment identified 3 trajectory classes of MM patients: (A) variably high levels of opiate use, but consistently low cocaine use; (B) low and diminishing opiate and cocaine use; and (C) consistently high cocaine use, with diminishing opiate use. In an 18-month period, after these trends were observed, Cluster C had significantly more criminal charges than Cluster B had (3 times as many), but not significantly more than those of Cluster A. Clusters A and B did not differ significantly in criminal charges. Regardless of cluster membership, subjects with increasing levels of cocaine use in the first 6 months of MM had more hospitalizations for drug and alcohol problems during the follow-up period than subjects without increasing levels of cocaine use had. The results provide evidence of negative sequelae of cocaine use during MM that underscore the importance of clinical efforts to reduce levels of cocaine and other nonopiate drug use by MM patients.

Methadone maintenance at different dosages for opioid dependence

BACKGROUND

Methadone maintenance treatment (MMT) is a long term opioid replacement therapy, recognised as effective in the management of opioid dependence. Even if MMT at high dosage is recommended as therapy for reducing illicit opioid use and promoting longer retention in treatment, at present day "the organisation and regulation of the methadone maintenance treatment varies widely".

OBJECTIVES

To evaluate the efficacy of different dosages of MMT for opioid dependence in modifying health and social outcomes and in promoting patients' familial, occupational and relational functioning.

SEARCH STRATEGY

The following sources were scanned: - MEDLINE (OVID 1966-2001)- EMBASE (1988-2001)- ERIC (1988-2001)- Psychinfo (1947-2001)- Cochrane Controlled Trials Register (CCTR) (1947-2001)- Register of the Cochrane Drug and Alcohol Group (CDAG) (1947-2001)The CDAG search strategy was applied together with a specific MESH strategy. Further studies were searched through: letters to the authors of selected trials or to experts in order to obtain unpublished data. check of references of relevant reviews.

SELECTION CRITERIA

Randomised Controlled Trials (RCT) and Controlled Prospective Studies (CPS) evaluating methadone maintenance at different dosages in the management of opioid dependence were included in the review. Non-randomised trials were included when proper adjustment for confounding factors was performed at the analysis stage.

DATA COLLECTION AND ANALYSIS

Extraction of data was performed separately by two reviewers. Discrepancies were resolved by a third reviewer. RevMan software was used for analysis. Quality assessments of the methodology of studies were carried out using CDAG checklist.

MAIN RESULTS

22 studies were excluded from the review. 21 studies were included; of them, 11 were RCTs with 2279 people randomised and 10 were CPSs with 3715 people followed-up.

OUTCOMES

Retention rate - RCTs: High vs low doses at shorter follow-ups: RR=1.36 [1.13,1.63], and at longer ones: RR=1.62 [0.95,2.77]. Opioid use (self reported), times/w - RCTs: high vs low doses WMD= -2.00 [-4.77,0.77] high vs middle doses WMD= -1.89[-3.43, -0.35] Opioid abstinence, (urine based) at >3-4 w - RCTs: high vs low ones: RR=1.59 [1.16,2.18] high vs middle doses RR=1.51[0.63,3.61] Cocaine abstinence (urine based) at >3-4 w - RCTs: high vs low doses RR=1.81 [1.15,2.85]Overdose mortality - CPSs: high dose vs low dose at 6 years follow up: RR=0.29 [0.02-5.34] high dose vs middle dose at 6 years follow up: RR=0.38 [0.02-9.34] middle dose vs low dose at 6 years follow up: RR=0.57 [0.06-5.06]

REVIEWER'S CONCLUSIONS

Methadone dosages ranging from 60 to 100 mg/day are more effective than lower dosages in retaining patients and in reducing use of heroin and cocaine during treatment. To find the optimal dose is a clinical ability, but clinician must consider these conclusions in treatment strategies.

A novel cognitive-behavioral approach for treatment-resistant drug dependence

Despite the application of treatments that combine methadone administration, weekly counseling, and contingency reinforcement strategies, many opiate-dependent patients continue illicit drug use. In this controlled study we piloted a novel cognitive-behavioral treatment (CBT) designed to reduce illicit drug use among patients receiving methadone treatment. The treatment targeted the reduction of sensitivity to interoceptive cues associated with drug craving, and trained alternative responses to these cues. Patients (N = 23) were randomly assigned to either this novel CBT program or a program of increased counseling, such that the two programs of treatment were equated for therapist contact, assessment time, and contingency-reinforcement strategies. We found that, compared to a doubling of contact with their outpatient counselor, the new program was associated with significantly greater reductions in illicit drug use for women, but not for men. Reasons for differential performance by women and men and future directions for this new treatment are discussed.

The impact of harm-reduction-based methadone treatment on mortality among heroin users

OBJECTIVES

The purpose of this study was to investigate the impact of harm-reduction-based methadone programs on mortality among heroin users.

METHODS

A prospective cohort investigation was conducted among 827 participants in the Amsterdam Cohort Study. Poisson regression was used to identify methadone maintenance treatment characteristics (dosage, frequency of program attendance, and type of program) that are significantly and independently associated with mortality due to natural causes and overdose.

RESULTS

From 1985 to 1996, 89 participants died of natural causes, and 31 died as a result of an overdose. After adjustment for HIV and underweight status, there was an increase in natural-cause mortality among subjects who left methadone treatment (relative risk [RR] = 2.38, 95% confidence interval [CI] = 1.28, 4.55). Leaving treatment was also related to higher overdose mortality, but only among injection drug users (RR = 4.55, 95% CI = 1.89, 10.00).

CONCLUSIONS

Harm-reduction-based methadone treatment, in which the use of illicit drugs is tolerated, is strongly related to decreased mortality from natural causes and from overdoses. Provision of methadone in itself, together with social-medical care, appears more important than the actual methadone dosage.

Cost of drug use and criminal involvement before and during methadone treatment

AIMS

To examine criminal behaviour in methadone clients as a function of expenditure on illicit drugs. To quantify the benefit of treatment for this group and to identify individuals who do not reduce criminal behaviour or substance use as a consequence of treatment.

DESIGN

Cross-sectional examination of key methadone-treatment variables (age, methadone dose and length of time in treatment), and self-reported levels of spending on illicit drugs before and during methadone treatment.

SETTING

All interviews were conducted in the community-based treatment centre of the Maudsley's addiction treatment services in South London.

PARTICIPANTS

One hundred consecutive opiate-dependent attenders at a community treatment clinic.

MEASUREMENTS

Data were collected using a self-report questionnaire and treatment characteristic data were collected from clinical case notes.

FINDINGS

There was a major overall reduction in spending on illicit drugs from before treatment to during treatment, consistent with previous findings; however, 15% of the sample either showed no change or actually increased their spending after entry to treatment. This group did not differ in terms of key treatment characteristics (age, methadone dose and length of time in treatment) and there was no significant correlation between levels of spending before and during treatment.

CONCLUSIONS

Despite substantial overall benefit, there is a subgroup of individuals for whom long-term treatment, even on high range doses of methadone, has no beneficial effect on criminal activity or drug use. Further research is required to establish the dynamics of this indirect treatment-benefit, and to explore the apparent resistance to treatment of the criminal behaviour of a small sub-group.

A framework for the evaluation of activities and programs with harm-reduction objectives

This paper presents a framework for the evaluation of activities and programs with harm-reduction objectives that draws attention to the logic, implementation, outcomes, costs, and cost-effectiveness of these initiatives and encompasses stakeholder concerns and theoretical models. Evaluations of harm-reduction initiatives are essential if their proponents wish to establish them as viable alternatives to abstinence-oriented approaches. [Translations are provided in the International Abstracts Section of this issue.]