Cost and cost-effectiveness of standard methadone maintenance treatment compared to enriched 180-day methadone detoxification

Spatial proximity and access to buprenorphine or methadone treatment for opioid use disorder in a sample of people misusing opioids in Southern California

BACKGROUND

In response to the opioid crisis, over the last 10 years substantial strides have been made to increase the availability of evidence-based treatments for opioid use disorder, in particular buprenorphine maintenance, in the United States. Despite these worthwhile efforts, uptake rates of evidence-based treatment remain relatively low. As part of a broader study of opioid misuse, we examined proximity to evidence-based treatment as a potential barrier to treatment access.

METHODS

In 2017-2018, we surveyed 218 individuals misusing prescription opioids or using street opioids in three Southern Californian counties. The study calculated driving distance from place of residence to the closest treatment provider offering buprenorphine or methadone treatment for opioid use disorders.

RESULTS

Median distance to providers was 3.8 km (2.4 miles). Seventy one (33%) participants had received some form of treatment in the last 3 months; however, only 26 (40%) of these had received buprenorphine or methadone maintenance treatment. Participants receiving treatment at the time of their interview were traveling an average 16.8 km (10.4 miles) to reach treatment, indicating that as a group this population was both willing and able to seek and engage with treatment.

CONCLUSIONS

In the suburban and exurban communities in which our study was based, our findings suggest that simple physical proximity to providers of evidence-based treatment for opioid use disorder is no longer a critical barrier. Other barriers to uptake of buprenorphine or methadone maintenance treatment clearly remain and need to be addressed.

DISCLAIMER

Findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

A Systematic Review of Simulation Models to Track and Address the Opioid Crisis

The opioid overdose crisis is driven by an intersecting set of social, structural, and economic forces. Simulation models offer a tool to help us understand and address this complex, dynamic, and nonlinear social phenomenon. We conducted a systematic review of the literature on simulation models of opioid use and overdose up to September 2019. We extracted modeling types, target populations, interventions, and findings. Further, we created a database of model parameters used for model calibration, and evaluated study transparency and reproducibility. Of the 1,398 articles screened, we identified 88 eligible articles. The most frequent types of models were compartmental (36%), Markov (20%), system dynamics (16%), and Agent-Based models (16%). Over a third evaluated intervention cost-effectiveness (40%), and another third (39%) focused on treatment and harm reduction services for people with opioid use disorder (OUD). More than half (61%) discussed calibrating their models to empirical data, and 31% discussed validation approaches used in their modeling process. From the 63 studies that provided model parameters, we extracted the data sources on opioid use, OUD, OUD treatment, cessation/relapse, emergency medical services, and mortality parameters. This database offers a tool that future modelers can use to identify potential model inputs and evaluate comparability of their models to prior work. Future applications of simulation models to this field should actively tackle key methodological challenges, including the potential for bias in the choice of parameter inputs, investment in model calibration and validation, and transparency in the assumptions and mechanics of simulation models to facilitate reproducibility.

Diversity inclusion in United States opioid pharmacological treatment trials: A systematic review

Pharmacological treatments for opioid use disorders (OUDs) may have mixed efficacy across diverse groups, i.e., sex/gender, race/ethnicity, and socioeconomic status (SES). The present systematic review aims to examine how diverse groups have been included in U.S. randomized clinical trials examining pharmacological treatments (i.e., methadone, buprenorphine, or naltrexone) for OUDs. PubMed was systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The initial search yielded 567 articles. After exclusion of ineligible articles, 50 remained for the present review. Of the included articles, 14.0% (n = 7) reported both full (i.e., accounting for all participants) sex/gender and race/ethnicity information; only two of those articles also included information about any SES indicators. Moreover, only 22.0% (n = 11) reported full sex/gender information, and 42.0% (n = 21) reported full racial/ethnic information. Furthermore, only 10.0% (n = 5) reported that their lack of subgroup analyses or diverse samples was a limitation to their studies. Particularly underrepresented were American Indian/Alaska Native (AI/AN), Asian, Native Hawaiian/Other Pacific Islander (NH/OPI), and multiracial individuals. These results also varied by medication type; Black individuals were underrepresented in buprenorphine randomized controlled trials (RCTs) but were well represented in RCTs for methadone and/or naltrexone. In conclusion, it is critical that all people receive efficacious pharmacological care for OUDs given the ongoing opioid epidemic. Findings from the present review, however, support that participants from diverse or marginalized backgrounds are underrepresented in treatment trials, despite being at increased risk for disparities related to OUDs. Suggestions for future research are advanced. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Examining a migration-based phenomenon of heroin use in an urban drug scene in Sao Paulo, Brazil

Purpose

Brazil’s street-based drug use is mostly characterized by non-injection psychostimulant (e.g. crack-cocaine) drug use in Brazil, with limited interventions and service availability. Recently, an influx of multi-ethnic migrants within an urban drug scene in Sao Paulo was associated with heroin use, a drug normatively absent from Brazil. The purpose of this paper is to characterize and compare heroin use-related characteristics and outcomes for an attending sub-sample of clients from a large community-based treatment centre (“CRATOD”) serving Sao Paulo’s local urban drug scene.

Design/methodology/approach

All non-Brazilian patients (n = 109) receiving services at CRATOD for 2013–2016 were identified from patient files, divided into heroin users (n = 40) and non-heroin users (n = 69). Based on chart reviews, select socio-demographic, drug use and health status (including blood-borne-virus and other infections per rapid test methods) were examined and bi-variately compared. Multi-variate analyses examined factors independently associated with heroin use.

Findings

Most participants were male and middle-aged, poly-drug users and socio-economically marginalized. While heroin users primarily originated from Africa, they reported significantly more criminal histories, drug (e.g. injection) and sex-risk behaviors and elevated rates of BBV (e.g. Hepatitis C Virus and HIV). A minority of heroin users attending the clinic was provided methadone treatment, mostly for detoxification.

Originality/value

This study documented information on a distinct sample of mostly migration-based heroin users in Sao Paulo, Brazil. Based on the local experience, global migration dynamics can bring changes to established drug use cultures and services, including new challenges for drug use-related related behaviors and therapeutic interventions that require effective understanding and addressing.

Economic Evaluation in Opioid Modeling: Systematic Review

OBJECTIVES

The rapid increase in opioid overdose and opioid use disorder (OUD) over the past 20 years is a complex problem associated with significant economic costs for healthcare systems and society. Simulation models have been developed to capture and identify ways to manage this complexity and to evaluate the potential costs of different strategies to reduce overdoses and OUD. A review of simulation-based economic evaluations is warranted to fully characterize this set of literature.

METHODS

A systematic review of simulation-based economic evaluation (SBEE) studies in opioid research was initiated by searches in PubMed, EMBASE, and EbscoHOST. Extraction of a predefined set of items and a quality assessment were performed for each study.

RESULTS

The screening process resulted in 23 SBEE studies ranging by year of publication from 1999 to 2019. Methodological quality of the cost analyses was moderately high. The most frequently evaluated strategies were methadone and buprenorphine maintenance treatments; the only harm reduction strategy explored was naloxone distribution. These strategies were consistently found to be cost-effective, especially naloxone distribution and methadone maintenance. Prevention strategies were limited to abuse-deterrent opioid formulations. Less than half (39%) of analyses adopted a societal perspective in their estimation of costs and effects from an opioid-related intervention. Prevention strategies and studies' accounting for patient and physician preference, changing costs, or result stratification were largely ignored in these SBEEs.

CONCLUSION

The review shows consistently favorable cost analysis findings for naloxone distribution strategies and opioid agonist treatments and identifies major gaps for future research.

Factors Associated with Low Bone Density in Opioid Substitution Therapy Patients: A Systematic Review

Background: Long-term opioid therapy is a risk factor for low bone mineral density (BMD). However, other factors may also contribute to low BMD. Several studies have examined the variables that might contribute to low BMD in patients receiving opioid replacement therapy (OST). However, to our knowledge, there was no systemic review conducted to address this particular issue. Thus, we reviewed the articles on the factors associated with low BMD in the population of opioid use disorder receiving substitution therapy. Methods: The articles that examined correlates or risk factors of low BMD in OST population were retrieved from OVID, SCOPUS, and PUBMED from inception until July 2020 by two independent investigators. Results: A total of 429 articles from three databases were retrieved initially. After screening based on eligibility criteria, five articles were included in the final analysis. The risk factors or correlates found to be significantly associated with low BMD in the OST population include male gender, low body mass index, low testosterone level, methadone or heroin use, and longer duration of heavy alcohol use. The review limitations include small sample sizes and inconsistent definition of variables. Conclusion: OST patients should be screened for BMD and its associated factors. Guidelines and training of practitioners involving in the OST service should be provided to increase the detection of low BMD in the OST population.

Economic Evaluation of Interventions to Address Opioid Misuse: A Systematic Review of Methods Used in Simulation Modeling Studies

OBJECTIVES

Several evidence-based interventions exist for people who misuse opioids, but there is limited guidance on optimal intervention selection. Economic evaluations using simulation modeling can guide the allocation of resources and help tackle the opioid crisis. This study reviews methods employed by economic evaluations using computer simulations to investigate the health and economic effects of interventions meant to address opioid misuse.

METHODS

We conducted a systematic mapping review of studies that used simulation modeling to support the economic evaluation of interventions targeting prevention, treatment, or management of opioid misuse or its direct consequences (ie, overdose). We searched 6 databases and extracted information on study population, interventions, costs, outcomes, and economic analysis and modeling approaches.

RESULTS

Eighteen studies met the inclusion criteria. All of the studies considered only one segment of the continuum of care. Of the studies, 13 evaluated medications for opioid use disorder, and 5 evaluated naloxone distribution programs to reduce overdose deaths. Most studies estimated incremental cost per quality-adjusted life-years and used health system and/or societal perspectives. Models were decision trees (n = 4), Markov (n = 10) or semi-Markov models (n = 3), and microsimulations (n = 1). All of the studies assessed parameter uncertainty though deterministic and/or probabilistic sensitivity analysis, 4 conducted formal calibration, only 2 assessed structural uncertainty, and only 1 conducted expected value of information analyses. Only 10 studies conducted validation.

CONCLUSIONS

Future economic evaluations should consider synergies between interventions and examine combinations of interventions to inform optimal policy response. They should also more consistently conduct model validation and assess the value of further research.

What place for prolonged-release buprenorphine depot-formulation Buvidal® in the treatment arsenal of opioid dependence? Insights from the French experience on buprenorphine

Introduction: Since the 1990s, opioid maintenance treatments (OMTs), i.e. mostly methadone and buprenorphine, have represented the therapeutic cornerstone of opioid dependence. In France, the public health strategy on opioid dependence, identified here as the 'French model', has consisted of offering a facilitated access to buprenorphine, to reach a large treatment coverage and reduce opioid-related mortality. Areas covered: Recently, a new formulation of subcutaneous buprenorphine depot (Buvidal®) has been approved in Europe for treatment of opioid dependence. The place of Buvidal® among the pre-existing arsenal of OMTs is discussed in the light of the pharmacological specificities of this new formulation, and with the particular standpoint of the French model on opioid dependence. Expert opinion: Buvidal® could constitute a promising treatment option mainly in case of: 1) OMT initiation, including in non-specialized addiction medicine care; 2) Discharge from prison or hospital; Diversion/misuse of 3) buprenorphine or 4) methadone; 5) Clinically stabilized patients wishing to avoid daily oral taking of the medication. As such, this new formulation should be highly accessible, which will require specific pathways through care as the product is intended to be administered by a healthcare professional.

Probuphine® (buprenorphine implant): a promising candidate in opioid dependence

Opioid dependence leads to physical dependence and addiction which finally results in profound medical, psychological and social dysfunction. One of the useful medications for opioid dependence is buprenorphine, the partial opioid agonist, which is used alone or in combination with naloxone. However, buprenorphine is the victim of its own success due to its illicit use and accidental poisoning in children. Also, buprenorphine typically requires daily self-administration and its effectiveness heavily depends on patient adherence. So, poor treatment adherence results in ineffective treatment manifesting as craving and withdrawal symptoms. Short-term use of buprenorphine in opioid dependence is also often followed by relapse. Buprenorphine when used sublingually often results in inadequate or fluctuating blood concentrations and poorer treatment retention compared with methadone. All of these led to the development of Probuphine®, a polymeric matrix composed of ethylene vinyl acetate and buprenorphine in the form of implants, that are implanted subdermally in office practice and deliver the active drug over 6 months. Buprenorphine release from such implant is fairly consistent, avoiding plasma peaks and troughs, and the implant is also reported to be safe. In this review article, we have highlighted these aspects of treatment of opioid addiction, stressing on the pharmacology of buprenorphine and Probuphine®, and relevant clinical trials addressing the efficacy and safety of Probuphine®. This sustained-release implantable formulation of buprenorphine has the potential to be a suitable alternative to daily or alternate day sublingual buprenorphine which can thereby eliminate the need for daily supervision, minimizing fluctuations in plasma concentrations, and allowing these patients to reduce clinic or pharmacy visits.

A systematic review of health economic models of opioid agonist therapies in maintenance treatment of non-prescription opioid dependence

BACKGROUND

Opioid dependence is a chronic condition with substantial health, economic and social costs. The study objective was to conduct a systematic review of published health-economic models of opioid agonist therapy for non-prescription opioid dependence, to review the different modelling approaches identified, and to inform future modelling studies.

METHODS

Literature searches were conducted in March 2015 in eight electronic databases, supplemented by hand-searching reference lists and searches on six National Health Technology Assessment Agency websites. Studies were included if they: investigated populations that were dependent on non-prescription opioids and were receiving opioid agonist or maintenance therapy; compared any pharmacological maintenance intervention with any other maintenance regimen (including placebo or no treatment); and were health-economic models of any type.

RESULTS

A total of 18 unique models were included. These used a range of modelling approaches, including Markov models (n = 4), decision tree with Monte Carlo simulations (n = 3), decision analysis (n = 3), dynamic transmission models (n = 3), decision tree (n = 1), cohort simulation (n = 1), Bayesian (n = 1), and Monte Carlo simulations (n = 2). Time horizons ranged from 6 months to lifetime. The most common evaluation was cost-utility analysis reporting cost per quality-adjusted life-year (n = 11), followed by cost-effectiveness analysis (n = 4), budget-impact analysis/cost comparison (n = 2) and cost-benefit analysis (n = 1). Most studies took the healthcare provider's perspective. Only a few models included some wider societal costs, such as productivity loss or costs of drug-related crime, disorder and antisocial behaviour. Costs to individuals and impacts on family and social networks were not included in any model.

CONCLUSION

A relatively small number of studies of varying quality were found. Strengths and weaknesses relating to model structure, inputs and approach were identified across all the studies. There was no indication of a single standard emerging as a preferred approach. Most studies omitted societal costs, an important issue since the implications of drug abuse extend widely beyond healthcare services. Nevertheless, elements from previous models could together form a framework for future economic evaluations in opioid agonist therapy including all relevant costs and outcomes. This could more adequately support decision-making and policy development for treatment of non-prescription opioid dependence.

Improvement of saccadic functions after dosing with methadone in opioid addicted individuals

In the current experiment, we used the saccadometric test to study the effect of a single therapeutic dose of methadone on the integrity of cortico-subcortical brain functioning. In this prospective study, we used the Saccadometer System (Advanced Clinical Instrumentation, Cambridge, UK). The saccadometric test was performed before and 1.5 hours after methadone dosing. We analyzed the following saccadic parameters: latency, duration, amplitude, average and peak velocity, and processing performance (promptness) as well as a number of different types of saccades (like correct/incorrect, under/overshoot, and left-sided/right-sided). The sample consists of 40 subjects with an average 18 years of opioid addiction. The mean age is 35.3 ± 7 (80% males and 20% females). The mean period of heroin dependence is 15.3 ± 6.3 years. The mean daily dose of methadone in substitution therapy is 90 ± 26.5 mg. After administration of a single therapeutic dose of methadone, there were statistically significant differences in the values of saccade duration and latency when compared to the values before the drug administration. Average duration of saccade was significantly longer [51.40 ± 8.75 ms versus 48.93 ± 6.91 ms, z = 2.53, p = .01] and average latency was significantly longer [198.85 ± 52.57 ms versus 183.05 ± 30.95 ms, z = 2.09 p < .03]. This is the first study to test the therapeutic effect of daily methadone dosing on the integrity of the cortico-subcortical brain functions as measured by the saccadometry. More research is needed to explore the effect of illicit opioid use on the integrity of brain structures and functions, and the protective effect of opioid agonist therapy on reversing the damaging effects of illicit opioid use.

Behavioral and quality-of-life outcomes in different service models for methadone maintenance treatment in Vietnam

BACKGROUND

Integrating HIV/AIDS and methadone maintenance treatment (MMT) services with existing health care delivery system is critical in sustaining efforts to fight HIV/AIDS in large injection-driven epidemics. However, efficiency of different integrative service models is unknown. This study assessed behavioral and health-related quality-of-life (HRQOL) outcomes of MMT in four service delivery models and explored factors associated with these outcomes of interest.

METHODS

A cross-sectional survey was conducted in two HIV epicenters in Vietnam: Hanoi and Nam Dinh Province. All patients in five selected MMT clinics were invited to participate, and 1016 were interviewed (80-90% response rate).

RESULTS

Respondents had a mean age of 35.8, taken MMT for average 16.5 months and 3.3% on MMT for 36-60 months. The MMT integrated with rural district health center (DHC) has the highest prevalence of concurrent drug use (11.3%). The percentage of condom use (last sexual intercourse) with primary and casual partners was lowest in the MMT at urban DHCs. Patients at the rural DHC reported very high proportions of pain/discomfort (37.8%), anxiety/depression (43.1%), and mobility (13.3%). In regression models, poorer HRQOL outcomes were found in MMT models in the rural areas or without general health care, and among those patients who were HIV positive, reported concurrent drug use, and had higher numbers of previous drug rehabilitation episodes. Mobility and anxiety/depression are factors that increased the likelihood of concurrent drug use among MMT patients.

CONCLUSIONS

Outcomes of MMT were diverse across different integrative service models. Policies on rapid expansion of the MMT program in Vietnam should also emphasize on the integration with comprehensive health care services including psychological supports for patients.

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.

Medication-assisted treatment of opioid use disorder: review of the evidence and future directions

Medication-assisted treatment of opioid use disorder with physiological dependence at least doubles rates of opioid-abstinence outcomes in randomized, controlled trials comparing psychosocial treatment of opioid use disorder with medication versus with placebo or no medication. This article reviews the current evidence for medication-assisted treatment of opioid use disorder and also presents clinical practice imperatives for preventing opioid overdose and the transmission of infectious disease. The evidence strongly supports the use of agonist therapies to reduce opioid use and to retain patients in treatment, with methadone maintenance remaining the gold standard of care. Combined buprenorphine/naloxone, however, also demonstrates significant efficacy and favorable safety and tolerability in multiple populations, including youth and prescription opioid-dependent individuals, as does buprenorphine monotherapy in pregnant women. The evidence for antagonist therapies is weak. Oral naltrexone demonstrates poor adherence and increased mortality rates, although the early evidence looks more favorable for extended-release naltrexone, which has the advantages that it is not subject to misuse or diversion and that it does not present a risk of overdose on its own. Two perspectives-individualized treatment and population management-are presented for selecting among the three available Food and Drug Administration-approved maintenance therapies for opioid use disorder. The currently unmet challenges in treating opioid use disorder are discussed, as are the directions for future research.

Psychosocial functioning of drug treatment court clients: a study of the prosecutor's files in Ghent, Belgium

Purpose

– Problem solving courts are a result of the therapeutic jurisprudence movement. Drug treatment courts (DTCs), for instance, aim to divert substance using offenders away from the criminal justice system (CJS) to (drug) treatment services. DTCs are associated with reduced criminal offending and substance use. Psychosocial outcomes of DTCs, such as employment, health and family relations, received only little attention. The paper aims to discuss these issues.

Design/methodology/approach

– This paper focuses on the outcomes regarding substance use and psychosocial variables of a Belgian DTC situated in the Ghent region, which were investigated by a naturalistic evaluation study with a pre- post-design using judicial files.

Findings

– The results show that Ghent DTC clients were diverted to drug treatment and financial counselling services. Next the Ghent DTC produced beneficial outcomes regarding employment. Contrary to criminal offending (De Keulenaer and Thomaes, 2013), substance use was not significantly reduced in the Ghent DTC sample. Yet more compliance with opioid maintenance treatment was observed. Information on more client centred outcomes such as health and social relations was lacking, precluding a full outcome measurement of psychosocial variables.

Research limitations/implications

– Future DTC studies should address more client centreed outcomes by gathering information through DTC clients and treatment services instead of solely relying on judicial data sources. In addition, DTCs should develop a clear and uniform registration system regarding these outcomes.

Originality/value

– Since the therapeutic jurisprudence movement continues to expand, discussion regarding the roles and tasks of the CJS as well as treatment and counselling services is vital. Each actor should maintain its own role and task, regarding monitoring and substantive work, to insure a “problem solving approach” that is in line with the recovery philosophy.

Impact of methadone maintenance on health utility, health care utilization and expenditure in drug users with HIV/AIDS

BACKGROUND

This study assessed the impact of methadone maintenance treatment (MMT) on health utility, health care service utilization, and out-of-pocket (OOP) health expenditure in drug users with HIV/AIDS in Vietnam.

METHODS

Using the 2012 Vietnam HIV Service Users Survey data, a post-evaluation was designed to compare 121 MMT patients with 347 non-MMT patients who were matched using propensity scores of MMT covariates. Health utility was measured using the EuroQOL - five dimensions - five levels (EQ-5D-5L) and a visual analogue scale (EQ-VAS).

RESULTS

The mean EQ-5D-5L single index and EQ-VAS score of MMT patients were 0.68 (95% CI=0.64-0.73) and 71.5% (95% CI=68.2-74.9). Compared with the control group, the adjusted differences in health utility were 0.08 and 4.43% (p=0.07), equivalent to 12.1% and 6.5% increases during MMT. There was a 45.9% decrease in the frequency of health care service utilization that was attributable to MMT. Although, antiretroviral treatment and MMT services were free-of-charge, MMT and non-MMT patients still paid their OOP for health care for averagely US$ 16.3/month and US$ 28.9/month. The adjusted difference between the two groups was US$ 19.3/month ($ 231.6/year) that equivalents to a reduction of 66.7% in OOP health expenditure related to MMT.

CONCLUSION

MMT was associated with a clinically important difference in health utility, large reductions in health care service utilization and OOP health expenditure in HIV-positive drug users. Scaling up MMT in large drug-using population could help improve the outcomes of HIV/AIDS interventions and reduce economic vulnerability of affected households.

Pharmacological therapies for maintenance treatments of opium dependence

BACKGROUND

Pharmacologic therapies for maintenance treatment of heroin dependence have been used and studied widely. Systematic reviews have demonstrated the effectiveness of such therapies. Opium dependence is associated with less problems and impairments and is less likely to be used by injecting, with consequent reductions in risk of overdose and blood-borne diseases. Although it is a common substance use disorder in many countries, a systematic review of the literature is lacking on the maintenance treatment for opium dependence.

OBJECTIVES

To evaluate the effectiveness and safety of various pharmacological therapies on maintenance of opium dependence (alone or in combination with psychosocial interventions) compared to no intervention, detoxification, different doses of the same intervention, other pharmacologic interventions and any psychosocial interventions.

SEARCH METHODS

We searched the following sources up to February 2012: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, regional databases (IMEMR and ASCI), national databases (Iranmedex and Iranpsych), main electronic sources of ongoing trials and reference lists of all relevant papers. Also, we contacted known investigators from some Asian countries to obtain details about unpublished trials.

SELECTION CRITERIA

Randomised controlled clinical trials (RCTs) comparing any maintenance pharmacologic intervention versus no intervention, other pharmacologic or non-pharmacologic intervention for opium dependence.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed the risks of biases and extracted data, independently.

MAIN RESULTS

Three RCTs recruiting 870 opium dependents were included. The studies made different comparisons so it was not possible to pool data. Only retention rate was assessed by the studies. Two studies compared different doses of buprenorphine: in one study, 4 mg/day of buprenorphine was compared with doses of 2 mg/day and 1 mg/day and in another study, 8 mg/day of buprenorphine was compared with doses of 3 mg/day and 1 mg/day. Comparisons showed a statistically significant difference between groups; higher doses of buprenorphine increased the probability of retention in treatment. The studies had high risks of biases. In the third study, after a process of detoxification, baclofen (60 mg/day) was compared with placebo for maintenance treatment. The difference in retention rate between groups was high, but it was not statistically significant.

AUTHORS' CONCLUSIONS

It is not possible to conclude about the use of any kind of pharmacologic therapies for maintenance treatment of opium dependence.

Cost-effectiveness of family-based substance abuse treatment

In order to compete in a financially sensitive health care system, family systems-based treatments must demonstrate effective clinical results as well as cost-effectiveness. Cost-effectiveness research can demonstrate to health care insurers and policy makers which treatments are viable options for implementation. The present literature review identified eight cost-effectiveness family-based substance abuse treatment studies. The results suggest that certain family-based treatments are cost-effective and warrant consideration for inclusion in health care delivery systems.

Persistence of heroin use despite methadone treatment: poor coping self-efficacy predicts continued heroin use

AIM

To evaluate the association between coping self-efficacy and persistent use of heroin by patients enrolled in a methadone treatment program.

DESIGN AND METHODS

Cross-sectional survey. One hundred and ninety-one patients attending outpatient methadone clinics in South-East England, United Kingdom. Validated questionnaires were used to assess drug use (Maudsley Addiction Profile), alcohol use (Alcohol Use Disorders Identification Test), mental health (Hospital Anxiety and Depression Scale) and coping self-efficacy (brief 8-item Drug Taking Confidence Questionnaire).

RESULTS

Half of the participants (95/191) reported heroin use in the preceding 14-day period. Heroin use during methadone treatment was associated with financial problems (P = 0.008), spending time with other drug users (P < 0.001), cocaine use (P = 0.002), low mood (P = 0.002) and dissatisfaction with the daily methadone dose (P = 0.014). Compared with 'Heroin-abstinent' patients, the 'Heroin' group reported significantly lower mean coping self-efficacy scores (t = 9.8, d.f. = 182, P < 0.001, effect size 1.17). After correcting for the effects of co-variants in a logistic regression model, the main determinants of persistent heroin use were 'coping self-efficacy' [B -0.05; standard error (SE) 0.008; Wald 36.6; odds ratio (OR) 0.95, 95% confidence interval (CI) 0.94, 0.97; P < 0.001] and 'dissatisfaction with methadone dose' (B 0.93; SE 0.46; Wald 4.1; OR 2.5, 95% CI 1.03, 6.25; P = 0.042). Satisfaction with methadone dose showed no association with self-efficacy. DISCUSSION AND CONCLUSIONS; While heroin use during methadone treatment can partly be explained by inadequate dosing, our data suggest a more complex picture with significant contribution from poor coping self-efficacy. Efforts aimed at enhancing and maintaining the patients' self-efficacy and social skills are likely to improve heroin and other drug use outcomes with added benefits for treatment completion rates and the throughput of methadone programs.

Costs of hospital-based methadone maintenance treatment in HIV/AIDS control among injecting drug users in Indonesia

OBJECTIVE

To assess the cost of hospital-based methadone maintenance treatment (MMT) for injecting drug users (IDUs) in Bandung, Indonesia; to address concerns of financial sustainability at the hospital level and financial accessibility and economic attractiveness at the health care policy level.

METHODS

In a 1 year observation period in 2006-2007, MMT service delivery costs were estimated on the basis of a micro-costing approach. Patient costs were estimated on the basis of a survey among 48 methadone clients.

RESULTS

A total number of 129 clients attended the MMT clinic, resulting in a total of 16,335 client visits. Total annual societal costs of running the MMT clinic equalled Rp 1130 mln (US$123,672), or Rp 69,206 (US$7.57) per client visit. Of total costs, patient costs established the largest share (65%), followed by that of central government (20%), and the hospital (15%). Present consultation tariffs already cover hospital costs and the patient costs of accessing MMT services constitute almost 70% of their income.

CONCLUSION

Under current circumstances, MMT services are financially sustainable to the hospital. MMT services are subsidized by the central government, and this is warranted considering the important role of the program in HIV/AIDS among IDUs. Still, the present user fee seems a barrier to utilization, and a higher level of subsidy might be justified to reduce the cost to the patient.

Medicaid coverage, methadone maintenance, and felony arrests: outcomes of opiate treatment in two states

A modest number of clinics in Oregon and Washington provide MMT maintenance treatment (MMT) services. More than 10,000 clients in each state were followed for 3 years after an initial admission for opiate use between 1993 and 2000. Medicaid clients in both states had far greater access to MMT than their non-Medicaid counterparts, controlling for differences in client characteristics using propensity scores. Months in MMT were associated with much lower arrest rates than time not in treatment, but unexpectedly this was only true for clients participating in MMT for many months. Despite differences in the treatment systems for opiate addiction in these two states observed in previous studies, the current findings generalized across both states.

Attitudes toward methadone among out-of-treatment minority injection drug users: implications for health disparities

Injection drug use (IDU) continues to be a significant public health issue in the U.S. and internationally, and there is evidence to suggest that the burden of injection drug use and associated morbidity and mortality falls disproportionately on minority communities. IDU is responsible for a significant portion of new and existing HIV/AIDS cases in many parts of the world. In the U.S., the prevalence of HIV and hepatitis C virus is higher among populations of African-American and Latino injection drug users (IDUs) than among white IDUs. Methadone maintenance therapy (MMT) has been demonstrated to effectively reduce opiate use, HIV risk behaviors and transmission, general mortality and criminal behavior, but opiate-dependent minorities are less likely to access MMT than whites. A better understanding of the obstacles minority IDUs face accessing treatment is needed to engage racial and ethnic disparities in IDU as well as drug-related morbidity and mortality. In this study, we explore knowledge, attitudes and beliefs about methadone among 53 out-of-treatment Latino and African-American IDUs in Providence, RI. Our findings suggest that negative perceptions of methadone persist among racial and ethnic minority IDUs in Providence, including beliefs that methadone is detrimental to health and that people should attempt to discontinue methadone treatment. Additional potential obstacles to entering methadone therapy include cost and the difficulty of regularly attending a methadone clinic as well as the belief that an individual on MMT is not abstinent from drugs. Substance use researchers and treatment professionals should engage minority communities, particularly Latino communities, in order to better understand the treatment needs of a diverse population, develop culturally appropriate MMT programs, and raise awareness of the benefits of MMT.

The effect of alternative staff time data collection methods on drug treatment service cost estimates

Although a limited number of service cost estimates exist, no study has evaluated how differences in the method used to collect the staff time allocation across treatment services contribute to differences in service cost estimates. Three alternative data collection methods for estimating service-level costs in methadone treatment programs were evaluated: key informants, staff surveys, and staff diaries. We analyzed data from 25 methadone clinics across the United States. Results indicate that for the three primary services offered at methadone clinics-individual counseling, group counseling, and methadone dosing-no statistically significant differences exist in the mean estimates of costs per session across programs. Of the other five services analyzed, we found no statistically significant differences in two of the mean costs per session and a small but statistically significant difference in another service. We found large and statistically significant differences in mean costs for two services, initial patient assessment and initial medical services. Although there is no gold standard available to judge which method is the best to use, we concluded that the key informant method yields more reliable cost estimates compared with the staff methods and is less burdensome to both the treatment programs and to researchers. Our findings suggest that the key informant method is the preferred method for costing substance abuse treatment services.

Economic evaluation of interventions to treat opiate dependence : a review of the evidence

Opiate dependence imposes a significant economic burden on society in terms of treatment-related costs and prevention services, other healthcare costs, the work absenteeism of patients, productivity loss arising from premature death of patients, costs associated with crime, and social welfare expenditure. The objective of this research is to review the literature on economic evaluation of treatment of opiate dependence (including detoxification, maintenance and psychosocial support).A literature review was performed on several electronic databases, including MEDLINE (Ovid), Cochrane Database of Systematic Reviews, NHS Economic Evaluation Library Database (via Cochrane Library), Web of Science, Social Science Citations Index, EMBASE and PsycINFO. A sensitive approach was used in order to maximize the number of articles retrieved; no language or publication year limitations were applied to the searches. A combination of subject heading term searches and natural word searches were used. The Drummond checklist was applied to assess the quality of economic evaluations.A total of 259 articles were considered relevant, with eight review studies identified. The treatment spectrum ranged from detoxification to maintenance treatments involving the use of agonist and/or antagonist treatments. The evidence suggests that, although the quality of economic evaluations is reasonably good, there is a dearth of knowledge about the cost effectiveness of treatments for opiate dependence. The majority of the literature reporting the results of cost-effectiveness analyses used surrogate outcome measures and adopted a narrow treatment provider perspective. Studies that have conducted cost-benefit analyses, in spite of methodological divergences, generally adopted a societal perspective and consistently demonstrated positive economic returns from opiate treatment. A paucity of research examined the extent to which psychosocial or behavioural interventions support or replace conventional pharmacological approaches. Economic evaluation provides a useful framework to assist policy makers in allocating resources across competing needs. Opiate dependence is a considerable burden on society's resources, and treatment provides a cost-beneficial solution to address these consequences. However, to better inform the decision-making process, researchers must continue to produce high-quality, methodological, comparable and scientifically credible economic evaluations.

A vision of the next generation of behavioral therapies research in the addictions

Whither, or wither, empirically supported therapies? Increasingly rigorous research in behavioral therapies has yielded a large number of effective therapies, but comparatively little work, demonstrating that integrating empirically supported therapies (ESTs) into standard practice results in meaningful improvements in patient outcomes. Methodology and strategies for evaluating ESTs and their effectiveness in clinical practice is a fairly recent innovation, and a host of unanswered questions remain regarding issues such as selection among different ESTs and what type of ESTs should be emphasized in dissemination efforts, what type of clinicians should be trained in what type of ESTs, the most effective training strategies for various types of clinicians, the need for ongoing supervision to maintain minimum levels of treatment fidelity and skill. In this review, we call for broader use of new research strategies and methods relevant to dissemination of ESTs; these may include adaptive designs, identification of mechanisms of action to foster greater emphasis on effective change principles, training and adoption trials, as well as novel implementation strategies including computer-assisted therapy and computer-assisted training.

Linking opioid-dependent hospital patients to drug treatment: Health care use and costs 6 months after randomization

AIMS

To conduct an economic evaluation of the first 6 months' trial of treatment vouchers and case management for opioid-dependent hospital patients.

DESIGN

Randomized clinical trial and evaluation of administrative data.

SETTING

Emergency department, wound clinic, in-patient units and methadone clinic in a large urban public hospital.

PARTICIPANTS

The study randomized 126 opioid-dependent drug users seeking medical care.

INTERVENTIONS

Participants were randomized among four groups. These received vouchers for 6 months of methadone treatment, 6 months of case management, both these interventions, or usual care.

FINDINGS

During the first 6 months of this study, 90% of those randomized to vouchers alone enrolled in methadone maintenance, significantly more than the 44% enrollment in those randomized to case management without vouchers (P < 0.001). The direct costs of substance abuse treatment, including case management, was 4040 dollars for those who received vouchers, 4177 dollars for those assigned to case management and 5277 dollars for those who received the combination of both interventions. After 3 months, the vouchers alone group used less heroin than the case management alone group. The difference was not significant at 6 months. There were no significant differences in other health care costs in the 6 months following randomization.

CONCLUSION

Vouchers were slightly more effective but no more costly than case management during the initial 6 months of the study. Vouchers were as effective and less costly than the combination of case management and vouchers. The finding that vouchers dominate is tempered by the possibility that case management may lower medical care costs.

Value for money in drug treatment: economic evaluation of prison methadone

BACKGROUND

Although methadone maintenance treatment in community settings is known to reduce heroin use, HIV infection and mortality among injecting drug users (IDU), little is known about prison methadone programs. One reason for this is the complexity of undertaking evaluations in the prison setting. This paper estimates the cost-effectiveness of the New South Wales (NSW) prison methadone program.

METHODS

Information from the NSW prison methadone program was used to construct a model of the costs of the program. The information was combined with data from a randomised controlled trial of provision of prison methadone in NSW. The total program cost was estimated from the perspective of the treatment provider/funder. The cost per heroin free day, compared with no prison methadone, was estimated. Assumptions regarding resource use were tested through sensitivity analysis.

RESULTS

The annual cost of providing prison methadone in NSW was estimated to be 2.9 million Australian dollars (or 3,234 Australian dollars per inmate per year). The incremental cost effectiveness ratio is 38 Australian dollars per additional heroin free day.

CONCLUSIONS

From a treatment perspective, prison methadone is no more costly than community methadone, and provides benefits in terms of reduced heroin use in prisons, with associated reduction in morbidity and mortality.

Pharmaco-economics of community maintenance for opiate dependence: a review of evidence and methodology

This literature review synthesizes and appraises evidence on the pharmaco-economic value of community maintenance for opiate dependence. Included studies enrolled opiate-dependent subjects aged 18 years or over participating in a community maintenance programme. Cost-effectiveness/cost-utility analyses provided some evidence supporting the value of methadone maintenance in combination with psychosocial services and of heroin co-prescription. Evidence on the pharmaco-economic profile of maintenance with buprenorphine as compared with methadone is mixed. Few studies carried out an economic evaluation alongside a randomised controlled trial and studies adopting a modelling approach suffered from problems with the quality and validity of parameter estimates. Studies were also limited in the range of costs and consequences considered. The cost-benefit literature showed positive net benefits from community maintenance programmes. A longer length of stay of subjects in methadone maintenance was associated with greater reductions in criminal activity. However, measurement of benefits was limited to savings from reduced crime rates. Health benefits were rarely considered. Cost-benefit studies based on a before-and-after comparison were not able to consider the impact of treatment on mortality of opiate-dependent subjects. There is a need for better-designed economic evaluations that examine whether treatment benefits exceed costs, in terms of both financial benefits and health gain.

Medicaid coverage and access to publicly funded opiate treatment

This observational study examines changes in access to methadone maintenance treatment following Oregon's decision to remove substance abuse treatment from the Medicaid benefit for an expansion population. Access was compared before and after the benefit change for two cohorts of adults addicted to opiates presenting for publicly funded treatment. Propensity score analysis helped model some selective disenrollment from Medicaid that occurred after the benefit change. Logistic regression was used to compare access to methadone by cohort controlling for client characteristics. Opiate users presenting for publicly funded treatment after the change were less than half as likely (OR = 0.40) to be placed in an opiate treatment program compared to the prior year. Further analysis revealed that those with no recent treatment history were less likely to present for treatment after the benefit change. These results have implications for states considering Medicaid cuts, especially if the anticipated increases in illegal activity, emergency room utilization, unemployment, and mortality can be demonstrated.

Randomized trial of drug abuse treatment-linkage strategies

A clinical trial contrasted 2 interventions designed to link opioid-dependent hospital patients to drug abuse treatment. The 126 out-of-treatment participants were randomly assigned to (a) case management, (b) voucher for free methadone maintenance treatment (MMT), (c) case management plus voucher, or (d) usual care. Services were provided for 6 months. MMT enrollment at 3 months was 47% (case management), 89% (voucher), 93% (case management plus voucher), and 11% (usual care); at 6 months enrollment was 48%, 68%, 79%, and 21%, respectively. Case management and vouchers can be valuable in health settings to link substance abusers with medical problems to drug abuse treatment.

Models for integrating buprenorphine therapy into the primary HIV care setting

Opiate dependence among human immunodeficiency virus (HIV)-infected patients has been associated with negative clinical outcomes, yet few affected patients receive appropriate and coordinated treatment for both conditions. The introduction of buprenorphine maintenance therapy into HIV care settings provides an opportunity for providers to integrate treatment for opiate dependence into their practices. Buprenorphine maintenance therapy has been associated with reductions in opiate use, increased social stability, improved adherence to antiretroviral therapy, and lowered rates of injection drug use. We describe the following 4 models for the integration of buprenorphine maintenance therapy into HIV care: (1) a primary care model, in which the highly active antiretroviral therapy-administering clinician also prescribes buprenorphine; (2) a model that relies on an on-site specialist in addiction medicine or psychiatry to prescribe the buprenorphine; (3) a hybrid model, in which an on-site specialist provides the induction (with or without stabilization phases) and the HIV care provider provides the maintenance phase; and (4) a drug treatment model that provides buprenorphine maintenance therapy services with HIV services in the substance abuse clinic setting. The key barriers against effective integration of buprenorphine maintenance therapy and primary HIV services are discussed, and we suggest several mechanisms to overcome such obstacles.

Addiction – who is not affected?

Addiction and addiction-related behaviour increased during the past decades. Several substances with psychoactive attributes, like opioids, cocaine or alcohol, can lead to dependence with physical and/or mental symptoms. In addition to substance-related addiction, non-substance-related dependence requires special attention. Increasing numbers of workaholics and patients suffering from internet-addiction, gambling or eating-disorders can be observed. To meet international treatment standards for addiction, diversification of therapy is necessary and, additionally, gender-related aspects in development and treatment of dependence and addiction-related behaviour are essential for state-of-the-art therapy of this patient population.

Cost utility analysis of co-prescribed heroin compared with methadone maintenance treatment in heroin addicts in two randomised trials

OBJECTIVE

To determine the cost utility of medical co-prescription of heroin compared with methadone maintenance treatment for chronic, treatment resistant heroin addicts.

DESIGN

Cost utility analysis of two pooled open label randomised controlled trials.

SETTING

Methadone maintenance programmes in six cities in the Netherlands.

PARTICIPANTS

430 heroin addicts.

INTERVENTIONS

Inhalable or injectable heroin prescribed over 12 months. Methadone (maximum 150 mg a day) plus heroin (maximum 1000 mg a day) compared with methadone alone (maximum 150 mg a day). Psychosocial treatment was offered throughout.

MAIN OUTCOME MEASURES

One year costs estimated from a societal perspective. Quality adjusted life years (QALYs) based on responses to the EuroQol EQ-5D at baseline and during the treatment period.

RESULTS

Co-prescription of heroin was associated with 0.058 more QALYs per patient per year (95% confidence interval 0.016 to 0.099) and a mean saving of 12,793 euros (8793 pounds sterling, 16,122 dollars) (1083 to 25,229 euros) per patient per year. The higher programme costs (16 222 euros; lower 95% confidence limit 15,084 euros) were compensated for by lower costs of law enforcement (- 4129 euros; upper 95% confidence limit - 486 euros) and damage to victims of crime (- 25,374 euros; upper 95% confidence limit - 16,625 euros). The results were robust for the use of national EQ-5D tariffs and for the exclusion of the initial implementation costs of heroin treatment. Completion of treatment is essential; having participated in any abstinence treatment in the past is not.

CONCLUSIONS

Co-prescription of heroin is cost effective compared with treatment with methadone alone for chronic, treatment resistant heroin addicts.