Provider-Client Interaction in Methadone Treatment Clinics in China

Culturally adapted evidence-based treatments for adults with substance use problems: A systematic review and meta-analysis

BACKGROUND

This systematic review/meta-analysis aimed to synthesize empirical evidence from randomized controlled trials on the efficacy of culturally adapted interventions (CAIs) for substance use and related consequences for adults of color.

METHODS

Six electronic databases were searched to identify eligible studies. Two reviewers independently screened studies, extracted data, and assessed risks of bias. We used robust variance estimation in meta-regression to synthesize effect size estimates and conduct moderator analyses.

RESULTS

Twenty-two studies met the inclusion criteria and were included in the review. The overall effect size was 0.23 (95 % Confidence Interval [CI] = 0.12, 0.35). The subgroup effect sizes for comparing CAIs with inactive controls and with active controls were 0.31 (CI = 0.14, 0.48) and 0.14 (CI=-0.02, 0.29), respectively. The effect sizes for alcohol use, illicit drug use, unspecified substance use outcomes, and substance use related consequences were 0.25 (CI = 0.08, 0.43), 0.35 (CI =-0.30, 1.00), 0.22 (CI=-0.17, 0.62), and 0.02 (CI=-0.11, 0.16), respectively. Moderator analysis showed that CAIs' effects might not vary significantly by treatment model, dose, country, follow-up assessment timing, participant age, or gender/sex.

CONCLUSIONS

Research on substance use interventions that are culturally adapted for people of color is growing, and more high-quality studies are needed to draw definitive conclusions about CAIs' treatment effects. Our study found CAIs to be a promising approach for reducing substance use and related consequences. We call for more efficacy/effectiveness and implementation research to further advance the development and testing of evidence-based CAIs that meet the unique needs and sociocultural preferences of diverse populations.

A systematic review of stigma interventions for providers who treat patients with substance use disorders

BACKGROUND

Stigma surrounding substance use disorders (SUDs) is a frequently cited barrier to treatment engagement. Research consistently demonstrates that healthcare professionals' attitudes towards patients with addiction problems are often negative and may adversely impact service delivery. The current study presents a systematic review of stigma interventions for providers who treat patients with SUDs, in order to evaluate the quality of existing studies and potential for implementation in clinical settings.

METHODS

This systematic literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases included PubMed, APA PsycInfo and the Cochrane Database of Systematic Reviews. Of the 1462 records identified between 2011 and 2019, 15 studies were eligible for inclusion. A narrative synthesis of stigma interventions summarized the change in stigmatizing attitudes held by providers.

RESULTS

Studies included heterogeneous and culturally diverse samples of providers (N = 1324), who varied by age, location, discipline, and experience, with the exception of primarily female providers (75%). Results delineated six types of provider stigma interventions with components including online education, in-person education, in-person contact with consumers in recovery, or some combination of these elements. The highest quality studies incorporated motivational interviewing or communication training interventions, and many interventions combined either in-person mentorship or contact with individuals in recovery. Positive effects on provider attitudes occurred at several levels of educational and consumer contact interventions. Interventions with consumer contact demonstrated long-term maintenance of attitudinal shifts. Despite significant methodological limitations and low-quality assessment ratings, several studies utilized real-world providers and patients, as well as practical, innovative, brief, and potentially cost-effective interventions, particularly in locations with limited technological resources.

CONCLUSIONS

Research on provider stigma interventions increased in recent years, indicating greater worldwide attention to the negative impact of stigma. While educational interventions alone can be helpful in attitudinal change, contact with individuals in recovery from SUDs is a vital component of provider stigma interventions, particularly for lasting effects. This review highlights the importance of including implementation outcomes, such as sustainability and cost-effectiveness, in the study of stigma interventions for providers of addiction treatment.

Job Satisfaction Among Methadone Maintenance Treatment Clinic Service Providers in Jiangsu, China: A Cross-sectional Survey

OBJECTIVE

Service providers' job satisfaction is critical to the stability of the work force and thereby the effectiveness of methadone maintenance treatment (MMT) programs. This study aimed to explore MMT clinic service providers' job satisfaction and associated factors in Jiangsu, China.

METHODS

This secondary study used baseline data of a randomized interventional trial implemented in Jiangsu, China. A survey was conducted among 76 MMT service providers using the computer-assisted self-interview (CASI) method. Job satisfaction responses were assessed via a 30-item scale, with a higher score indicating a higher level of job satisfaction. Perceived institutional support and perceived stigma due to working with drug users were measured using a 9-item scale. Correlation and multiple linear regression analyses were performed to identify factors associated with job satisfaction.

RESULTS

Correlation analyses found a significant association between job satisfaction and having professional experience in the prevention and control of HIV, other sexually transmitted infections, or other infectious diseases (P = 0.046). Multiple regression analyses revealed that working at MMT clinics affiliated with Center for Disease Control and Prevention sites was associated with a lower level of job satisfaction (P = 0.014), and perception of greater institutional support (P = 0.001) was associated with a higher level of job satisfaction.

CONCLUSION

Job satisfaction among MMT clinic service providers was moderate in our study. Our findings suggest that institutional support for providers should be improved, and that acquisition of additional expertise should be encouraged.

Stigma towards people who use drugs: A case vignette study in methadone maintenance treatment clinics in China

BACKGROUND

Drug use stigma among service providers has been recognized as a barrier to improving the accessibility and outcomes of addiction treatment. This study examined the stigmatizing attitudes towards people who use drugs (PWUD) among service providers in methadone maintenance treatment (MMT) clinics in China and its associated factors.

METHODS

The cross-sectional study used the baseline data of a randomized intervention trial conducted in China, and the data were collected from January 2012 to August 2013. A total of 418 MMT service providers were included in the study. Stigma towards PWUD was measured via a 10-item scale embedded in two case vignettes (PWUD and non-PWUD). The Wilcoxon signed-rank test was performed to evaluate the vignette difference for each item of the scale. The linear mixed model was used to identify the adjusted association between drug use stigma and other interested variables including demographics, professional background, and MMT knowledge of the service providers.

RESULTS

The Wilcoxon signed-rank tests showed that the participants had a higher level of stigmatizing attitudes towards PWUD than non-PWUD (p-value<0.001 for all items of the stigma scale). The linear mixed model identified that the reception of national MMT training was associated with a lower degree of drug use stigma (estimate=-1.79; 95% CI: -3.13, -0.45; p-value = 0.009).

CONCLUSION

The findings of the study provide evidence of the existence of drug use stigma among MMT providers in China. The expansion of national-level training and the development of stigma reduction interventions are needed to address this issue.

An intervention to improve provider-patient interaction at methadone maintenance treatment in China

BACKGROUND

This study evaluated an intervention aiming to improve methadone maintenance therapy (MMT) service providers' interaction with their patients in China.

METHODS

Sixty-eight MMT clinics were randomized to either an intervention or a control condition. Providers in the intervention group attended three group training sessions to enhance their communication skills. Trained providers were encouraged to practice the taught communication skills through provider-initiated individual sessions with their patients. A total of 418 service providers completed assessments from baseline to 24-month. Linear mixed-effects regression models were used to compare self-reported short-term and sustained improvement in provider-patient interaction between the intervention and the control conditions.

RESULTS

The intervention group service providers perceived significantly greater short-term and sustained improvement in provider-patient interaction compared to the control group service providers (estimated difference (±SE): 1.20 (0.24) and 1.35 (0.33), respectively; p-values < 0.0001). Providers' baseline job satisfaction was significantly associated with a greater perceived improvement in provider-patient interaction for both periods (reg. coef. (±SE): 0.02 (0.01) and 0.04 (0.01) for short-term and sustained periods, respectively; p-values < 0.01).

CONCLUSION

Study findings suggest that the intervention could be beneficial for improving perceived provider-patient interaction in MMT programs. Service providers' job satisfaction should be addressed in training programs for the improvement of provider-patient interaction.

An intervention trial targeting methadone maintenance treatment providers to improve clients' treatment retention in China

BACKGROUND

Service providers including doctors, nurses, and other healthcare professionals play an essential role in methadone maintenance treatment (MMT). This study evaluated the impact of an intervention targeting MMT providers on their clients' treatment retention.

METHODS

This study was conducted in 68 MMT clinics in five provinces of China with 36 clients randomly selected from each clinic. The clinics were randomized to intervention or control condition. The MMT CARE intervention started with group sessions to enhance providers' communication skills. The trained providers were encouraged to conduct individual sessions with clients to promote treatment engagement. The outcomes, which include client retention (main outcome) and their reception of provider-delivered individual sessions (process outcome), were measured over a 24-month period.

RESULTS

Significantly fewer intervention clients dropped out from MMT than control clients during the study period (31% vs. 41%; p < 0.0001). Dropout hazard was significantly lower in the intervention condition compared to the control condition (HR = 0.71, 95% CI: 0.57, 0.89). More intervention clients had individual sessions than control clients (93% vs. 70%; p < 0.0001). Having individual sessions was associated with a significantly lower dropout hazard (HR = 0.30, 95% CI: 0.23, 0.40). The intervention clients had a significantly lower dropout hazard than the control clients if they started the individual sessions during the first six months (HR = 0.68, 95% CI: 0.51, 0.90).

CONCLUSIONS

The MMT CARE intervention focusing on provider capacity building has demonstrated efficacy in reducing clients' treatment dropout. This study sheds light on MMT service improvement in China and other global community-based harm reduction programs.

Service providers' adherence to methadone maintenance treatment protocol in China

BACKGROUND

Methadone maintenance treatment (MMT) programs have expanded rapidly in China during the last decade. However, variance in service providers' practice may have an impact on the quality of care received by the patients. This study examined Chinese service providers' adherence to the MMT protocol and its associated factors.

METHODS

The study used baseline data from a randomized intervention trial implemented in MMT clinics in five provinces of China. The data were collected from January 2012 to August 2013. A total of 418 service providers from 68 MMT clinics participated in the study. Demographic and job-related characteristics were collected. The providers' adherence to the MMT protocol, MMT knowledge, negative attitudes towards people who use drugs (PWUD), and perceived institutional support were assessed.

RESULTS

The average adherence score was 36.7 ± 4.3 (out of 9-45). Fewer providers adhered to the protocol items where communications with patients or families were required. After controlling for potential confounders, adherence to the MMT protocol was positively associated with perceived institutional support (standardized β = 0.130; p = 0.0052), and negatively associated with prejudicial attitudes towards PWUD (standardized β = -0.357; p < 0.0001). Reception of national-level MMT training was not associated with higher level of adherence to protocol.

CONCLUSION

The findings suggest the potential benefits of providing institutional support to MMT providers to enhance their level of adherence to the MMT protocol. Intervention effort is needed to reduce negative attitudes towards PWUD among MMT service providers to achieve greater consistency with best-practice recommendations.

Commune Health Workers' Methadone Maintenance Treatment (MMT) Knowledge and Perceived Difficulties Providing Decentralized MMT Services in Vietnam

BACKGROUND

With the initial establishment of countrywide methadone maintenance therapy (MMT) system, Vietnam is in the process of expanding and decentralizing the MMT program to community-based healthcare settings.

OBJECTIVE

The study aimed to measure the MMT-related knowledge and perceived difficulties in treating patient who use drugs (PWUD) among community-based healthcare providers, e.g., commune health workers (CHW), and examine its correlated factors.

METHODS

A total of 300 CHW from 60 communes in two provinces of Vietnam completed a survey using Audio Computer-Assisted Self-Interview (ACASI) method. Twelve true-or-false questions were used to assess the CHW's MMT-related knowledge. The CHW's background characteristics and perceived difficulties treating PWUD were recorded.

RESULTS

The mean MMT knowledge score was 8.2 (SD = 1.2; range: 5-11). Misconceptions toward the benefits, procedure, and side effects of MMT were prevalent. The participants perceived varying degrees of difficulties in recruiting, engaging, and communicating with PWUD. With all covariates holding constant, younger age (standardized ẞ = -0.166; p = 0.0078) was associated with less MMT-related knowledge. Number of PWUD seen in a month and MMT-related knowledge was associated with less perceived difficulties treating PWUD. Conclusions/importance: The finding shed lights on the CHW's knowledge gap, which need to be addressed to facilitate the decentralization of MMT services in Vietnam. In preparation for a decentralized MMT service delivery model, specially designed training is warranted to equip CHW with knowledge and confidence to provide MMT-related services to PWUD.

Report on Provider-Client Interaction From 68 Methadone Maintenance Clinics in China

Provider-client interaction is an integral of clinical practice and central to the delivery of high-quality medical care. This article examines factors related to the provider-client interaction in the context of methadone maintenance treatment (MMT). Data were collected from 68 MMT clinics in China. In total, 418 service providers participated in the survey. Linear mixed effects regression models were performed to identify factors associated with provider-client interaction. It was observed that negative attitude toward drug users was associated with lower level of provider-client interaction and less time spent with each client. Other factors associated with lower level of interaction included being female, being younger, being a nurse, and fewer years in medical field. Higher provider-client interaction was associated with provider reported job satisfaction. The findings of this study call for a need to address provider negative attitudes that can impact provider-client interaction and the effectiveness of MMT. Future intervention efforts targeting MMT providers should be tailored by gender, provider type, and medical experiences.

Factors related to client satisfaction with methadone maintenance treatment in China

BACKGROUND

This study examined clients' treatment satisfaction with the services provided by methadone maintenance treatment (MMT) in China and explored relevant factors that are directly or indirectly associated with treatment satisfaction.

METHODS

The study used baseline data from a randomized controlled trial conducted among 2,448 clients from 68 MMT clinics in five provinces of China. The participants reported their demographic characteristics, treatment-related factors, depressive symptoms, treatment progression, counseling rapport, and treatment satisfaction. Structural equation modeling (SEM) was used to test the direct and indirect relationships among various factors and treatment satisfaction.

RESULTS

Clients' demographic characteristics, such as older age, had both a direct effect on treatment satisfaction and an indirect effect mediated by counseling rapport. Depressive symptoms and a lack of social support had a direct negative impact on treatment satisfaction and an indirect effect mediated by treatment progression and counseling rapport. Both mediators: treatment progression (estimate=0.227, p<0.01) and counseling rapport (estimate=0.229, p<0.01), showed positive associations with treatment satisfaction.

CONCLUSION

The findings reiterate the complex nature of MMT clients' treatment satisfaction and its interrelationship with multidimensional factors. The study has implications for evaluating the quality of care provided by MMT programs and suggests several strategies that can potentially improve MMT clients' level of treatment satisfaction.

Client Acceptability for Integrating Antiretroviral Therapy in Methadone Maintenance Therapy Clinics in Sichuan, China

BACKGROUND

Using methadone maintenance therapy (MMT) clinics to deliver antiretroviral therapy (ART) has proven to be effective for promoting treatment initiation and adherence in drug users living with HIV.

OBJECTIVES

The objective of this study was to investigate the HIV-positive client acceptability of integrated ART services and to identify the reasons for and factors associated with service acceptability.

METHODS

A total of 86 HIV-positive MMT clients were recruited from 12 MMT clinics in Sichuan Province, China. They participated in a cross-sectional survey that queried their willingness to receive seven different types of MMT-based ART services. The reasons for their willingness/unwillingness to accept these services were documented. The association between service acceptability and background characteristics was examined.

RESULTS

The most accepted integrated services were ART-related counseling (75.6%) and referral (73.2%). Concerns regarding the provider's lack of ART expertise and confidentiality issues were common barriers for the acceptance of MMT-based ART services. A trust relationship with MMT providers was a reason for service acceptance. Service acceptability was associated with a poorer perceived health status. Conclusions/Importance: ART-related services, based on the client perspective, can be delivered at MMT clinics. However, service provider training and the protection of confidentiality must be strengthened for the effective implementation of integrated service delivery.

Retention and its predictors among methadone maintenance treatment clients in China: a six-year cohort study

BACKGROUND

To investigate factors associated with retention among the first cohort of drug users attending methadone maintenance treatment (MMT) clinics in China.

METHODS

A six-year cohort of 1511 drug users was enrolled in the first 8 MMT clinics in China in 2004 and followed between March, 2004 and December, 2010. Six-year retention rates were calculated and compared by methadone dosage, clinic location, and length of follow-up. Factors associated with retention were evaluated using Cox proportional hazard regression models.

RESULTS

The overall retention rate over 6-year was 35.7%. Highest drop-out occurred within the first 12 months of treatment. The retention rates for the 6-year by low (≤ 30 mg/day), medium (31-60 mg/day), and high (>60 mg/day) methadone dosage groups were 20.8%, 34.8% and 53.2%, respectively (p < 0.001). The highest 6-year retention rate among eight clinics was 43.8%, while the lowest one was 17.7% (p < 0.001). The results from Cox proportional hazard models indicate that clients having >30 mg daily methadone dosage (p < 0.001), having relatives receiving MMT (p = 0.027), and having >10% urine morphine positive result (p < 0.001) were more likely to be retained in MMT over the six-year period. It has also found that drug injection (p = 0.005) and needle sharing (p < 0.0001) were significantly associated with better retention.

CONCLUSIONS

Health workers should adjust individuals' methadone dosages as a method to prevent early treatment termination. Further studies are needed to explore the impact of severity of opiate addiction on long-term retention of MMT clients. Careful assessment of drug users upon MMT enrollment may be helpful for providing additional care to clients.

An intervention targeting service providers and clients for methadone maintenance treatment in China: a cluster-randomized trial

AIMS

This study examines the preliminary outcomes of an intervention targeting service providers in methadone maintenance therapy (MMT) clinics in China. The intervention effects on both service providers and clients are reported.

DESIGN

The MMT CARE intervention pilot was developed and implemented collaboratively with local health educators. After three group intervention sessions, trained providers in intervention clinics delivered two individual motivational interviewing sessions with their clients.

SETTINGS

Six clinics in Sichuan, China, were randomized to either the MMT CARE intervention condition or a standard care condition.

PARTICIPANTS

A total of 41 providers and 179 clients were sampled from the six clinics.

MEASUREMENTS

At baseline and three-, six-, and nine-month assessments, providers completed self-administrated paper/pencil questionnaires regarding provider-client interaction, MMT knowledge, perceived job-related stigma and clinic support. Clients completed a face-to-face survey about their concurrent drug use and drug avoidance self-efficacy. Mixed-effects regression models with clinic-level random effect were used to assess the intervention effects.

FINDINGS

Significant intervention effects for providers were found in improved MMT knowledge, provider-client interaction and perceived clinic support. For clients, better improvements in drug avoidance self-efficacy and reduced concurrent drug use were observed for the intervention compared with the standard care group.

CONCLUSIONS

The MMT CARE intervention targeting providers in methadone maintenance clinics can improve providers' treatment knowledge and their interaction with clients. The intervention can also reduce clients' drug-using behavior through motivational interviewing sessions conducted by trained providers.