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Baker P, Genberg BL, Astemborski J, Mehta SH, Kirk GD, Cepeda J. Relationship between patient activation and utilisation of health care and harm reduction services among people who inject drugs in Baltimore, Maryland. Drug Alcohol Rev 2024. [PMID: 38951716 DOI: 10.1111/dar.13893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 02/20/2024] [Accepted: 06/10/2024] [Indexed: 07/03/2024]
Abstract
INTRODUCTION Given structural barriers, access to services is key for preventing drug-related harms and managing chronic disease among people who inject drugs (PWID). The Patient Activation Measure (PAM), a validated scale to assess self-efficacy in navigating one's own health care, was operationalised to improve service utilisation and outcomes but has not been assessed among PWID. We characterised PAM and its association with healthcare and harm reduction utilisation among PWID in the AIDS Linked to IntraVenous Experience cohort in Baltimore. METHODS From 2019 to 2020, participants completed surveys on PAM, service utilisation and drug use. We used log-binomial regression to identify correlates of "Lower" PAM and modelled the association between lower PAM and service utilisation, stratified by recent IDU. RESULTS Participants (n = 351) were primarily male (67%), Black (85%) and 24% reported recent IDU. Lower PAM was significantly more common in those reporting IDU (aPR 1.45; 95% CI 1.03, 2.04), heavy alcohol (aPR 1.77; 95% CI 1.24, 2.51) and marijuana (aPR: 1.70; 95% CI 1.23, 2.36) but less common among women (aPR 0.57; 95% CI 0.38, 0.84) and those living with HIV (APR 0.52; 95% CI 0.35, 0.78). In modelling service utilisation, lower PAM was associated with a lower prevalence of methadone utilisation (aPR 0.27; 95% CI 0.09, 0.84) among those reporting IDU, but a higher prevalence of methadone utilisation (aPR 2.72; 95% CI 1.46, 5.08) among those not reporting IDU, after controlling for correlates of PAM. DISCUSSION AND CONCLUSION PAM-tailored interventions targeting methadone utilisation warrant consideration but should account for socio-structural barriers to utilisation and correlates of PAM among PWID.
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Affiliation(s)
- Pieter Baker
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, USA
| | - Becky L Genberg
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Jacquie Astemborski
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Shruti H Mehta
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Gregory D Kirk
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
- School of Medicine, Johns Hopkins University, Baltimore, USA
| | - Javier Cepeda
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
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Hoffman KA, Foot C, Levander XA, Cook R, Terashima JP, McIlveen JW, Korthuis PT, McCarty D. Treatment retention, return to use, and recovery support following COVID-19 relaxation of methadone take-home dosing in two rural opioid treatment programs: A mixed methods analysis. J Subst Abuse Treat 2022; 141:108801. [PMID: 35589443 PMCID: PMC9080674 DOI: 10.1016/j.jsat.2022.108801] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 03/21/2022] [Accepted: 05/04/2022] [Indexed: 11/25/2022]
Abstract
Objectives In March 2020, the Substance Abuse and Mental Health Services Administration permitted Opioid Treatment Programs (OTPs) to relax restrictions on take-home methadone and promoted telehealth to minimize potential exposures to COVID-19. We assessed the effects of COVID-19-related changes on take-home methadone dosing in two OTPs serving five rural Oregon counties. Methods We used a mixed-methods convergent design. The OTPs extracted urine drug test (UDT) results, take-home methadone regimens, and treatment retention from the electronic health record (EHR) for patients (n = 377). A mixed-effects negative binomial regression model assessed patient-level differences in take-home doses before and after the COVID-19 policy changes and the associations with treatment discontinuation, and UDT positivity. Semi-structured qualitative interviews (n = 32) explored patient reactions to increased take-home dosing and reduced clinic visits to provide context for quantitative findings. Results The number of take-home doses increased in the post-COVID-19 period for patients engaged in treatment for more than 180 days (median: 8 vs 13 take-home doses per month, p = 0.011). Take-homes did not increase for patients with fewer days of treatment. Each percentage point increase in take-home dosing above what would be expected without COVID-19 policy changes was negatively associated with the percent of UDT positive for opioids (B = −0.12, CI [−0.21, −0.04], p = 0.005) and the probability of treatment discontinuation (aOR = 0.97, CI [0.95, 0.99], p = 0.003). Qualitative analysis revealed three themes explaining how increased take-home dosing supported recovery: 1) value of feeling trusted with increased responsibility; 2) reduced travel time permitted increased employment and recreation; and 3) reduced exposure to individuals less stable in recovery and potential triggers. Conclusions Take-home methadone dose relaxations were associated with increased methadone take-home doses, improved retention, and decreased UDT opioid positive results among clinically stable patients. Qualitative findings suggest that fewer take-home restrictions are feasible and desirable and do not pose safety or public health harms.
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McCarty D, Bougatsos C, Chan B, Hoffman KA, Priest KC, Grusing S, Chou R. Office-Based Methadone Treatment for Opioid Use Disorder and Pharmacy Dispensing: A Scoping Review. Am J Psychiatry 2021; 178:804-817. [PMID: 34315284 PMCID: PMC8440363 DOI: 10.1176/appi.ajp.2021.20101548] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors conducted a scoping review to survey the evidence landscape for studies that assessed outcomes of treating patients with opioid use disorder with methadone in office-based settings. METHODS Ovid MEDLINE and the Cochrane Database of Systematic Reviews were searched, and reference lists were reviewed to identify additional studies. Studies were eligible if they focused on methadone treatment in office-based settings conducted in the United States or other highly developed countries and reported outcomes (e.g., retention in care). Randomized trials and controlled observational studies were prioritized; uncontrolled and descriptive studies were included when stronger evidence was unavailable. One investigator abstracted key information, and a second verified data. A scoping review approach broadly surveyed the evidence, and therefore study quality was not rated formally. RESULTS Eighteen studies of patients treated with office-based methadone were identified, including six trials, eight observational studies, and four additional articles discussing use of pharmacies to dispense methadone. Studies on office-based methadone treatment, including primary care-based dispensing, were limited but consistently found that stable methadone patients valued office-based care and remained in care with low rates of drug use; outcomes were similar compared with stable patients in regular care. Office-based methadone treatment was associated with higher treatment satisfaction and quality of life. Limitations included underpowered comparisons and small samples. CONCLUSIONS Limited research suggests that office-based methadone treatment and pharmacy dispensing could enhance access to methadone treatment for patients with opioid use disorder without adversely affecting patient outcomes and, potentially, inform modifications to federal regulations. Research should assess the feasibility of office-based care for less stable patients.
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Affiliation(s)
- Dennis McCarty
- Pacific Northwest Evidence-Based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, BICC, 3181 SW Sam Jackson Park Road, Portland, OR 97239
- OHSU-PSU School of Public Health, Oregon Health & Science University, CB669
| | - Christina Bougatsos
- Pacific Northwest Evidence-Based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, BICC, 3181 SW Sam Jackson Park Road, Portland, OR 97239
| | - Brian Chan
- Pacific Northwest Evidence-Based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, BICC, 3181 SW Sam Jackson Park Road, Portland, OR 97239
- Department of Medicine, OHSU Medical School, Oregon Health & Science University
| | - Kim A. Hoffman
- OHSU-PSU School of Public Health, Oregon Health & Science University, CB669
| | - Kelsey C. Priest
- OHSU School of Medicine, MD/PhD Program, Oregon Health & Science University
| | - Sara Grusing
- Pacific Northwest Evidence-Based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, BICC, 3181 SW Sam Jackson Park Road, Portland, OR 97239
| | - Roger Chou
- Pacific Northwest Evidence-Based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, BICC, 3181 SW Sam Jackson Park Road, Portland, OR 97239
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Kmiec J. President’s message: Will COVID-19 have a lasting impact on opioid treatment program regulations? J Addict Dis 2020; 38:239-240. [DOI: 10.1080/10550887.2020.1795335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Julie Kmiec
- American Osteopathic Academy of Addiction Medicine, Chicago, IL, USA
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Cavaiola AA, Fulmer BA, Stout D. The Impact of Social Support and Attachment Style on Quality of Life and Readiness to Change in a Sample of Individuals Receiving Medication-Assisted Treatment for Opioid Dependence. Subst Abus 2016; 36:183-91. [PMID: 25839214 DOI: 10.1080/08897077.2015.1019662] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND A basic principle within the addictions treatment field is that social support is a vital ingredient in the recovery process. This study examines the nature of social support in a sample of opioid-dependent men and women who are currently being treated in a medication-assisted treatment program (methadone). This research examines the types of social support behaviors that the opioid-dependent individuals consider helpful and explores whether attachment style (i.e., secure, ambivalent, or anxious attachment) was a determining factor in whether social support was perceived as helpful. The dependent variables included readiness to change addictive behaviors and abstinence from other mood-altering drugs. METHODS Participants (N = 159) completed a demographic questionnaire, the Significant Others Scale, the Experiences in Close Relationships Scale, the Multidimensional Scale of Perceived Social Support Assessment, the Readiness to Change Scale, and an Attachment Style Questionnaire. The demographic questionnaire included subjective ratings of self-improvement. RESULTS Social support predicted perceived improvement in all of the areas examined (e.g., health, family/social relationships) and abstinence; however, attachment style did not predict improvement or with readiness to change. CONCLUSIONS Social support is an important factor in one's recovery from substance use disorders. Yet attachment style (i.e., anxious, avoidant, or secure) did not predict abstinence or overall improvement in functioning.
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Affiliation(s)
- Alan A Cavaiola
- a Department of Psychological Counseling , Monmouth University , West Long Branch , New Jersey , USA
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Novick DM, Salsitz EA, Joseph H, Kreek MJ. Methadone Medical Maintenance: An Early 21st-Century Perspective. J Addict Dis 2016; 34:226-37. [PMID: 26110221 DOI: 10.1080/10550887.2015.1059225] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Methadone medical maintenance is the treatment of stable methadone-maintained patients in primary care physicians' offices under an exemption from federal methadone regulations. Reports from seven such programs in six states show high retention and low frequencies of illicit drug use. Patients and physicians indicate high levels of satisfaction. Although methadone maintenance has a long history of safety and efficacy, most methadone medical maintenance programs are no longer operating or accepting new patients. Federal regulations for standard methadone clinics allow some features of methadone medical maintenance, and advocacy for state approval of these changes is strongly recommended.
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Affiliation(s)
- David M Novick
- a Laboratory of the Biology of Addictive Diseases, The Rockefeller University , New York , New York , USA
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Flynn PM, Brown BS. Matching Treatment to Rhetoric - A Challenge to Policy and Programming. J Subst Abuse Treat 2016; 64:1-2. [PMID: 26774843 DOI: 10.1016/j.jsat.2015.06.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 06/05/2015] [Accepted: 06/17/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Patrick M Flynn
- Institute of Behavioral Research, Texas Christian University, Fort Worth, TX USA.
| | - Barry S Brown
- University of North Carolina at Wilmington, Wilmington, NC USA
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Schwartz RP, Kelly SM, Gryczynski J, Mitchell SG, O’Grady KE, Jaffe JH. Heroin Use, HIV-Risk, and Criminal Behavior in Baltimore: Findings from Clinical Research. J Addict Dis 2015; 34:151-61. [PMID: 26079104 PMCID: PMC4550504 DOI: 10.1080/10550887.2015.1059222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - Jerome H. Jaffe
- Friends Research Institute, Inc, Baltimore, MD, USA
- University of Maryland School of Medicine, Department of Psychiatry, Baltimore, MD USA
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Earning "take-home" privileges and long-term outcome in a methadone maintenance treatment program. J Addict Med 2011; 5:92-8. [PMID: 21769054 DOI: 10.1097/adm.0b013e3181e6ad48] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This observational prospective study aimed to determine whether duration to the earning of privileges of "take-home" methadone doses (as a part of behavioral enforcement) reflects long-term outcome of patients in methadone maintenance treatment (MMT). METHODS All 657 former heroin addicts admitted to our MMT clinic between June 1993 and June 2008 were prospectively studied and followed up. Duration from admission to first take-home dose (until October 2008), to leaving (retention, until June 2009), and to dying (survival, until June 2008) was calculated. RESULTS Most patients (n = 435; 66.2%) ever achieved take-home privileges. Retention was longest (10 years, 95% confidence interval [CI]: 8.8 to 11.2) for 110 patients who achieved their first take-home dose after 3 to 6 months, followed by 9 years (95% CI: 7.7 to 10.3) for 98 patients who achieved it after >6 months and ≤1 year, and 8.3 years (95% CI: 7.2 to 9.4) for 127 patients who managed to achieve it only after >1 year. Retention was lower among patients who were given exceptional take-home doses (not respecting policy regulations) <3 months since admission: 5.1 years (95% CI: 3.4 to 7.8) for 30 patients (who got it for medical reasons), 9 years (95% CI: 6.7 to 11.3) for 14 patients admitted from another MMT, and 6.3 years (95% CI: 5 to 7.6) for 56 patients who got it for unjustified (mistakes) reasons. The shortest retention in MMT was 2.2 years (95% CI: 1.8 to 2.7, P < 0.0005) for 222 patients who never managed to achieve any take-home privileges. Survival was longer among patients who ever versus never received take-home privileges (13.2 years [95% CI: 12.8 to 13.6] vs 12.3 years [95% CI: 11.5 to 13.1], respectively; P = 0.04) and longest (14.1 years [95% CI: 13.4 to 14.7]) among those who received take-home privileges after 3 to 6 months. CONCLUSIONS The group with the shortest time (3 to 6 months) to the achievement of first take-home dose had the best outcome. Further studies are needed to characterize this group.
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De Maeyer J, Vanderplasschen W, Camfield L, Vanheule S, Sabbe B, Broekaert E. A good quality of life under the influence of methadone: a qualitative study among opiate-dependent individuals. Int J Nurs Stud 2011; 48:1244-57. [PMID: 21481390 DOI: 10.1016/j.ijnurstu.2011.03.009] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 03/17/2011] [Accepted: 03/19/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Attention from researchers and health care workers to the quality of life (QoL) of opiate users is growing, but most studies are quantitative, giving limited attention to the consumer's perspective. No information is available on how opiate-dependent individuals themselves perceive QoL and what they see as the important components that contribute to a good QoL. OBJECTIVES This qualitative study aims to expand our knowledge concerning opiate-dependent individuals' perceptions of a good QoL and the impact of methadone on components of a good QoL. METHODS In-depth interviews were conducted with 25 opiate-dependent individuals aged between 26 and 46 years old who started a methadone maintenance treatment at least 5 years ago. Purposive sampling was used to recruit participants with different socio-demographic characteristics and drug use profiles. The interviews were audio-tape recorded, transcribed verbatim and analysed thematically. RESULTS Thematic analyses revealed five key themes contributing to a good QoL for opiate-dependent individuals: (1) having social relationships, (2) holding an occupation, (3) feeling good about one's self, (4) being independent and (5) having a meaningful life. Opiate-dependent individuals valued methadone's ability to help them function normally, overcome their psychological problems and dependence on illicit opiates, and support them in achieving certain life goals. On the other hand, stigmatisation, discrimination, dependence on methadone and the drug's paralysing effects on their emotions were mentioned as common negative consequences. CONCLUSIONS The findings of this study highlight the importance of supporting opiate-dependent individuals in their daily life by means of practical, social and environmental support (alongside pharmacological treatment) in order to improve their QoL. This study further illustrates the ambivalent influence of methadone on opiate-dependent individuals' QoL, and demonstrates how something commonly perceived as a 'good' can also be a 'bad' for some people. Efforts should be made to limit the negative consequences of methadone on opiate-dependent individuals' QoL, while increasing its potential benefits.
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Yen CN, Wang CSM, Wang TY, Chen HF, Chang HC. Quality of life and its correlates among heroin users in Taiwan. Kaohsiung J Med Sci 2011; 27:177-83. [PMID: 21527184 DOI: 10.1016/j.kjms.2010.09.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 09/29/2010] [Indexed: 11/19/2022] Open
Abstract
The aims of this study were to compare the quality of life (QOL) between subjects with and without heroin use and to examine the association of QOL with sociodemographic characteristics, characteristics of heroin use, family support, and depression among heroin users at entry to a methadone maintenance treatment program. A group of 123 heroin users who visited an outpatient addiction treatment clinic in southern Taiwan for methadone maintenance treatment were recruited into this study. We also recruited 106 subjects who had never used heroin as the control group. Their QOL status was assessed by the short form of the Taiwan Version of the World Health Organization Questionnaire on Quality of Life (the WHOQOL-BREF Taiwan version). The level of QOL between subjects with and without heroin use was compared, and the correlates of QOL among heroin users were examined. Heroin users had poorer QOL than nonusers in the physical, psychological, and social relationship domains but not the environment domain of the WHOQOL-BREF after controlling for the influences of other factors. In addition, heroin users with obvious depression had poorer QOL in all four domains than those without obvious depression. Also, heroin users who perceived higher family support had better QOL in the social relationship and environment domains. Heroin users had poorer QOL than nonusers in multiple domains. Relief of depressive symptoms and enhancement of family support should be important strategies to improve QOL in heroin users.
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Affiliation(s)
- Chia-Nan Yen
- Department of Psychiatry, Tainan Hospital, Department of Health, Executive Yuan, Tainan City, Taiwan.
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Karow A, Verthein U, Pukrop R, Reimer J, Haasen C, Krausz M, Schäfer I. Quality of life profiles and changes in the course of maintenance treatment among 1,015 patients with severe opioid dependence. Subst Use Misuse 2011; 46:705-15. [PMID: 21047149 DOI: 10.3109/10826084.2010.509854] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Studies indicate that different areas of mental, physical, social and daily life functioning need to be considered in order to improve intervention outcomes in substance user patients. The aim of the study was to assess health-related quality of life (HRQOL) in patients diagnosed with opioid dependence as compared to healthy controls and patients diagnosed with depression and schizophrenia. METHODS A total of 1,015 outpatients diagnosed with opioid dependence were investigated during 12 months of maintenance treatment. HRQOL (MSQoL), addiction (EUROP-ASI), and sociodemographic characteristics were assessed. RESULTS HRQOL in opioid dependence improved significantly (p < .001), but was lower as compared to that of healthy controls and patients diagnosed with schizophrenia. HRQOL in opioid dependence comprises addiction-specific aspects, most importantly low material satisfaction, physical health, and social stability. CONCLUSIONS HRQOL measurement provides valuable information for course and outcome in opioid dependence treatment.
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Affiliation(s)
- A Karow
- University Medical Centre Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Hamburg, Germany.
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Karow A, Reimer J, Schäfer I, Krausz M, Haasen C, Verthein U. Quality of life under maintenance treatment with heroin versus methadone in patients with opioid dependence. Drug Alcohol Depend 2010; 112:209-15. [PMID: 20728288 DOI: 10.1016/j.drugalcdep.2010.06.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Revised: 03/22/2010] [Accepted: 06/17/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND There is increasing evidence that health-related quality of life (HRQOL) is associated with a successful treatment and better outcome in opioid addiction. The aim of the present study was the longitudinal investigation of HRQOL in patients with severe opioid dependence, who were randomly assigned to four groups of medical and psychosocial treatment: heroin (diacetylmorphine) versus methadone and case management (CM) versus psychoeducation (PSE) respectively. METHODS HRQOL (MSQoL) and physical health (OTI) were investigated in 938 subjects, who participated in the German multi-centre study examining the effects of heroin-assisted treatment in patients with severe opioid dependence. Data for the present analysis were taken from baseline and 12-month follow up. RESULTS Under both forms of maintenance and psychosocial treatment HRQOL improved significantly during the observation period. HRQOL improvement under maintenance with heroin exceeded improvement under methadone, especially with regard to subjective physical health. HRQOL improvement was significantly associated with better expert-rated physical health. Further analyses showed significant better improvement of HRQOL in subjects treated with PSE compared with CM. CONCLUSIONS The advantage of heroin with regard to the improvement of HRQOL may be partially explained by a better improvement of physical health under maintenance with heroin compared with methadone, which highlights the importance of a comprehensive model of health care for patients with severe opioid dependence. Future studies need to investigate the benefits of PSE for patients in maintenance therapy.
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Affiliation(s)
- A Karow
- University Medical Centre Hamburg Eppendorf, Department of Psychiatry and Psychotherapy, Martinistr. 52, 20246 Hamburg, Germany.
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Managing la malilla: Exploring drug treatment experiences among injection drug users in Tijuana, Mexico, and their implications for drug law reform. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2010; 21:459-65. [PMID: 20800464 DOI: 10.1016/j.drugpo.2010.06.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Revised: 06/25/2010] [Accepted: 06/28/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND In August 2009, Mexico reformed its drug laws and decriminalized small quantities of drugs for personal use; offenders caught three times will be mandated to enter drug treatment. However, little is known about the quality or effectiveness of drug treatment programs in Mexico. We examined injection drug users' (IDUs) experiences in drug treatment in Tijuana, Mexico, with the goal of informing program planning and policy. METHODS We examined qualitative and quantitative data from Proyecto El Cuete, a multi-phased research study on HIV risk among IDUs in Tijuana. Phase I consisted of 20 in-depth interviews and Phase II employed respondent-driven sampling to recruit 222 IDUs for a quantitative survey. We also reviewed national drug policy documents, surveillance data, and media reports to situate drug users' experiences within the broader sociopolitical context. RESULTS Participants in the qualitative study were 50% male with a mean age of 32; most injected heroin (85.0%) and methamphetamine (60.0%). The quantitative sample was 91.4% male with a mean age of 35; 98.2% injected heroin and 83.7% injected heroin and methamphetamine together. The majority of participants reported receiving treatment: residential treatment was most common, followed by methadone; other types of services were infrequently reported. Participants' perceptions of program acceptability and effectiveness were mixed. Mistreatment emerged as a theme in the qualitative interviews and was reported by 21.6% of Phase II participants, primarily physical (72.0%) and verbal (52.0%) abuse. CONCLUSIONS Our results point to the need for political, economic, and social investment in the drug treatment system before offenders are sentenced to treatment under the revised national drug law. Resources are needed to strengthen program quality and ensure accountability. The public health impact of the new legislation that attempts to bring drug treatment to the forefront of national drug policy should be systematically evaluated.
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Brekke M, Vetlesen A, Høiby L, Skeie I. [Quality of life among patients in drug-assisted rehabilitation programmes]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010; 130:1340-2. [PMID: 20596114 DOI: 10.4045/tidsskr.09.1117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Drug-assisted rehabilitation programmes reduce mortality and improve somatic and mental health among opioid abusers. We have explored changes in patients' perception of their QoL (quality of life) after enrollment in such a programme, and their explanations for these changes. MATERIAL AND METHODS 26 patients, enrolled a drug-assisted rehabilitation programme, were interviewed according to a semi-structured guide. Changes in QoL were recorded on a five-point scale; from much worse to much better. Answers to the question "What are your two main explanations for improved/reduced QoL?" were recorded literally and analysed by systematic text condensation. RESULTS The informants made 42 statements on reasons for improved QoL and six for reduced QoL. Important explanations for improved QoL were that life is no longer ruled by addiction, fewer social problems, and improved relationships to family and friends. Improved physical and psychological health was rarely mentioned. Loneliness and isolation, as well as the control imposed on them by the programme were explanations for reduced QoL. INTERPRETATION A large majority of patients experienced improved QoL, and having regained control of their life was the most important explanation. Some felt the treatment dominated their life too much, and therefore expressed a poorer QoL.
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Affiliation(s)
- Mette Brekke
- Institutt for helse og samfunn, Universitetet i Oslo, Postboks 1130 Blindern, 0318 Oslo, Norway.
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In the Shadow of Academic Medical Centers: A Systematic Review of Urban Health Research in Baltimore City. J Community Health 2010; 35:433-52. [PMID: 20422444 DOI: 10.1007/s10900-010-9258-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Villeneuve PJ, Challacombe L, Strike CJ, Myers T, Fischer B, Shore R, Hopkins S, Millson PE. Change in health‐related quality of life of opiate users in low‐threshold methadone programs. JOURNAL OF SUBSTANCE USE 2009. [DOI: 10.1080/14659890500256945] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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18
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Hogan B, Hershey L, Ritchey S. A case study using a patient satisfaction survey to improve the delivery and effectiveness of drug addiction treatment services: marketing implications and organizational impact. Health Mark Q 2009; 24:93-106. [PMID: 19042522 DOI: 10.1080/07359680802125923] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Drug abuse and addiction continues to negatively impact many lives in this country. The United States health care system has grappled with how to best serve this vulnerable population. Since the personal and societal costs of addiction are high, all recent iterations of the United States strategic health plans (such as Healthy People 2010) have prioritized this area for improvement. At the local level, health care providers who care for those with addictions are challenged with shrinking insurance coverage for services, a difficult patient population, lack of treatment options, growing ranks of indigent patients, as well as a plethora of additional management challenges. It is known that successful treatment is integrally linked with patient satisfaction with services. The most critical factors in successful addiction treatment (from a patient's perspective) are (1) their belief that the counselor cares about them and, (2) their belief that they can recover. This paper reports a case study in the use of a patient satisfaction survey as a quality management/service refinement tool within a methadone treatment setting. Results indicate that the use of the survey itself provides patients with a tangible cue supporting the presence of the critical success factors. Further, the use of a survey provides a baseline for future measurements and trending. The paper concludes with a discussion of the marketing and organizational implications of incorporating the patient satisfaction survey into the ongoing delivery program for addiction services.
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Affiliation(s)
- Beth Hogan
- Department of Management, Fayetteville State University, Fayetteville, NC 28301-4298, USA.
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Tuchman E. A model-guided process evaluation: Office-based prescribing and pharmacy dispensing of methadone. EVALUATION AND PROGRAM PLANNING 2008; 31:376-381. [PMID: 18582940 DOI: 10.1016/j.evalprogplan.2008.04.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2007] [Revised: 04/24/2008] [Accepted: 04/27/2008] [Indexed: 05/26/2023]
Abstract
This article presents an exemplar of a model-guided process evaluation that specifies the treatment model, assesses its implementation, monitors the fidelity of the model throughout the project, assesses model exposure and absorption, and helps understand the program's intermediate effects (proximal outcomes) as well as final effects (distal outcomes). The New Mexico study on office-based prescribing and community pharmacy dispensing of methadone is a research demonstration project that phases a small group of female methadone maintenance patients out of methadone clinics and into a program where they will obtain their scheduled doses of methadone at pharmacies that work in collaboration with physicians and a social worker.The patient's methadone treatment will in this way become part of their overall health care. Early detection of problems of implementation (e.g., the omission of program content or the delivery of inaccurate information) enables the researcher to make adjustments before the problems become unmanageable and the integrity of the original research design is compromised. A model-guided process evaluation can critically inform health services research demonstrations designed for enabling continuous, ongoing feedback and improvement of client-related services.
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Affiliation(s)
- Ellen Tuchman
- Silver School of Social Work, New York University, 1 Washington Square North, New York, NY 10003, USA
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20
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Implementing methadone medical maintenance in community-based clinics: Disseminating evidence-based treatment. J Subst Abuse Treat 2008; 35:312-21. [DOI: 10.1016/j.jsat.2007.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2007] [Revised: 12/17/2007] [Accepted: 12/24/2007] [Indexed: 11/17/2022]
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21
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Karow A, Verthein U, Krausz M, Schafer I. Association of personality disorders, family conflicts and treatment with quality of life in opiate addiction. Eur Addict Res 2008; 14:38-46. [PMID: 18182771 DOI: 10.1159/000110409] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
AIM The purpose of this study was to investigate the association of the current status and longitudinal changes in different clinical and social variables with quality of life (QOL) in opiate addiction. Our hypotheses were that drug use, comorbid personality disorders and social problems are associated with worse QOL. METHODS 107 participants with long-term opiate addiction were included and interviewed at entry with the Europ-ASI and the PDQ-R. QOL (SF-36) and changes in different domains of the Europ-ASI were assessed after 2 years. RESULTS Personality disorders, interpersonal conflicts with the family or partner and ongoing need for somatic and psychiatric treatment were significantly associated with worse subjective QOL, whereas changes in drug and alcohol use, the economic situation, legal problems and social problems with persons outside of the family showed no relevant association with QOL. CONCLUSION Our results provide support for an emphasis in treatment on helping clients to reduce intra- and interpersonal conflicts according to comorbid conditions and among family members and partnerships. In addition, the present data provide further support for the advantages of extended interventions in long-term opiate addiction.
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Affiliation(s)
- A Karow
- Department of Psychiatry und Psychotherapy, University Hospital Hamburg Eppendorf, Hamburg, Germany.
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22
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Becker WC, Fiellin DA. Provider satisfaction with office-based treatment of opioid dependence: a systematic review. Subst Abus 2007; 26:15-22. [PMID: 16492659 DOI: 10.1300/j465v26n01_02] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE New federal regulations allow for office-based treatment of opioid dependent patients with opioid agonist medication (e.g., buprenorphine). We sought to evaluate the literature on office-based physicians' acceptance of this practice. METHODS We searched the MEDLINE database for original research examining office-based providers' acceptance or satisfaction with office-based treatment. Articles included in the analysis met the following criteria: (1) discussed the treatment of patients with substance abuse disorders, (2) focused on the treatment of opioid dependent patients, (3) discussed treatment with opioid agonist therapy, (4) discussed treatment by office-based physicians, (5) presented original research, and (6) provided data examining physician acceptance or satisfaction. RESULTS Eight studies met the criteria. Their heterogeneity precluded aggregate analysis. Four of 8 studies revealed that providers had a positive perception concerning the efficacy of opioid agonist treatment, 4/8 indicated that providers believed that opioid dependent patients were more complex than others in their practices, and 3/8 studies indicated the need for additional support services. CONCLUSIONS There are few studies of provider satisfaction with office-based treatment of opioid dependence. This literature reveals overall provider acceptance of this practice but highlights the need for support services. Further research, designed to identify the barriers to provider satisfaction with office-based opioid agonist therapy, is needed to ensure that these barriers do not limit expansion of this practice.
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Affiliation(s)
- William C Becker
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520-8025, USA
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23
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Maremmani I, Pani PP, Pacini M, Perugi G. Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroin-addicted patients. J Subst Abuse Treat 2007; 33:91-8. [PMID: 17588494 DOI: 10.1016/j.jsat.2006.11.009] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2006] [Revised: 11/04/2006] [Accepted: 11/24/2006] [Indexed: 10/23/2022]
Abstract
The purpose of this study was to investigate the effects of methadone treatment and buprenorphine treatment on retention in treatment, urine drug testing results, psychiatric status, social adjustment, and quality of life among patients involved in long-term treatment with the cited medications. Two hundred thirteen patients (106 on buprenorphine treatment and 107 on methadone treatment) were enrolled in this open study at the 3rd month of their treatment and followed up until the 12th month; those who left the program before the end of the 3rd month of their treatment were not included in the study sample. The results of this study show statistically significant improvements in opioid use, psychiatric status, and quality of life between the 3rd and 12th months for both medications. This study suggests the long-term efficacy of methadone treatment and buprenorphine treatment on symptoms of opioid addiction and quality of life.
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Affiliation(s)
- Icro Maremmani
- Vincent P Dole Research Team, Department of Psychiatry NPB, Santa Chiara University Hospital, University of Pisa, Pisa, Italy.
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24
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Fiellin DA, Friedland GH, Gourevitch MN. Opioid Dependence: Rationale for and Efficacy of Existing and New Treatments. Clin Infect Dis 2006; 43 Suppl 4:S173-7. [PMID: 17109303 DOI: 10.1086/508180] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Opioid dependence is a chronic and relapsing medical disorder with a well-established neurobiological basis. Opioid agonist treatments, such as methadone and the recently approved buprenorphine, stabilize opioid receptors and the intracellular processes that lead to opioid withdrawal and craving. Both methadone and buprenorphine have been proven effective for the treatment of opioid dependence and can contribute to a decreased risk of human immunodeficiency virus (HIV) transmission. In addition, a buprenorphine/naloxone combination appears to have a decreased potential for abuse or diversion, compared with that associated with methadone. Largely because of these properties, recent legislation now affords an unprecedented opportunity for general physicians to offer opioid agonist treatment through their offices. This review focuses on the neurobiological basis of opioid dependence, the rationale for methadone and buprenorphine treatments, and issues in prescribing these medications to patients with HIV infection.
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Affiliation(s)
- David A Fiellin
- Yale University School of Medicine, New Haven, CT 06520-8025, USA.
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25
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King VL, Kidorf MS, Stoller KB, Schwartz R, Kolodner K, Brooner RK. A 12-month controlled trial of methadone medical maintenance integrated into an adaptive treatment model. J Subst Abuse Treat 2006; 31:385-93. [PMID: 17084792 DOI: 10.1016/j.jsat.2006.05.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2006] [Revised: 04/27/2006] [Accepted: 05/14/2006] [Indexed: 12/21/2022]
Abstract
Methadone medical maintenance (MMM) reduces the reporting schedule for stable and well-functioning methadone maintenance patients to once a month, with counseling provided by medical staff. We report on the 12-month outcomes of 92 highly stable methadone maintenance patients randomly assigned to one of three study conditions: routine care, MMM at the methadone maintenance program, and MMM at a physician's office. Methadone medical maintenance patients received a 28-day supply of methadone, whereas routine care patients received five or six take-home methadone doses each week. All patients performed a medication recall once a month and submitted two urine samples each month. An adaptive stepped-care system of treatment intensification was used for patients who failed recall or who had drug-positive urine specimens. Seventy-seven patients completed the 12-month study period. Dropout was caused primarily by problems with handling methadone and disliking the recall frequency. There were low rates of drug use or failed medication recall. Treatment satisfaction was high in all groups, but the MMM patients initiated more new employment or family/social activities than did routine care patients over the study period. The stepped-care approach was well tolerated and matched patients to an appropriate step of service within a continuum of treatment intensity.
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Affiliation(s)
- Van L King
- The Johns Hopkins University School of Medicine and Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, USA.
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26
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Harris KA, Arnsten JH, Joseph H, Hecht J, Marion I, Juliana P, Gourevitch MN. A 5-year evaluation of a methadone medical maintenance program. J Subst Abuse Treat 2006; 31:433-8. [PMID: 17084798 PMCID: PMC2692058 DOI: 10.1016/j.jsat.2006.05.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2005] [Revised: 05/24/2006] [Accepted: 05/24/2006] [Indexed: 11/29/2022]
Abstract
Methadone medical maintenance (MMM) is a model for the treatment of opioid dependence in which a monthly supply of methadone is distributed in an office setting, in contrast to more highly regulated settings where daily observed dosing is the norm. We assessed patient characteristics and treatment outcomes of an MMM program initiated in the Bronx, New York, in 1999 by conducting a retrospective chart review. Participant characteristics were compared with those of patients enrolled in affiliated conventional methadone maintenance treatment programs. Patients had diverse ethnicities, occupations, educational backgrounds, and income levels. Urine toxicology testing detected illicit opiate and cocaine use in 0.8% and 0.4% of aggregate samples, respectively. The retention rate was 98%, which compares favorably with the four other MMM programs that have been reported in the medical literature. This study demonstrates that selected patients from a socioeconomically disadvantaged population remained clinically stable and engaged in treatment in a far less intensive setting than traditional methadone maintenance.
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Affiliation(s)
- Kenneth A Harris
- Division of Substance Abuse, Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY 10461, USA.
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27
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Safety, Efficacy, and Feasibility of Office-based Prescribing and Community Pharmacy Dispensing of Methadone. ADDICTIVE DISORDERS & THEIR TREATMENT 2006. [DOI: 10.1097/01.adt.0000210713.80198.d1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Saxon AJ, McCarty D. Challenges in the adoption of new pharmacotherapeutics for addiction to alcohol and other drugs. Pharmacol Ther 2006; 108:119-28. [PMID: 16055196 DOI: 10.1016/j.pharmthera.2005.06.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2005] [Accepted: 06/23/2005] [Indexed: 11/17/2022]
Abstract
The adoption of pharmacotherapies for the treatment of alcohol and drug use disorders has progressed slowly despite the approval of new and effective medications. This paper begins with overviews of the prevalence of alcohol and drug abuse and dependence, the costs of addiction to the nation, and the value of treatment services. The role of pharmacotherapy in the treatment of addictive diseases is examined, and factors that affect the adoption and use of medications for alcohol and drug treatment are identified and discussed. Investigations that tested the effectiveness of buprenorphine for treatment of opioid dependence in new settings illustrate physician and counselor training and mentorship strategies that may promote the adoption of medications in the treatment of alcohol and drug use disorders. The paper concludes with a discussion of barriers and ways to surmount the barriers and to foster greater use of medications in alcohol and drug treatment.
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Affiliation(s)
- Andrew J Saxon
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98108, USA.
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29
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Giacomuzzi S, Kemmler G, Ertl M, Riemer Y. Opioid addicts at admission vs. slow-release oral morphine, methadone, and sublingual buprenorphine maintenance treatment participants. Subst Use Misuse 2006; 41:223-44. [PMID: 16393744 DOI: 10.1080/10826080500391845] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
With use of a randomized study design, quality of life (QOL) and physical symptoms of opioid addicts at admission were compared with slow-release oral morphine, methadone, and sublingual buprenorphine maintenance program participants after 6 months of treatment. The study was conducted from February to July 2004 in the outpatient drug user treatment center at University Department of Psychiatry at Innsbruck, providing maintenance treatment programs and detoxification in Tyrol, Austria. One hundred twenty opioid users seeking treatment were compared with 120 opioid-dependent patients retained for 6 months on a slow-release oral morphine, methadone, or sublingual buprenorphine maintenance program. The German version ("Berlin Quality of Life Profile") of the Lancashire Quality of Life Profile was used, and illicit opioid use was determined by urinalysis. Physical symptoms were measured by using the Opioid Withdrawal Scale. Urinalyses revealed a significantly lower consumption of cocaine and opioids in all three substitution groups than in patients at admission (p < 0.001 and p < or = 0.004, respectively). Both the buprenorphine and the methadone maintenance group showed significantly more favorable values than opioid clients at admission for stomach cramps (p < or = 0.002), muscular tension (p < or = 0.027), general pain (p < or = 0.001), feelings of coldness (p < or = 0.000), heart pounding (p < or = 0.008), runny eyes (p < or = 0.047), and aggressions (p < or = 0.009). Patients who received slow-release oral morphine treatment generally showed the least favorable QOL scores compared with patients at admission or sublingual buprenorphine and methadone clients. Patients in the sublingual buprenorphine or methadone program showed nearly the same QOL scores. The buprenorphine and the methadone maintenance group showed significantly more favorable values than opioid clients at admission regarding leisure time (p < or = 0.019), finances (p < or = 0.014), mental health (p < or = 0.010), and overall satisfaction (p < or = 0.010). Slow-release oral morphine is a well-established treatment for pain, but more research is required to evaluate it as a treatment for heroin dependence. The present data indicate that slow-release oral morphine could have some disadvantages compared with sublingual buprenorphine and methadone in QOL, physical symptoms, and additional consumption. The results further suggest that buprenorphine treatment is as effective as methadone in effects on quality of life and physical symptoms.
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Affiliation(s)
- S Giacomuzzi
- University Department of Psychiatry, Innsbruck, Austria.
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30
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Merrill JO, Jackson TR, Schulman BA, Saxon AJ, Awan A, Kapitan S, Carney M, Brumback LC, Donovan D. Methadone medical maintenance in primary care. An implementation evaluation. J Gen Intern Med 2005; 20:344-9. [PMID: 15857492 PMCID: PMC1490098 DOI: 10.1111/j.1525-1497.2005.04028.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Methadone is effective treatment for opioid addiction, but regulations restrict its use. Methadone medical maintenance treats stabilized methadone patients in a medical setting, but only experimental programs have been studied. OBJECTIVE To evaluate the implementation of the first methadone medical maintenance program established outside a research setting. DESIGN One-year program evaluation. SETTING A public hospital and a community opioid treatment program. PARTICIPANTS Methadone patients with >1 year of clinical stability. Eleven generalist physicians and 4 hospital pharmacists. INTERVENTIONS Regulatory exemptions were requested. Physicians and pharmacists were trained. Patients were transferred to the medical setting and permitted 1-month supplies of methadone. MEASUREMENTS Patient eligibility and willingness to enroll, treatment retention, urine toxicology results, change in addiction severity and functional status, medical services provided, patient and physician satisfaction, and physician attitudes toward methadone maintenance. RESULTS Regulatory exemptions were obtained after a 14-month process, and the program was cited in federal policy as acceptable for widespread implementation. Forty-nine of 684 patients (7.2%) met stability criteria, and 30 enrolled. Twenty-eight were retained for 1 year, and 2 transferred to other programs. Two patients had opioid-positive urine tests and were managed in the medical setting. Previously unmet medical needs were addressed, and the Addiction Severity Index (ASI) medical composite score improved over time (P=.02). Patient and physician satisfaction were high, and physician attitudes toward methadone maintenance treatment became more positive (P=.007). CONCLUSIONS Methadone medical maintenance is complex to arrange but feasible outside a research setting, and can result in good clinical outcomes.
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Affiliation(s)
- Joseph O Merrill
- Department of Medicine, University of Washington, Seattle, WA, USA.
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31
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Giacomuzzi SM, Riemer Y, Ertl M, Kemmler G, Rossler H, Hinterhuber H, Kurz M. Gender differences in health-related quality of life on admission to a maintenance treatment program. Eur Addict Res 2005; 11:69-75. [PMID: 15785067 DOI: 10.1159/000083035] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We compared the gender differences in health-related quality of life (QOL) on admission to a maintenance program. 103 opioid users (65 men and 38 women) admitted to a maintenance treatment program during 2000-2002 were studied. During this period we assessed the QOL status using the German version ('Berlin Quality of Life Profile') of the Lancashire Quality of Life Profile. Physical symptoms were measured using the Opioid Withdrawal Scale. 312 urine screening tests were carried out to evaluate consumption. The female group showed significantly less additional consumption of other opiates (p = 0.043) compared with the male group. The male group showed significantly better QOL scores in self-esteem (p = 0.015), psychical health (p = 0.027), and law and security (p = 0.008). The outcome measures for withdrawal scores showed significantly less symptoms for males in twitching of muscles (p = 0.034), vomiting (p = 0.002), depressions (p = 0.004) and poor appetite (p = 0.008). In summary, both genders showed only a few significant differences on admission in terms of QOL and physical symptoms. The predominant effects of drug use appear to eclipse the gender-related role pattern. Further exploration of gender and QOL could have important theoretical and treatment implications.
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Affiliation(s)
- S M Giacomuzzi
- Department of Psychiatry, University of Innsbruck, AT-6020 Innsbruck, Austria.
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32
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Corkery JM, Schifano F, Ghodse AH, Oyefeso A. The effects of methadone and its role in fatalities. Hum Psychopharmacol 2004; 19:565-76. [PMID: 15378662 DOI: 10.1002/hup.630] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Methadone is a synthetic opioid, used both as an analgesic in severe pain relief and now mainly in the treatment of opiate dependence. Such use of the drug has increased as its advantages have become widely recognized. There are undesirable outcomes from its greater use, including a substantial market in diverted methadone and a high number of deaths where the drug has been implicated. It is important to understand how and why methadone causes death so that such fatalities can be minimized, and to disseminate such information. This paper presents an overview of the chief effects of methadone on the human body, considering its metabolism, drug interactions and tolerance. The principal mechanisms by which methadone causes death are discussed: respiratory depression, aspiration of vomit, pulmonary oedema, bronchopneumonia, cardiac problems and renal failure. Many such deaths are preventable, if drug interactions and polydrug use are avoided, its longer period of metabolism and individuals' tolerance levels are considered. It is hoped that this paper will (a) help guide health professionals in their management and treatment of patients participating in methadone treatment programmes, and (b) provide some basic information for those dealing with individuals who have consumed methadone.
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Affiliation(s)
- John M Corkery
- National Programme on Substance Abuse Deaths, Department of Mental Health-Addictive Behaviour, St George's Hospital Medical School, Cranmer Terrace, London SW17 0RE, UK.
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33
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Sizemore GM, Davies HML, Martin TJ, Smith JE. Effects of 2beta-propanoyl-3beta-(4-tolyl)-tropane (PTT) on the self-administration of cocaine, heroin, and cocaine/heroin combinations in rats. Drug Alcohol Depend 2004; 73:259-65. [PMID: 15036548 DOI: 10.1016/j.drugalcdep.2003.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2003] [Revised: 09/30/2003] [Accepted: 10/15/2003] [Indexed: 11/17/2022]
Abstract
Pharmacotherapies utilizing long-acting agonists and mixed function agonists-antagonists have been successful in the treatment of opiate addiction but no comparable treatment exists for cocaine abuse. Long-acting tropane analogues have been synthesized that could be candidates for such pharmacotherapies. 2beta-propanoyl-3beta-(4-tolyl)-tropane (PTT) is one such compound that is a relatively selective dopamine (DA) transporter blocker that has a significantly longer duration of action than cocaine. The purpose of this study was to assess the effects of PTT on the intravenous self-administration of cocaine, heroin, or cocaine/heroin combinations. Groups of rats were trained to self-administer cocaine, heroin, or cocaine/heroin combinations using a within session dosing procedure in which three doses were available each session. PTT pretreatment reduced cocaine and cocaine/heroin combinations intake in a dose-dependent manner while having only minor effects on heroin intake. These results suggest that the neurobiological substrates of cocaine and heroin self-administration are different, and that these cocaine/heroin combinations may function more like cocaine alone, even when the dose of heroin in the mixture will function independently as a reinforcer. These results further support the potential use of long-acting dopamine reuptake inhibitors as pharmacotherapeutic adjuncts to a comprehensive treatment program for cocaine and cocaine/heroin abuse.
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Affiliation(s)
- Glen M Sizemore
- Department of Psychology, University of Florida, Box 112250, Gainesville, FL 32611, USA
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34
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Fiellin DA, Barthwell AG. Guideline development for office-based pharmacotherapies for opioid dependence. J Addict Dis 2004; 22:109-20. [PMID: 14723481 DOI: 10.1300/j069v22n04_09] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The success of opioid agonist maintenance has stimulated efforts to make this form of treatment more available. Methadone medical maintenance, coordination of methadone services from a physician's office, has been offered as an alternative to narcotic treatment programs for stable, recovered and socially rehabilitated opioid dependent patients. Despite the successful implementation of methadone medical maintenance programs, a number of important questions regarding the appropriate guidelines for the use of this model of care remain. The current paper reviews the process and outcome of the Medical Maintenance Consensus Panel, which was convened for the federal Center for Substance Abuse Treatment. We outline the process and describe the two guidelines that were produced by this process that are targeted at physicians, narcotic treatment programs, and policy makers.
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Affiliation(s)
- David A Fiellin
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520-8025, USA.
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35
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Giacomuzzi SM, Riemer Y, Ertl M, Kemmler G, Rössler H, Hinterhuber H, Kurz M. Buprenorphine versus methadone maintenance treatment in an ambulant setting: a health-related quality of life assessment. Addiction 2003; 98:693-702. [PMID: 12751987 DOI: 10.1046/j.1360-0443.2003.00352.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND To compare the effects on quality of life (QOL) of oral methadone with sublingual buprenorphine. METHODS We performed an open-label, non-randomized, two-site (methadone-buprenorphine) study. During 6 months we assessed the quality of life status of 53 opioid-dependent patients admitted to a methadone or buprenorphine maintenance programme using the German version (Berlin Quality of Life Profile) of the Lancashire Quality of Life Profile. Physical symptoms were measured using the Opioid Withdrawal Scale. Five hundred and thirty urine screening tests were carried out randomly to detect additional consumption. RESULTS Sixty-seven opioid-dependent subjects (38 on methadone and 29 on buprenorphine) were enrolled in the study, and 53 completed it (30 subjects treated with buprenorphine and 23 subjects with racemic methadone). The subjects were comparable on all baseline measures. At the first follow-up (week 8), the buprenorphine-maintained group showed significantly less additional consumption of opioids (P = 0.013) compared with the methadone group. Patients retained in the buprenorphine or methadone programme (week 24) showed no significant differences in all quality of life scores. At the end of the study period, the buprenorphine-maintained group showed significantly less additional consumption of opioids (P = 0.001) and cocaine (P = 0.018) compared with the methadone group. The outcome measures for withdrawal symptoms after 24 weeks of treatment with buprenorphine showed slight advantages in stomach cramps, fatigue or tiredness, feelings of coldness and heart pounding. CONCLUSIONS These results suggest that buprenorphine treatment is as effective as methadone regarding effects on quality of life and withdrawal symptoms. Buprenorphine has the potential to reduce the harm caused by drug abuse. Further research is needed to determine if buprenorphine is more effective than methadone in particular subgroups of patients.
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Affiliation(s)
- S M Giacomuzzi
- University Department of Psychiatry, Innsbruck, Austria.
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Affiliation(s)
- David A Fiellin
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn 06520-8025, USA.
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Abstract
Overdosing with methadone is a growing phenomenon in Britain and other countries due to the increase in prescription and the availability of this compound. Little is known of the circumstances surrounding methadone death due to some extent to the difficulty of defining drug-related death and also the difficulty of collecting clinical and biographical data in a predominantly illegal and marginal milieu. However, the evidence points to highest risk at night (to this end manifestations of its toxicity often go unrecognized) in those whose usual tolerance has been reduced and occurring some considerable time after ingestion. Further investigations are needed to elucidate fully the mechanism and spectrum of methadone overdose. Death from methadone is eminently preventable more so because of the long-term nature of the clinical sequelae. Indeed the key issue with methadone that sets it apart from other opioids is its potential for delayed toxicity. Consequently steps should be taken to disseminate the salient facts to all those who come into contact with the drug.
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Affiliation(s)
- Kim Wolff
- National Addiction Centre, London, United Kingdom.
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Abstract
Medical treatment of heroin addiction with methadone and other pharmacotherapies has important benefits for individuals and society. However, regulatory policies have separated this treatment from the medical care system, limiting access to care and contributing to the social stigma of even effective addiction pharmacotherapy. Increasing problems caused by heroin addiction have added urgency to the search for policies and programs that improve the access to and quality of opiate addiction treatment. Recent initiatives aiming to reintegrate methadone maintenance and other addiction pharmacotherapies into medical practice may promote both expanded treatment capacity and increased physician expertise in addiction medicine. These initiatives include changes in federal oversight of the opiate addiction treatment system, the approval of physician office-based methadone maintenance programs for stabilized patients, and federal legislation that could enable physicians to treat opiate addiction with new medications in regular medical practice.
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Affiliation(s)
- Joseph O Merrill
- Division of General Internal Medicine, Harborview Medical Center, Department of Medicine, and the Alcohol and Drug Abuse Institute, University of Washington, Seattle 98104, USA.
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King VL, Stoller KB, Hayes M, Umbricht A, Currens M, Kidorf MS, Carter JA, Schwartz R, Brooner RK. A multicenter randomized evaluation of methadone medical maintenance. Drug Alcohol Depend 2002; 65:137-48. [PMID: 11772475 DOI: 10.1016/s0376-8716(01)00155-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Methadone medical maintenance (MMM) is a rational, cost-effective method to match treatment intensity to level of needed services. In the present study, 73 highly stable methadone maintenance patients were randomly assigned to either a routine methadone treatment, MMM--a once monthly reporting schedule--at the methadone maintenance program or MMM at a physician office. A 'stepped care' intensified treatment approach was used for patients who had drug-positive urine specimens or failed the medication recall procedure. Patients left two urine specimens for analysis each month (at least one on a random basis) and responded to one medication recall each month. Results are presented for the first 6 months of the 1-year trial. Only 1% of urine specimens were positive for illicit drugs, there was no evidence of methadone diversion and there were very low rates of medication misuse, with no between group differences. MMM patients initiated more new employment or family/social activities than the routine care patients. MMM patients were more satisfied with their treatment than the routine treatment patients, but all patients rated themselves satisfied or very satisfied with their treatment. Stepped care was well-tolerated and helped match patients to an appropriate intensity of service. The good outcomes observed with the present sample suggest that MMM can be implemented effectively as part of a continuum of care in clinic and office-based sites.
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Affiliation(s)
- Van L King
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Behavioral Biology Research Center, 5510 Nathan Shock Drive, Ste. 1500, Baltimore, MD 21224, USA.
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Vignau J, Duhamel A, Catteau J, Legal G, Pho AH, Grailles I, Beauvillain J, Petit P, Beauvillain P, Parquet PJ. Practice-based buprenorphine maintenance treatment (BMT): how do French healthcare providers manage the opiate-addicted patients? J Subst Abuse Treat 2001; 21:135-44. [PMID: 11728787 DOI: 10.1016/s0740-5472(01)00189-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED France was the first country to promote the extensive use of buprenorphine for the treatment of drug-addicted subjects through the primary care system. To assess both professional commitment and patients' characteristics, all the physicians and pharmacists of a French area having prescribed/dispensed buprenorphine from 2/12/96 (the official release date) to 1/31/98 were identified from data files of the Health Insurance and then interviewed. During the first 61 weeks of buprenorphine maintenance treatment (BMT), 27.5% of physicians and 51.2% of pharmacists of that area were involved; 142 patient records were documented. Features of the clinical routines spontaneously implemented for practice-based BMT were: a high level of on-site supervised dispensation by the pharmacist (71% at treatment induction and 23% thereafter); the absence of objective measurement of illicit drug use; and a low buprenorphine dosage. These features are consistent with the lack of physicians' experience and training, and also the relatively good status of the population treated (no HIV-positives, heroin use duration averaging 4.2 +/- 3.1 years, and 81.7% with stable accommodations). Despite liberal regulations guiding BMT, a negligible proportion of cases had a "nomadic" attitude (multiple buprenorphine prescribers/deliverers). The treatment outcomes (no deaths, three drug overdoses, improvement in occupational status) are encouraging. CONCLUSION Practice-based BMT appears to be a safe and acceptable response to moderate heroin addiction, but further training of the professionals involved and longitudinal investigations of individual outcomes are needed.
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Affiliation(s)
- J Vignau
- University Hospital, Lille, France.
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