Predictors of One-Year Retention in Methadone Maintenance Treatment (MMT) in Iran, Rafsanjan

Retention of people who inject drugs enrolled in a 'medications for opioid use disorder' (MOUD) programme in Uganda

BACKGROUND

Injection Drug use is associated with increased HIV risk behaviour that may result in the transmission of HIV and poor access to HIV prevention and treatment. In 2020, Uganda introduced the 'medication for opioid use disorder (MOUD) treatment' for People who inject drugs (PWID). We analysed the 12-month retention and associated factors among PWID enrolled on MOUD treatment in Kampala, Uganda.

METHODS

We conducted a retrospective analysis of 343 PWID with OUD who completed 14 days of methadone induction from September 2020 to July 2022. Retention was defined as the number of individuals still in the programme divided by the total number enrolled, computed at 3-, 6-, 9-, and 12 months using lifetable and Kaplan-Meier survival analyses. Cox proportional regression analyses were conducted to assess factors associated with retention in the programme in the first 12 months.

RESULTS

Overall, 243 (71%) of 343 participants stabilized at a methadone dose of 60 mg or more. The majority of participants were males (n = 284, 82.8%), and the median (interquartile range, IQR) age was 31 (26-38) years. Most participants (n = 276, 80.5%) lived 5 km or more away from the MOUD clinic. Thirty (8.8%) were HIV-positive, 52 (15.7%) had a major mental illness and 96 (27.9%) had a history of taking alcohol three months before enrollment. The cumulative retention significantly declined from 83.4% (95%CI = 79.0-87.0) at 3months to 71.9% (95%CI = 67.2-76.6) at 6months, 64% 95%CI = 58.7-68.9) at 9months, and 55.2%; 95% CI (49.8-60.3% at 12months. The 12-month retention was significantly higher for participants on methadone doses of 60 mg or more (adj.HR = 2.1, 95%CI = 1.41-3.22), while participants resident within 5 km of the MOUD clinic were 4.9 times more likely to be retained at 12 months, compared to those residing 5 km or more, (adj. HR = 4.81, 95%CI = 1.54-15). Other factors, including predisposing, need, and enabling factors, were not associated with retention.

CONCLUSION

Our study demonstrates acceptable 12-month retention rates for people who inject drugs, comparable to previous studies done in both developing and developed countries. Sustaining and improving retention may require enhanced scaling up of MOUD dose to an optimal level in the first 14 days and reducing the distance between participant locale and MOUD clinics.

Outcome in methadone maintenance treatment of immigrants from the former Union of Soviet Socialist Republics

CONTEXT

Immigrants from the former Union of Soviet Socialist Republics (USSR) are more prevalent in Methadone maintenance treatment (MMT) in Israel than their percentage in the general population.

AIMS

To compare their characteristics and outcomes to those of Israeli-born and other immigrant patients.

METHODS

Retention and survival since admission (June/1993-Dec/2022) until leaving treatment (for retention), or at the end of follow-up were analyzed. Vital data was taken from a national registry. Predictors were estimated using Kaplan-Meier and Cox regression models.

RESULTS

The USSR patients (N = 262) compared with other immigrants (N = 132) and Israeli-born (N = 696) were more educated (≥ 12y) (p < 0.001), admitted to MMT at a younger age (p < 0.001), following a shorter duration of opioid usage (p < 0.001). More of them ever injected drugs (p < 0.001) and ever drank alcohol (p < 0.001). One-year retention was comparable (77.2% vs. 75.6% and 72%, p = 0.2) as did opioid discontinuation in those who stayed (p = 0.2). Former USSR patients had longer cumulative retention of their first admission (p = 0.05) with comparable overall retention since first admission, and survival, although the age of death was younger. Specific origin within the former USSR found immigrants from the Russian Federation with the best outcome, and those from Ukraine as having high HIV seropositive and shorter retention.

CONCLUSIONS

Despite several characteristics known to be associated with poor outcomes, former USSR immigrants showed better adherence to MMT, reflected by their longer cumulative retention in their first admission, lower rate of readmissions, and a comparable survival and overall retention in treatment. An in depth study is needed in order to understand why they decease at a younger age.

A Guide to Expanding the Use of Buprenorphine Beyond Standard Initiations for Opioid Use Disorder

Buprenorphine has become an important medication in the context of the ongoing opioid epidemic. However, complex pharmacologic properties and varying government regulations create barriers to its use. This narrative review is intended to facilitate buprenorphine use-including non-traditional initiation methods-by providers ranging from primary care providers to addiction specialists. This article briefly discusses the opioid epidemic and the diagnosis and treatment of opioid use disorder (OUD). We then describe the basic and complex pharmacologic properties of buprenorphine, linking these properties to their clinical implications. We guide readers through the process of initiating buprenorphine in patients using full agonist opioids. As there is no single recommended approach for buprenorphine initiation, we discuss the details, advantages, and disadvantages of the standard, low-dose, bridging-strategy, and naloxone-facilitated initiation techniques. We consider the pharmacology of, and evidence base for, buprenorphine in the treatment of pain, in both OUD and non-OUD patients. Throughout, we address the use of buprenorphine in children and adolescent patients, and we finish with considerations related to the settings of pregnancy and breastfeeding.

Retention rate in methadone maintenance treatment and factors associated among referred patients from the compulsory residential centers compared to voluntary patients

Introduction

Compulsory treatment has decades of history in Iran; both before and after the Islamic Revolution, but there are many debates regarding its efficacy and effectiveness. Retention Rate is one of the best indices to estimate the efficacy of treatment. This study will compare Retention Rate among people referred from compulsory treatment centers and volunteer participants.

Methods

This was a retrospective (historical) cohort study that has been conducted among people who were taking methadone maintenance treatment (MMT). The study sample was selected from the MMT centers that admit both referral patients from compulsory centers and voluntary patients. All newly admitted patients from March 2017 to March 2018 were enrolled and followed up until March 2019.

Results

A total of 105 participants were recruited for the study. All were males with a mean age of 36.6 ± 7.9 years. Fifty-six percent of individuals were referred from compulsory residential centers. The total one-year retention rate of participants in this study was 15.84%. The one-year retention rate for the patients referred from compulsory residential centers and the non-referred patients was 12.28 and 20.45%, respectively (value of p = 0.128). Among the other studied factors, only marital status was significantly associated with MMT retention (p = 0.023).

Conclusion

Although the average treatment adherence time for non-referred patients was about 60 days higher than those referred from compulsory residential centers, this study found no significant differences in retention days and a one-year retention rate. Further studies with larger sample sizes and longer follow-ups are needed to explore the efficacy of compulsory treatment methods in Iran.

Opium dependence and the potential impact of changes in treatment coverage level: A dynamic modeling study

Background : The most common drug, illegally used in Iran is opium. The treatment of people with substance use disorder is one of the most important strategies in reducing its burden. The aim of this study was to investigate the effect of different increasing and decreasing opium treatment coverage on the patterns of abstinence, transition to heroin dependence and mortality, over 30 years. Methods: This study was a dynamic compartmental modeling conducted in three stages: 1) presenting a conceptual model of opium dependence treatment in Iran, 2) estimating model's parameters value, and 3) modeling of opium dependence treatment and examining the outcomes for different treatment coverage scenarios. The input parameters of the model were extracted from the literature, and secondary data analysis, which were finalized in expert panels. Results: The number of opium dependence will increase from 1180550 to 1522063 [28.93% (95% CI: 28.6 to 29.2)] over 30 years. With a 25% decrease in coverage compared to the status quo, the number of deaths will increase by 459 cases [3.28% (95% CI: 0.91 to 5.7)] in the first year, and this trend will continue to be 2989 cases [15.63% (95% CI: 13.4 to 17.9)] in the 30th year. A 25% increase in treatment coverage causes a cumulative decrease of heroin dependence by 14451 cases [10.1% (95% CI: 9.5 to 10.8)] in the first decade. Conclusion: The modeling showed that the treatment coverage level reduction has a greater impact than the coverage level increase in the country and any amount of reduction in the coverage level, even to a small extent, may have a large negative impact in the long run.

The determinants of methadone maintenance treatment in opioids dependence users: A survival analysis study

Background: Staying in treatment is one of the basic principles in maintenance treatment with methadone and it is considered as a success criterion in the treatment procedure. This study aimed at analyzing effective determinants on staying in treatment in methadone treatment procedure.

Methods: This was a retrospective cohort study, in which 6 MMT centers were randomly selected to be studied. The data were collected using the patients’ medical records. Therefore, 1008 medical record files belonging to the patients who received methadone treatment from April 2013 to August 2017 were investigated. Proportional hazard Cox regression (extended) was used to specify the determinants of the methadone maintenance treatment and STATA 11 was used for data analysis.

Results: The patients’ mean age was 38.8 years (±1.08), and 75.8% were married and only 39.1% had full-time jobs. The mean age for the first substance abuse was at 24.31years (±7.93). The average time of staying in the treatment was 28.8 months. The results of the adjusted Cox proportional hazards regression showed among the 14 variables entered into the model, in the 1-12-month interval age of first drug use (HR=0.945, 95 % CI=0.908-0.983, p=0.005), specific drug use (HR=1.14, 95 % CI=1.026-1.268, p=0.014), and the frequency of treatment (HR=0.974, 95 % CI=0.959-0.990, p=0.002) were significantly correlated with survival status. The 13-36- month interval drug use (HR=0.931, 95 % CI=0.886-0.978, p=0.005) was significantly correlated with survival status. Also, the range of 37-53 month drug use (HR=1.058, 95 % CI=1.001-1.119, p= .044) had a significant relationship with survival status.

Conclusion: This study showed age of first drug use, specific drug use, the frequency of treatment and drug use were correlated with a decrease in staying duration in treatment. Therefore, taking these factors into consideration in designing and administering various interventions in addiction treatment and consulting centers is of paramount importance.

Childhood Trauma, Cognitive Emotion Regulation and Motivation for Behavior Change Among Clients of Opioid Substitution Treatment With and Without Past Year Synthetic Cathinone Use During Therapy

Background

With a decrease in heroin's purity and availability in the European drug market, Hungarian opioid dependent patients started to substitute heroin with novel psychoactive substances (NPS) and especially with synthetic cathinones.

Goal

This study aims to assess whether clients of opioid substitution treatment (OST) with and without a history of synthetic cathinone use during therapy differ in (1) the rate and type of experienced childhood trauma, (2) the way they cope with negative life events, (3) their motivation to change substance use behavior, (4) the rate of treatment retention.

Methods

A total of 198 clients of an outpatient centers (Nyírõ Gyula National Institute of Psychiatry and Addictions, Budapest) OST were asked to provide information about their general substance use experiences, including the consumption of NPS during treatment, their childhood traumatic experiences (Childhood Trauma Questionnaire), cognitive emotion regulation strategies (Cognitive Emotion Regulation Questionnaire), their motivation to change substance use behavior (University of Rhode Island Change Assessment Scale) and current psychiatric symptoms (Brief Symptom Inventory). Baseline data was collected in the summer of 2015, while 4 years follow-up data on treatment retention was obtained in the summer of 2019.

Results

The majority of the clients were male (N = 141, 71.2%), receiving methadone as a substitute for opioids (N = 178, 89.9%), while mean age of the full sample was 39.7 (SD = 6.8). Based on a logistic regression model, the odds for past year synthetic cathinone use was higher among clients with more severe psychiatric symptoms (B = 0.8, OR = 2.2, p < 0.01) and among clients who were in treatment for a shorter period of time (B = 0.1, OR = 0.9, p < 0.05). Synthetic cathinone use during treatment was further associated with less adaptive strategies to cope with negative life events. Synthetic cathinone use was also a risk factor for reduced treatment retention (B = -0.8, OR = 0.4, p < 0.05) and was associated with lower odds of being member of a latent class with less severe psychopathological profile (B = -0.9, OR = 0.4, p < 0.05).

Conclusion

Synthetic cathinone use during treatment is associated with poorer treatment outcomes and might be characterized by more severe psychiatric symptoms and amotivation to change substance use among opioid dependent clients.

Effectiveness of a Psycho-Social Intervention Aimed at Reducing Attrition at Methadone Maintenance Treatment Clinics: A Propensity Score Matching Analysis

Methadone maintenance treatment (MMT) is an important approach to address opioid dependence. However, MMT clinics usually report high attrition rates. Our previous randomized controlled trial demonstrated additional psycho-social services delivered by social workers could reduce attrition rates compared to MMT alone. This study aimed to evaluate the effectiveness of psycho-social service in a real-world context. A quasi-experimental design and propensity score matching was adopted. 359 clients were recruited from five MMT clinics in Guangzhou from July 2013 to April 2015. One 20-minute counseling session was offered to the control group after enrolment. The intervention group received six sessions of psycho-social services. The baseline characteristics were unbalanced between two arms in the original sample. After propensity score matching, 248 participants remained in the analysis. At month six, the intervention group had a lower attrition rate [intervention (39.5%) versus control (52.4%), P = 0.041], higher monthly income [monthly income of 1000 CNY or higher: intervention (55.9%) versus control (39.0%), P = 0.028)], higher detoxification intention score [full intention score: intervention (51.6%) versus control (32.5%), P = 0.012)], higher family support in MMT participation [intervention (77.9%) versus control (61.4%), P = 0.049)]. This study demonstrated that psycho-social services delivered by social workers can reduce MMT clients' attrition and improve their well-being in real-world settings.

Prevalence of Coaddictions and Rate of Successful Treatment Among a French Sample of Opioid-Dependent Patients With Long-Term Opioid Substitution Therapy: The OPAL Study

Background: Opioid use disorder (OUD) is a worldwide major health concern due to increased early mortality and morbidity. Opioid substitution therapy (OST) is approved in the context of a global OUD treatment (OUDT), in conjunction with psychosocial interventions. Many factors can explain why unsuccessful treatment rates remain high. While the phenomenon of addiction switching is often proposed, it is not known whether this also includes gambling addiction. The primary objective of the OPAL study was to determine the prevalence of coaddictions, including problem gambling, among patients with OUDT. Secondary objectives were to assess the rate of unsuccessful OUDT and to characterize the associated factors. Methods: For this observational transversal multicenter study, patients with OUDT including OST for at least 6 months were recruited. Clinical assessment was based on a clinically structured interview and a set of self-reported questionnaires. Coaddictions were screened using the Fagerström, the CRAFFT, and the Lie/Bet questionnaires. Unsuccessful OUDT was defined as the persistence of opioid use and/or the worsening of another substance use or gambling practice. After a descriptive analysis, a multivariate analysis was performed to identify the factors associated with unsuccessful OUDT. Results: The sample consisted of 263 patients. Prevalence of coaddictions reached 97% of the sample. Problem gambling was associated with 10% of the patients. OUDT was considered as "unsuccessful" for 60% of the patients. Associated factors included having drug-using friends, psychiatric and professional negative consequences related to opioid use, more than one OST-prescribing physician, and impulsivity, especially high scores for lack of premeditation and sensation seeking. Conclusions: This study provides further evidence of the need to consider coaddictions and the usefulness of global addictive evaluations. Poor prognostic factors must alert the clinician to initiate more sustained care. Further implications are discussed.

Variation Overtime among Patients of the Six Methadone Maintenance Treatment Clinics in Thai Nguyen from 2011 to 2015

Background

Methadone Maintenance Treatment (MMT) program's success depends on the likelihood of reducing drop-out rate and keeping patients remaining in the program. There have been neither comprehensive studies about variation among patients who have been experiencing MMT for long period nor prediction of MMT period in which the risk of drop-out would be the highest in Thai Nguyen, a northern mountainous province where the MMT was established in 2011.

Objectives

To analyze variation of the MMT population through indicators of drop-out and death, re-enrolment, and retention rate in the six Thai Nguyen MMT clinics.

Methods

A retrospective study by reviewing daily treatment notebooks of the six MMT clinics in Thai Nguyen to identify events of drop-out, death, reenrolment among 2,567 patients registered from 12 May 2011 to 6 September 2015.

Results

Cumulative hazard of drop-out over period from the first to the fourth year of MMT treatment has an increasing trend at 0.15; 0.31; 0.46; and 0.61, respectively. The cumulative probability of re-enrolment among 740 patients who have already quit the MMT program and then returned slightly increased from 0.07 to 0.16 between the first years and the fourth year in which the highest returning rate occurred within the first 2 years after drop-out. The cumulative retention rate decreased annually and stayed at 71.7% after 4 years of running the MMT.

Conclusions

MMT patients and their families should be informed and consulted about the highest risk period of drop-out and also about period when drop-out patients are most likely to reenter the MMT. Counseling adherence for patients should be conducted not only at the beginning but also during the ongoing MMT and play an extremely important role in reducing drop-out of the program while special counseling should also be reenforced for the re-enrolment patients of MMT.

Why People Who Inject Drugs Voluntarily Transition Off Methadone in Ukraine

Methadone maintenance therapy (MMT) treats opioid use disorder among people who inject drugs (PWID). To understand why PWID may voluntarily discontinue MMT, we analyzed data from 25 focus groups conducted in five Ukrainian cities from February to April 2013 with 199 participants who were currently, previously, or never on MMT. Using constant comparison method, we uncovered three themes explaining why PWID transition off MMT: (a) purposeful resistance to rigid social control associated with how MMT is delivered and to power asymmetries in provider-patient relationships, (b) self-management of a PWID's "wounded identity" that is common in socially stigmatized and physically sick persons-MMT serves as a reminder of their illness, and (c) the quest for a "normal life" uninterrupted by daily MMT site visits, harassment, and time inefficiencies, resources, and social capital. Focusing on holistic principles of recovery would improve addiction treatment and HIV prevention in Ukraine and globally.