Client satisfaction among participants in a randomized trial comparing oral methadone and injectable diacetylmorphine for long-term opioid-dependency

Predictors of retention in heroin-assisted treatment in Denmark 2010-2018 - A record-linkage study

INTRODUCTION

While randomized-controlled trials have shown that heroin-assisted treatment (HAT) is superior to methadone maintenance alone in treatment of refractory clients, little is known about client factors associated with retention in HAT in routine care.

METHODS

This retrospective cohort study assessed predictors of retention in first treatment episode among a consecutive cohort of clients admitted to HAT in Denmark from 2010 to 2018, who could be matched to the Danish population register and for whom a Short Form Health Survey (SF-36) was available at admission (N = 432). The study derived predictors from client self-reports at intake and administrative data available in national registers. Cox proportional hazards regression modelled retention in treatment.

RESULTS

The one-year retention rate was 69.63 % (95 % CI 65.06 %-73.74 %), and the median time in treatment was 2.45 years (95 % CI, 1.83-3.12). Bivariate analyses showed that retention was lower for clients who had recent cocaine or benzodiazepine use and among those who had experienced an overdose in the year prior to enrollment in HAT. Age below 40, recent illegal activity, poorer emotional wellbeing, previous residential treatment experience, and previous intensive outpatient treatment were also predictors of dropout from HAT.

CONCLUSIONS

This observational study found that retention in HAT in routine care was similar to rates observed in randomized-controlled trials conducted in other countries. The results suggest that addressing polysubstance use as part of the HAT program may promote long-term retention, as may directing resources to certain subgroups identified at intake, including clients under 40 years and those who report recent criminal activity, emotional problems, or overdoses. The findings that previous residential treatment and intensive outpatient treatment were associated with dropout were unexpected.

Results From a Pilot Study of an Automated Directly Observed Therapy Intervention Using Artificial Intelligence With Conditional Economic Incentives Among Young Adults With HIV

BACKGROUND

Despite improvements in antiretroviral therapy (ART) availability, suboptimal adherence is common among youth with HIV (YWH) and can increase drug resistance and poor clinical outcomes. Our study examined an innovative mobile app-based intervention that used automated directly observed therapy (aDOT) using artificial intelligence, along with conditional economic incentives (CEIs) to improve ART adherence and enhance viral suppression among YWH.

SETTING

We conducted a pilot study of the aDOT-CEI intervention, informed by the operant framework of Key Principles in Contingency Management Implementation, to improve ART adherence among YWH (18-29) in California and Florida who had an unsuppressed HIV viral load.

METHODS

We recruited 28 virally unsuppressed YWH from AIDS Healthcare Foundation clinics, who used the aDOT platform for 3 months. Study outcomes included feasibility and acceptability, self-reported ART adherence, and HIV viral load.

RESULTS

Participants reported high satisfaction with the app (91%), and 82% said that it helped them take their medication. Comfort with the security and privacy of the app was moderate (55%), and 59% indicated the incentives helped improve daily adherence.

CONCLUSIONS

Acceptability and feasibility of the aDOT-CEI intervention were high with potential to improve viral suppression, although some a priori metrics were not met. Pilot results suggest refinements which may improve intervention outcomes, including increased incentive amounts, provision of additional information, and reassurance about app privacy and security. Additional research is recommended to test the efficacy of the aDOT-CEI intervention to improve viral suppression in a larger sample.

Access to tablet injectable opioid agonist therapy in rural and smaller urban settings in British Columbia, Canada: a qualitative study

BACKGROUND

Rural and smaller urban settings in Canada are disproportionately impacted by the overdose crisis, highlighting the need for novel public health interventions within these jurisdictions. Tablet injectable opioid agonist therapy (TiOAT) programs have been implemented in select rural communities as a means to address drug-related harms. However, little is known about the accessibility of these novel programs. Therefore, we conducted this study to understand the rural context and factors that affected access of TiOAT programs.

METHODS

Between October 2021 to April 2022, individual qualitative semi-structured interviews were conducted with 32 individuals enrolled in a TiOAT program at participating rural and smaller urban sites in British Columbia, Canada. Interview transcripts were coded using NVivo 12 and data were analyzed thematically.

RESULTS

TiOAT access varied considerably. TiOAT delivery in rural settings is complicated due to geographic challenges. Participants who were homeless and staying at a nearby shelter or those in centrally-located supportive housing had minimal issues compared to those living in more affordable housing on the outskirts of town with limited transportation options. Dispensing policies that required daily-witnessed ingestion multiple times daily were challenging for most. Only one site provided evening take-home doses whereas participants at the other site could only resort to the illicit opioid supply to address withdrawal outside of program hours. Participants described the clinics as providing a positive and familial social environment compared to experiences of stigma elsewhere. Medication interruptions did occur when participants were in hospital and custodial settings, leading to withdrawal, program discontinuation, and overdose risk.

CONCLUSIONS

This study highlights the beneficial ways in which health services tailored for people who use drugs can create a stigma-free environment with an emphasis on social bonds. Other factors such as transportation access, dispensing policies, and access in rural hospitals and custodial settings produced unique challenges for rural people who use drugs. Public health authorities in rural and smaller settings should consider these factors when designing, implementing, and scaling up future substance use services, including TiOAT programs.

Measuring the preferences of injectable opioid agonist treatment (iOAT) clients: Development of a person-centered scale (best-worst scaling)

BACKGROUND

Injectable opioid agonist treatment (iOAT) is effective for opioid use disorder (OUD), yet little is known about client preferences for accessing iOAT (e.g., with diacetylmorphine, hydromorphone, buprenorphine, fentanyl, etc.). Best-worst scaling (BWS) is a preference elicitation method from health economics that has never been applied to addiction care broadly, or iOAT specifically. We describe the stages of developing a BWS scale that assesses iOAT clients' treatment delivery preferences to inform program planning and maximize healthcare efficiency.

METHODS

We underwent several steps to reveal the relevant attributes/levels and design the scale structure. An initial list of potential attributes and levels was established from a literature review and prior qualitative data. Then, we conducted semi-structured interviews and focus groups with clients (n=21) on their iOAT preferences to confirm the attributes and prioritize/include new ones. Next, we conducted semi-structured interviews and focus groups with iOAT experts and stakeholders to receive their input on the draft list of attributes and levels. A BWS profile case design was piloted with iOAT clients (n=18) from different sites during a think aloud interview. After several rounds of revisions, the final version was tested by iOAT clients (n=2) before the scale was launched.

RESULTS

We developed a person-centered scale that assesses current and former iOAT clients' most and least wanted aspects of iOAT delivery. The final version yielded 7 unique attributes: choice of medication, choice of dose, convenience, location & space, scheduling & routines, staff & training, and types of services offered.

CONCLUSION

This scale can help expand iOAT programs in a way that is person-centered, rapid, and affordable. The methodology is a guide for other regions with similar populations who aim to develop strong quantitative methodologies that prioritize client collaboration.

The Effect of Creative Arts Therapy on Psychological Distress in Health Care Professionals

BACKGROUND

Work-related psychological distress is common among health care professionals. We determined whether 4 creative arts therapy (CAT) programs were acceptable, feasible, and improved psychological distress and job turnover intention in health care professionals with burnout symptoms.

METHODS

Health care professionals were enrolled during the coronavirus disease (COVID-19) pandemic from September 2020 until July 2021. Participants attended in-person weekly 90-minute group session for 12 consecutive weeks. Intervention and control subjects completed surveys before the beginning and after the end of their cohort. The study outcomes were session attendance (feasibility), program satisfaction (acceptability), and change in symptoms of anxiety, depression, burnout, posttraumatic stress disorder (PTSD), and job turnover intention.

RESULTS

We randomized 165 participants into 4 CAT interventions and 1 common control group across 3 sequential cohorts. Thirty-five randomized participants dropped out before the start of the cohort, and 16 were replaced from a waiting list. Therefore, the cohort consisted of 146 participants. On average, participants were 35 years old, white (85%), and female (92%). Overall, 52% were nurses, 10% were doctors, and 16% were behavioral health specialists. Participants attended a median of 9.5 [8-11] sessions. Program satisfaction was high with a median Client Satisfaction Questionnaire (CSQ-8) score of 31 [17-32] out of a possible score of 32. Participants randomized to the intervention had improvements in anxiety (P < .0001) and depression scores (P = .0007), total posttraumatic stress disorder score (P =.0002), burnout scores (P = .001, .003, .008), and turnover intention (P = .001).

CONCLUSIONS

A CAT program is feasible, acceptable, and may reduce psychological distress and turnover intention for health care professionals.

Safety and efficacy of a digital therapeutic for substance use disorder: Secondary analysis of data from a NIDA clinical trials network study

Background: Traditional treatments for substance use disorders (SUDs) rely heavily on face-to-face interactions, which pose substantial limitations for patients. A clinical trial of a digital therapeutic (DT), delivering behavioral therapy demonstrated safety and efficacy in a population including patients with opioid use disorder (OUD) not treated with buprenorphine, which is not a guideline-recommended approach. This study re-analyzed the data excluding patients with OUD to more closely approximate real-world patient populations. Methods: Secondary analysis of patients with substance use disorders related to alcohol, cannabis, cocaine, or other stimulants (n = 399, patients with OUD excluded) from a previously-published randomized controlled trial. Patients received 12-weeks of outpatient treatment-as-usual (TAU; n = 193) or TAU with reduced counseling plus a DT (n = 206) providing computerized cognitive behavioral therapy and contingency management. Primary outcomes were abstinence in weeks 9-12 and retention in treatment. Results: The 399 patients in this analysis (206 in the DT group and 193 in the TAU group) reported substance use disorders related to alcohol, cannabis, cocaine, or other stimulants (e.g., methamphetamines). Demographic and baseline characteristics including age, sex, race, education, and reported primary substance use disorder were balanced between treatment groups. Abstinence was significantly higher in the DT group compared to TAU (40.3 vs. 17.6%; p < 0.001) as was retention in therapy (76.2 vs. 63.2%, p = 0.004). Intergroup adverse event rates were not significantly different (p = 0.68). Conclusions: The results demonstrate that use of a DT safely increased abstinence (reduced substance use) and retention in treatment among patients with substance use disorders related to alcohol, cannabis, cocaine, or other stimulants (including methamphetamines).

Patient Engagement With a Game-Based Digital Therapeutic for the Treatment of Opioid Use Disorder: Protocol for a Randomized Controlled Open-Label, Decentralized Trial

BACKGROUND

Prescription digital therapeutics are software-based disease treatments that are regulated by the US Food and Drug Administration; the reSET-O prescription digital therapeutic was authorized in 2018 and delivers behavioral treatment for individuals receiving buprenorphine for opioid use disorder. Although reSET-O improves outcomes for individuals with opioid use disorder, most of the therapeutic content is delivered as narrative text. PEAR-008 is an investigational device based on reSET-O that uses an interactive, game-based platform to deliver similar therapeutic content designed to enhance patient engagement, which may further improve treatment outcomes.

OBJECTIVE

We aim to investigate how participants interact with the prescription digital therapeutic's new content delivery format. Secondary objectives include evaluating treatment success, symptoms of co-occurring mental health disorders, recovery capital, and skill development.

METHODS

Due to the COVID-19 pandemic, this study was redesigned using a decentralized model because it was not possible to conduct medication initiation and study visits in person, as initially intended. A decentralized, randomized controlled trial design will be utilized to compare patient engagement with PEAR-008 and that with reSET-O using both subjective and objective assessments. The study population will consist of approximately 130 individuals with opioid use disorder (based on Diagnostic and Statistical Manual of Mental Disorders 5 criteria) who have recently started buprenorphine treatment for opioid use disorder. Participants will be virtually recruited and randomly assigned to receive either PEAR-008 or reSET-O. All study sessions will be virtual, and the duration of the study is 12 weeks. The primary outcome measure of engagement is operationalized as the number of active sessions per week with either PEAR-008 or reSET-O. (An active session is any session that contains some active participation in the app, such as navigating to a different screen, engaging with a learning module, or responding to a notification.) Subjective dimensions of engagement will be assessed with participant surveys. The hypothesis is that PEAR-008 will have significantly greater participant engagement than reSET-O.

RESULTS

As of February 2021, participant enrollment is ongoing.

CONCLUSIONS

This randomized controlled trial will investigate if changing the delivery format and enhancing the content of a prescription digital therapeutic for opioid use disorder will affect how participants use and interact with the prescription digital therapeutic. The study design may serve as a useful model for conducting decentralized studies in this patient population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04542642; https://clinicaltrials.gov/ct2/show/NCT04542642.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32759.

Real-world use and clinical outcomes after 24 weeks of treatment with a prescription digital therapeutic for opioid use disorder

PURPOSE

To evaluate real-world prescription digital therapeutic (PDT) use and associated clinical outcomes among patients with opioid use disorder (OUD).

PATIENTS AND METHODS

A real-world observational evaluation of patients who filled either a 12- or 24-week (refill) prescription for the reSET-O® PDT. The PDT content consists of 67 interactive lessons unlocked in sequence during use as well as the chance to earn rewards for progress and/or negative urine screens. Engagement/retention data (ongoing engagement in weeks 9-12, or 21-24) were collected via the PDT and analyzed with descriptive statistics. Substance use was evaluated as a composite of patient self-reports and urine drug screens (UDS). Missing UDS data were assumed to be positive. A regression analyses of hospital encounters for 12- vs. 24-week prescriptions controlling for covariates was conducted.

RESULTS

In a cohort of 3,817 individuals with OUD who completed a 12-week PDT prescription, a cohort of 643 was prescribed a second 12-week 'refill' prescription, for a total treatment time of 24 weeks. Mean age of the 24-week cohort was 39 years, 56.7% female. At 24 weeks of total treatment: abstinence in the last 4 weeks of treatment was 86% in an analysis in which patients with no data are assumed to be positive for illicit opioids. Over 91% of patients were retained in treatment. An analysis of matched insurance claims showed that those treated for 24 weeks had a 27% decrease in unique hospital encounters compared to those who got the first 12-week prescription only.

CONCLUSIONS

These data present real-world evidence that a second prescription (24 weeks) of a PDT for OUD is associated with improved outcomes, high levels of retention, and fewer hospital encounters compared to a single prescription for a PDT.PLAIN LANGUAGE SUMMARYPrescription digital therapeutics (PDTs) are software-based treatments that are FDA-authorized to improve clinical outcomes for serious diseases and conditions. The reSET-O PDT consists of 67 interactive lessons unlocked in sequence during use as well as the chance to earn rewards for progress and/or negative urine screens. Multiple studies show that a single 12-week PDT prescription for opioid use disorder (OUD) helps patients engage in treatment, reduces substance use, and helps patients remain in treatment, but to date there has been no evaluation of how patients who receive a 'refill' second prescription engage with the therapeutic and whether the positive effects on substance use and retention are durable across a second 12 weeks (total of 24 weeks) of treatment.This real-world analysis evaluated 643 patients from 12 U.S. states who were prescribed a second PDT prescription. 93% of this cohort completed 8 or more core lesson modules in the second prescription period, 85% completed at least half of core modules, and 64% completed all 32 core modules. Patients used the PDT outside of clinic hours about 40% of the time. 94.4% of patients had 80% or greater negative reports of opioid use across the second 12 weeks of treatment. A 27% decrease in unique hospital encounters was observed in patients who completed a second prescription vs. patients who completed only one prescription.These data show that a second prescription of a PDT for OUD is associated with postive patient outcomes. Patients showed durable and high levels of engagement with the PDT, reduced substance use, and improved treatment retention through 24 weeks of treatment.

A multi-methods and longitudinal study of patients' perceptions in injectable opioid agonist treatment: Implications for advancing patient-centered methodologies in substance use research

BACKGROUND

Patients' perceptions are vital to the delivery and evaluation of substance use treatment. They are most frequently collected at one time-point and measured using patient satisfaction questionnaires or qualitative methodologies. Interestingly, the findings of these studies often diverge, as satisfaction scores tend to be highly positive, while qualitative findings suggest dissatisfaction and areas for improvement. This divergence limits current understandings of patients' perceptions and their potential change over time in treatment.

OBJECTIVE

This study explores the relationship between open-ended positive and negative perceptions of treatment and patient satisfaction scores over time.

METHODS

The RUTH (Research on the Utilization of Therapeutic Hydromorphone) prospective cohort study included 131 participants receiving injectable diacetylmorphine or hydromorphone in Canada's first injectable opioid agonist treatment (iOAT) program. The study collected the Client Satisfaction Questionnaire (CSQ-8) at eight time-points over an 18-month period. Following a multi-methods approach, the study complemented the CSQ-8 with open-ended positive and negative comments of iOAT. The research team analyzed these comments thematically at each time-point to develop positive and negative perception themes. We then used growth curve modeling to explore the relationship between positive and negative perception themes and patient satisfaction over time.

FINDINGS

Over the eight time-points, six positive and eight negative perception themes emerged, broadly reflecting structural (e.g., expansion of iOAT), process (e.g., schedules), relational (e.g., interactions with providers), and outcome-related (e.g., met/unmet needs) perceptions of iOAT. On average, participants reported high satisfaction (grand mean = 29.2 out of 32), and scores did not significantly change over time. However, we did find significant unexplained variation within participants in their satisfaction trajectories and between participants in their initial satisfaction scores. In conditional growth curve models, the theme "unfavorable interactions with providers" had the strongest independent effect on overall satisfaction trajectories.

CONCLUSIONS

This study provides an example of how open-ended comments can be integrated with patient satisfaction questionnaire data to gather a comprehensive and patient-centered evaluation of substance use treatment. Considering the iOAT context specifically, relational dynamics and daily treatment access were significant predictors of patient satisfaction over time and may be attributes of iOAT that require further investigation.

Real-world evidence for a prescription digital therapeutic to treat opioid use disorder

OBJECTIVES

To evaluate patient engagement and usage of a prescription digital therapeutic (PDT) and associated outcomes of opioid use and treatment retention in a large real-world dataset of patients with opioid use disorder (OUD) treated with buprenorphine medication for opioid use disorder (MOUD). PDTs are software-based disease treatments evaluated for safety and effectiveness in randomized clinical trials (RCTs), and authorized by the U.S. Food and Drug Administration (FDA) to treat disease with approved directions for use (label).

METHODS

A real-world observational evaluation of an all-comer population of patients who redeemed a 12-week prescription for the reSET-O PDT. Engagement and therapeutic use data were collected and analysed on a population level. Substance use was evaluated as a composite of self-reports recorded with reSET-O and urine drug screens (UDS).

RESULTS

Data from 3144 individuals with OUD were evaluated. 45.5% were between ages 30 and 39 years. 80% completed at least 8 of the 67 possible therapeutic modules, 66% completed half of all modules, and 49% completed all modules. Abstinence during the last 4 weeks of treatment was calculated with two imputation methodologies: 66% abstinent using "missing data excluded (patients with no data as positive)", and 91% abstinent with "missing data removed (patients with no data excluded)". 91% of patients met the responder definition of ≥80% of self-report or UDS negative. 74.2% of patients were retained through the last 4 weeks of treatment. Subgroup analysis of patients using reSET-O appropriately (4 or more modules per week for the first 4 weeks) showed 88.1% abstinence using "missing data excluded (patients with no data as positive)", and retention at weeks 9-12 of 85.8%.

CONCLUSIONS

Results demonstrate that reSET-O is readily and broadly used by patients with OUD and that high real-world engagement with the therapeutic is positively associated with abstinence and retention in treatment. ReSET-O is a potentially valuable adjunct to buprenorphine MOUD therapy for patients with OUD.

Comparison of Treatment Options for Refractory Opioid Use Disorder in the United States and Canada: a Narrative Review

Amidst the opioid overdose crisis, there are increased efforts to expand access to medications for opioid use disorder (MOUD). Hospitalization for the complications of substance use in the United States (US) provides an opportunity to initiate methadone, buprenorphine, and extended release naltrexone and link high-risk, not otherwise engaged, patients into outpatient care. However, treatment options for patients are quickly exhausted when these medications are not desired, tolerated, or beneficial. As an example, we discuss the case of a man who was hospitalized 27 times over 2 years for complications related to his opioid use disorder (OUD), including recurring methicillin-resistant Staphylococcus aureus vertebral osteomyelitis, increasing antimicrobial resistance, new infections, and multiple overdoses in and out of the hospital. The patient suffered these complications despite efforts to treat his OUD with methadone and buprenorphine while hospitalized, and repeated attempts to link him to outpatient care. We use this case to review evidence-based treatments for refractory OUD, which are not approved in the US, but are available in Canada. If hospitalized in Vancouver, Canada, this patient could have been offered slow-release oral morphine and injectable opioid agonist therapy, as well as access to sterile syringes and injection equipment at an in-hospital supervised injection facility. Each of these approaches is supported by evidence and has been implemented successfully in Canada, yet none are available in the US. In order to combat the multiple harms from opioids, it is critical that we consider every evidence-based tool.

Slow release oral morphine versus methadone for opioid use disorder in the fentanyl era (pRESTO): Protocol for a non-inferiority randomized clinical trial

BACKGROUND

North America is facing an unprecedented public health crisis of opioid-related morbidity and mortality, increasingly as a result of the introduction of illicitly manufactured fentanyl into the street drug market. Although the treatment of opioid use disorder (OUD) is a key element in the response to the opioid overdose epidemic, currently available pharmacotherapies (e.g., methadone, buprenorphine) may not be acceptable to or effective in all patients. Available evidence suggests that slow-release oral morphine (SROM) has similar efficacy rates as methadone with respect to promoting abstinence, and with improvements in a number of patient-reported outcomes among persons using heroin. However, little is known about the relative effectiveness and acceptability of SROM compared to methadone in the context of fentanyl use. This study aims to address this research gap.

METHODS

pRESTO is a 24-week, open-label, two arm, non-inferiority, randomized controlled trial comparing SROM versus methadone for the treatment of OUD. Participants will be 298 clinically stable, non-pregnant adults with OUD, recruited from outpatient clinics in Vancouver, Canada, where the majority of the illicit opioids are contaminated with fentanyl. The primary outcome is suppression of illicit opioid use, measured by bi-weekly urine drug screens. Secondary outcomes include: treatment retention, medication safety, overdose events, treatment satisfaction, psychological functioning, changes in drug-related problems, changes in quality of life, opioid cravings, other substance use, and cost-effectiveness.

DISCUSSION

pRESTO will be among the first studies to evaluate treatment options for individuals primarily using synthetic street opioids, providing important evidence to guide treatment strategies for this population.

Addiction Recovery Among Opioid-Dependent Patients Treated With Injectable Subcutaneous Depot Buprenorphine: Study Protocol of a Non-randomized Prospective Observational Study (ARIDE)

Introduction: Once-weekly or once-monthly injectable depot buprenorphine is a new opioid substitution treatment (OST) medication that provides clinically relevant plasma concentrations without daily peaks. Together with a high tolerability and acceptance reported by patients, the prolonged release of injectable depot buprenorphine might have beneficial implications on the patients' quality of life and social participation. The primary objective of this prospective non-interventional observational study is to evaluate the effects of subcutaneous injectable depot buprenorphine on the quality of life of patients in routine OST care in Germany. Secondary outcomes like illicit substance use, psychological distress, social participation and activity are assessed to provide an overall evaluation toward addiction recovery. Methods and Analysis: The present study is a non-randomized prospective observational study with a control group (treatment-as-usual). To ensure comparability between both patient groups, suitable control patients (n = 213) from the same OST unit will be matched pairwise to each patient treated with injectable depot buprenorphine (n = 213). Matching variables are gender, duration of OST, take-home prescription and psychosocial functioning (according to the Global Assessment of Functioning scale). Primary study endpoint is the difference of change in quality of life, assessed with the recently developed Opioid Substitution Treatment Quality of Life scale (OSTQOL), within the depot buprenorphine group between baseline and month 12. The primary analysis will be carried out according to the intention-to-treat principle (ITT) by comparing OSTQOL mean scores using dependent t-tests. For secondary analyses, group comparisons will be done by mixed model approaches with baseline OSTQOL score and the (pairwise) cluster term as covariates. Discussion: The study combines clinical, routine OST care data with relevant patient reported outcome data. The pairwise matching allows conclusions on effects of different OST medications. The study findings will provide new insights in the addiction recovery processes of OST patients treated with depot buprenorphine. Ethics and Dissemination: The study protocol has been approved by the Ethics Committee of the Hamburg Chamber of Physicians (Ärztekammer Hamburg) (reference number: PV7078). The study results will be disseminated through peer-reviewed publications and presentations on scientific conferences. Clinical Trial Registration: German Clinical Trials Register DRKS-ID: DRKS00020797.

Patient experiences questionnaire for interdisciplinary treatment for substance dependence (PEQ-ITSD): reliability and validity following a national survey in Norway

BACKGROUND

Patient experiences are an important aspect of health care quality, but there is a lack of validated instruments for their measurement in the substance dependence literature. A new questionnaire to measure inpatients' experiences of interdisciplinary treatment for substance dependence has been developed in Norway. The aim of this study was to psychometrically test the new questionnaire, using data from a national survey in 2013.

METHODS

The questionnaire was developed based on a literature review, qualitative interviews with patients, expert group discussions and pretesting. Data were collected in a national survey covering all residential facilities with inpatients in treatment for substance dependence in 2013. Data quality and psychometric properties were assessed, including ceiling effects, item missing, exploratory factor analysis, and tests of internal consistency reliability, test-retest reliability and construct validity.

RESULTS

The sample included 978 inpatients present at 98 residential institutions. After correcting for excluded patients (n = 175), the response rate was 91.4%. 28 out of 33 items had less than 20.5% of missing data or replies in the "not applicable" category. All but one item met the ceiling effect criterion of less than 50.0% of the responses in the most favorable category. Exploratory factor analysis resulted in three scales: "treatment and personnel", "milieu" and "outcome". All scales showed satisfactory internal consistency reliability (Cronbach's alpha ranged from 0.75-0.91) and test-retest reliability (ICC ranged from 0.82-0.85). 17 of 18 significant associations between single variables and the scales supported construct validity of the PEQ-ITSD.

CONCLUSION

The content validity of the PEQ-ITSD was secured by a literature review, consultations with an expert group and qualitative interviews with patients. The PEQ-ITSD was used in a national survey in Norway in 2013 and psychometric testing showed that the instrument had satisfactory internal consistency reliability and construct validity.

Evaluation of medication-assisted treatment of opioid dependence-The physicians' perspective

BACKGROUND

There is controversy about which outcome parameters should be employed to assess substance use treatment. Subjective measures of medication-assisted treatment (MAT) of opioid dependence are increasingly important. However, while patients' perspectives have been examined, the caregivers' views remain largely unknown. Here, we explore how physicians evaluate MAT, and which predictors are most relevant.

METHODS

We conducted a retrospective cohort study of all MAT episodes with oral opioid agonists in the canton of Zurich between 1998 and 2013 using a case register. Termination forms of the register include a physician-completed assessment on the course of the treatment episode. Mixed model analysis was applied to determine relevant predictors.

RESULTS

The analysis was based on 17,234 episodes from 7432 patients. Mean global assessment of the course of MAT was 'moderate'. The most important predictors for treatment evaluation by physicians were treatment break off as reason for termination (p<0.0001), psychological improvement throughout treatment (p<0.0001), wish for abstinence from the substitute (p<0.0001), social integration index at termination (p<0.0001), and social (p<0.0001) as well as medical (p<0.0001) improvement. The negative association of treatment break off with MAT assessment was more pronounced in semi-rural than urban areas (p<0.0001).

CONCLUSION

Predictors relating to the well-being and functioning of the patient as well as the reasons underlying treatment termination appear to be more important for the treating physician's evaluation of medication-assisted treatment episodes than on-going substance use. Coming off the opioid medication plays a central role, independent of ongoing illicit substance use.

Patient Satisfaction with Methadone Maintenance Treatment in Vietnam: A Comparison of Different Integrative-Service Delivery Models

BACKGROUND

Patient satisfaction is an important component of quality in healthcare delivery. To inform the expansion of Methadone Maintenance Treatment (MMT) services in Vietnam, we examined the satisfaction of patients with regards to different services delivery models and identified its associated factors.

METHODS

We interviewed 1,016 MMT patients at 5 clinics in Hanoi and Nam Dinh province. The modified SATIS instrument, a 10-item scale, was used to measure three dimensions: "Services quality and convenience", "Health workers' capacity and responsiveness" and "Inter-professional care".

RESULTS

The average score was high across three SATIS dimensions. However, only one third of patients completely satisfied with general health services and treatment outcomes. Older age, higher education, having any problem in self-care and anxiety/depression were negatively associated with patient's satisfaction. Meanwhile, patients receiving MMT at clinics, where more comprehensive HIV and general health care services were available, were more likely to report a complete satisfaction.

CONCLUSION

Patients were highly satisfied with MMT services in Vietnam. However, treatment for drug users should go beyond methadone maintenance to address complicated health demands of drug users. Integrating MMT with comprehensive HIV and general health services together with improving the capacity of health workers and efficiency of services organisation to provide interconnected health care for drug users are critical for improving the outcomes of the MMT program.

Social networks and substance use among at-risk emerging adults living in disadvantaged urban areas in the southern United States: a cross-sectional naturalistic study

BACKGROUND AND AIMS

Substance use and risk-taking are common during emerging adulthood, a transitional period when peer influences often increase and family influences decrease. Investigating relationships between social network features and substance use can inform community-based prevention programs. This study investigated whether substance use among emerging adults living in disadvantaged urban areas was influenced by peer and family social network messages that variously encouraged and discouraged substance use.

DESIGN

Cross-sectional, naturalistic field study.

SETTING AND PARTICIPANTS

Lower-income neighborhoods in Birmingham, Alabama, USA with 344 participants (110 males, 234 females, ages 15-25 years; mean = 18.86 years), recruited via respondent-driven sampling.

MEASUREMENTS

During structured interviews conducted in community locations, the Alcohol, Smoking and Substance Involvement Screening Test assessed substance use and related problems. Predictor variables were network characteristics, including presence of substance-using peers, messages from friends and family members about substance use and network sources for health information.

FINDINGS

Higher substance involvement was associated with friend and family encouragement of use and having close peer network members who used substances (Ps < 0.001). Peer discouragement of substance use was associated with reduced risk (b = - 1.46, P < 0.05), whereas family discouragement had no protective association.

CONCLUSIONS

Social networks appear to be important in both promoting and preventing substance use in disadvantaged young adults in the United States.

The Role of Gender in Factors Associated With Addiction Treatment Satisfaction Among Long-Term Opioid Users

OBJECTIVES

To identify factors associated with Opioid Agonist Treatment (OAT) satisfaction and to determine whether these relationships are gender specific.

METHODS

This study was based on data collected in a cross-sectional study among long-term opioid-dependent individuals (n = 160; 46.3% women). Participants completed the Client Satisfaction Questionnaire in reference to OAT episodes. Sociodemographic, illicit substance use, health, and addiction treatment history data were collected. Multivariable linear regression was used to determine the relationship between these variables and treatment satisfaction. To explore the potential role of gender in these identified relationships stratified multivariable models were tested. Additional open-ended questions regarding positive and negative perceptions of treatment were collected, and a thematic analysis was conducted.

RESULTS

In the multivariable linear regression model, participants who were older, of Aboriginal ancestry, and currently receiving OAT had higher OAT satisfaction scores, whereas participants who had methadone dose preferences of 30 mg or less had lower OAT satisfaction. In stratified analyses among women, the relationship between preferred methadone dose and current OAT remained significantly associated with satisfaction. Open-ended positive and negative perceptions complemented and provided further valuable data to interpret these identified relationships.

CONCLUSIONS

To our knowledge, this is the first study to explore the potential role of gender in factors associated with OAT satisfaction. These findings provide valuable information to health care providers working in OAT settings regarding how to address women and men's OAT needs and improve treatment satisfaction.

Heroin on trial: systematic review and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction†

BACKGROUND

Supervised injectable heroin (SIH) treatment has emerged over the past 15 years as an intensive treatment for entrenched heroin users who have not responded to standard treatments such as oral methadone maintenance treatment (MMT) or residential rehabilitation.

AIMS

To synthesise published findings for treatment with SIH for refractory heroin-dependence through systematic review and meta-analysis, and to examine the political and scientific response to these findings.

METHOD

Randomised controlled trials (RCTs) of SIH treatment were identified through database searching, and random effects pooled efficacy was estimated for SIH treatment. Methodological quality was assessed according to criteria set out by the Cochrane Collaboration.

RESULTS

Six RCTs met the inclusion criteria for analysis. Across the trials, SIH treatment improved treatment outcome, i.e. greater reduction in the use of illicit 'street' heroin in patients receiving SIH treatment compared with control groups (most often receiving MMT).

CONCLUSIONS

SIH is found to be an effective way of treating heroin dependence refractory to standard treatment. SIH may be less safe than MMT and therefore requires more clinical attention to manage greater safety issues. This intensive intervention is for a patient population previously considered unresponsive to treatment. Inclusion of this low-volume, high-intensity treatment can now improve the impact of comprehensive healthcare provision.

Satisfaction with substance use treatment and 12-step groups predicts outcomes

INTRODUCTION

Satisfaction is a critical component of patient-centered care, yet little is known about the degree to which patient satisfaction is linked to subsequent outcomes, especially in substance use disorder (SUD) treatments and 12-step groups. The current study assessed the degree to which satisfaction with Department of Veterans Affairs (VA) outpatient SUD treatment and with 12-step groups, both measured at 6 months after treatment initiation, was associated with additional treatment utilization and better substance-related outcomes during the next 6 months, that is, up to 1 year after treatment initiation.

METHODS

Participants were 345 patients entering the VA SUD treatment program.

RESULTS

More satisfaction with treatment and with 12-step groups at 6 months was associated with less alcohol use severity and more abstinence at 1 year. More treatment satisfaction was related to less subsequent medical severity, whereas more 12-step group satisfaction was related to less subsequent psychiatric severity. More 12-step group satisfaction was related to subsequent increases in 12-step group attendance and involvement. A single item assessing overall satisfaction appeared best related to subsequent outcomes.

CONCLUSIONS

Satisfied SUD treatment patients and 12-step mutual help members appeared to have better subsequent service utilization patterns and treatment outcomes. SUD treatments can improve outcomes by monitoring and enhancing patient satisfaction.

Coverage of overdose prevention programs for opiate users and injectors: a cross-sectional study

Background

The use of opiates, particularly heroin, remains an important cause of morbidity and mortality. Half of the deaths among heroin consumers are attributed to overdose. In response to this problem, overdose prevention programs (OPPs) were designed. The objective of our study was to assess coverage of OPPs among the target population in a specific Spanish region (Catalonia) and to identify characteristics related to attendance.

Methods

A cross-sectional survey recruited individuals from outpatient treatment centers (OTCs), therapeutic communities (ThCs), and harm reduction facilities (HRFs) in Catalonia. From 513 participants, 306 opiate users and/or injectors were selected for this study. Coverage was calculated as the proportion of subjects who declared having participated in an OPP. A Poisson regression with robust variance was used to assess factors (socio-demographic aspects and psychoactive substance use patterns) associated to OPP participation, taking into account recruitment strategy.

Results

Average age of the 306 subjects was 39.7 years (s.d.: 7.7); 79% were male; 79.2% lived in urban areas and 56.3% were unemployed or had never worked. Overall OPP coverage was 43.5% (95% CI: 37%–49%). Training was received mostly in HRF (60%), followed by OTC (24.4%), prison (19%), and ThC (16%). OPP sessions were attended by 41% of Spanish-born study participants and by 63.3% of foreigners; 92.2% of the participants lived in urban areas. The Poisson regression analysis adjusted by age, sex, and type of recruitment center showed that OPP participation rates were higher for individuals with foreign nationality (PR = 1.3; 95% CI: 1.04–1.72), for those living in municipalities with more than 100,000 inhabitants (PR = 2.0; 95% CI: 1.37–2.81) or the Barcelona conurbation (PR = 2.5; 95% CI: 1.68–3.77), and for those having ever been in prison (PR = 1.6; 95% CI: 1.41–1.81) and had first consumption when they were less than 12 years old (PR = 1.2; 95% CI: 1.06–1.45).

Conclusion

Coverage as a whole can be considered high. However, in Catalonia, new strategies ought to be developed in order to attract opiate users and injectors not currently participating, by expanding OPP offer to services and regions where coverage is poor.

A chance to stop and breathe: participants' experiences in the North American Opiate Medication Initiative clinical trial

Background

The North American Opiate Medication Initiative (NAOMI) clinical trial compared the effectiveness of injectable diacetylmorphine (DAM) or hydromorphone (HDM) to oral methadone maintenance treatment (MMT). This study aimed to determine participants’ perceptions of treatment delivered in NAOMI.

Methods

A qualitative sub-study was conducted with 29 participants (12 female): 18 (62.1%) received injectable DAM or HDM and 11 (37.9%) received MMT. A phenomenological theoretical framework was used. Semi-structured interviews were audio-recorded and transcribed verbatim. A thematic analysis was used over successive phases and was driven by the semantic meanings of the data.

Results

Participants receiving injectable medications suggested that the supervised delivery model was stringent but provided valuable stability to their lives. Females discussed the adjustment required for the clinical setting, while males focused on the challenging clinic schedule and its impact on employment abilities. Participants receiving MMT described disappointment with being randomized to this treatment; however, positive aspects, including the quick titration time and availability of auxiliary services, were also discussed.

Conclusion

Treatment with injectable DAM (or HDM) is preferred by participants and considered effective in reducing the burden of opioid dependency. Engaging patients in research regarding their perceptions of treatment provides a comprehensive assessment of treatment needs and barriers.

Clinical trial registration

NCT00175357

A critical analysis of user satisfaction surveys in addiction services: opioid maintenance treatment as a representative case study

BACKGROUND

Satisfaction with services represents a key component of the user's perspective, and user satisfaction surveys are the most commonly used approach to evaluate the aforementioned perspective. The aim of this discursive paper is to provide a critical overview of user satisfaction surveys in addiction treatment and harm reduction services, with a particular focus on opioid maintenance treatment as a representative case.

METHODS

We carried out a selective critical review and analysis of the literature on user satisfaction surveys in addiction treatment and harm reduction services.

RESULTS

Most studies that have reported results of satisfaction surveys have found that the great majority of users (virtually all, in many cases) are highly satisfied with the services received. However, when these results are compared to the findings of studies that use different methodologies to explore the patient's perspective, the results are not as consistent as might be expected. It is not uncommon to find that "highly satisfied" patients report significant problems when mixed-methods studies are conducted. To understand this apparent contradiction, we explored two distinct (though not mutually exclusive) lines of reasoning, one of which concerns conceptual aspects and the other, methodological questions.

CONCLUSION

User satisfaction surveys, as currently designed and carried out in addiction treatment and harm reduction services, do not significantly help to improve service quality. Therefore, most of the enthusiasm and naiveté with which satisfaction surveys are currently performed and interpreted - and rarely acted on in the case of nonoptimal results - should be avoided. A truly participatory approach to program evaluation is urgently needed to reshape and transform patient satisfaction surveys.

Coaching Older Adults and Carers to have their preferences Heard (COACH): A randomised controlled trial in an intermediate care setting (study protocol)

BACKGROUND

Frail older people who are considering movement into residential aged care or returning home following a hospital admission often face complex and difficult decisions.Despite research interest in this area, a recent Cochrane review was unable to identify any studies of interventions to support decision-making in this group that met the experimental or quasi-experimental study design criteria.

AIMS

This study tests the impact of a multi-component coaching intervention on the quality of preparation for care transitions, targeted to older adults and informal carers. In addition, the study assesses the impact of investing specialist geriatric resources into consultations with families in an intermediate care setting where decisions about future care needs are being made.

METHOD

This study was a randomised controlled trial of 230 older adults admitted to intermediate care in Australia. Masked assessment at 3 and 12 months examined physical functioning, health-related quality of life and utilisation of health and aged care resources. A geriatrician and specialist nurse delivered a coaching intervention to both the older person and their carer/family. Components of the intervention included provision of a Question Prompt List prior to meeting with a geriatrician (to clarify medical conditions and treatments, medications, 'red flags', end of life decisions and options for future health care) and a follow-up meeting with a nurse who remained in telephone contact. Participants received a printed summary and an audio recording of the meeting with the geriatrician.

CONCLUSION

The costs and outcomes of the intervention are compared with usual care.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12607000638437).