Expanding co-payment for methadone maintenance services in Vietnam: the importance of addressing health and socioeconomic inequalities

"If they get out of drug rehab centers, they're on their own": Opportunities and challenges for people released from compulsory drug rehabilitation centers to communities in Vietnam

INTRODUCTION

Compulsory drug rehabilitation is a major governmental response to illicit drug use in Vietnam and other countries in Asia. Long-term compulsory rehabilitation is associated with negative health, social and economic outcomes. The transition to community-based services for people released from compulsory drug rehabilitation has been problematic not only in Vietnam. This study utilized the WHO Health System Building Blocks Framework to examine the opportunities and challenges for people with substance use disorders (SUD) who are released from compulsory drug rehabilitation back into the community.

METHODS

Between October 2021 and August 2022, we interviewed people with SUD who had recently returned from or were preparing to leave compulsory drug rehabilitation (n = 25), their family members (n = 20) and professionals working in the field of drug rehabilitation (n = 28) across three cities in Vietnam. Additionally, we conducted a review of policy documents to complement the interview data.

RESULTS

The study identified opportunities and challenges within Vietnam's drug rehabilitation system concerning leadership and governance, financing, workforce, information systems and service delivery for people with SUD. Key opportunities include a legal framework that emphasizes community-based support for people with SUD, a government-funded national network of lay social workers, and ongoing efforts to connect people to community-based services. We found significant challenges caused by the lack of clear instructions for implementing supportive policies, inadequate funding for community-based services, persisting stigma from providers towards people with SUD and unavailability of community-based drug treatment other than methadone.

CONCLUSION

Vietnam continues with compulsory drug rehabilitation yet endorses recovery-oriented policies to address substance use issues. Substantial challenges hinder the effective implementation of these policies. Our study recommends reinforcing existing policies and enhancing recovery-oriented community-based services by improving the quality of data collection, building capacity of lay social workers who facilitate linkages to services and expanding community-based drug treatment options.

Factors Associated with Willingness to Pay for Cost-Sharing under Universal Health Coverage Scheme in Yogyakarta, Indonesia: A Cross-Sectional Survey

BACKGROUND

National Health Insurance (NHI) in Indonesia requires an appropriate cost-sharing policy, particularly for diseases that require the largest financing. This study examined factors that influence willingness to pay (WTP) for cost-sharing under the universal health coverage scheme among patients with catastrophic illnesses in Yogyakarta, Indonesia.

METHODS

This was a cross-sectional study using structured questionnaires through direct interviews. The factors related to the WTP for cost-sharing under the NHI scheme in Indonesia were identified by a bivariable logistic regression analysis.

RESULTS

Two out of every five (41.2%) participants had willingness to pay for cost-sharing. Sex [AOR = 0.69 (0.51, 0.92)], education [AOR = 1.54 (0.67, 3.55)], family size [AOR = 1.71 (1.07, 2.73)], occupation [AOR = 1.35 (0.88, 2.07)], individual income [AOR = 1.50 (0.87, 2.61)], household income [AOR = 1.47 (0.90, 2.39)], place of treatment [AOR = 2.54 (1.44, 4.45)], a health insurance plan [AOR = 1.22 (0.87, 1.71)], and whether someone receives an inpatient or outpatient service [AOR = 0.23 (0.10, 0.51)] were found to affect the WTP for a cost-sharing scheme with p < 0.05.

CONCLUSION

Healthcare (place of treatment, health insurance plan, and whether someone receives an inpatient or outpatient service) and individual socioeconomic (sex, educational, family size, occupational, income) factors were significantly related to the WTP for cost-sharing.

Correlates of methamphetamine use severity among patients receiving methadone maintenance treatment for opioid use disorder in Vietnam

OBJECTIVES

To assess the severity of methamphetamine use among methadone maintenance treatment (MMT) patients in Vietnam with opioid use disorder and concurrent methamphetamine use, and to identify risk factors associated with higher severity of methamphetamine use.

METHODS

We used survey data and medical record abstractions from 428 people with opioid use disorder who also use methamphetamine while partaking in methadone treatment in five clinics in Hanoi, Vietnam. We used multinomial logistic regression to assess other risk factors and problems associated with high methamphetamine use severity.

RESULTS

Those who reported injecting heroin in the past 3 months (AOR = 4.05, 95% CI [1.30, 12.55], p = 0.02), having a longer history of lifetime heroin use (AOR = 1.13, 95% CI [1.03, 1.24], p < 0.01), and having higher cravings (AOR = 1.97, 95% CI [1.31, 2.98], p < 0.01) and fatigue (AOR = 1.25, 95% CI [0.96, 1.61], p = 0.09) related to methamphetamine withdrawal had greater odds of high methamphetamine use severity. One of five clinics had a significantly higher percentage of methamphetamine use severity than others.

CONCLUSION

Successful MMT in patients with opioid use disorder in Vietnam may additionally require methamphetamine-focused screening and intervention.

Contingent Valuation: A Pilot Study for Eliciting Willingness to Pay for a Reduction in Mortality From Vaccine-Preventable Illnesses for Children and Adults in Bangladesh

OBJECTIVES

The contingent valuation (CV) method elicits willingness to pay (WTP) for calculating the value of statistical life (VSL). CV approaches for assessing VSL are uncommon in many low and middle-income countries (LMICs). Between 2008 and 2018 only 44 articles utilized WTP in a health-related field and of these only 5 (11%) utilized CV to assess the WTP for a mortality risk reduction. We elicit WTP estimates and compute VSL using the CV method in Bangladesh.

METHODS

The pilot study was primarily aimed at developing best practice guidelines for CV studies in LMICs to get more robust WTP estimates. To this end, we explored three methodological a) Varying the name of the intervention, keeping all other characteristics constant; b) varying the effectiveness of the health intervention and c) offering an overnight period to think about the WTP scenario. The survey was administered 413 randomly selected participants. VSL was for a 1/3000 mortality risk reduction.

RESULTS

We had more males (54%) than females (46%) and the mean annual self-reported income was $5,683.36. Mean VSL is $11,339.70 with a median of $10,413. The ratio of child: adult WTP is approximately 1 by both gender and age category. The vaccine intervention had the largest amount of $0 WTP and protest responses (52% and 58% respectively). 93% of the participants were able to describe (teach-back) the vaccine effectiveness using their own family as an example.

CONCLUSION

Our study provides empirical evidence on how to better generate CV surveys to produce more robust WTP estimates.

Treatment adherence amongst drug users attending public and private methadone maintenance clinics in a northern province of Vietnam

Background

Methadone maintenance treatment (MMT) has been proven to be effective in improving health status and the quality of life of illicit drug users. Due to the quick expand of methadone program, socialization through co-payment service is a critical to the success of it. In Nam Dinh, Vietnam, MMT has been used in public clinics and one private clinic. Such effectiveness of this treatment has been found to depend largely on adherence to treatment. This study aims to explore the compliance rate and its influencing factors among drug users between public and private clinics in Nam Dinh province, Vietnam.

Methods

A cross-sectional study was conducted on 395 participants from January to September in 2018 in three MMT clinics in Nam Dinh, Vietnam. We applied the convenience sampling technique to recruit respondents. Data on socioeconomics characteristics, MMT adherence (measured by Visual Analogue Scale – VAS) and level of social/family support were collected.

Results

43.3% of participants reported complete adherence to the MMT program during the time of research. Significant factors affect MMT adherence among illicit drug users including family income, history of drug rejections, concurrence in drug usage, far distance from MMT clinics, and having only peer. Patients in MMT private clinic had higher complete adherence than that of public MMT (OR = 1.82, 95% CI = 1.13; 2.94). Having contacts with peer drug users associated with a higher rate of incomplete adherence (OR = 2.83, 95% CI = 1.39; 5.73).

Conclusions

The findings support the establishment of private MMT clinics alongside public ones, while further researches to determine the optimal dose and ways to reduce the impact of peer drug user’s influence are encouraged to be conducted.

Polysubstance Use among Patients Enrolling in Methadone Maintenance Treatment Program in a Vietnam Province with Drug-Driven HIV Epidemic

Methadone maintenance treatment (MMT) has been scaled up significantly in recent years. This study aimed to investigate the pattern of polysubstance use in 395 MMT patients and its contextualized associated factors. A cross-sectional study was performed in three outpatient MMT clinics in Nam Dinh Province. Multivariate Poisson regression was used to identify factors associated with polysubstance use status. The mean MMT duration and the current MMT dose was 3.3 years and 69.2 mg, respectively. Among participants, 24.8% reported daily alcohol use, 68.6% smoked regularly, and 6% used illicit drugs. Peer pressure and MMT suboptimal adherence were found to associate with continual usage of drugs (47.8%). Participants who lived with a spouse/partner, were self-employed, and smoked were more likely to drink alcohol. Those who drink were also more likely to smoke, and vice versa. Recommendations for policymakers include community-based education and promotional programs aiming to decrease substance usage in the community as well as encouraging and supporting the private health sector in establishing private MMT services and clinics. Further longitudinal studies on polysubstance usage among MMT patients should also be conducted.

Concurrent drug use among methadone maintenance patients in mountainous areas in northern Vietnam

OBJECTIVES

With the rise in methadone maintenance therapy (MMT) for drug users in Vietnam, there has been growing interest in understanding if and how often MMT patients engage in concurrent illicit drug use while on methadone therapy in various settings. This study examined factors associated with concurrent opioid use among patients on MMT in a mountainous area in Vietnam.

SETTING

One urban and one rural MMT clinics in Tuyen Quang province.

PARTICIPANTS

Survey participants consisted of patients who were taking MMT at the selected study sites. A convenience sampling approach was used to recruit the participants.

PRIMARY AND SECONDARY OUTCOME MEASURES

Participants were asked a series of questions about their socioeconomic status, current alcohol and tobacco use, health problems (measured by the EuroQol-Five Dimension-Five Level instrument), psychological distress (measured by Kessler score), and factors associated with current and/or previous drug use. Regression models were used to determine factors associated with concurrent drug use among MMT patients.

RESULTS

Among the 241 male MMT patients included in the study, 13.4% reported concurrent opioid use. On average, the longer patients had been enrolled in MMT, the less likely they were to concurrently use drugs. Conversely, patients with higher levels of psychological distress were more likely to engage in concurrent drug use while on MMT.

CONCLUSION

Longer duration of MMT was significantly correlated with reduced illicit drug use among participants. Higher levels of psychological distress were associated with increased use of illicit drugs among MMT patients. Regardless of distance, long-term MMT is still effective and should be expanded in mountainous areas.

Social and structural barriers for adherence to methadone maintenance treatment among Vietnamese opioid dependence patients

Introduction

Methadone maintenance treatment (MMT) services may reduce the risk of HIV transmission if patients completely adhere to the treatment. Identifying adherence patterns and potential related factors is vital for the sustainability of MMT program in Vietnam. This study examined social and structural factors associated with adherence to MMT among patients in different service delivery models.

Materials and methods

A total of 510 patients at three MMT clinics in Hanoi were interviewed. Measures of self-reported adherence included the number of missed doses in the past 7 days and the level of adherence in the past 30 days using a visual analog scale (VAS) scoring from 0 (non-adherence) to 100 (perfect adherence). Multivariate regressions were employed to identify factors associated with non-adherence to MMT.

Results

A total of 17.7% of participants reported incomplete MMT adherence in the last 30 days and 8.3% reported missing a dose in the last seven days, respectively. Living with HIV/AIDS, poor self-care and usual activities, and disclosure of health issues to spouses or intimate partners were associated with non-adherence. Those patients with pain or depression were more likely to report better adherence. Disclosing health status to spouse/partner increased the risk of incomplete adherence, while disclosing to friends reduced the number of missed dose in the last seven days. Patients attending clinics with comprehensive services had a lower VAS score of adherence compared to those enrolling in clinics with only MMT and general health care.

Conclusions

Sustaining the compliance of patients to MMT is principal in the rapid expansion of this service in Vietnam. It is necessary to address the complexity of health care demands of drug users, their difficulties to be rehabilitated into workforce and society, and the stigmatization to maximize the outcomes of MMT program.