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Liu C, Li Y. Psychosocial combined with methadone maintenance treatments versus methadone maintenance treatments alone for treatment of opioid use disorder: A meta-analysis. J Addict Dis 2024; 42:126-135. [PMID: 36607171 DOI: 10.1080/10550887.2022.2158664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Psychosocial combined with methadone maintenance treatment aimed at opioid use disorder is effective, but the efficacy of the psychosocial intervention in such treatment is questionable. OBJECTIVES This study aims to evaluate the effectiveness of psychosocial plus methadone maintenance treatment versus methadone maintenance treatment alone for opioid use disorder in improving treatment retention and reducing drug use. METHODS An exhaustive literature search was conducted in PubMed, EMBASE, Cochrane Library, Web of Science, PsycINFO, CINAHL, China National Knowledge Infrastructure database, "the Wan Fang database, the VIP database, and the Chinese Biomedical Literature Database", and randomized controlled trials were identified from their inception to February 2021. RESULTS Twenty-four studies were included. The results of this meta-analysis showed that adding any psychosocial treatment to standard methadone maintenance treatment significantly improved the illicit drug use during the treatment relative risk (RR) 0.62 (95% CI 0.48 to 0.79), and retention in treatment RR 1.18 (95% CI 1.11 to 1.25). No statistically significant additional benefit was detected in terms of retention at follow-up RR 1.08 (95% CI 0.95 to 1.22). CONCLUSIONS The present evidence suggests that adding psychosocial intervention to methadone maintenance treatment significantly improves the nonuse of opioids and retention in treatment. It should be noted that psychosocial treatment is only beneficial for methadone treatment when methadone is provided in subtherapeutic doses. Additionally, the finding about the improvement effect of retention at follow-up did not achieve statistical significance. Due to the diversity of outcome indicators in relevant original studies, the included studies are limited.
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Affiliation(s)
- Chengbin Liu
- School of Sociology, Huazhong University of Science and Technology, Wuhan, China
| | - Yangyang Li
- School of Sociology, Huazhong University of Science and Technology, Wuhan, China
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Harris LM, Marsh JC, Khachikian T, Serrett V, Kong Y, Guerrero EG. What can we learn from COVID-19 to improve opioid treatment? Expert providers respond. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 154:209157. [PMID: 37652210 PMCID: PMC10923184 DOI: 10.1016/j.josat.2023.209157] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/15/2023] [Accepted: 08/28/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND The COVID-19 pandemic has had devasting effects on drug abuse treatment systems already stressed by the opioid crisis. Providers within opioid use disorder (OUD) outpatient treatment programs have had to adjust to rapid change and respond to new service delivery provisions such as telehealth and take-home medication. Using the COVID-19 pandemic and subsequent organizational challenges as a backdrop, this study explores providers' perspectives about strategies and policies that, if made permanent, can potentially improve access to and quality of OUD treatment. METHODS This qualitative study was conducted in Los Angeles County, which has one of the largest substance use disorder (SUD) treatment systems in the United States serving a diverse population, including communities impacted by the opioid crisis. We collected qualitative interview data from 30 high-performing programs (one manager/supervisor per program) where we based high performance on empirical measures of access, retention, and program completion outcomes. The study team completed data collection and analysis using constructivist grounded theory (CGT) to describe the social processes in which the participating managers engaged when faced with the pandemic and subsequent organizational changes. We developed 14 major codes and six minor codes with definitions. The interrater reliability tests showed pooled Cohen's kappa statistic of 93 %. RESULTS Our results document the impacts of COVID-19 on SUD treatment systems, their programmatic responses, and the strategic innovations they developed to improve service delivery and quality and which managers plan to sustain within their organizations. CONCLUSION Providers identified three primary areas for strategic innovation designed to improve access and quality: (1) designing better medication utilization, (2) increasing telemedicine capacity, and (3) improving reimbursement policies. These strategies for system transformation enable us to use lessons from the COVID-19 pandemic to direct policy and programmatic reform, such as expanding eligibility for take-home medication and enhancing access to telehealth services.
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Affiliation(s)
- Lesley M Harris
- University of Louisville, Kent School of Social Work & Family Science, 2217 S 3rd St, Louisville, KY, USA.
| | - Jeanne C Marsh
- University of Chicago, Crown Family School of Social Work, Policy, and Practice, 969 East 60th Street, Chicago, IL, USA.
| | - Tenie Khachikian
- University of Chicago, Crown Family School of Social Work, Policy, and Practice, 969 East 60th Street, Chicago, IL, USA.
| | - Veronica Serrett
- I-Lead Institute, Research to End Healthcare Disparities Corp, 150 Ocean Park Blvd, 418, Santa Monica, CA, USA.
| | - Yinfei Kong
- California State University, Fullerton, Department of Information Systems and Decision Sciences, College of Business and Economics, CA, USA.
| | - Erick G Guerrero
- I-Lead Institute, Research to End Healthcare Disparities Corp, 150 Ocean Park Blvd, 418, Santa Monica, CA, USA
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Taylor EA, Cantor JH, Bradford AC, Simon K, Stein BD. Trends in Methadone Dispensing for Opioid Use Disorder After Medicare Payment Policy Changes. JAMA Netw Open 2023; 6:e2314328. [PMID: 37204793 PMCID: PMC10199341 DOI: 10.1001/jamanetworkopen.2023.14328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/06/2023] [Indexed: 05/20/2023] Open
Abstract
Importance A significant proportion of Medicare beneficiaries have a diagnosed opioid use disorder (OUD). Methadone and buprenorphine are both effective medications for the treatment of OUD (MOUDs); however, Medicare did not cover methadone until 2020. Objective To examine trends in methadone and buprenorphine dispensing among Medicare Advantage (MA) enrollees after 2 policy changes in 2020 related to methadone access. Design, Setting, and Participants This cross-sectional analysis of temporal trends in methadone and buprenorphine treatment dispensing assessed MA beneficiary claims from January 1, 2019, through March 31, 2022, captured by Optum's Clinformatics Data Mart. Of 9 870 791 MA enrollees included in the database, 39 252 had at least 1 claim for methadone, buprenorphine, or both during the study period. All available MA enrollees were included. Subanalyses by age and dual eligibility for Medicare and Medicaid status were conducted. Exposures Study exposures were (1) the Centers for Medicare & Medicaid Services (CMS) Medicare bundled payment reimbursement policy for OUD treatment and (2) the Substance Abuse and Mental Health Administration and CMS Medicare policies designed to facilitate access to treatment for OUD, specifically during the COVID-19 pandemic. Main Outcomes and Measures Study outcomes were trends in methadone and buprenorphine dispensing by beneficiary characteristics. National methadone and buprenorphine dispensing rates were calculated as claims-based dispensing rates per 1000 MA enrollees. Results Among the 39 252 MA enrollees with at least 1 MOUD dispensing claim (mean age, 58.6 [95% CI, 58.57-58.62] years; 45.9% female), 195 196 methadone claims and 540 564 buprenorphine pharmacy claims were identified, for a total of 735 760 dispensing claims. The methadone dispensing rate for MA enrollees was 0 in 2019 because the policy did not allow any payment until 2020. Claims rates per 1000 MA enrollees were low initially, increasing from 0.98 in the first quarter of 2020 to 4.71 in the first quarter of 2022. Increases were primarily associated with dually eligible beneficiaries and beneficiaries younger than 65 years. National buprenorphine dispensing rates were 4.64 per 1000 enrollees in quarter 1 of 2019, increasing to 7.45 per 1000 enrollees in quarter 1 of 2022. Conclusions and Relevance This cross-sectional study found that methadone dispensing increased among Medicare beneficiaries after the policy changes. Rates of buprenorphine dispensing did not provide evidence that beneficiaries substituted buprenorphine for methadone. The 2 new CMS policies represent an important first step in increasing access to MOUD treatment for Medicare beneficiaries.
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Affiliation(s)
| | | | - Ashley C. Bradford
- The Paul H. O’Neill School of Public and Environmental Affairs, Indiana University, Bloomington
| | - Kosali Simon
- The Paul H. O’Neill School of Public and Environmental Affairs, Indiana University, Bloomington
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Factors associated with the adoption of evidence-based innovations by substance use disorder treatment organizations: A study of HIV testing. J Subst Abuse Treat 2023; 144:108929. [PMID: 36402124 DOI: 10.1016/j.jsat.2022.108929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 09/12/2022] [Accepted: 10/30/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Though prior research shows that a range of important regulatory, market, community, and organizational factors influence the adoption of evidence-based practices (EBPs) among health care organizations, we have little understanding of how these factors relate to each other. To address this gap, we test a conceptual model that emphasizes indirect, mediated effects among key factors related to HIV testing in substance use disorder treatment organizations (SUTs), a critical EBP during the US opioid epidemic. METHODS We draw on nationally representative data from the 2014 (n = 697) and 2017 (n = 657) National Drug Abuse Treatment System Survey (NDATSS) to measure the adoption of HIV testing among the nation's SUTs and their key organizational characteristics; we also draw on data from the US Census Bureau; Centers for Disease Control; and legislative sources to measure regulatory and community environments. We estimate cross-sectional and longitudinal structural equation models (SEM) to test the proposed model. RESULTS Our longitudinal model of the adoption of HIV testing by SUTs in the United States identifies a pathway by which community and market characteristics (rurality and the number of other SUTs in the area) are related to key sociotechnical characteristics of these organizations (alignment of clients, staff, and harm-reduction culture) that, in turn, are related to the adoption of this EBP. CONCLUSIONS Results also show the importance of developing conceptual models that include indirect effects to account for organizational adoption of EBPs.
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Feasibility of a Brief Intervention to Decrease Harmful Alcohol Use Among Methadone Maintenance Treatment Clients in Shanghai: A Randomized Controlled Trial. J Addict Med 2022:01271255-990000000-00109. [PMID: 36300816 DOI: 10.1097/adm.0000000000001101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES In this study, we aimed to examine the prevalence of alcohol consumption among methadone maintenance treatment (MMT) clients in Shanghai and to determine whether a brief intervention (BI) affects drinking among them. METHODS A total of 837 clients from 14 local MMT clinics were invited to complete the Alcohol Use Disorders Identification Test (AUDIT). One hundred one were included in the study and randomly assigned to the BI group or the control group. Clients in the BI group received a BI and general health education, whereas clients in the control group received the general health education only. Baseline and postintervention assessments were conducted by using the AUDIT, the Drinking Attitude Questionnaire, the Depression Module of the Patient Health Questionnaire, the Generalized Anxiety Disorder Scale, and the General Well-Being Schedule. RESULTS Two hundred fifty-nine (30.9%) reported drinking during the last year, and 103 (12.3%) met the criteria for harmful use. At the 3-month follow-up, the AUDIT scores of the 2 groups were significantly decreased, and the time effect was statistically significant ( F = 6.224, P = 0.018), but there was no group difference in AUDIT scores ( F = 1.953, P = 0.172). Both groups had a main time effect of time on the improvement of depression ( F = 8.044, P = 0.008), anxiety ( F = 9.650, P = 0.004), and general well-being ( F = 5.056, P = 0.033). However, there was no statistical difference between the 2 groups ( P > 0.05), and no statistical difference in the time ( F = 1.738, P = 0.198) and group ( F = 0.658, P = 0.424) effect of drinking attitude. CONCLUSIONS Alcohol consumption is common among MMT clients in China. Brief intervention, in its current form, could not effectively help them reduce their alcohol consumption.
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G Guerrero E, Amaro H, Khachikian T, Zahir M, Marsh JC. A bifurcated opioid treatment system and widening insidious disparities. Addict Behav 2022; 130:107296. [PMID: 35255242 PMCID: PMC9078400 DOI: 10.1016/j.addbeh.2022.107296] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 01/24/2022] [Accepted: 02/26/2022] [Indexed: 11/20/2022]
Affiliation(s)
- Erick G Guerrero
- I-Lead Institute, Research to End Healthcare Disparities (REHD) Corp, 12300 Wilshire Blvd, Suite 210, Los Angeles, CA 90025, United States.
| | - Hortensia Amaro
- Florida International University, Herbert Werthein College of Medicine and Robert Stempel College of Public Health and Social Work, 11200 SW 8(th) ST, AHC4, Miami, FL 33199, United States.
| | - Tenie Khachikian
- University of Chicago, Crown Family School of Social Work, Policy, and Practice, 969 E. 60(th) Street, Chicago, IL 60637, United States
| | - Mona Zahir
- I-Lead Institute, Research to End Healthcare Disparities (REHD) Corp, 12300 Wilshire Blvd, Suite 210, Los Angeles, CA 90025, United States
| | - Jeanne C Marsh
- University of Chicago, Crown Family School of Social Work, Policy, and Practice, 969 E. 60(th) Street, Chicago, IL 60637, United States.
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Ng SY, Chong JH, Mohd Mazlan MI, Lau BT. Illicit substance use among methadone maintenance therapy patients in a tertiary hospital in Malaysia: a cross-sectional study. JOURNAL OF SUBSTANCE USE 2021. [DOI: 10.1080/14659891.2021.2018733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Siew Yen Ng
- Department of Pharmacy, Hospital Tuanku Ja’afar Seremban, Ministry of Health Malaysia, Seremban, Malaysia
| | - Jian Hui Chong
- Department of Pharmacy, Hospital Tuanku Ja’afar Seremban, Ministry of Health Malaysia, Seremban, Malaysia
| | - Mohamad Ikhwan Mohd Mazlan
- Department of Pharmacy, Hospital Tuanku Ja’afar Seremban, Ministry of Health Malaysia, Seremban, Malaysia
| | - Boon-Tiang Lau
- Department of Pharmacy, Hospital Port Dickson, Ministry of Health Malaysia, Port Dickson, Malaysia
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Andraka-Christou B. Addressing Racial And Ethnic Disparities In The Use Of Medications For Opioid Use Disorder. Health Aff (Millwood) 2021; 40:920-927. [PMID: 34097509 DOI: 10.1377/hlthaff.2020.02261] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Social discourse about the opioid crisis in the US has focused on White populations, even though opioid-related deaths have grown at a higher rate among people of color than among non-Hispanic White people in recent years. Medications for opioid use disorder (OUD) are the gold standard for treating OUD and preventing overdose but are underused among people with OUD, with disproportionately low treatment initiation and retention among people of color. Methadone, which is highly stigmatized and has a more burdensome treatment regimen, is the predominant medication for OUD available to people of color. To address disparities in the initiation and retention of treatment using medication for OUD, policy makers should consider strategies such as Medicaid expansion, increased grant funding for federally qualified health centers to provide buprenorphine treatment, retention of temporary telehealth policies that allow remote buprenorphine induction, and regulatory changes to allow methadone treatment in office-based practices.
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Affiliation(s)
- Barbara Andraka-Christou
- Barbara Andraka-Christou is an assistant professor in the Department of Health Management and Informatics, University of Central Florida, in Orlando, Florida, with a secondary joint appointment in the Department of Internal Medicine. She is also a licensed attorney in the state of Florida
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9
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Pro G, Zaller N. Interaction effects in the association between methadone maintenance therapy and experiences of racial discrimination in U.S. healthcare settings. PLoS One 2020; 15:e0228755. [PMID: 32027723 PMCID: PMC7004348 DOI: 10.1371/journal.pone.0228755] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 01/22/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Disparities in methadone maintenance therapy (MMT) outcomes have received limited attention, but there are important negative outcomes associated with MMT that warrant investigation. Racial discrimination is common in healthcare settings and affects opioid use disorder (OUD) treatment and comorbidities. However, race/ethnicity alone may not fully explain experiences of discrimination. MMT remains highly stigmatized and may compound the effect of race/ethnicity on discrimination in healthcare settings. We sought to quantify differential associations between MMT and experiences of racial discrimination between racial/ethnic groups in a U.S. national sample. METHODS We used the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013) to identify a subset of individuals with a lifetime OUD who had ever used MMT (survey n = 766; weighted population n = 5,276,507). We used multivariable logistic regression to model past-year experience of racial discrimination in a healthcare setting. We included an interaction term between race/ethnicity and MMT status to identify the odds of discrimination (MMT vs. no MMT [referent]) within racial/ethnic groups. We used survey procedures with weights to account for the parent study's complex survey design. FINDINGS Twenty-two percent of our sample experienced racial discrimination in a healthcare setting in the past year. Discrimination was more common among those who had ever used MMT (x2 = 10.00, p = 0.001) and racial/ethnic minorities (x2 = 23.15, p<0.001). The interaction effect was much stronger than the main effects of race/ethnicity and MMT status. MMT status (versus no MMT) was positively associated with discrimination among Blacks (aOR = 3.93, 95% CI = 3.87-3.98, p<0.001), Whites (aOR = 2.25, 95% CI = 2.23-2.27, p<0.001), and Latino/Latinas (aOR = 1.59, 95% CI = 1.55-1.62, p<0.001). Among American Indian/Alaska Natives (AI/AN), those who had used MMT had over thirty times the odds of racial discrimination, compared to their non-MMT counterparts (aOR = 32.78, 95% CI = 31.16-34.48, p<0.001). CONCLUSION Race/ethnicity alone did not sufficiently account for racial discrimination in healthcare settings among those with a lifetime OUD. MMT status was strongly associated with racial discrimination among AI/AN. Our strong interaction effect is indicative of an additional barrier to health services utilization among AI/AN, which has important implications for OUD treatment outcomes and comorbidities. Health promotion programs aimed at increased adoption of MMT are promising, but should be considered in the context of racial/ethnic disparities, drug use and MMT stigma, and implicit biases in clinical settings.
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Affiliation(s)
- George Pro
- Center for Health Equity Research, Northern Arizona University, Flagstaff, Arizona, United States of America
| | - Nick Zaller
- University of Arkansas for Medical Sciences College of Public Health, Little Rock, Arkansas, United States of America
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Winograd RP, Presnall N, Stringfellow E, Wood C, Horn P, Duello A, Green L, Rudder T. The case for a medication first approach to the treatment of opioid use disorder. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2019; 45:333-340. [DOI: 10.1080/00952990.2019.1605372] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Rachel P. Winograd
- Missouri Institute of Mental Health, University of Missouri, St. Louis, USA
| | - Ned Presnall
- Clayton Behavioral, Washington University, St. Louis, USA
| | - Erin Stringfellow
- Missouri Institute of Mental Health, University of Missouri, St. Louis, USA
| | - Claire Wood
- Missouri Institute of Mental Health, University of Missouri, St. Louis, USA
| | - Phil Horn
- Missouri Institute of Mental Health, University of Missouri, St. Louis, USA
| | - Alex Duello
- Missouri Institute of Mental Health, University of Missouri, St. Louis, USA
| | - Lauren Green
- Missouri Institute of Mental Health, University of Missouri, St. Louis, USA
| | - Tim Rudder
- Missouri Department of Mental Health, Jefferson, Missouri, USA
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Lister JJ, Brown S, Greenwald MK, Ledgerwood DM. Gender-specific predictors of methadone treatment outcomes among African Americans at an urban clinic. Subst Abus 2019; 40:185-193. [PMID: 30888262 DOI: 10.1080/08897077.2018.1547810] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background: African American patients with opioid use disorder (OUD) have demonstrated poorer methadone maintenance treatment (MMT) outcomes compared with white patients. This issue is further complicated in urban settings, where African Americans experience high rates of poverty and publicly funded treatment. Despite interrelated factors that disadvantage African Americans, the literature focusing on this population is scant. To address this shortcoming, we conducted the first investigation of gender differences and gender-specific MMT outcome predictors among African Americans (or any racial minority population). This study provides gender-specific findings to improve African American MMT outcomes. Methods: We studied 211 African American patients (male: n = 137, 64.9%) at an urban, university-affiliated MMT clinic. We used existing intake data to assess baseline demographic, substance use, mental health, and interpersonal factors. Primary outcomes were 3-month drug+ (positive) urine drug screen (UDS) results and treatment retention. Results: Women were more likely (than men) to endorse histories of interpersonal violence, substance abuse in their social network, and mental health problems. Men reported a greater likelihood (than women) for early opioid-use onset and a lack of prior MMT. There were no gender differences in 3-month drug+ UDS or treatment retention. In multivariable analyses among women, no baseline factors predicted 3-month opioid+ UDS and physical abuse history predicted a higher proportion of 3-month cocaine+ UDS. Among men, primary injection opioid use and older age best predicted a higher proportion of 3-month cocaine+ UDS and parent substance abuse predicted shorter retention. In both gender-stratified analyses, higher proportions of 3-month opioid+ UDS and cocaine+ UDS predicted shorter retention. Conclusions: This study offers an analysis of gender differences in risk factors, MMT outcomes, and gender-specific predictors among African American patients. MMT clinics should tailor assessment and treatment protocols to address gender-specific needs.
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Affiliation(s)
- Jamey J Lister
- School of Social Work, Wayne State University , Detroit , Michigan , USA.,Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine , Detroit , Michigan , USA
| | - Suzanne Brown
- School of Social Work, Wayne State University , Detroit , Michigan , USA
| | - Mark K Greenwald
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine , Detroit , Michigan , USA.,Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University , Detroit , Michigan , USA
| | - David M Ledgerwood
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine , Detroit , Michigan , USA
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Lovrecic B, Lovrecic M, Gabrovec B, Carli M, Pacini M, Maremmani AGI, Maremmani I. Non-Medical Use of Novel Synthetic Opioids: A New Challenge to Public Health. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16020177. [PMID: 30634521 PMCID: PMC6352208 DOI: 10.3390/ijerph16020177] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/03/2019] [Accepted: 01/05/2019] [Indexed: 01/28/2023]
Abstract
Background: In the last decade there has been a progressive increase in the use of new psychoactive substances (NPSs) that are not yet under international control. In particular, novel synthetic opioids (NSOs) have reappeared on the recreational drug market in the last few years. As a result, the use of NSOs has increased rapidly. This poses an emerging and demanding challenge to public health. Aim: To raise awareness among clinicians and other professionals about NPSs, especially NSOs, to summarize current knowledge about pharmacological properties, forms of NSO on the market, pattern of use, effects and consequences of use. Methods: An electronic search was carried out on the Medline/PubMed and Google Scholar databases to find selected search terms. Results: Some NPSs are already controlled, while others can be legally sold directly on the drug market (mainly via internet, less so by drug dealers) or be used as precursors for the synthesis of other designer drugs that mimic the psychoactive effects of controlled substances. Potential side-effects of NSOs include miosis, sedation, respiratory depression, hypothermia, inhibition of gastrointestinal propulsion, death (from opioid overdose). Conclusions: The severity of the opioid crisis has intensified with the introduction of highly potent NSOs on the drug market. As long as addicts are dying from overdose or similar causes, there is something more constructive to do than waiting for addicts to overdose on heroin at a place located near a remedy, as if to say, within reach of naloxone.
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Affiliation(s)
| | - Mercedes Lovrecic
- National Institute of Public Health, 1000 Ljubljana, Slovenia.
- Centre for Psychiatry and Addiction Medicine, Izola Health Centre, 6310 Izola, Slovenia.
| | - Branko Gabrovec
- National Institute of Public Health, 1000 Ljubljana, Slovenia.
| | - Marco Carli
- Department of Translational Research and New Technologies, University of Pisa, 56100 Pisa, Italy.
| | - Matteo Pacini
- G. De Lisio Institute of Behavioral Sciences, 56100 Pisa, Italy.
| | - Angelo G I Maremmani
- Department of Psychiatry, North-Western Tuscany Region NHS Local Health Unit, Versilia Zone, 55049 Viareggio, Italy.
- Association for the Application of Neuroscientific Knowledge to Social Aims (AU-CNS), Pietrasanta, 55045 Lucca, Italy.
| | - Icro Maremmani
- G. De Lisio Institute of Behavioral Sciences, 56100 Pisa, Italy.
- Association for the Application of Neuroscientific Knowledge to Social Aims (AU-CNS), Pietrasanta, 55045 Lucca, Italy.
- Vincent P. Dole Dual Disorder Unit, Santa Chiara University Hospital, University of Pisa, 56100 Pisa, Italy.
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D'Aunno T, Park SE, Pollack HA. Evidence-based treatment for opioid use disorders: A national study of methadone dose levels, 2011-2017. J Subst Abuse Treat 2019; 96:18-22. [PMID: 30466543 PMCID: PMC6258192 DOI: 10.1016/j.jsat.2018.10.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 10/12/2018] [Accepted: 10/15/2018] [Indexed: 10/28/2022]
Abstract
The nation's methadone maintenance treatment (MMT) programs play a central role in addressing the current opioid epidemic. Considerable evidence documents the treatment effectiveness of MMT and, in turn, the importance of adequate dosing to MMT's effectiveness. Yet, as recently as 2011, 41% of patients received doses below the level of 80 mg/day. Using survey data from a nationally representative sample of MMT programs in 2011 and 2017, we examine (1) the extent to which the nation's MMT programs are meeting evidence-based standards for methadone dose level and (2) characteristics of MMT programs that are associated with variation in performance. Our results show that 43% of MMT patients receive <80 mg/day in 2017, and 23% of methadone maintenance patients receive daily doses below 60 mg. Results from multivariate regression analysis of the 2017 survey data show that private for-profit and public organizations significantly under-dosed patients compared to private nonprofit providers. Under-dosing also was more common in programs that serve high proportions of African-American patients. These results are concerning because MMT remains the medication of choice for vulnerable patients with the most severe opioid use disorders, and for-profit providers treat a growing proportion of MMT patients.
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Frimpong JA, Shiu‐Yee K, D'Aunno T. The Role of Program Directors in Treatment Practices: The Case of Methadone Dose Patterns in U.S. Outpatient Opioid Agonist Treatment Programs. Health Serv Res 2017; 52:1881-1907. [PMID: 27618580 PMCID: PMC5583309 DOI: 10.1111/1475-6773.12558] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE To describe changes in characteristics of directors of outpatient opioid agonist treatment (OAT) programs, and to examine the association between directors' characteristics and low methadone dosage. DATA SOURCE Repeated cross-sectional surveys of OAT programs in the United States from 1995 to 2011. STUDY DESIGN We used generalized linear regression models to examine associations between directors' characteristics and methadone dose, adjusting for program and patient factors. DATA COLLECTION Data were collected through telephone surveys of program directors. PRINCIPAL FINDINGS The proportion of OAT programs with an African American director declined over time, from 29 percent in 1995 to 16 percent in 2011. The median percentage of patients in each program receiving <60 mg/day declined significantly, from 48.5 percent in 1995 to 29 percent in 2005 and 23 percent in 2011. Programs with an African American director were significantly more likely to provide low methadone doses than other programs. This association was even stronger in programs with an African American director who served populations with higher percentages of African American patients. CONCLUSIONS Demographic characteristics of OAT program directors (e.g., their race) may play a key role in explaining variations in methadone dosage across programs and patients. Further research should investigate the causal pathways through which directors' characteristics affect treatment practices. This may lead to new, multifaceted managerial interventions to improve patient outcomes.
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Affiliation(s)
- Jemima A. Frimpong
- The Johns Hopkins Carey Business SchoolJohns Hopkins UniversityBaltimoreMD
| | - Karen Shiu‐Yee
- Department of Sociomedical SciencesMailman School of Public HealthColumbia UniversityNew YorkNY
| | - Thomas D'Aunno
- Robert F. Wagner Graduate School of Public ServiceNew York UniversityNew YorkNY
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Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: A model-based analysis. PLoS Med 2017; 14:e1002312. [PMID: 28542184 PMCID: PMC5443477 DOI: 10.1371/journal.pmed.1002312] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 04/28/2017] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The risks of HIV transmission associated with the opioid epidemic make cost-effective programs for people who inject drugs (PWID) a public health priority. Some of these programs have benefits beyond prevention of HIV-a critical consideration given that injection drug use is increasing across most United States demographic groups. To identify high-value HIV prevention program portfolios for US PWID, we consider combinations of four interventions with demonstrated efficacy: opioid agonist therapy (OAT), needle and syringe programs (NSPs), HIV testing and treatment (Test & Treat), and oral HIV pre-exposure prophylaxis (PrEP). METHODS AND FINDINGS We adapted an empirically calibrated dynamic compartmental model and used it to assess the discounted costs (in 2015 US dollars), health outcomes (HIV infections averted, change in HIV prevalence, and discounted quality-adjusted life years [QALYs]), and incremental cost-effectiveness ratios (ICERs) of the four prevention programs, considered singly and in combination over a 20-y time horizon. We obtained epidemiologic, economic, and health utility parameter estimates from the literature, previously published models, and expert opinion. We estimate that expansions of OAT, NSPs, and Test & Treat implemented singly up to 50% coverage levels can be cost-effective relative to the next highest coverage level (low, medium, and high at 40%, 45%, and 50%, respectively) and that OAT, which we assume to have immediate and direct health benefits for the individual, has the potential to be the highest value investment, even under scenarios where it prevents fewer infections than other programs. Although a model-based analysis can provide only estimates of health outcomes, we project that, over 20 y, 50% coverage with OAT could avert up to 22,000 (95% CI: 5,200, 46,000) infections and cost US$18,000 (95% CI: US$14,000, US$24,000) per QALY gained, 50% NSP coverage could avert up to 35,000 (95% CI: 8,900, 43,000) infections and cost US$25,000 (95% CI: US$7,000, US$76,000) per QALY gained, 50% Test & Treat coverage could avert up to 6,700 (95% CI: 1,200, 16,000) infections and cost US$27,000 (95% CI: US$15,000, US$48,000) per QALY gained, and 50% PrEP coverage could avert up to 37,000 (22,000, 58,000) infections and cost US$300,000 (95% CI: US$162,000, US$667,000) per QALY gained. When coverage expansions are allowed to include combined investment with other programs and are compared to the next best intervention, the model projects that scaling OAT coverage up to 50%, then scaling NSP coverage to 50%, then scaling Test & Treat coverage to 50% can be cost-effective, with each coverage expansion having the potential to cost less than US$50,000 per QALY gained relative to the next best portfolio. In probabilistic sensitivity analyses, 59% of portfolios prioritized the addition of OAT and 41% prioritized the addition of NSPs, while PrEP was not likely to be a priority nor a cost-effective addition. Our findings are intended to be illustrative, as data on achievable coverage are limited and, in practice, the expansion scenarios considered may exceed feasible levels. We assumed independence of interventions and constant returns to scale. Extensive sensitivity analyses allowed us to assess parameter sensitivity, but the use of a dynamic compartmental model limited the exploration of structural sensitivities. CONCLUSIONS We estimate that OAT, NSPs, and Test & Treat, implemented singly or in combination, have the potential to effectively and cost-effectively prevent HIV in US PWID. PrEP is not likely to be cost-effective in this population, based on the scenarios we evaluated. While local budgets or policy may constrain feasible coverage levels for the various interventions, our findings suggest that investments in combined prevention programs can substantially reduce HIV transmission and improve health outcomes among PWID.
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Lister JJ, Greenwald MK, Ledgerwood DM. Baseline risk factors for drug use among African-American patients during first-month induction/stabilization on methadone. J Subst Abuse Treat 2017; 78:15-21. [PMID: 28554598 DOI: 10.1016/j.jsat.2017.04.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 04/09/2017] [Accepted: 04/11/2017] [Indexed: 12/17/2022]
Abstract
Drug use during methadone induction/stabilization negatively influences later methadone-maintenance-treatment [MMT] outcomes (retention, abstinence). Our study examined the association of baseline risk factors to drug use during the first month of methadone treatment as well as longer-term treatment retention. We conducted these analyses among a race/ethnic minority group at high risk for worse MMT outcomes. African-American MMT patients (N=212) were interviewed at intake to assess clinical (drug use history), psychosocial (close family member substance abuse, psychosocial problems), and demographic factors. Outcomes were first-month opioid+ and cocaine+ urine drug screen [UDS] results and retention (days in treatment). In bivariate analyses, co-occurring cocaine abuse/dependence was associated with worse outcomes for opioid+ UDS, cocaine+ UDS, and retention. Being a primary injection opioid user and residing farther from the clinic were associated with a higher proportion of cocaine+ UDS and shorter retention, respectively. Patients with a significant other substance abuse history provided a higher proportion of both opioid+ and cocaine+ UDS. Sibling and parent substance abuse histories were associated with a higher proportion of opioid+ UDS and shorter retention. Psychosocial problems (economic, housing) were associated with a higher proportion of cocaine+ UDS. In multivariate analyses, co-occurring cocaine abuse/dependence and primary injection opioid use best accounted for first-month opioid+ and cocaine+ UDS, respectively. A higher proportion of first-month opioid+ and cocaine+ UDS and living farther from the clinic accounted for retention. African-American patients reporting baseline risk factors (particularly clinical) experience worse short- and long-term MMT outcomes. Recommendations for improving standards of care are discussed.
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Affiliation(s)
- Jamey J Lister
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA; School of Social Work, Wayne State University, Detroit, MI, USA.
| | - Mark K Greenwald
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA; Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
| | - David M Ledgerwood
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA.
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Nielsen S, Gisev N, Bruno R, Hall W, Cohen M, Larance B, Campbell G, Shanahan M, Blyth F, Lintzeris N, Pearson S, Mattick R, Degenhardt L. Defined daily doses (DDD) do not accurately reflect opioid doses used in contemporary chronic pain treatment. Pharmacoepidemiol Drug Saf 2017; 26:587-591. [PMID: 28101968 DOI: 10.1002/pds.4168] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 12/01/2016] [Accepted: 12/19/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess how well the defined daily dose (DDD) metric reflects opioid utilisation among chronic non-cancer pain patients. DESIGN Descriptive, cross-sectional study, utilising a 7-day medication diary. SETTING Community-based treatment settings, Australia. SUBJECTS A sample of 1101 people prescribed opioids for chronic non-cancer pain. METHODS Opioid dose data was collected via a self-completed 7-day medication diary capturing names, strengths and doses of each medication taken in the past week. Median daily dose was calculated for each opioid. Comparisons were made to the World Health Organization's (WHO) DDD metric. RESULTS WHO DDDs ranged from 0.6 to 7.1 times the median opioid doses used by the sample. For transdermal fentanyl and oral hydromorphone, the median dose was comparable with the DDD. The DDD for methadone was 0.6 times lower than the median doses used by this sample of chronic pain patients. In contrast, the DDD for oxycodone and transdermal buprenorphine, the most commonly used strong opioids for chronic pain in Australia, was two to seven times higher than actual doses used. CONCLUSIONS For many opioids, there are key differences between the actual doses used in clinical practice and the WHO's DDDs. The interpretation of opioid utilisation studies using population-level DDDs may be limited, and a recalibration of the DDD for many opioids or the reporting of opioid utilisation in oral morphine equivalent doses is recommended. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Suzanne Nielsen
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.,Drug and Alcohol Services, South Eastern Sydney Local Health District, NSW, Australia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Raimondo Bruno
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.,School of Medicine (Psychology), University of Tasmania, Hobart, Tas., Australia
| | - Wayne Hall
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.,Centre for Youth Substance Abuse Research, University of Queensland, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Milton Cohen
- St Vincent's Clinical School, UNSW, Darlinghurst, NSW, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Gabrielle Campbell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Marian Shanahan
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Fiona Blyth
- Concord Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Nicholas Lintzeris
- Drug and Alcohol Services, South Eastern Sydney Local Health District, NSW, Australia.,Discipline of Addiction Medicine, University of Sydney, Sydney, NSW, Australia
| | - Sallie Pearson
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Richard Mattick
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Louisa Degenhardt
- School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia.,Murdoch Children's Research Institute, The Royal Children's Hospital, Flemington, VIC, Australia.,Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
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18
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Frimpong JA, D'Aunno T, Helleringer S, Metsch LR. Spillover effects of HIV testing policies: changes in HIV testing guidelines and HCV testing practices in drug treatment programs in the United States. BMC Public Health 2016; 16:666. [PMID: 27473519 PMCID: PMC4966765 DOI: 10.1186/s12889-016-3322-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 07/19/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To examine the extent to which state adoption of the Centers for Disease Control and Prevention (CDC) 2006 revisions to adult and adolescent HIV testing guidelines is associated with availability of other important prevention and medical services. We hypothesized that in states where the pretest counseling requirement for HIV testing was dropped from state legislation, substance use disorder treatment programs would have higher availability of HCV testing services than in states that had maintained this requirement. METHODS We analyzed a nationally representative sample of 383 opioid treatment programs from the 2005 and 2011 National Drug Abuse Treatment System Survey (NDATSS). Data were collected from program directors and clinical supervisors through telephone surveys. Multivariate logistic regression models were used to measure associations between state adoption of CDC recommended guidelines for HIV pretest counseling and availability of HCV testing services. RESULTS The effects of HIV testing legislative changes on HCV testing practices varied by type of opioid treatment program. In states that had removed the requirement for HIV pretest counseling, buprenorphine-only programs were more likely to offer HCV testing to their patients. The positive spillover effect of HIV pretest counseling policies, however, did not extend to methadone programs and did not translate into increased availability of on-site HCV testing in either program type. CONCLUSIONS Our findings highlight potential positive spillover effects of HIV testing policies on HCV testing practices. They also suggest that maximizing the benefits of HIV policies may require other initiatives, including resources and programmatic efforts that support systematic integration with other services and effective implementation.
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Affiliation(s)
- Jemima A Frimpong
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, 600 West 168th Street, New York, NY, 10032, USA.
| | - Thomas D'Aunno
- Robert F. Wagner Graduate School of Public Service, New York University, 295 Lafayette Street, New York, NY, 10012, USA
| | - Stéphane Helleringer
- Department of Population, Family and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Lisa R Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA
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19
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Affiliation(s)
- Marc A Schuckit
- From the Department of Psychiatry, University of California, San Diego, La Jolla
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20
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Merlo LJ, Campbell MD, Skipper GE, Shea CL, DuPont RL. Outcomes for Physicians With Opioid Dependence Treated Without Agonist Pharmacotherapy in Physician Health Programs. J Subst Abuse Treat 2016; 64:47-54. [PMID: 26971079 DOI: 10.1016/j.jsat.2016.02.004] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 02/04/2016] [Accepted: 02/09/2016] [Indexed: 11/18/2022]
Abstract
AIMS To compare treatment outcome among substance dependent physicians enrolled in a physician health program (PHP) who have a history of alcohol use only, any opioid use, or non-opioid drug use, in order to determine whether the distinctive PHP system of care management is as effective for individuals with opioid use disorders as for those with alcohol or other drug use disorders. METHODS A 5-year, retrospective chart review, intent-to-treat analysis was conducted for all physicians admitted to 16 physician health programs (N=702; 85.5% male; age range=24-75). Analyses compared treatment outcomes for participants based upon their substance(s) of abuse [i.e., 1) "Alcohol Only" (n=204), 2) "Any Opioid" with or without alcohol use (n=339), and 3) "Non-Opioid" drug use with or without alcohol use (n=159)]. RESULTS In this sample, 75-80% of physicians across the three groups never tested positive for alcohol or drugs during their extended care management period with random drug testing. This included physicians with opioid dependence who did not receive opioid substitution therapy (OST). Of the 22.1% of physicians who had a positive test, two thirds (i.e., 14.5% of the total sample) had just one positive test, and only one third (i.e., 7.6% of the total sample) had more than one positive test. These results were similar in all three groups. CONCLUSIONS These results indicate that individuals with opioid use disorders who are managed by PHPs can achieve long-term abstinence from opioids, alcohol, and other drugs without OST through participation in abstinence-based psychosocial treatment with extended, intensive care management following discharge.
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Affiliation(s)
- Lisa J Merlo
- University of Florida, Department of Psychiatry, 4001 SW 13th St, Gainesville, FL 32608.
| | - Michael D Campbell
- Institute for Behavior and Health, Inc., 6191 Executive Blvd, Rockville, MD 20852 USA.
| | - Gregory E Skipper
- Promises Treatment Centers, 2515 Wilshire Blvd, Santa Monica, CA 90403.
| | - Corinne L Shea
- Institute for Behavior and Health, Inc., 6191 Executive Blvd, Rockville, MD 20852 USA.
| | - Robert L DuPont
- Institute for Behavior and Health, Inc., 6191 Executive Blvd, Rockville, MD 20852 USA.
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21
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Bizzarri JV, Casetti V, Sanna L, Maremmani AGI, Rovai L, Bacciardi S, Piacentino D, Conca A, Maremmani I. The newer Opioid Agonist Treatment with lower substitutive opiate doses is associated with better toxicology outcome than the older Harm Reduction Treatment. Ann Gen Psychiatry 2016; 15:34. [PMID: 27933094 PMCID: PMC5124303 DOI: 10.1186/s12991-016-0109-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 08/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Charge-free heroin use disorder treatment in Italy follows two main approaches, i.e., harm reduction treatment (HRT) strategy in community low-threshold facilities for drug addiction and opioid agonist treatment (OAT) in high-threshold facilities for opioid addiction, focusing on pharmacological maintenance according to the Dole and Nyswander strategy. We aimed to compare the impact of HRT and OAT on patient outcome, as assessed through negativity for drugs on about 1-year urinalyses. METHODS We examined retrospectively the urinalyses of HRT and OAT patients for which at least four randomly sampled urinalyses per month were available for about 1 year, during which patients were undergoing methadone or buprenorphine maintenance; urinalyses focused on heroin, cocaine, cannabinoids, and their metabolites. RESULTS Included were 189 HRT and 58 OAT patients. The latter were observed for a significantly longer period. There was a higher proportion of heroin- and cocaine-clean urinalyses in OAT patients, with cocaine-clean urinalyses discriminating best between the two groups. OAT patients were older, with longer dependence duration, more severe addiction history, and received lower methadone doses. Buprenorphine maintenance was more often associated with heroin-clean urinalyses. The higher the methadone doses, the lower were the percentage of heroin-clean urinalyses in HRT patients (negative correlation). CONCLUSIONS The OAT approach was related to higher recovery and polyabuse abstinence rates compared to the HRT approach, despite greater severity of substance use, psychiatric and physical comorbidities. Our results are consistent with the possibility to use lower maintenance opiate doses (after induction and stabilization in methadone treatment according to Dole and Nyswander methodology) in treating heroin addiction. This seemed to be impossible adopting the currently accepted HRT model.
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Affiliation(s)
| | | | - Livia Sanna
- Department of Psychiatry of Bolzano, Bolzano, Italy
| | - Angelo Giovanni Icro Maremmani
- Vincent P. Dole Dual Diagnosis Unit, Department of Neurosciences, Santa Chiara University Hospital, University of Pisa, Via Roma, 67 56100 Pisa, Italy ; AU-CNS-Association for the Application of Neuroscientific Knowledge to Social Aims, Pietrasanta, Italy
| | - Luca Rovai
- Vincent P. Dole Dual Diagnosis Unit, Department of Neurosciences, Santa Chiara University Hospital, University of Pisa, Via Roma, 67 56100 Pisa, Italy
| | - Silvia Bacciardi
- Vincent P. Dole Dual Diagnosis Unit, Department of Neurosciences, Santa Chiara University Hospital, University of Pisa, Via Roma, 67 56100 Pisa, Italy
| | | | | | - Icro Maremmani
- Vincent P. Dole Dual Diagnosis Unit, Department of Neurosciences, Santa Chiara University Hospital, University of Pisa, Via Roma, 67 56100 Pisa, Italy ; AU-CNS-Association for the Application of Neuroscientific Knowledge to Social Aims, Pietrasanta, Italy ; G De Lisio Institute of Behavioural Sciences, Pisa, Italy
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22
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Marienfeld C, Liu P, Wang X, Schottenfeld R, Zhou W, Chawarski MC. Evaluation of an implementation of methadone maintenance treatment in China. Drug Alcohol Depend 2015; 157:60-7. [PMID: 26601934 PMCID: PMC4663107 DOI: 10.1016/j.drugalcdep.2015.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 08/24/2015] [Accepted: 10/01/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Methadone maintenance treatment (MMT) reduces the harms of opioid use disorder and is being rapidly scaled-up in China. This study evaluated the real-world implementation of MMT system in Wuhan, China. METHODS Data extracted from electronic medical records collected in 2010 on 8811 patients were used to compute for each patient indices of the prescribed and consumed daily methadone doses, an adherence index, dose adjustments following missed doses, the rates of opiate positive urine tests, self-reported drug use, injection drug use (IDU), and the duration of MMT exposure. FINDINGS The modal daily doses prescribed were 60 mg and above for 68.5% of patients. Adherence was variable: 51% of patients attended less than 60% and 26% attended 80-100% of their treatment days; and patients with long MMT exposure had significantly higher adherence rates than patients with short MMT exposure. The differences between doses dispensed immediately before and after the interruption in dosing days ranged from 0 to 7 mg, independently of the length of the interruption or the prescribed dosing level. The overall rate of opiate positive tests was 20%; 45% of patients had at least one opiate positive test; 29% reported past month drug use and 53% of them reported past month IDU. Adherence and MMT exposure duration correlated significantly with the proportion of opiate negative urine tests (r=0.355, p<0.001; r=0.351, p<0.001, respectively). Treatment for males and females was comparable. CONCLUSIONS Provision of safe methadone dosing after absences and improving daily attendance are identified as priority improvement areas.
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Affiliation(s)
- Carla Marienfeld
- Yale School of Medicine, Department of Psychiatry, 34 Park Street, New Haven, CT 06519, United States
| | - Pulin Liu
- Wuhan Centers for Disease Prevention and Control, 24 Jianghan North Road, Wuhan, PR China; Tongji Medical College, School of Public Health, Huazhong University of Science & Technology, 13 Hangkong Road, Wuhan, PR China
| | - Xia Wang
- Wuhan Centers for Disease Prevention and Control, 24 Jianghan North Road, Wuhan, PR China
| | - Richard Schottenfeld
- Yale School of Medicine, Department of Psychiatry, 34 Park Street, New Haven, CT 06519, United States
| | - Wang Zhou
- Wuhan Centers for Disease Prevention and Control, 24 Jianghan North Road, Wuhan, PR China.
| | - Marek C Chawarski
- Yale School of Medicine, Department of Psychiatry, 34 Park Street, New Haven, CT 06519, United States.
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23
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Monico LB, Gryczynski J, Mitchell SG, Schwartz RP, O'Grady KE, Jaffe JH. Buprenorphine Treatment and 12-step Meeting Attendance: Conflicts, Compatibilities, and Patient Outcomes. J Subst Abuse Treat 2015; 57:89-95. [PMID: 25986647 PMCID: PMC4560966 DOI: 10.1016/j.jsat.2015.05.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 05/04/2015] [Accepted: 05/10/2015] [Indexed: 11/16/2022]
Abstract
This analysis examines patient experiences and outcomes with 12-step recovery group attendance during buprenorphine maintenance treatment (BMT), two approaches with traditionally divergent philosophies regarding opioid medications for treatment of opioid use disorder. Using quantitative (n = 300) and qualitative (n = 20) data collected during a randomized trial of counseling services in buprenorphine treatment, this mixed-methods analysis of African Americans in BMT finds the number of NA meetings attended in the prior 6 months was associated with a higher rate of retention in BMT (p < .001) and heroin/cocaine abstinence at 6 month follow-up (p = .005). However, patients whose counselors required them to attend 12-step meetings did not have better outcomes than patients not required to attend such meetings. Qualitative narratives highlighted patients' strategies for managing dissonant viewpoints on BMT and disclosing BMT status in community 12-step meetings. Twelve-step meeting attendance is associated with better outcomes for BMT patients over the first 6 months of treatment. However, there is no benefit to requiring meeting attendance as a condition of treatment, and clinicians should be aware of potential philosophical conflicts between 12-step and BMT approaches.
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Affiliation(s)
- Laura B Monico
- Friends Research Institute, 1040 Park Ave., Suite 103, Baltimore, MD, 21201, USA.
| | - Jan Gryczynski
- Friends Research Institute, 1040 Park Ave., Suite 103, Baltimore, MD, 21201, USA.
| | | | - Robert P Schwartz
- Friends Research Institute, 1040 Park Ave., Suite 103, Baltimore, MD, 21201, USA.
| | - Kevin E O'Grady
- Department of Psychology, University of Maryland, Biology/Psychology Building, College Park, MD, 20742, USA.
| | - Jerome H Jaffe
- Friends Research Institute, 1040 Park Ave., Suite 103, Baltimore, MD, 21201, USA; University of Maryland School of Medicine, Department of Psychiatry, 110 South Paca St. 4th floor, Baltimore, MD, USA.
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24
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Bogh SB, Falstie-Jensen AM, Bartels P, Hollnagel E, Johnsen SP. Accreditation and improvement in process quality of care: a nationwide study. Int J Qual Health Care 2015; 27:336-43. [PMID: 26239473 DOI: 10.1093/intqhc/mzv053] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2015] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To examine whether performance measures improve more in accredited hospitals than in non-accredited hospital. DESIGN AND SETTING A historical follow-up study was performed using process of care data from all public Danish hospitals in order to examine the development over time in performance measures according to participation in accreditation programs. PARTICIPANTS All patients admitted for acute stroke, heart failure or ulcer at Danish hospitals. INTERVENTION Hospital accreditation by either The Joint Commission International or The Health Quality Service. MEASUREMENTS The primary outcome was a change in opportunity-based composite score and the secondary outcome was a change in all-or-none scores, both measures were based on the individual processes of care. These processes included seven processes related to stroke, six processes to heart failure, four to bleeding ulcer and four to perforated ulcer. RESULTS A total of 27 273 patients were included. The overall opportunity-based composite score improved for both non-accredited and accredited hospitals (13.7% [95% CI 10.6; 16.8] and 9.9% [95% 5.4; 14.4], respectively), but the improvements were significantly higher for non-accredited hospitals (absolute difference: 3.8% [95% 0.8; 8.3]). No significant differences were found at disease level. The overall all-or-none score increased significantly for non-accredited hospitals, but not for accredited hospitals. The absolute difference between improvements in the all-or-none score at non-accredited and accredited hospitals was not significant (3.2% [95% -3.6:9.9]). CONCLUSIONS Participating in accreditation was not associated with larger improvement in performance measures for acute stroke, heart failure or ulcer.
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Affiliation(s)
- Søren Bie Bogh
- Institute of Regional Health Research, University of Southern Denmark, Winsløwparken 19, 3, Odense C DK-5000, Denmark Centre for Quality, Region of Southern Denmark, P.V. Tuxenvej 5, Middelfart DK-5500, Denmark
| | - Anne Mette Falstie-Jensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, Aarhus N DK-8200, Denmark
| | - Paul Bartels
- The Danish Clinical Registries, Olof Palmes Allé 15, Aarhus N DK-8200, Denmark
| | - Erik Hollnagel
- Institute of Regional Health Research, University of Southern Denmark, Winsløwparken 19, 3, Odense C DK-5000, Denmark Centre for Quality, Region of Southern Denmark, P.V. Tuxenvej 5, Middelfart DK-5500, Denmark
| | - Søren Paaske Johnsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, Aarhus N DK-8200, Denmark
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Pan S, Jiang H, Du J, Chen H, Li Z, Ling W, Zhao M. Efficacy of Cognitive Behavioral Therapy on Opiate Use and Retention in Methadone Maintenance Treatment in China: A Randomised Trial. PLoS One 2015; 10:e0127598. [PMID: 26107818 PMCID: PMC4479610 DOI: 10.1371/journal.pone.0127598] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 03/30/2015] [Indexed: 12/12/2022] Open
Abstract
Aims Methadone maintenance treatment (MMT) is widely available in China; but, high rates of illicit opiate use and dropout are problematic. The aim of this study was to test whether cognitive behavioral therapy (CBT) in conjunction with MMT can improve treatment retention and reduce opiate use. Method A total of 240 opiate-dependent patients in community-based MMT clinics were randomly assigned to either weekly CBT plus standard MMT (CBT group, n=120) or standard MMT (control group, n=120) for 26 weeks. The primary outcomes were treatment retention and opiate-negative urine test results at 12 weeks and 26 weeks. The secondary outcomes were composite scores on the Addiction Severity Index (ASI) and total scores on the Perceived Stress Scale (PSS) at 12 weeks and 26 weeks. Results Compared to the control group in standard MMT, the CBT group had higher proportion of opiate-negative urine tests at both 12 weeks (59% vs. 69%, p<0.05) and 26 weeks (63% vs. 73%, p<0.05); however, the retention rates at 12 weeks (73.3% vs. 74.2%, p=0.88) and 26 weeks were not different (55.8% vs. 64.2%, p=0.19) between the two groups. At both 12 and 26 weeks, all of the ASI component scores and PSS total scores in the CBT group and control group decreased from baseline; but the CBT group exhibited more decreases in ASI employment scores at week 26 and more decrease in the PSS total score at week 12 and week 26. Conclusions CBT counselling is effective in reducing opiate use and improving employment function and in decreasing stress level for opiate-dependent patients in MMT in China. Trial Registration ClinicalTrials.gov NCT01144390
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Affiliation(s)
- Shujun Pan
- Shanghai Mental Health Center, Shanghai JiaoTong University School of Medicine, Shanghai, China, 200030
| | - Haifeng Jiang
- Shanghai Mental Health Center, Shanghai JiaoTong University School of Medicine, Shanghai, China, 200030
| | - Jiang Du
- Shanghai Mental Health Center, Shanghai JiaoTong University School of Medicine, Shanghai, China, 200030
| | - Hanhui Chen
- Shanghai Mental Health Center, Shanghai JiaoTong University School of Medicine, Shanghai, China, 200030
| | - Zhibin Li
- Shanghai Mental Health Center, Shanghai JiaoTong University School of Medicine, Shanghai, China, 200030
| | - Walter Ling
- Integrated Substance Abuse Programs, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, United States of America
| | - Min Zhao
- Shanghai Mental Health Center, Shanghai JiaoTong University School of Medicine, Shanghai, China, 200030
- * E-mail:
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Andrews C, Abraham A, Grogan CM, Pollack HA, Bersamira C, Humphreys K, Friedmann P. Despite Resources From The ACA, Most States Do Little To Help Addiction Treatment Programs Implement Health Care Reform. Health Aff (Millwood) 2015; 34:828-35. [PMID: 25941285 PMCID: PMC4706741 DOI: 10.1377/hlthaff.2014.1330] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Affordable Care Act (ACA) dramatically expands health insurance for addiction treatment and provides unprecedented opportunities for service growth and delivery model reform. Yet most addiction treatment programs lack the staffing and technological capabilities to respond successfully to ACA-driven system change. In light of these challenges, we conducted a national survey to examine how Single State Agencies for addiction treatment--the state governmental organizations charged with overseeing addiction treatment programs--are helping programs respond to new requirements under the ACA. We found that most Single State Agencies provide little assistance to addiction treatment programs. Most agencies are helping programs develop collaborations with other health service programs. However, fewer than half reported providing help in modernizing systems to support insurance participation, and only one in three provided assistance with enrollment outreach. In the absence of technical assistance, it is unlikely that addiction treatment programs will fully realize the ACA's promise to improve access to and quality of addiction treatment.
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Affiliation(s)
- Christina Andrews
- Christina Andrews is an assistant professor of social work at the University of South Carolina, in Columbia
| | - Amanda Abraham
- Amanda Abraham is an assistant professor of health policy and management at the University of Georgia, in Athens
| | - Colleen M Grogan
- Colleen M. Grogan is a professor of health policy at the University of Chicago, in Illinois
| | - Harold A Pollack
- Harold A. Pollock is an associate professor of health policy at the University of Chicago
| | - Clifford Bersamira
- Clifford Bersamira is a doctoral student in social work at the University of Chicago
| | - Keith Humphreys
- Keith Humphreys is a professor of psychiatry and behavioral sciences at the Veterans Affairs and Stanford University Medical Centers, both in Stanford, California
| | - Peter Friedmann
- Peter Friedmann is a professor of medicine at the Providence Veteran Affairs Medical Center, the Rhode Island Hospital, and the Alpert Medical School of Brown University, all in Providence, Rhode Island
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Pacini M, Maremmani AGI, Ceccanti M, Maremmani I. Former Heroin-Dependent Alcohol Use Disorder Patients. Prevalence, Addiction History and Clinical Features. Alcohol Alcohol 2015; 50:451-7. [PMID: 25827777 DOI: 10.1093/alcalc/agv028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 03/05/2015] [Indexed: 01/28/2023] Open
Abstract
AIMS To examine the prevalence of former heroin dependence (FHA) in Alcohol Use Disorder (AUD) patients; to compare the clinical characteristics of FHA-AUD patients versus AUD patients without any past use of heroin at alcohol treatment entry; to document the heroin dependence history of FHA-AUD patients, and review treatment strategies for this group. METHODS Retrospective case review of 448 consecutive AUD patients. RESULTS The annual entry of FHA-AUD showed stability over the study period of 3 years overall 60/448 (13.3%). FHA-AUD patients showed higher concomitant use of cocaine, benzodiazepines, cannabis and hallucinogens than other heroin addicts. They consumed higher amounts of alcohol at the beginning of their alcohol dependence history, and reached a high maximum level of alcohol consumption, than other AUD patients, and tended to have more physical disorders. The most important signals of FHA-AUD were polyabuse and older age at the time of presentation. FHA-AUD patients tended to have had a severe pattern of heroin dependence associated with inadequate agonist opiate treatment. CONCLUSIONS The prevalence of FHA-AUD patients is not negligible. This may relate to previous inadequate treatment of heroin addiction contributing to the development of severe AUD. For these patients we propose a reconsideration of 'soft' (low dose) agonist opiate treatment.
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Affiliation(s)
- Matteo Pacini
- G. De Lisio Institute of Behavioural Sciences, Pisa, Italy
| | - Angelo Giovanni Icro Maremmani
- Vincent P. Dole Dual Diagnosis Unit, Department of Neurosciences, Santa Chiara University Hospital, University of Pisa, Pisa, Italy AU-CNS, Association for the Application of Neuroscientific Knowledge to Social Aims, Pietrasanta, Lucca, Italy
| | - Mauro Ceccanti
- Centre for the Assessment and Treatment of Alcohol-Related Pathology, La Sapienza University, Rome, Italy
| | - Icro Maremmani
- G. De Lisio Institute of Behavioural Sciences, Pisa, Italy Vincent P. Dole Dual Diagnosis Unit, Department of Neurosciences, Santa Chiara University Hospital, University of Pisa, Pisa, Italy AU-CNS, Association for the Application of Neuroscientific Knowledge to Social Aims, Pietrasanta, Lucca, Italy
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Levine AR, Lundahl LH, Ledgerwood DM, Lisieski M, Rhodes GL, Greenwald MK. Gender-specific predictors of retention and opioid abstinence during methadone maintenance treatment. J Subst Abuse Treat 2015; 54:37-43. [PMID: 25795601 DOI: 10.1016/j.jsat.2015.01.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 01/20/2015] [Accepted: 01/26/2015] [Indexed: 11/30/2022]
Abstract
AIMS Retention in methadone maintenance treatment (MMT) for 1 year is associated with positive outcomes including opioid abstinence, however, most studies have not investigated gender differences. We hypothesized that predictors of retention and opioid abstinence would differ between men and women, and aimed to determine which factors best predict retention and abstinence for each gender. METHODS Data were available for 290 patients (173 M, 117 F) admitted to outpatient MMT. Regression analyses, stratified by gender, were conducted to identify unique predictors of MMT retention (<1 vs. >1 year) and opioid abstinence rate (proportion of opioid-free urine samples up to 1 year retention). RESULTS Gender did not significantly predict treatment retention (mean = 231 days, 39% retained > 1 year) or opioid abstinence (49% overall). For males, significant predictors of > 1-year retention were urine samples negative for opioids (odds ratio [OR] = 6.67) and cannabinoids (OR = 5.00) during the first month, and not cocaine dependent (OR = 2.70). Significant predictors of higher long-term opioid abstinence were first-month urine samples negative for opioids and cocaine metabolites. For females, significant predictors of >1-year retention were first-month urine samples negative for cocaine metabolites (OR = 4.00) and cannabinoids (OR = 9.26), and no history of sexual victimization (OR = 3.03). The only significant predictor of higher opioid abstinence rate was first-month opioid-free urine samples. CONCLUSIONS These findings indicate gender-specific predictors of MMT retention and opioid abstinence. Future studies on MMT outcomes should examine each gender separately, and consider unique pathways by which females and males adhere to, and benefit from MMT.
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Affiliation(s)
- Amanda R Levine
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, 3901 Chrysler Service Drive, Detroit, MI 48201, USA.
| | - Leslie H Lundahl
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, 3901 Chrysler Service Drive, Detroit, MI 48201, USA.
| | - David M Ledgerwood
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, 3901 Chrysler Service Drive, Detroit, MI 48201, USA.
| | - Michael Lisieski
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, 3901 Chrysler Service Drive, Detroit, MI 48201, USA.
| | - Gary L Rhodes
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, 3901 Chrysler Service Drive, Detroit, MI 48201, USA.
| | - Mark K Greenwald
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, 3901 Chrysler Service Drive, Detroit, MI 48201, USA; Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave., Detroit, MI 48201, USA.
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Sullivan SG, Wu Z, Rou K, Pang L, Luo W, Wang C, Cao X, Yin W, Liu E, Mi G. Who uses methadone services in China? Monitoring the world's largest methadone programme. Addiction 2015; 110 Suppl 1:29-39. [PMID: 25533862 DOI: 10.1111/add.12781] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 12/20/2012] [Accepted: 09/30/2014] [Indexed: 11/30/2022]
Abstract
AIMS To describe the data collected by the Chinese methadone maintenance treatment (MMT) system and the characteristics of clients entering the programme. DESIGN Descriptive study using routinely collected data from the MMT data management system for the period March 2004 and March 2010. SETTING All MMT clinics in China. PARTICIPANTS Clients who enrolled for services between March 2004 and March 2010. MEASUREMENTS Routinely collected data included: demographic information; drug use, sexual and criminal behaviours; status of infection with human immunodeficiency virus (HIV), hepatitis C virus (HCV) and syphilis; random urine-opiate test results; and the daily methadone dose received. Differences among clients by year were examined. FINDINGS During the period examined, there were 251,974 clients attending 684 clinics in 27 provinces. Overall, the mean age was 34.4 years, 83.8% were male, 70.2% were unemployed, 75% had ever injected drugs, 17% had shared needles and 7.4% were HIV-positive. The profile of clients changed over time, with fewer HIV-positive individuals, fewer injecting drug users, fewer needle-sharers, fewer females and fewer unemployed. Half the clients dropped out within 6 months. The average final dose received was 49.4 mg. The estimated probability of interrupting treatment before 6 months was 52.5%. CONCLUSIONS The profile of clients enrolling in methadone maintenance treatment in China is continually changing and appears to be associated with reduced risk of HIV. High dropout in the programme may limit its effectiveness. The availability of a centralized, real-time data system was extremely useful for monitoring the progress of the Chinese methadone maintenance treatment programme.
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Affiliation(s)
- Sheena G Sullivan
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China; Department of Epidemiology, University of California, Los Angeles, CA, USA
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D'Aunno T, Pollack HA, Frimpong JA, Wutchiett D. Evidence-based treatment for opioid disorders: a 23-year national study of methadone dose levels. J Subst Abuse Treat 2014; 47:245-50. [PMID: 25012549 PMCID: PMC4139092 DOI: 10.1016/j.jsat.2014.06.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 06/02/2014] [Accepted: 06/03/2014] [Indexed: 10/25/2022]
Abstract
Effective treatment for patients with opioid use problems is as critical as ever given the upsurge in heroin and prescription opioid abuse. Yet, results from prior studies show that the majority of methadone maintenance treatment (MMT) programs in the US have not provided dose levels that meet evidence-based standards. Thus, this paper examines the extent to which US MMT programs have made changes in the past 23 years to provide adequate methadone doses; we also identify factors associated with variation in program performance. Program directors and clinical supervisors of nationally-representative methadone treatment programs were surveyed in 1988 (n=172), 1990 (n=140), 1995 (n=116), 2000 (n=150), 2005 (n=146), and 2011 (n=140). Results show that the proportion of patients who received doses below 60 mg/day-the minimum recommended-declined from 79.5 to 22.8% in a 23-year span. Results from random effects models show that programs that serve a higher proportion of African-American or Hispanic patients were more likely to report low-dose care. Programs with Joint Commission accreditation were more likely to provide higher doses, as were a program that serves a higher proportion of unemployed and older patients. Efforts to improve methadone treatment practices have made substantial progress, but 23% of patients across the nation are still receiving doses that are too low to be effective.
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Affiliation(s)
- Thomas D'Aunno
- Columbia University, 600W. 168th St., #403, New York, New York 10032.
| | - Harold A Pollack
- University of Chicago, School of Social Administration, 969 E. 60th Street, Chicago, IL 60637.
| | - Jemima A Frimpong
- Mailman School of Public Health, Columbia University, 600W. 168th St., #604, New York, New York 10032.
| | - David Wutchiett
- Mailman School of Public Health, Columbia University, 600W. 168th St., New York, New York 10032.
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31
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Zhao L, Holzemer WL, Tulsky JP, Johnson MO, Dawson Rose C. Effect of Methadone Dose on Maintenance Treatment and Health Consequences Among Heroin Addicts in South China. Subst Use Misuse 2014; 49:13-21. [PMID: 23879378 DOI: 10.3109/10826084.2013.817425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A retrospective cross-sectional study was conducted with a convenience sample of 197 adults receiving methadone maintenance treatment in Kunming city, South China, in 2010. The aim of the study was to determine the association of methadone maintenance dose on a variety of treatment outcomes. Treatment modalities, the adverse reactions to methadone treatment, the physical and mental outcomes of the treatment, and risk behavior changes were assessed. Multilevel negative and logistic binomial regression analyses were carried out, which demonstrated that methadone maintenance dose in this sample was not associated with improved treatment adherence or with quality of life. We concluded that dose had a small, if negligible, influence on the changes in adverse effects of methadone. Further research in dose differences between the genders should be conducted.
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Affiliation(s)
- Lin Zhao
- a 1Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston , Melbourne, Australia
| | - William L Holzemer
- b 2College of Nursing -Newark & New Brunswick Rutgers, The State University of New Jersey , Newark, USA
| | - Jacqueline P Tulsky
- c 3San Francisco General Hospital, School of Medicine, Box: 0874 Bldg: SFGH Bldg 80 Room: W84 , San Francisco, USA
| | - Mallory O Johnson
- d 4UCSF, Box: 0886 Bldg: 50 Beale Street Room: 1300 , San Francisco, USA
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Sullivan SG, Wu Z, Cao X, Liu E, Detels R. Continued drug use during methadone treatment in China: a retrospective analysis of 19,026 service users. J Subst Abuse Treat 2013; 47:86-92. [PMID: 24629884 DOI: 10.1016/j.jsat.2013.12.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 12/05/2013] [Accepted: 12/09/2013] [Indexed: 10/25/2022]
Abstract
This study examined nation-wide data from China to assess client outcomes after 6-months of methadone treatment. Data on 19,026 clients enrolled between April 2008 and March 2010 were reviewed for changes in HIV-risk behaviours and emergence of new HIV cases. Multivariable logistic regression was used to identify factors associated with illicit drug use while in MMT. Clients reported reduced drug use and related risk behaviours and improved social functioning. There were 24 newly-identified cases of HIV. Continued drug use was associated with low attendance (OR=5.98, 95% CI=4.69-7.63), frequently seeing drug using friends (OR=3.72 for daily vs. never, 95% CI=3.18-4.34) and having a difficult family relationship (OR=2.03 for difficult vs. good, 95% CI=1.63-2.52). Methadone dose was not associated with continued drug use while in treatment. The Chinese MMT programme appears to be having a positive influence on those clients who remain in treatment, but needs to explore strategies to increase accessibility.
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Affiliation(s)
- Sheena G Sullivan
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China; Department of Epidemiology, University of California, Los Angeles, USA
| | - Zunyou Wu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
| | - Xiaobin Cao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Enwu Liu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Roger Detels
- Department of Epidemiology, University of California, Los Angeles, USA
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Ducharme LJ, Chandler RK, Wiley TRA. Implementing drug abuse treatment services in criminal justice settings: Introduction to the CJ-DATS study protocol series. HEALTH & JUSTICE 2013; 1:5. [PMID: 24707454 PMCID: PMC3975625 DOI: 10.1186/2194-7899-1-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 10/10/2013] [Indexed: 05/20/2023]
Abstract
BACKGROUND Despite a growing pipeline of effective clinical treatments, there remains a persistent research-to-practice gap in drug abuse services. Delivery of effective treatment services is especially lacking in the U.S. criminal justice system, where half of all incarcerated persons meet the need for drug abuse or dependence, yet few receive needed care. Structural, financial, philosophical and other barriers slow the pace of adoption of available evidence-based practices. These challenges led to the development of a multi-site cooperative research endeavor known as the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS), funded by the National Institute on Drug Abuse (NIDA). CJ-DATS engages university-based research teams, criminal justice agencies, and community-based treatment providers in implementation research studies to test strategies for enhancing treatment service delivery to offender populations. METHODS This Introduction reviews the mission of NIDA, the structure and goals of the CJ-DATS cooperative, and the implementation studies being conducted by the participating organizations. The component Study Protocols in this article collection are then described. DISCUSSION CJ-DATS applies implementation science perspectives and methods to address a vexing problem - the need to link offender populations with effective treatment for drug abuse, HIV, and other related conditions for which they are at high risk. Applying these principles to the U.S. criminal justice system is an innovative extension of lessons that have been learned in mainstream healthcare settings. This collection is offered as both an introduction to NIDA's work in this area, as well as a window onto the challenges of conducting health services research in settings in which improving public health is not the organization's core mission.
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Affiliation(s)
- Lori J Ducharme
- National Institute on Drug Abuse, 6001 Executive Blvd., Rm 5185 MSC 9589, Bethesda, MD 20892-9589 USA
| | - Redonna K Chandler
- National Institute on Drug Abuse, 6001 Executive Blvd., Rm 5185 MSC 9589, Bethesda, MD 20892-9589 USA
| | - Tisha RA Wiley
- National Institute on Drug Abuse, 6001 Executive Blvd., Rm 5185 MSC 9589, Bethesda, MD 20892-9589 USA
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The long-term outcomes of heroin dependent-treatment-resistant patients with bipolar 1 comorbidity after admission to enhanced methadone maintenance. J Affect Disord 2013; 151:582-589. [PMID: 23931828 DOI: 10.1016/j.jad.2013.06.054] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 06/28/2013] [Accepted: 06/29/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to compare the long-term outcomes of treatment-resistant bipolar 1 heroin addicts with peers who were without DSM-IV axis I psychiatric comorbidity (dual diagnosis). METHOD 104 Heroin-dependent patients (TRHD), who also met criteria for treatment resistance - 41 of them with DSM-IV-R criteria for Bipolar 1 Disorder (BIP1-TRHD) and 63 without DSM-IV-R axis I psychiatric comorbidity (NDD-TRHD) - were monitored prospectively (3 years on average, min. 0.5, max. 8) along a Methadone Maintenance Treatment Programme (MMTP). RESULTS The rates for survival-in-treatment were 44% for NDD-TRHD patients and 58% for BIP1-TRHD patients (p=0.062). After 3 years of treatment such rates tended to become progressively more stable. BIP1-TRHD patients showed better outcome results than NDD-TRHD patients regarding CGI severity (p<0.001) and DSM-IV GAF (p<0.001). No differences were found regarding urinalyses for morphine between groups during the observational period. Bipolar 1 patients needed a higher methadone dosage in the stabilization phase, but this difference was not statistically significant. LIMITATIONS The observational nature of the protocol, the impossibility of evaluating a follow-up in the case of the patients who dropped out, and the multiple interference caused by interindividual variability, the clinical setting and the temporary use of adjunctive medications. CONCLUSIONS Contrary to expectations, treatment-resistant patients with bipolar 1 disorder psychiatric comorbidity showed a better long-term outcome than treatment-resistant patients without psychiatric comorbidity.
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Andrews CM, D'Aunno TA, Pollack HA, Friedmann PD. Adoption of evidence-based clinical innovations: the case of buprenorphine use by opioid treatment programs. Med Care Res Rev 2013; 71:43-60. [PMID: 24051897 DOI: 10.1177/1077558713503188] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article examines changes from 2005 to 2011 in the use of an evidence-based clinical innovation, buprenorphine use, among a nationally representative sample of opioid treatment programs and identifies characteristics associated with its adoption. We apply a model of the adoption of clinical innovations that focuses on the work needs and characteristics of staff; organizations' technical and social support for the innovation; local market dynamics and competition; and state policies governing the innovation. Results indicate that buprenorphine use increased 24% for detoxification and 47% for maintenance therapy between 2005 and 2011. Buprenorphine use was positively related to reliance on private insurance and availability of state subsidies to cover its cost and inversely related to the percentage of clients who injected opiates, county size, and local availability of methadone. The results indicate that financial incentives and market factors play important roles in opioid treatment programs' decisions to adopt evidence-based clinical innovations such as buprenorphine use.
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Abstract
BACKGROUND Methadone maintenance for heroin dependence reduces illicit drug use, crime, HIV risk, and death. Typical dosages have increased over the past few years, based on strong experimental and clinical evidence that dosages under 60 mg/day are inadequate and that dosages closer to 100mg/day produce better outcomes. However, there is little experimental evidence for the benefits of exceeding 100 mg/day, or for individualizing methadone dosages. We sought to provide such evidence. METHODS We combined individualized methadone dosages over 100 mg/day with voucher-based cocaine-targeted contingency management (CM) in 58 heroin- and cocaine-dependent outpatients. Participants were randomly assigned to receive a fixed dose increase from 70 mg/day to 100mg/day, or to be eligible for further dose increases (up to 190 mg/day, based on withdrawal symptoms, craving, and continued heroin use). All dosing was double-blind. The main outcome measure was simultaneous abstinence from heroin and cocaine. RESULTS We stopped the study early due to slow accrual. Cocaine-targeted CM worked as expected to reduce cocaine use. Polydrug use (effect-size h=.30) and heroin craving (effect-size d=.87) were significantly greater in the flexible/high-dose condition than in the fixed-dose condition, with no trend toward lower heroin use in the flexible/high-dose participants. CONCLUSIONS Under double-blind conditions, dosages of methadone over 100mg/day, even when prescribed based on specific signs and symptoms, were not better than 100mg/day. This counterintuitive finding requires replication, but supports the need for additional controlled studies of high-dose methadone.
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Trujols J, Siñol N, Pérez De Los Cobos J. Trends in the average prescribed dose of methadone: more than a proxy for the evolution of severity of opioid dependence. J OBSTET GYNAECOL 2013; 33:430. [PMID: 23654341 DOI: 10.3109/01443615.2013.765395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Retention in methadone and buprenorphine treatment among African Americans. J Subst Abuse Treat 2013; 45:287-92. [PMID: 23566446 DOI: 10.1016/j.jsat.2013.02.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 01/15/2013] [Accepted: 02/20/2013] [Indexed: 11/20/2022]
Abstract
Methadone has been the most commonly used pharmacotherapy for the treatment of opioid dependence in U.S. public sector treatment, but availability of buprenorphine as an alternative medication continues to increase. Drawing data from two community-based clinical trials that were conducted nearly contemporaneously, this study examined retention in methadone versus buprenorphine treatment over 6 months among urban African Americans receiving treatment in one of four publicly-funded programs (N=478; 178 methadone; 300 buprenorphine). Adjusting for confounds related to medication selection, survival analysis revealed that buprenorphine patients are at substantially higher risk of dropout compared to methadone patients (HR=2.43; p<.001). Buprenorphine's retention disadvantage appears to be concentrated in the earlier phases of treatment (approximately the first 50 days), after which risk of subsequent dropout becomes similar for the two medications. These findings confirm a retention disparity between methadone and buprenorphine in this population, and suggest potential avenues for future research to enhance retention in buprenorphine treatment.
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Methadone dose, take home status, and hospital admission among methadone maintenance patients. J Addict Med 2013; 6:186-90. [PMID: 22694929 DOI: 10.1097/adm.0b013e3182584772] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Among patients receiving methadone maintenance treatment (MMT) for opioid dependence, receipt of unobserved dosing privileges (take homes) and adequate doses (ie, ≥ 80 mg) are each associated with improved addiction treatment outcomes, but the association with acute care hospitalization is unknown. We studied whether take-home dosing and adequate doses (ie, ≥80 mg) were associated with decreased hospital admission among patients in an MMT. METHODS We reviewed daily electronic medical records of patients enrolled in one MMT program to determine receipt of take-home doses, methadone dose 80 mg or more, and hospital admission date. Nonlinear mixed-effects logistic regression models were used to evaluate whether take-home doses or dose 80 mg or more on a given day were associated with hospital admission on the subsequent day. Covariates in adjusted models included age, sex, race/ethnicity, human immunodeficiency virus status, medical illness, mental illness, and polysubstance use at program admission. RESULTS Subjects (n = 138) had the following characteristics: mean age 43 years; 52% female; 17% human immunodeficiency virus-infected; 32% medical illness; 40% mental illness; and 52% polysubstance use. During a mean follow-up of 20 months, 42 patients (30%) accounted for 80 hospitalizations. Receipt of take homes was associated with significantly lower odds of a hospital admission (adjusted odds ratio [AOR] = 0.26; 95% confidence interval [CI], 0.11-0.62), whereas methadone dose 80 mg or more was not (AOR = 1.01; 95% CI, 0.56-1.83). CONCLUSIONS Among MMT patients, receipt of take homes, but not dose of methadone, was associated with decreased hospital admission. Take-home status may reflect not only patients' improved addiction outcomes but also reduced health care utilization.
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Lin HC, Chen KY, Wang PW, Yen CF, Wu HC, Yen CN, Yeh YC, Chung KS, Chang HC. Predictors for dropping-out from methadone maintenance therapy programs among heroin users in southern Taiwan. Subst Use Misuse 2013; 48:181-91. [PMID: 23368704 DOI: 10.3109/10826084.2012.749411] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study examined the methadone maintenance therapy (MMT) retention rates of heroin users in Taiwan and the predictors for dropout in the 18-month period after starting MMT. We consecutively recruited 368 intravenous heroin users receiving MMT in 2007-2008 and applied Cox proportional hazards regression analysis to determine the predictive effect of pre- and in-treatment variables on early discontinuation of MMT. The retention rate at 18 months was 32.3%. High heroin expenses, more severe harm caused by heroin use, perceived lower family support, and lower methadone dosage at 3 months after starting MMT increased the risk of dropout in the follow-up period.
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Affiliation(s)
- Huang-Chi Lin
- Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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41
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Novotná G, Dobbins M, Jack SM, Sword W, Niccols A, Brooks S, Henderson J. The influence of lived experience with addiction and recovery on practice-related decisions among professionals working in addiction agencies serving women. DRUGS-EDUCATION PREVENTION AND POLICY 2012. [DOI: 10.3109/09687637.2012.714015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hinchcliff R, Greenfield D, Moldovan M, Westbrook JI, Pawsey M, Mumford V, Braithwaite J. Narrative synthesis of health service accreditation literature. BMJ Qual Saf 2012; 21:979-91. [PMID: 23038406 DOI: 10.1136/bmjqs-2012-000852] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To systematically identify and synthesise health service accreditation literature. METHODS A systematic identification and narrative synthesis of health service accreditation literature published prior to 2012 were conducted. The search identified 122 empirical studies that examined either the processes or impacts of accreditation programmes. Study components were recorded, including: dates of publication; research settings; levels of study evidence and quality using established rating frameworks; and key results. A content analysis was conducted to determine the frequency of key themes and subthemes examined in the literature and identify knowledge-gaps requiring research attention. RESULTS The majority of studies (n=67) were published since 2006, occurred in the USA (n=60) and focused on acute care (n=79). Two thematic categories, that is, 'organisational impacts' and 'relationship to quality measures', were addressed 60 or more times in the literature. 'Financial impacts', 'consumer or patient satisfaction' and 'survey and surveyor issues' were each examined fewer than 15 times. The literature is limited in terms of the level of evidence and quality of studies, but highlights potential relationships among accreditation programmes, high quality organisational processes and safe clinical care. CONCLUSIONS Due to the limitations of the literature, it is not prudent to make strong claims about the effectiveness of health service accreditation. Nonetheless, several critical issues and knowledge-gaps were identified that may help stimulate and inform discussion among healthcare stakeholders. Ongoing effort is required to build upon the accreditation evidence-base by using high quality experimental study designs to examine the processes, effectiveness and financial value of accreditation programmes and their critical components in different healthcare domains.
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Affiliation(s)
- Reece Hinchcliff
- Centre for Clinical Governance Research, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia.
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Chuang E, Wells R, Alexander J, Green S. How outpatient substance abuse treatment unit director activities may affect provision of community outreach services. DRUGS-EDUCATION PREVENTION AND POLICY 2012; 20:149-159. [PMID: 29170607 DOI: 10.3109/09687637.2012.703261] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Aims Community outreach services play an important role in infectious disease prevention and engaging drug users not currently in treatment. However, fewer than half of US substance abuse treatment units provide these services and many have little financial incentive to do so. Unit directors generally have latitude about scope of services, including the level of outreach provided to the community. The current study examines how directors' interactions with external stakeholders affect substance abuse treatment units' provision of community outreach services. Methods Cross-sectional logistic and Poisson regression analyses were conducted on a national sample of US outpatient substance abuse treatment units (N = 547). Results Findings suggest that the amount of time directors spent with licensing and monitoring associations was associated with provision of a greater number of community outreach services, while time spent with professional and occupational associations was associated with provision of off-site human immunodeficiency virus and hepatitis C testing. Several other director attributes and organizational characteristics also emerged as significant. Conclusions External stakeholders with whom substance abuse treatment directors interact may influence community outreach through their effects on treatment directors' strategic priorities. Implications for policy and prevention efforts are discussed.
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Affiliation(s)
- Emmeline Chuang
- Division of Health Management and Policy, Graduate School of Public Health, San Diego State University, San Diego, CA, USA
| | - Rebecca Wells
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jeffrey Alexander
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Sherri Green
- Department of Maternal and Child Health, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Harris A, Selling D, Luther C, Hershberger J, Brittain J, Dickman S, Glick A, Lee JD. Rate of community methadone treatment reporting at jail reentry following a methadone increased dose quality improvement effort. Subst Abus 2012; 33:70-5. [PMID: 22263715 DOI: 10.1080/08897077.2011.620479] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
The Rikers Island Key Extended Entry Program (KEEP) has offered methadone treatment for opioid dependent inmates incarcerated in New York City's jails since 1986. In response to a trend toward low-dose methadone maintenance prescribing, a quality improvement (QI) protocol trained KEEP counselors, physicians, and pharmacists in the evidence base supporting moderate-to-high methadone maintenance doses in order to maximize therapeutic effects and rates of successful reporting to community methadone treatment programs (MTPs) post release. Discharge dose level and length of incarceration data were analyzed for 2 groups of KEEP patients discharged pre/post-QI. Among patients incarcerated for 21 or more days, the proportion of those on moderate-to-high doses of methadone increased significantly. Patients who reached a moderate-to-high methadone dose demonstrated higher rates of reporting to community MTP versus lower doses, both pre- and post-QI. Overall, a higher proportion of all patients reported to community MTP post-QI.
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Affiliation(s)
- Andiea Harris
- Prison Health Services, Inc., New York, New York, USA
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Duffy P, Baldwin H. The nature of methadone diversion in England: a Merseyside case study. Harm Reduct J 2012; 9:3. [PMID: 22243982 PMCID: PMC3285516 DOI: 10.1186/1477-7517-9-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 01/13/2012] [Indexed: 11/10/2022] Open
Abstract
Background Methadone maintenance treatment (MMT) is a key element in treatment for opiate addiction; however concerns about the diversion of methadone remain. More current empirical data on methadone diversion are required. This research investigated the market for diverted methadone in Merseyside, UK, in order to provide a case study which can be transferred to other areas undertaking methadone maintenance treatment on a large scale. Methods Questionnaires were completed (in interview format) with 886 past year users of methadone recruited both in and out of prescribing agencies. Topic areas covered included current prescribing, obtaining and providing methadone, reasons for using illicit methadone and other drug use. Results Large proportions of participants had obtained illicit methadone for use in the past year with smaller proportions doing so in the past month. Proportions of participants buying and being given methadone were similar. Exchange of methadone primarily took place between friends and associates, with 'dealers' rarely involved. Gender, age, whether participant's methadone consumption was supervised and whether the aims of their treatment had been explained to them fully, influenced the extent to which participants were involved in diverting or using diverted methadone. Conclusion Methadone diversion is widespread although drug users generally do not make use of illicit methadone regularly (every month). The degree of altruism involved in the exchange of methadone does not negate the potential role of this action in overdose or the possibility of criminal justice action against individuals. Treatment agencies need to emphasise these risks whilst ensuring that treatment aims are effectively shared with clients to ensure adherence to treatment.
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Affiliation(s)
- Paul Duffy
- Criminal Justice System Manager, Centre for Public Health, Liverpool John Moores University, 2nd Floor, Henry Cotton Campus, 15-21 Webster Street, Liverpool, L3 2ET, UK.
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Alkhenizan A, Shaw C. Impact of accreditation on the quality of healthcare services: a systematic review of the literature. Ann Saudi Med 2011; 31:407-16. [PMID: 21808119 PMCID: PMC3156520 DOI: 10.4103/0256-4947.83204] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Accreditation is usually a voluntary program in which trained external peer reviewers evaluate a healthcare organization's compliance and compare it with pre-established performance standards. The aim of this study was to evaluate the impact of accreditation programs on the quality of healthcare services METHODS We did a systematic review of the literature to evaluate the impact of accreditation programs on the quality of healthcare services. Several databases were systematically searched, including Medline, Embase, Healthstar, and Cinhal. RESULTS Twenty-six studies evaluating the impact of accreditation were identified. The majority of the studies showed general accreditation for acute myocardial infarction (AMI), trauma, ambulatory surgical care, infection control and pain management; and subspecialty accreditation programs to significantly improve the process of care provided by healthcare services by improving the structure and organization of healthcare facilities. Several studies showed that general accreditation programs significantly improve clinical outcomes and the quality of care of these clinical conditions and showed a significant positive impact of subspecialty accreditation programs in improving clinical outcomes in different subspecialties, including sleep medicine, chest pain management and trauma management. CONCLUSIONS There is consistent evidence that shows that accreditation programs improve the process of care provided by healthcare services. There is considerable evidence to show that accreditation programs improve clinical outcomes of a wide spectrum of clinical conditions. Accreditation programs should be supported as a tool to improve the quality of healthcare services.
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Dürsteler-MacFarland KM, Vogel M, Wiesbeck GA, Petitjean SA. There is no age limit for methadone: a retrospective cohort study. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2011; 6:9. [PMID: 21592331 PMCID: PMC3118116 DOI: 10.1186/1747-597x-6-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 05/18/2011] [Indexed: 12/21/2022]
Abstract
Background Data from the US indicates that methadone-maintained populations are aging, with an increase of patients aged 50 or older. Data from European methadone populations is sparse. This retrospective cohort study sought to evaluate the age trends and related developments in the methadone population of Basel-City, Switzerland. Methods The study included methadone patients between April 1, 1995 and March 31, 2003. Anonymized data was taken from the methadone register of Basel-City. For analysis of age distributions, patient samples were split into four age categories from '20-29 years' to '50 years and over'. Cross-sectional comparisons were performed using patient samples of 1996 and 2003. Results Analysis showed a significant increase in older patients between 1996 and 2003 (p < 0.001). During that period, the percentage of patients aged 50 and over rose almost tenfold, while the proportion of patients aged under 30 dropped significantly from 52.8% to 12.3%. The average methadone dose (p < 0.001) and the 1-year retention rate (p < 0.001) also increased significantly. Conclusions Findings point to clear trends in aging of methadone patients in Basel-City which are comparable, although less pronounced, to developments among US methadone populations. Many unanswered questions on medical, psychosocial and health economic consequences remain as the needs of older patients have not yet been evaluated extensively. However, older methadone patients, just as any other patients, should be accorded treatment appropriate to their medical condition and needs. Particular attention should be paid to adequate solutions for persons in need of care.
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Affiliation(s)
- Kenneth M Dürsteler-MacFarland
- Division of Substance Use Disorders, Psychiatric Hospital of the University of Basel, Wilhelm Klein-Strasse 27, 4012 Basel, Switzerland.
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Fareed A, Casarella J, Amar R, Vayalapalli S, Drexler K. Methadone maintenance dosing guideline for opioid dependence, a literature review. J Addict Dis 2010; 29:1-14. [PMID: 20390694 DOI: 10.1080/10550880903436010] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
To date, methadone dosing is still an issue of debate and controversy among clinicians who are involved in methadone maintenance programs. The authors conducted a literature review to update clinicians about this issue and provide recommendations for proper methadone dosing. Studies eligible for inclusion in the review were retrieved from the PubMed database by searching for reports published between 1990 and September 2008 using the major medical subject headings Methadone (all fields) and dose. Only articles written in English were included. Additional reports were identified from the reference lists of retrieved articles and by manual review of the tables of contents of journals on drug of abuse included in the psychiatry and substance abuse subject category listing 2008 of the Journal Citation Reports. Abstracts of medical meetings were excluded. Twenty-four articles were included in the review. Twelve are randomized, controlled, or double-blind clinical trials, 10 are non-randomized and observational studies, and 2 are meta-analyses. Currently, the consensus is to have a goal for methadone dosing in the range of 60 to 100 mg daily. For patients who continue to use illicit opiates while prescribed this dose range, clinicians may consider doses greater than 100 mg daily. However, this is not the current consensus but rather is based on the limited promising data the authors have; it could be considered if the benefits outweigh the risks for some patients.
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Affiliation(s)
- Ayman Fareed
- Department of Psychiatry, Emory University, School of Medicine, Decatur, GA 30033, USA.
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Gjersing L, Waal H, Caplehorn JRM, Gossop M, Clausen T. Staff attitudes and the associations with treatment organisation, clinical practices and outcomes in opioid maintenance treatment. BMC Health Serv Res 2010; 10:194. [PMID: 20604924 PMCID: PMC2911430 DOI: 10.1186/1472-6963-10-194] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Accepted: 07/06/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In opioid maintenance treatment (OMT) there are documented treatment differences both between countries and between OMT programmes. Some of these differences have been associated with staff attitudes. The aim of this study was to 1) assess if there were differences in staff attitudes within a national OMT programme, and 2) investigate the associations of staff attitudes with treatment organisation, clinical practices and outcomes. METHODS This study was a cross-sectional multicentre study. Norwegian OMT staff (n = 140) were invited to participate in this study in 2007 using an instrument measuring attitudes towards OMT. The OMT programme comprised 14 regional centres. Data describing treatment organisation, clinical practices and patient outcomes in these centres were extracted from the annual OMT programme assessment 2007. Centres were divided into three groups based upon mean attitudinal scores and labelled; "rehabilitation-oriented", "harm reduction-oriented" and "intermediate" centres. RESULTS All invited staff (n = 140) participated. Staff attitudes differed between the centres. "Rehabilitation-oriented" centres had smaller caseloads, more frequent urine drug screening and increased case management (interdisciplinary meetings). In addition these centres had less drug use and more social rehabilitation among their patients in terms of long-term living arrangements, unemployment, and social security benefits as main income. "Intermediate" centres had the lowest treatment termination rate. CONCLUSIONS This study identified marked variations in staff attitudes between the regional centres within a national OMT programme. These variations were associated with measurable differences in caseload, intensity of case management and patient outcomes.
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Affiliation(s)
- Linn Gjersing
- SERAF- Norwegian Centre for Addiction Research, Institute of Clinical Medicine, University of Oslo, Kirkeveien 166, Oslo 0407, Norway.
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Fareed A, Casarella J, Roberts M, Sleboda M, Amar R, Vayalapalli S, Drexler K. High dose versus moderate dose methadone maintenance: is there a better outcome? J Addict Dis 2010; 28:399-405. [PMID: 20155609 DOI: 10.1080/10550880903183042] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Methadone dosing has been an issue of controversy among clinicians for a long time. Few recent studies reported that doses above 100 mg daily seem promising in better control of illicit opiate use for some patients, but more research is needed to support that notion. A retrospective chart review for patients maintained on methadone at Atlanta Veterans Affairs Medical Center was conducted. Patients were categorized into two groups: patients on a methadone dose of 60 to 100 mg daily (n = 34) and patients on a methadone dose greater than 100 mg daily (n = 25). Those charts were compared for urine drug screens for opiates and cocaine (first four from admission and most recent four screens), retention or drop out from the program, and Addiction Severity Index (ASI) composite score at admission and most recent score. The results of the first and last four urine drug screens for opiates showed that the moderate dose group was positive 23% and 17%, respectively. However, the high dose group was positive 14% and 8%, respectively. These results showed statistical significance (Chi-Square = 8.04, df = 3 and p =.03). ASI scores for drugs did not show statistically significant improvement for the moderate dose group (p =.19) but showed statistically significant improvement for the high dose group (p =.0002) when the result of the first and last ASI scores among each group were compared. The ASI scores for family problems showed statistically significant improvement for the moderate dose group (p =.03). High doses of methadone greater than 100 mg daily may provide a better outcome for illicit opiate use among some patients who would not respond to moderate doses.
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Affiliation(s)
- Ayman Fareed
- School of Medicine, Emory University, Decatur, GA, USA.
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