Referring heroin users from compulsory detoxification centers to community methadone maintenance treatment: a comparison of three models

Innovating for real-world care: A systematic review of interventions to improve post-detoxification outcomes for opioid use disorder

BACKGROUND

Inpatient detoxification is a common health care entry point for people with Opioid Use Disorder (OUD). However, many patients return to opioid use after discharge and also do not access OUD treatment. This systematic review reports on the features and findings of research on interventions developed specifically to improve substance use outcomes and treatment linkage after inpatient detoxification for OUD.

METHODS

Of 6419 articles, 64 met inclusion criteria for the current review. Articles were coded on key domains including sample characteristics, study methods and outcome measures, bias indicators, intervention type, and findings.

RESULTS

Many studies did not report sample characteristics, including demographics and co-occurring psychiatric and substance use disorders, which may impact postdetoxification OUD treatment outcomes and the generalizability of interventions. Slightly more than half of studies examined interventions that were primarily medical in nature, though only a third focused on initiating medication treatment beyond detoxification. Medical and combination interventions that focused on initiating medications for OUD generally performed well, as did psychological interventions with one or more reinforcement-based components.

CONCLUSIONS

Research efforts to improve post-detoxification outcomes would benefit from clearer reporting of sample characteristics that are associated with treatment and recovery outcomes, including diagnostic comorbidities. Findings also support the need to identify ways to introduce medication for opioid use disorder (MOUD) and other effective treatments including reinforcement-based interventions during detoxification or soon after.

Detaining people who use drugs in Cambodia: A dual-track system

Reports focusing on drug detention centres in Cambodia have predominantly been concerned with documenting conditions and human rights abuses in the government centres, while highlighting the failure of the Royal Government of Cambodia (RGC) to adopt a human rights and public health-based approach to substance use issues. They have not focused as extensively on the underlying institutional, legal and regulatory reasons that help explain, though not justify, the RGC's law-enforcement-based approach to illicit substance use in Cambodia. Therefore, this policy analysis examines Cambodia's legal and regulatory set-up, in particular how the criminal provisions of the laws governing substance use combined with the administrative mechanisms in place shape the county's drug-related practices. This paper is based on a wide-ranging literature review of primary legislative and interpretive material; international human rights, public health and drug control instruments; research papers and international reports from multilateral agencies, international non-governmental organisations, civil society and academic experts. Qualitative interviews were also carried out with key international agency, national and international NGO officers. By examining the Law on the Control of Drugs (2012), the RGC's main law covering substance use, as well as relevant administrative provisions, it becomes apparent that there are two parallel systems in place for sending people to drug detention centres in Cambodia: one based on criminal law and the other through an 'alternative' administrative avenue. This division constitutes a structural fragmentation, or two 'parallel tracks', that provide law enforcement and other relevant RGC agencies with a wide sphere of discretion for how to address drug-related issues. The result is an enhanced risk of serious human rights violations for people who use drugs in Cambodia.

Compulsory drug detention centers in East and Southeast Asia

Over the last three decades in response to a rise in substance use in the region, many countries in East and Southeast Asia responded by establishing laws and policies that allowed for compulsory detention in the name of treatment for people who use drugs. These centers have recently come under international scrutiny with a call for their closure in a Joint Statement from United Nations entities in March 2012. The UN's response was a result of concern for human rights violations, including the lack of consent for treatment and due process protections for compulsory detention, the lack of general healthcare and evidence based drug dependency treatment and in some centers, of forced labor and physical and sexual abuse (United Nations, 2012). A few countries have responded to this call with evidence of an evolving response for community-based voluntary treatment; however progress is likely going to be hampered by existing laws and policies, the lack of skilled human resource and infrastructure to rapidly establish evidence based community treatment centers in place of these detention centers, pervasive stigmatization of people who use drugs and the ongoing tensions between the abstinence-based model of treatment as compared to harm reduction approaches in many of these affected countries.

The impact of dispensing fees on compliance with opioid substitution therapy: a mixed methods study

BACKGROUND

Opioid substitution therapy (OST) programs involve the dispensing of OST medicines to patients to address their dependence on heroin and/or other opioid substances. OST medicines are subsidised by the Australian government but patients need to pay the dispensing fees. This study explored opinions from OST patients and stakeholders about the potential impact of dispensing fees on compliance and OST program retention. Current and past experiences and the potential impact of OST dispensing fees were evaluated.

METHODS

Mixed methodology was used to obtain data from OST patients and stakeholders. This involved 1) interviews with OST stakeholders, 2) a focus group of OST patients and 3) surveys of OST patients in Perth, Australia, between June and August 2013.

RESULTS

The majority of the eight stakeholders declared cost as the factor mostly impacting on OST compliance. Almost all of the stakeholders commented that there was a positive correlation between time on the OST program and success in terms of relapse. Most stakeholders advocated for OST fees to contribute towards the Pharmaceutical Benefits Scheme Safety Net, and for fee subsidy. Focus group themes supported stakeholder interview findings. A total of 138 surveys were completed. Survey analysis illustrated a strong correlation between patient debt and impacted lifestyle: 82.4% (p < 0.001, Chi-square test) of the 138 survey participants stated that dispensing fees impacted significantly on patients' finances and lifestyle, specifically those patients with major debt. The cost of dispensing fees was identified by 46.3% (64/138) of survey participants as the biggest impacting factor on patient success. Logistic regression models showed that the cost of dispensing fees was also found to significantly influence both the occurrence of debt (57.7%, p < 0.0001) and lifestyle difficulties (80.0%, p = 0.0004).

CONCLUSION

Findings provided insight into OST patients' financial difficulties with data suggesting that dispensing fees are likely to have a negative impact on OST patients' compliance with therapy, retention in the OST program and lifestyle. Government sponsorship of the OST dispensing fees should be considered as sponsorship would potentially increase the retention rates of income-poor OST program recipients.