Impact of Methadone Program Philosophy Changes on Early Treatment Outcomes

Exploring correlates of involuntary treatment in substance use disorders: a global systematic review and meta-analysis

Given the legislative heterogeneity about involuntary treatment and psychoactive substance users, we opted to perform a systematic review and meta-analysis of the correlates of involuntary substance use disorders (SUD) treatment across different countries. We conducted research on the Pubmed database, searching for involuntary SUD treatment data worldwide. The systematic review analysed a total of 36 articles and included a sample of 47,739 patients. Our review highlights the elevated risk of involuntary treatment among male, unmarried individuals with alcohol and/or opioid use disorders. Targeted preventive and therapeutic interventions should focus on addressing the underlying factors contributing to involuntary treatment, such as psychosis, aggressiveness, suicidal ideation, legal problems, and severe social exposure. By targeting these factors and providing comprehensive care, we can strive to improve outcomes and reduce the burden of substance use disorders in this vulnerable population. It is essential to critically examine and understand the factors contributing to the selection of patients for compulsory treatment. By doing so, we can identify potential gaps or inconsistencies in the current processes and work towards ensuring that decisions regarding compulsory treatment are based on sound clinical and ethical principles.

Treatment options and shared decision-making in the treatment of opioid use disorder: A scoping review

BACKGROUND

Shared decision-making (SDM) is an approach to clinical decision-making that includes patients' values and preferences during health-related decisions. Previous research suggests that SDM may be beneficial in the treatment of substance use disorders; however, the impact of SDM in the treatment of opioid use disorder (OUD) remains unclear.

OBJECTIVES

To identify relevant peer-reviewed literature related to SDM in the treatment of adults with OUD, and to summarize the main findings according to patient outcomes.

METHODS

The research team conducted a scoping review. The team searched five electronic health databases from database inception until September 2019 using MeSH and keywords related to SDM. The team included only peer-reviewed studies where adults (≥18 years) with OUD were provided a choice and/or allowed input into their treatment plan. Two independent reviewers screened, extracted, and assessed the quality of included studies.

RESULTS

Fourteen studies (n = 1748 participants) met inclusion criteria, including seven randomized controlled trials, three non-randomized controlled trials, two observational studies, and one qualitative study. Treatment options included: patient regulated methadone dosing vs. fixed dosing (n = 4 studies), optional vs. mandatory counseling (n = 4 studies), home vs. office buprenorphine inductions (n = 2 studies), and inpatient vs. outpatient treatment (n = 1 study). None of the studies measured SDM with a validated instrument. Seven of 14 studies reported at least one improved patient outcome.

CONCLUSIONS

The review found few studies that explored whether providing treatment options and/or encouraging participation in decision-making are beneficial for adults with OUD. Preliminary evidence suggests that SDM may be promising for this population. However, the field needs more research on person-centered care and SDM.

Treatment of opioid use disorder in primary care

Opioid use disorder (OUD) is a common, treatable chronic disease that can be effectively managed in primary care settings. Untreated OUD is associated with considerable morbidity and mortality-notably, overdose, infectious complications of injecting drug use, and profoundly diminished quality of life. Withdrawal management and medication tapers are ineffective and are associated with increased rates of relapse and death. Pharmacotherapy is the evidence based mainstay of OUD treatment, and many studies support its integration into primary care settings. Evidence is strongest for the opioid agonists buprenorphine and methadone, which randomized controlled trials have shown to decrease illicit opioid use and mortality. Discontinuation of opioid agonist therapy is associated with increased rates of relapse and mortality. Less evidence is available for the opioid antagonist extended release naltrexone, with a meta-analysis of randomized controlled trials showing decreased illicit opioid use but no effect on mortality. Treating OUD in primary care settings is cost effective, improves outcomes for both OUD and other medical comorbidities, and is highly acceptable to patients. Evidence on whether behavioral interventions improve outcomes for patients receiving pharmacotherapy is mixed, with guidelines promoting voluntary engagement in psychosocial supports, including counseling. Further work is needed to promote the integration of OUD treatment into primary care and to overcome regulatory barriers to integrating methadone into primary care treatment in the US.

Conceptualizing patient-centered care for substance use disorder treatment: findings from a systematic scoping review

BACKGROUND

Despite ongoing efforts aimed to improve treatment engagement for people with substance-related disorders, evidence shows modest rates of utilization as well as client-perceived barriers to care. Patient-centered care (PCC) is one widely recognized approach that has been recommended as an evidence-based practice to improve the quality of substance use disorder treatment. PCC includes four core principles: a holistic and individualized focus to care, shared decision-making and enhanced therapeutic alliance.

AIMS

This scoping review aimed to explore which PCC principles have been described and how they have defined and measured among people with substance-related disorders.

METHODS

Following the iterative stages of the Arksey and O'Malley scoping review methodology, empirical (from Medline, Embase, PsycINFO, CINAHL and ISI Web of Science) and grey literature references were eligible if they focused on people accessing treatment for substance-related disorders and described PCC. Two reviewers independently screened the title/abstract and full-texts of references. Descriptive analyses and a directed content analysis were performed on extracted data.

FINDINGS

One-hundred and forty-nine references met inclusion from the 2951 de-duplicated references screened. Therapeutic alliance was the most frequent principle of PCC described by references (72%); this was consistently defined by characteristics of empathy and non-judgment. Shared decision-making was identified in 36% of references and was primarily defined by client and provider strategies of negotiation in the treatment planning process. Individualized care was described by 30% of references and included individualized assessment and treatment delivery efforts. Holistic care was identified in 23% of references; it included an integrated delivery of substance use, health and psychosocial services via comprehensive care settings or coordination. Substance use and treatment engagement outcomes were most frequently described, regardless of PCC principle.

CONCLUSIONS

This review represents a necessary first step to explore how PCC has been defined and measured for people accessing substance use disorder treatment. The directed content analysis revealed population and context-specific evidence regarding the defining characteristics of PCC-principles that can be used to further support the implementation of PCC.

Patterns of physician prescribing for opioid maintenance treatment in Ontario, Canada in 2014

BACKGROUND

Despite concerns surrounding high patient volumes in methadone clinics, little is known about the practice patterns of opioid maintenance therapy (OMT) providers in Ontario. We examined the distribution of these services and how physician characteristics differ based on prescribing volume.

METHODS

We conducted a cross-sectional study among prescribers of methadone or buprenorphine to Ontario public drug beneficiaries in 2014 by stratifying physicians into low- (lower 50%), moderate- (51-89%) and high-volume (top 10%) prescribers. We summarized the distribution of OMT prescription days dispensed and urine drug screens (UDS) ordered using Lorenz curves and examined physician characteristics using descriptive statistics.

RESULTS

We identified 893 OMT prescribers in 2014. Physicians were mostly male (67.5%; N=603), and middle-aged (median was 50). High-volume methadone providers (N=57) prescribed approximately 56% (N=4,115,322) of the total days of methadone (Gini coefficient=0.76, 95% CI 0.74-0.79) while high-volume buprenorphine providers (N=64) prescribed 61% (N=589,463) of the total days of buprenorphine (Gini coefficient=0.78, 95% CI 0.75-0.80). On average, each high-volume methadone prescriber treated 435 OMT patients and billed 43 UDS per patient, while each high-volume buprenorphine prescriber treated 64 OMT patients and billed 22 UDS per patient. Daily OMT patient volume was on average 74 for high-volume methadone prescribers and 6 for high-volume buprenorphine prescribers.

CONCLUSIONS

OMT services are highly concentrated among a small portion of OMT providers who carry high daily patient volumes. Future research should examine the quality of primary care received by their patients to better elucidate the possible consequences of this highly unequal distribution of services.

Exploring the relationship between perceived inter-dose opioid withdrawal and patient characteristics in methadone maintenance treatment

BACKGROUND

Despite clinical optimization of methadone doses, as many as 53% of patients experience significant and unacceptable levels inter-dose opioid withdrawal some of the time. Little is known about the relationship between perceived inter-dose opioid withdrawal and patient characteristics in methadone maintenance treatment.

METHODS

Ninety stabilized MMT patients were recruited and divided into three satisfaction groups (holders (H), partial holders (PH), and nonholders (NH)) based on their perceived opioid withdrawal as assessed by a guided self-report process. A battery of subjective assessments was administered during the approximate trough methadone condition. The primary measures were the Subjective Opioid Withdrawal Scale (SubOWS), Hopkins Symptom Checklist-90 (SCL-90), Obsessive-Compulsive Drug Use Survey (OCDUS), Profile of Mood States (POMS), and Neo Personality Inventory (NEO).

RESULTS

Nonholders experienced more opioid withdrawal (SubOWS-NH: 22.0+/-8.8 vs. PH: 12.2+/-8.2 vs. H: 9.3+/-10.0, p<0.001) and craving (OCDUS-NH: 11.4+/-8.8 vs. PH: 6.4+/-6.9 vs. H: 6.5+/-6.2, p=0.016). Holders experienced less Obsessive/Compulsive psychological distress (SCL-90-NH: 15.3+/-8.1 vs. PH: 12.3+/-7.3 vs. H: 6.6+/-5.1, p<0.001), Depression/Dejection (POMS-NH: 19.7+/-13.7 vs. PH: 17.2+/-13.2 vs. H: 7.9+/-10.4, p=0.002), and neurotic personality (NEO-NH: 63.3+/-12.3 vs. PH: 60.9+/-10.0 vs. H: 54.0+/-8.8, p=0.006). Partial holders had a less agreeable personality (NEO-NH: 44.2+/-8.6 vs. PH: 38.0+/-10.6 vs. H: 47.6+/-11.7, p=0.002).

CONCLUSIONS

Physical opioid withdrawal is an important factor in understanding patient satisfaction with MMT. However, patient characteristics, such as level of psychological distress and negative mood, may also need to be considered because of their relationship with perceived inter-dose opioid withdrawal symptoms and patient satisfaction.

The impact of benzodiazepine use on methadone maintenance treatment outcomes

The purposes of this study were to examine predictors of benzodiazepine use among methadone maintenance treatment patients, to determine whether baseline benzodiazepine use influenced ongoing use during methadone maintenance treatment, and to assess the effect of ongoing benzodiazepine use on treatment outcomes (i.e., opioid and cocaine use and treatment retention). A retrospective chart review of 172 methadone maintenance treatment patients (mean age = 34.6 years; standard deviation = 8.5 years; 64% male) from January 1997 to December 1999 was conducted. At baseline, 29% were "non-users" (past year) of benzodiazepine, 36% were "occasional users," and 35% were "regular/problem users." Regular/problem users were more likely to have started opioid use with prescription opioids, experienced more overdoses, and reported psychiatric comorbidity. Being female, more years of opioid use, and a history of psychiatric treatment were significant predictors of baseline benzodiazepine use. Ongoing benzodiazepine users were more likely to have opioid-positive and cocaine-positive urine screens during methadone maintenance treatment. Only ongoing cocaine use was negatively related to retention. Benzodiazepine use by methadone maintenance treatment patients is associated with a more complex clinical picture and may negatively influence treatment outcomes.

Hepatitis infection in the treatment of opioid dependence and abuse

Many new and existing cases of viral hepatitis infections are related to injection drug use. Transmission of these infections can result directly from the use of injection equipment that is contaminated with blood containing the hepatitis B or C virus or through sexual contact with an infected individual. In the latter case, drug use can indirectly contribute to hepatitis transmission through the dis-inhibited at-risk behavior, that is, unprotected sex with an infected partner. Individuals who inject drugs are at-risk for infection from different hepatitis viruses, hepatitis A, B, or C. Those with chronic hepatitis B virus infection also face additional risk should they become co-infected with hepatitis D virus. Protection from the transmission of hepatitis viruses A and B is best achieved by vaccination. For those with a history of or who currently inject drugs, the medical management of viral hepatitis infection comprising screening, testing, counseling and providing care and treatment is evolving. Components of the medical management of hepatitis infection, for persons considering, initiating, or receiving pharmacologic therapy for opioid addiction include: testing for hepatitis B and C infections; education and counseling regarding at-risk behavior and hepatitis transmission, acute and chronic hepatitis infection, liver disease and its care and treatment; vaccination against hepatitis A and B infection; and integrative primary care as part of the comprehensive treatment approach for recovery from opioid abuse and dependence. In addition, participation in a peer support group as part of integrated medical care enhances treatment outcomes. Liver disease is highly prevalent in patient populations seeking recovery from opioid addiction or who are currently receiving pharmacotherapy for opioid addiction. Pharmacotherapy for opioid addiction is not a contraindication to evaluation, care, or treatment of liver disease due to hepatitis virus infection. Successful pharmacotherapy for opioid addiction stabilizes patients and improves patient compliance to care and treatment regimens as well as promotes good patient outcomes. Implementation and integration of effective hepatitis prevention programs, care programs, and treatment regimens in concert with the pharmacological therapy of opioid addiction can reduce the public health burdens of hepatitis and injection drug use.

Factors associated with methadone maintenance therapy use among a cohort of polysubstance using injection drug users in Vancouver

We identified methadone maintenance therapy (MMT) use during follow-up interviews and examined associations between MMT use and socio-demographic and drug-related variables using generalized estimating equations (GEE). Of the 1587 participants recruited into this cohort, 170 (11%) were enrolled in MMT at baseline and additional 498 (31%) initiated MMT during follow-up. Of those ever enrolled in MMT, 406 (61%) ceased MMT and re-initiated MMT on more than one occasion. The median treatment duration was 14.4 months. Factors that were negatively and significantly associated with MMT use in multivariate analyses included: Aboriginal ethnicity (adjusted odds ratio [AOR] = 0.40); recent incarceration (AOR = 0.79); sex trade involvement (AOR = 0.87); syringe lending (AOR = 0.72); heroin injection (AOR = 0.64), whereas female gender (AOR = 2.47), HIV positivity (AOR = 1.57), and crack cocaine smoking (AOR = 1.23) were positively and significantly associated with being on MMT. Unstable housing, syringe borrowing, non-fatal overdose, cocaine injection, and residence in Vancouver's Downtown Eastside were not associated with MMT use in multivariate analyses. Our study demonstrates high rates of initiation of and retention in MMT among local IDUs. While the use of MMT was associated with reductions in heroin use and HIV risk behavior, barriers to Aboriginal IDUs were evident, and the association with increased crack cocaine use deserves further study.