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CORK Bibliography: Methadone Maintenance

85 citations. January 2010 to present

Prepared: September 2011

Afriandi I; Siregar AYM; Meheus F; Hidayat T; van der Ven A; van Crevel R et al. Costs of hospital-based methadone maintenance treatment in HIV/AIDS control among injecting drug users in Indonesia. Health Policy 95(1): 69-73, 2010. (21 refs.)

Objective: To assess the cost of hospital-based methadone maintenance treatment (MMT) for injecting drug users (IDUs) in Bandung. Indonesia; to address concerns of financial sustainability at the hospital level and financial accessibility and economic attractiveness at the health care policy level. Methods: In a 1 year observation period in 2006-2007, MMT service delivery costs were estimated on the basis of a micro-costing approach. Patient costs were estimated on the basis of a survey among 48 methadone clients. Results: A total number of 129 clients attended the MMT clinic, resulting in a total of 16,335 client visits. Total annual societal costs of running the MMT clinic equalled Rp 1130 mln (US$123,672), or Rp 69,206 (US$7.57) per client visit. Of total costs, patient costs established the largest share (65%), followed by that of central government (20%), and the hospital (15%). Present consultation tariffs already cover hospital costs and the patient costs of accessing MMT services constitute almost 70% of their income. Conclusion: Under current circumstances, MMT services are financially sustainable to the hospital. MMT services are subsidized by the central government, and this is warranted considering the important role of the program in HIV/AIDS among IDUs. Still, the present user fee seems a barrier to utilization, and a higher level of subsidy might be justified to reduce the cost to the patient.

Al-Tayyib AA; Koester S. Injection drug users' experience with and attitudes toward methadone clinics in Denver, CO. Journal of Substance Abuse Treatment 41(1): 30-36, 2011. (36 refs.)

Clients' perceptions and attitudes toward methadone treatment programs are frequently overlooked in substance abuse research. Given the importance of methadone maintenance as a harm-reduction strategy and clients' concerns about treatment, it is essential to understand perceptions and attitudes toward existing programs. Using data from the 2009 National HIV Behavioral Surveillance system with injection drug users in Denver, CO, we evaluated participants' experiences with methadone clinics and examined predictive factors associated with ever being a client of a methadone clinic. Costs of services, perceptions of staff not caring about the client, and attitudes toward the counseling services seemed to be the major barriers to program retention. Besides heroin use, previous attempt at self-detoxification and being infected with hepatitis C were the strongest predictors of ever being on methadone treatment. Addressing the barriers to program retention and encouraging treatment engagement are essential to embracing methadone maintenance as a harm-reduction strategy for injection drug users.

Barry DT; Beitel M; Breuer T; Cutter CJ; Savant J; Peters S et al. Group-based strategies for stress reduction in methadone maintenance treatment: What do patients want? Journal of Addiction Medicine 5(3): 181-187, 2011. (44 refs.)

Objectives: To assess methadone maintenance treatment (MMT) patients' willingness to use, and perceived efficacy of, conventional and unconventional group stress reduction treatments. Methods: A survey, developed by the authors, was administered to 150 MMT patients. Results: Levels of treatment willingness and perceived efficacy for both conventional and unconventional treatments were relatively high; however, ratings for conventional interventions were, on average, significantly higher than those for unconventional ones. The highest rated conventional and unconventional treatments in terms of willingness and perceived efficacy were nutrition and spiritual counseling, respectively, whereas the lowest rated conventional and unconventional group treatments were anger management and visualization training, respectively. White race was a significant predictor of lower willingness to try conventional and unconventional group therapies and lower perceived efficacy of unconventional group treatment, whereas female sex and older age were significant predictors of higher levels of willingness to try unconventional group treatment. Higher levels of substance use problems were associated with increased willingness to try conventional group treatment. Higher levels of anxiety emerged as a significant independent predictor of treatment willingness and perceived efficacy for both conventional and unconventional group treatments. Conclusions: The relatively high levels of treatment willingness and perceived efficacy of conventional and unconventional group stress reduction treatments point to the feasibility of offering these interventions in MMT and suggest that, in particular, high levels of anxiety are associated with greater treatment willingness and perceived treatment efficacy.

Barry DT; Beitel M; Breuer T; Cutter CJ; Savant J; Schottenfeld RS et al. Conventional and unconventional treatments for stress among methadone-maintained patients: Treatment willingness and perceived efficacy. American Journal on Addictions 20(2): 137-142, 2011. (30 refs.)

We surveyed 150 methadone maintenance treatment (MMT) program patients about willingness to use, and perceived efficacy of, conventional and unconventional nonpharmacological stress-related treatments. Although levels of treatment willingness and perceived efficacy for both conventional and unconventional treatments were high, ratings for conventional interventions were, on average, significantly higher than those for unconventional ones. Dimensions of psychiatric distress-but not demographic or MMT characteristics-predicted treatment willingness for conventional therapies and treatment willingness and perceived efficacy for unconventional therapies. These findings are likely to have implications for resource and program planning in MMT programs.

Barry DT; Beitel M; Cutter CJ; Joshi D; Falcioni J; Schottenfeld RS. Conventional and nonconventional pain treatment utilization among opioid dependent individuals with pain seeking methadone maintenance treatment: A needs assessment study. Journal of Addiction Medicine 4(2): 81-87, 2010. (35 refs.)

Objective and Methods: We surveyed 293 individuals seeking methadone maintenance treatment (MMT) for opioid dependence about pain, pain treatment utilization, perceived efficacy of prior pain treatment, and interest in pursuing pain treatment while in MMT. Results: Among the 213 respondents reporting recent pain of at least moderate typical pain intensity, those with and those without a lifetime history of chronic pain endorsed similar rates of conventional (with the exception of past-week medical use of nonopiate medication), complementary, and alternative medicine utilization for pain reduction and a numerically smaller proportion endorsed last-week utilization of complementary and alternative medicine when compared with conventional medicine. The most frequently endorsed lifetime conventional pain treatments included opiate and over-the-counter medications, whereas the most frequently endorsed lifetime complementary and alternative medicine pain treatments included stretching, physical exercise, physical therapy, heat therapy, and prayer. Perceived efficacy of prior pain treatment but not interest in pain treatment was associated with chronic pain history status. Conclusion: These findings may have implications for resource and program planning in MMT programs.

Batki SL; Canfield KM; Ploutz-Snyder R. Psychiatric and substance use disorders among methadone maintenance patients with chronic hepatitis C infection: Effects on eligibility for hepatitis C treatment. American Journal on Addictions 20(4): 312-318, 2011. (52 refs.)

We set out to describe the prevalence and severity of psychiatric and substance use disorders (SUDs) in methadone maintenance treatment (MMT) patients with chronic hepatitis C virus (HCV) infection and to measure the impact on HCV-treatment eligibility. Psychiatric disorders, SUDs, and HCV-treatment eligibility were assessed in 111 MMT patients prior to a controlled trial of HCV treatment. Lifetime and current diagnosis rates, respectively were.. any non-SUD Axis I disorder 82% and 57%, any mood disorder: 67% and 35%, any anxiety disorder: 63% and 22%, any psychotic disorder: 11% and 9%. Antisocial personality disorder was present in 40%. A total of 56% met criteria for current SUDs. A total of 66% received psychiatric medications prior to HCV treatment; over half were receiving antidepressants. Despite psychiatric and substance use comorbidity, only 15% of patients were ineligible for HCV treatment: 10% clue to failure to complete the evaluation, and 5% due to psychiatric severity. Substance use did not lead to ineligibility in any participant. Multiple logistic regression showed the Beck Depression Inventory contributed significantly to predicting HCV treatment eligibility. Most MMT patients were ineligible for HCV treatment despite current SUD and non-SUD diagnoses. Depression severity may be a more significant predictor of HCV treatment eligibility than is substance use.

Batki SL; Canfield KM; Smyth E; Ploutz-Snyder R; Levine RA. Hepatitis C treatment eligibility and comorbid medical illness in methadone maintenance (MMT) and non-MMT patients: A case-control study. Journal of Addictive Diseases 29(3): 359-369, 2010. (52 refs.)

Comorbid medical illness is common in patients with chronic hepatitis C (HCV) infection and in methadone treatment (MMT) patients, yet little is known about the impact of medical illness on HCV treatment eligibility. Medical illness and HCV treatment eligibility were compared in a case-control study of 80 MMT patients entering an HCV treatment trial and 80 matched non-MMT patients entering HCV treatment in a gastroenterology clinic. 91% of MMT and 85% of non-MMT patients had chronic medical conditions. Despite similar medical severity ratings, a significantly higher proportion (77%) of non-MMT patients were eligible for HCV treatment than were MMT patients (56%) (p .01). Specific comorbid medical and psychiatric illness led to ineligibility in only 18% of MMT and 16% of non-MMT patients. However, failure to complete the medical evaluation process was significantly (p .001) more likely to cause ineligibility among MMT patients (19%) than non-MMT patients (0%).

Berg KM; Litwin A; Li XA; Heo M; Arnsten JH. Directly observed antiretroviral therapy improves adherence and viral load in drug users attending methadone maintenance clinics: A randomized controlled trial. Drug and Alcohol Dependence 113(2-3): 192-199, 2011. (39 refs.)

Objective: To determine if directly observed antiretroviral therapy (DOT) is more efficacious than self-administered therapy for improving adherence and reducing HIV viral load (VL) among methadone-maintained opioid users. Design: Two-group randomized trial. Setting: Twelve methadone maintenance clinics with on-site HIV care in the Bronx, New York. Participants: HIV-infected adults prescribed combination antiretroviral therapy. Main outcomes measures: Between group differences at four assessment points from baseline to week 24 in: (1) antiretroviral adherence measured by pill count, (2) VL, and (3) proportion with undetectable VI. (<75 copies/ml). Results: Between June 2004 and August 2007, we enrolled 77 participants. Adherence in the DOT group was higher than in the control group at all post-baseline assessment points; by week 24 mean DOT adherence was 86% compared to 56% in the control group (p<0.0001). Group differences in mean adherence remained significant after stratifying by baseline VL (detectable versus undetectable). In addition, during the 24-week intervention, the proportion of DOT participants with undetectable VL increased from 51% to 71%. Conclusions: Among HIV-infected opioid users, antiretroviral DOT administered in methadone clinics was efficacious for improving adherence and decreasing VL, and these improvements were maintained over a 24-week period. DOT should be more widely available to methadone patients.

Buxton JA; Kuo ME; Ramji S; Yu A; Krajden M. Methadone use in relation to hepatitis C virus testing in British Columbia. Canadian Journal of Public Health 101(6): 491-494, 2010. (27 refs.)

Objective: We examined methadone use among a large cohort of individuals undergoing serologic testing for hepatitis C virus (HCV) infection. Methods: In British Columbia, community pharmacy methadone dispensations are recorded in the PharmaNet database and HCV antibody (anti-HCV) test results are recorded by the Provincial Public Reference Laboratory. Provincial HCV laboratory testing records from 1992 to 2004 were linked to methadone dispensation records from 1995-2006. We describe methadone maintenance treatment (MMT) among individuals undergoing anti-HCV testing between 1992 and 2004. Results: Between 1992 and 2004, 404,941 individuals were tested for anti-HCV in BC; 32,918 (8%) were positive. Overall, methadone was dispensed to 10,314(2.5%) of individuals tested for anti-HCV; 1% of negative testers and 21% of positive testers. Of 10,314 individuals receiving methadone, 6,732 (65%) had a positive anti-HCV test during the study period. Laboratory anti-HCV serostatus was known at MMT initiation in 70%; of these, 2,596 (36%) were anti-HCV negative and 4,638 (64%) were anti-HCV positive at first methadone dispensation. Seroconversion from anti-HCV negative to positive following MMT initiation was confirmed in 288 persons. Conclusion: Methadone used in conjunction with other harm reduction initiatives can reduce the transmission of blood-borne infections among individuals who inject opiates, however many who enter the BC Methadone Program are already anti-HCV positive and others seroconvert after MMT initiation. Our data suggest there are missed prevention opportunities for MMT and other harm reduction services. Linkage of laboratory and health service data can provide a population lens to identify and evaluate potential prevention strategies.

Calsyn DA; Campbell ANC; Crits-Christoph P; Doyle SR; Tross S; Hatch-Maillette MA et al. Men in methadone maintenance versus psychosocial outpatient treatment: Differences in sexual risk behaviors and intervention effectiveness from a multisite hiv prevention intervention trial. Journal of Addictive Diseases 29(3): 370-382, 2010. (42 refs.)

The effectiveness of the Real Men Are Safe (REMAS) HIV prevention intervention was examined as a function of treatment program modality. REMAS was associated with significantly larger decreases in unprotected sexual occasions than an HIV education control condition in both treatment modalities. REMAS had superior effectiveness for reducing unprotected sexual occasions in the psychosocial outpatient compared to methadone. At the 6-month follow-up, the adjusted mean change for REMAS completers in psychosocial outpatient (M= 6.4, d= 0.38) was greater than for REMAS completers in methadone programs (M= 2.3, d= 0.25). Reasons for why REMAS appears to be especially effective in psychosocial outpatient programs are explored.

Canfield KM; Smyth E; Batki SL. Methadone maintenance patients' knowledge, attitudes, beliefs, and experiences concerning treatment for hepatitis C virus infection. Substance Use & Misuse 45(4): 496-514, 2010. (59 refs.)

Hepatitis C virus (HCV) knowledge, attitudes, beliefs, and experiences (KABE) of 64 HCV antibody positive methadone maintenance treatment (MMT) patients were assessed in conjunction with acceptability of an on-site semi-structured HCV education session, HCV RNA diagnostic testing, HCV treatment motivational assessment, and initiation of HCV treatment. The KABE interviews were conducted in 2006 and 2007 in an urban New York State MMT clinic in affiliation with a NIDA-funded HCV research project. The majority had basic knowledge of HCV disease, but poor understanding of HCV testing and treatment. While the majority of participants expressed fear of HCV treatment side effects, 88% accepted HCV RNA testing and 78% expressed willingness to start HCV treatment with the majority of chronically infected choosing to start HCV treatment medications. Study limitations and implications are discussed.

Carpentier PJ; van Gogh MT; Knapen LJM; Buitelaar JK; De Jong CAJ. Influence of Attention Deficit Hyperactivity Disorder and Conduct Disorder on opioid dependence severity and psychiatric comorbidity in chronic methadone-maintained patients. European Addiction Research 17(1): 10-20, 2011. (60 refs.)

Background: Persistent attention deficit hyperactivity disorder (ADHD) and a history of conduct disorder (CD) are highly prevalent among patients with substance use disorders (SUD). We examined the influence of both diagnoses on problem severity, psychiatric comorbidity, and quality of life in methadone-maintained patients. Methods: 193 patients in long-term methadone maintenance treatment (MMT) were assessed for ADHD through a semi-structured interview. Psychiatric disorders and SUD were assessed with the MINI, the CIDI-SAM, and the SIDP-IV. Results: Childhood ADHD was diagnosed in 68 (35.2%) patients; 48 (24.9%) had persisting ADHD; a CD history was present in 116 (60.1%). Patients with adult ADHD had significantly higher problem severity scores, lower quality of life scores, more comorbid SUD and more psychiatric comorbidity. Although both ADHD and CD contributed to problem severity, addictive pathology and psychopathology, ADHD was found to substantially increase the risk of psychiatric comorbidity, independent of CD. Conclusion: ADHD in MMT patients is characterised by greater addiction severity and more comorbid psychopathology, only partly explained by the influence of a coexisting CD. The presence of ADHD in a substantial minority of patients accentuates the need for early detection and treatment of this complicating disorder.

Che YH; Assanangkornchai S; McNeil E; Li JH; You J; Chongsuvivatwong V. Patterns of attendance in methadone maintenance treatment program in Yunnan Province, China. American Journal of Drug and Alcohol Abuse 37(3): 148-154, 2011. (28 refs.)

Objective: To describe the patterns of patients' attendance over the first three quarters of a year under methadone maintenance treatment (MMT) clinics in Yunnan Province, China. Methods: Data were obtained from drug abuse treatment databases from five MMT clinics in Yunnan Province. Patients registered between April 2007 and December 2007 were included in the analysis. The study period was divided into three phases consisting of 3 months each. Logistic regression was used to predict factors determining whether the patients attended the clinic on each day with repetition of the patients taken into account. Results: The median number of days attending the clinics was 61 in the total treatment period, and the likelihood of a patient attending the clinic in the second and third phases was significantly less [odds ratio (OR) = .44 and .30, 95% confidence interval (CI) = .40-.49 and .26-.34] compared with the first phase. The predictors for attendance at clinic were being unmarried (OR = .63, 95% CI = .49-.82), self-employed (OR = .18, 95% CI = .11-.28), having a history of syringe sharing (OR = .67, 95% CI = .48-.92), and having been in a detoxification program (OR = 1.59, 95% CI = 1.09-2.33). Conclusion: Heroin users attended MMT programs irregularly and their periods of attendance significantly declined by duration of the time they stayed in the treatment program. Additional interventions should be employed to help patients adhere to this long-term treatment program.

Chen IC; Chie WC; Hwu HG; Chou SY; Yeh YC; Yu CY et al. Alcohol use problem among patients in methadone maintenance treatment in Taiwan. Journal of Substance Abuse Treatment 40(2): 142-149, 2011. (29 refs.)

Aims: To examine the prevalence rate and predictors of alcohol use problems among patients undergoing methadone maintenance treatment (MMT). Design: This was a prospective follow-up study. Participants: Study population included 438 patients who underwent more than 6 months of MMT. Measurements: Demographic and clinical characteristics were collected for each patient prior to treatment, and treatment-related variables were collected during treatment process. Hazardous drinking, alcohol abuse, and dependence were measured using a Chinese version of the Alcohol Use Disorders Identification Test (AUDIT) and by measuring breath alcohol concentration. Findings: The prevalence rates of alcohol use problems, indicated by hazardous drinking are 31.4%. The protective predictors of alcohol use problems among MMT patients include an attendance rate of more than 90% (odds ratio [OR] = 0.54,95% confidence interval [Cl] = 0.30-0.97) and being older than 36 years (OR = 0.48, 95% CI = 0.27-0.86), and alcohol drinking problem at intake of study is a risk factor (OR = 5.30, 95% Cl = 2.87-9.76). Conclusions: High attendance rate, which is regarded as a component of clinical policy and a key component of therapeutic context, should be incorporated with brief interventions to lower alcohol use problems among MMT patients.

Cohen-Moreno R; Schiff M; Levitt S; Bar-Hamburger R; Strauss S et al. Knowledge about Hepatitis-C among methadone maintenance treatment patients in Israel. Substance Use & Misuse 45(1/2): 58-76, 2010. (71 refs.)

Ignorance about Hepatitis-C (HCV) among drug users, treatment staff, and policy makers thwarts treatment uptake and facilitates virus transmission. We assessed knowledge about HCV among methadone patients in Israel, where effective HCV-treatment is provided at low-cost within the national health insurance framework, yet few infected methadone patients are treated. In 2006, 5 12 patients in two methadone clinics in Israel were interviewed, of whom 53% were HCV-positive. The clinics were purposively selected from the 11 methadone clinics in the country. Respondents exhibited poor knowledge about HCV particularly about diagnosis and treatment. Lesser-educated respondents were three times more likely to score low on HCV-knowledge compared to those with 12+ years of schooling (AOR = 2.97, 95% CI = 1.5-5.7. HCV-negative patients were also three-times more likely than HCV-positive patients to score low on the HCV-knowledge scale (Adjusted Odds Ratio = 3.0, 95% Confidence Interval = 1.9-4.7). Enhancing HCV-knowledge may help patients avoid becoming infected and infecting others, allay exaggerated fears about hepatitis, and facilitate HCV-treatment initiation among those infected.

Comiskey CM; Cox G. Analysis of the impact of treatment setting on outcomes from methadone treatment. Journal of Substance Abuse Treatment 39(3): 195-201, 2010. (11 refs.)

How methadone setting, duration of drug career, and dose impact on treatment are assessed. Two hundred fifteen participants were recruited. revealed significant reductions in drug use at I year within all settings, but the pattern varied. Proportions using heroin reduced in all settings, unprescribed benzodiazepines reduced in community, and general practitioner settings and cocaine use reduced in community and Government health board settings. A logistic model controlling for intake methadone dose, setting, previous treatments, and intake heroin use revealed that setting was a significant factor in predicting heroin use at I year but was not significant in predicting changes in health. Findings illustrate that drug outcomes improved across all settings, and health did not improve in any setting. For optimum outcomes to be achieved, opiate users must be directed to settings that best match their needs and that the "one-stop-shop for methadone" is not the most effective solution.

Coviello DM; Zanis DA; Wesnoski SA; Lynch KG; Drapkin M. Characteristics and 9-month outcomes of discharged methadone maintenance clients. Journal of Substance Abuse Treatment 40(2): 165-174, 2011. (52 refs.)

This study is a secondary data analysis of a clinical trial assessing the effectiveness of outreach case management (OCM) in linking discharged methadone patients back into treatment. The original trial assessed the effectiveness of the OCM intervention compared to a passive referral among methadone clients who needed treatment postdischarge but had not reengaged. The purpose of this study was to assess the characteristics and long-term outcomes of all clients who were discharged from methadone maintenance treatment including those who had reengaged in treatment. A total of 230 methadone clients were interviewed 3 months and then again at 9 months following discharge from treatment. Compared with participants who needed treatment but had not reengaged (NoTx: 56%), those who had successfully reenrolled in treatment (Tx; 44%) were more likely to be female, not married, and unemployed; had a longer history of sedative use; reported more psychiatric hospitalizations; and were originally enrolled in a community-based rather than a Veterans Administration program. Despite having more severe problems, the Tx group had fewer opioid-positive urines and reported less IV drug use at 9 months postdischarge compared to the NoTx group. The findings highlight the importance of rapid treatment reengagement.

De Maeyer J; Vanderplasschen W; Lammertyn J; van Nieuwenhuizen C; Sabbe B; Broekaert E. Current quality of life and its determinants among opiate-dependent individuals five years after starting methadone treatment. Quality of Life Research 20(1): 139-150, 2011. (103 refs.)

This study explores the current QoL of opiate-dependent individuals who started outpatient methadone treatment at least 5 years ago and assesses the influence of demographic, psychosocial, drug and health-related variables on individuals' QoL. Participants (n = 159) were interviewed about their current QoL, psychological distress and severity of drug-related problems, using the Lancashire Quality of Life Profile, the Brief Symptom Inventory and the Addiction Severity Index. Potential determinants of QoL were assessed in a multiple linear regression analysis. Five years after the start of methadone treatment, opiate-dependent individuals report low QoL scores on various domains. No association was found between drug-related variables and QoL, but a significant negative impact of psychological distress was identified. Severity of psychological distress, taking medication for psychological problems and the inability to change one's living situation were associated with lower QoL. Having at least one good friend and a structured daily activity had a significant, positive impact on QoL. Opiate-dependent individuals' QoL is mainly determined by their psychological well-being and a number of psychosocial variables. These findings highlight the importance of a holistic approach to treatment and support in methadone maintenance treatment, which goes beyond fixing the negative physical consequences of opiate dependence.

dHiltunen AJ; Eklund C; Borg S. The first 38 methadone maintenance treatment patients in Stockholm: 15-year follow-up with a main focus on detoxification from methadone. Nordic Journal of Psychiatry 65(2): 106-111, 2011. (23 refs.)

Background/aims: The present study investigated the first 38 methadone maintenance treatment (MMT) patients in Stockholm. The aim was: (i) to investigate the possible predictive factors for successful treatment termination, and (ii) the long-term outcome effects and life situation of MMT patients and those who terminated the treatment. Methods: The patients were interviewed at the start and approximately 15 years later, and divided into four groups: (1) no withdrawal attempts, (2) forced to stop the treatment, (3) successful tapering and (4) non-successful tapering. Results: The predictive factor found that Group 1 showed a lower life quality compared with Groups 3 and 4. Fifteen years later, the life situations of Groups 3 and 4 were significantly more stable. Also the subjective well-being in Group 3 was significantly higher. Over all, Group 2 showed significantly more illicit drug use compared with Group 3. The social life situation was significantly improved for all patients during the 15 years. Conclusion: This study confirms our earlier findings that the ultimate goal of MMT for the motivated patients with good progress should be an opiate-free life. The life situation and subjective well-being seems to be higher after successful termination of MMT.

Dursteler-MacFarland KM; Vogel M; Wiesbeck GA; Petitjean SA. There is no age limit for methadone: A retrospective cohort study. Substance Abuse Treatment Prevention and Policy 6(e-article 9), 2011. (72 refs.)

Background: Data from the US indicates that methadone-maintained populations are aging, with an increase of patients aged 50 or older. Data from European methadone populations is sparse. This retrospective cohort study sought to evaluate the age trends and related developments in the methadone population of Basel-City, Switzerland. Methods: The study included methadone patients between April 1, 1995 and March 31, 2003. Anonymized data was taken from the methadone register of Basel-City. For analysis of age distributions, patient samples were split into four age categories from '20-29 years' to '50 years and over'. Cross-sectional comparisons were performed using patient samples of 1996 and 2003. Results: Analysis showed a significant increase in older patients between 1996 and 2003 (p < 0.001). During that period, the percentage of patients aged 50 and over rose almost tenfold, while the proportion of patients aged under 30 dropped significantly from 52.8% to 12.3%. The average methadone dose (p < 0.001) and the 1-year retention rate (p < 0.001) also increased significantly. Conclusions: Findings point to clear trends in aging of methadone patients in Basel-City which are comparable, although less pronounced, to developments among US methadone populations. Many unanswered questions on medical, psychosocial and health economic consequences remain as the needs of older patients have not yet been evaluated extensively. However, older methadone patients, just as any other patients, should be accorded treatment appropriate to their medical condition and needs. Particular attention should be paid to adequate solutions for persons in need of care.

Eiroa-Orosa FJ; Haasen C; Verthein U; Dilg C; Schafer I; Reimer J. Benzodiazepine use among patients in heroin-assisted vs methadone maintenance treatment: Findings of the German randomized controlled trial. Drug and Alcohol Dependence 112(3): 226-233, 2010. (32 refs.)

Benzodiazepine (BZD) use has been found to be associated with poorer psychosocial adjustment higher levels of polydrug use and more risk-taking behaviors among opioid dependent patients. The aim of this paper is to analyze the correlation between BZD use BZD prescription and treatment outcome among participants in the German trial on heroin-assisted treatment. 1015 patients who participated in the study comparing heroin-assisted and methadone maintenance treatment (HAT & MMT) for 12 months were included in the analysis. Analyses were carried out to assess the association of treatment outcome with baseline BZD use with ongoing BZD use and with different patterns of BZD prescription. Baseline BZD use correlated with lower retention rates but not with poorer outcome Ongoing BZD use correlated with poorer outcomes Significantly better outcomes were found in the course of phobic anxiety symptomatology for those with regular prescription of BZD. The percentage of BZD positive urine tests decreased more in HAT than in MMT. Poorer outcome for benzodiazepine users may be mediated by a higher severity of addiction. Cautious prescribing of benzodiazepines may be beneficial due to the reduction of overall illicit use.

Engstrom M; Shibusawa T; El-Bassel N; Gilbert L. Age and HIV sexual risk among women in methadone treatment. AIDS and Behavior 15(1): 103-113, 2011. (89 refs.)

This study examines the relationship between age and HIV sexual risk behaviors among a random sample of 372 women in methadone treatment in New York City. Logistic regression results indicate that women of all ages are at risk for HIV through inconsistent condom use. Exposure to intimate partner violence (IPV), alcohol use, and HIV-negative status are associated with inconsistent condom use during vaginal sex. Age (35-44), having a main sexual partner with an HIV risk factor, IPV, and alcohol use are associated with using crack or cocaine during sex. Similarly, age (35-44), having a main sexual partner with an HIV risk factor, IPV, and drug use are associated with consuming four or more drinks prior to sex. The findings highlight the importance of age-appropriate HIV prevention and intervention strategies, as well as the need to address intimate partner violence, mental health, polysubstance use, and relational factors associated with HIV sexual risk behaviors among women in methadone treatment.

Fareed A; Vayalapalli S; Stout S; Casarella J; Drexler K; Bailey SP. Effect of methadone maintenance treatment on heroin craving, a literature review. (review). Journal of Addictive Diseases 30(1): 27-38, 2011. (61 refs.)

Despite agreement that methadone maintenance treatment (MMT) is an effective and safe option for treatment of heroin dependence, there have been controversies about its effect on heroin craving. A systematic literature review of the PubMed database was used to find studies eligible for inclusion in the study. The authors present the results of 16 articles that met all inclusion criteria. Overall, 7 studies reported that methadone could reduce heroin craving, 4 studies reported that patients in MMT are still at risk of having heroin craving, 1 study reported that methadone could increase heroin craving, and 4 studies reported that methadone has a neutral effect on heroin craving. One may speculate from these data that methadone may help with heroin craving, but patients in MMT may still be at risk of cue-induced heroin cravings. Methadone provides a helpful tool for reducing some components of craving and risk of relapse for patient receiving MMT.

Farnia M; Ebrahimi B; Shams A; Zamani S. Scaling up methadone maintenance treatment for opioid-dependent prisoners in Iran. International Journal of Drug Policy 21(5): 422-424, 2010. (24 refs.)

Background: Research evidence indicates that prisoners in Iran are at risk of drug-related harm, including acquisition of blood-borne infections. In response, several prevention interventions including methadone maintenance treatment (MMT) have been introduced into prisons in Iran. Methods: This report reviews and presents some important information extracted from published articles, and available documents on HIV sentinel surveillance and provision of MMT inside correctional settings in Iran. Results: Biological surveillance data in 2005 showed that on average about 3% of prisoners in the country tested positive for HIV infection. MTT that constitutes a main component of the Prison Organisation's HIV prevention package is becoming increasingly accessible to opioid-dependent prisoners. Between 2002 and 2008, the number of opioid-dependent prisoners receiving MMT increased steadily from 100 to more than 25000. Conclusion: Experiences in Iran suggest that access to MMT would be helpful for reducing illicit drug injection in a prison setting and can be considered as a major intervention for preventing the transmission of blood-borne infections among prisoners.

Felsen UR; Fishbein DA; Litwin AH. Low rates of hepatitis A and B vaccination in patients with chronic hepatitis C at an urban methadone maintenance program. Journal of Addictive Diseases 29(4): 461-465, 2010. (16 refs.)

Patients with chronic hepatitis C virus (HCV) are at increased risk for complications of liver disease if they become infected with the hepatitis A (HAV) or hepatitis B (HBV) viruses. The authors examined the rates of testing for HAV, HBV, and HCV, as well as rates of vaccination against HAV and HBV in patients with chronic HCV in a random sample (N = 207) of medical records of patients enrolled in a methadone maintenance program. Almost all patients reviewed were tested for HAV, HBV, and HCV. Of the 111 patients with chronic HCV, 53 (48.6%) and 68 (63%) lacked immunity to HAV and HBV, respectively. Of those lacking immunity, 29 (54.7%) and 2 (2.9%) were vaccinated for HAV and HBV, respectively. Despite high rates of testing for HAV, HBV, and HCV at a methadone maintenance program, approximately half of those with chronic HCV eligible for the HAV vaccine received it, and few of those eligible for HBV vaccine received it.

Fonseca F; de la Torre R; Diaz L; Pastor A; Cuyas E; Pizarro N et al. Contribution of cytochrome P450 and ABCB1 genetic variability on methadone pharmacokinetics, dose requirements, and response. PLoS ONE 6(5): e19527, 2011. (76 refs.)

Although the efficacy of methadone maintenance treatment (MMT) in opioid dependence disorder has been well established, the influence of methadone pharmacokinetics in dose requirement and clinical outcome remains controversial. The aim of this study is to analyze methadone dosage in responder and nonresponder patients considering pharmacogenetic and pharmacokinetic factors that may contribute to dosage adequacy. Opioid dependence patients (meeting Diagnostic and Statistical Manual of Mental Disorders, [4(th) Edition] criteria) from a MMT community program were recruited. Patients were clinically assessed and blood samples were obtained to determine plasma concentrations of (R, S)-, (R) and (S)-methadone and to study allelic variants of genes encoding CYP3A5, CYP2D6, CYP2B6, CYP2C9, CYP2C19, and P-glycoprotein. Responders and nonresponders were defined by illicit opioid consumption detected in random urinalysis. The final sample consisted in 105 opioid dependent patients of Caucasian origin. Responder patients received higher doses of methadone and have been included into treatment for a longer period. No differences were found in terms of genotype frequencies between groups. Only CYP2D6 metabolizing phenotype differences were found in outcome status, methadone dose requirements, and plasma concentrations, being higher in the ultrarapid metabolizers. No other differences were found between phenotype and responder status, methadone dose requirements, neither in methadone plasma concentrations. Pharmacokinetic factors could explain some but not all differences in MMT outcome and methadone dose requirements.

Go F; Dykeman M; Santos J; Muxlow J. Supporting clients on methadone maintenance treatment: A systematic review of nurse's role. Journal of Psychiatric and Mental Health Nursing 18(1): 17-27, 2011. (42 refs.)

Accessible summary Nurses, regardless of where they practice need to play a major role in providing holistic care for persons who participate in methadone maintenance treatment programmes. Nursing tasks that were found to rank as the most important when caring for clients on methadone maintenance treatment were: to administer methadone, to observe the patient's general condition, to provide counselling, and offer ongoing support as needed. Nurses should be prepared to assess for drug dependency, screen for opiate use when high index of suspicion is present and assess for psychosocial factors. Furthermore, nurses should be also knowledgeable about appropriate dosage of methadone and its efficacy, as well as support case management and outreach interventions. Nurses need to know enough about addiction and methadone maintenance therapy to be able to gain an understanding of the client's attitude and perceptions regarding addiction and the treatment process. Abstract This paper discusses findings from a systematic review of literature pertaining to methadone maintenance in relation to the role of the nurse working in a general practice setting. Five electronic databases were searched for period of 2000-2008: Medline, CINAHL, Embase, PsycINFO and Cochrane Database of Systematic Reviews. Included studies were peer-reviewed literature articles that: (1) were dated no earlier than the year 2000; (2) represented a primary study (qualitative and quantitative), systematic review or meta-analysis; (3) focused on methadone maintenance for treatment of opiate dependence, not for pain; and (4) were published in English. In this review, three broad themes emerged as being significant to the role of the nurse in relation to methadone maintenance treatment (MMT) programming. These themes included: (1) identifying the client's personal characteristics; (2) having knowledge about methadone; and (3) supporting clients in MMT programmes. In conclusion, it is important to address the needs of health professionals working with clients on MMT, in order for them to provide the necessary care for this patient population. In particular, nurses need to gain knowledge about MMT to assist them in carrying out their nursing role competently when caring for this vulnerable population.

Guo S; Winslow M; Manning V; Thane KKW. Monthly take-home methadone maintenance regime for elderly opium-dependent users in Singapore. Annals of the Academy of Medicine (Singapore) 39(6): 429-434, 2010. (28 refs.)

Introduction: Research suggests that methadone maintenance treatment (MMT) effectively reduces opiate dependence and related health and social problems. However, few studies have examined its effectiveness among the elderly. This study examined a monthly MMT regime for elderly opium addicts attending the National Addictions Management Service, Singapore. Materials and Methods: This study used a cross-sectional design and comprised 40 patients attending the addiction service and 40 caregivers who monitored methadone consumption (mostly patients' sons and daughters). Participants completed a semi-structured interview comprising measures of opiate craving and withdrawal, physical and psychological health. Objective measures were urine drug screens and blood tests. Results: Participants who averaged 74.8 years old had been using opium for around 44 years and had been in MMT for an average of 35 months. The maintenance dose of methadone was 9.2 mg/day. At interview, no opiate usage (other than methadone) was detected in urine screens; however, clinical records indicated that 6 had tested positive during the previous 6 months of MMT. No major withdrawal symptoms, side effects, or incidents of diversion were reported. Quality-of-life scores were in the normal range and satisfaction with the treatment regime was expressed by caregivers. Conclusion: Whilst MMT is the predominant pharmacotherapy for opiate dependence for users of all ages elsewhere, our study group constitutes a unique population that differs markedly from younger opiate users who will eventually grow old. In Singapore, MMT appears to be an effective treatment for stable, elderly opium-dependent patients where families are fully engaged in the treatment regime.

Hamilton R; McGlone L; MacKinnon JR; Russell HC; Bradnam MS; Mactier H. Ophthalmic, clinical and visual electrophysiological findings in children born to mothers prescribed substitute methadone in pregnancy. British Journal of Ophthalmology 94(6): 696-700, 2010. (24 refs.)

Background and aims: There are growing concerns regarding visual outcome of infants exposed to opiates (including substitute methadone) and/or benzodiazepines in utero. We describe the combined ophthalmology and visual electrophysiology findings in 20 infants and children who had been exposed to substitute methadone and other drugs of misuse in utero. Methods: This was a descriptive case series of 20 patients, all of whom had been referred to a paediatric visual electrophysiology service because of concerns regarding visual function, and all of whom had been exposed to methadone in utero. All children underwent a full ophthalmic and orthoptic examination as well as visual electrophysiology testing deemed appropriate on an individual basis. A review was undertaken of paediatric case notes and of maternal antenatal urine toxicology. Results: Ophthalmic abnormalities included reduced acuity (95%), nystagmus (70%), delayed visual maturation (50%), strabismus (30%), refractive errors (30%), and cerebral visual impairment (25%). Visual electrophysiology was abnormal in 60%. A quarter of the children had associated neurodevelopmental abnormalities. The majority of children with nystagmus (79%) had been treated for neonatal abstinence syndrome (NAS). Conclusion: Infants born to drug-misusing mothers prescribed methadone in pregnancy are at risk of a range of visual problems, the underlying causes of which are not clear. Those infants with NAS severe enough to receive pharmaceutical treatment may be at particular risk of developing nystagmus. The inclusion of visual electrophysiology in comprehensive visual assessment of children exposed to substance misuse in utero may help clarify the underlying causes by differentiating abnormalities of retinal and cortical origin.

Harris KA; Arnsten JH; Litwin AH. Successful integration of hepatitis C evaluation and treatment services with methadone maintenance. Journal of Addiction Medicine 4(1): 20-26, 2010. (30 refs.)

Objectives: Despite high rates of hepatitis C virus (HCV) infection, relatively few current or former injection drug users receive evaluation and treatment for HCV. Here, we demonstrate the feasibility and effectiveness of integrating HCV care and methadone maintenance treatment (MMT). We hypothesized that colocation of these services would result in improved access to and utilization of HCV care. Methods: In this retrospective observational study, all patient charts from a single MMT clinic were reviewed 2 years after HCV care and MMT were integrated. Information obtained included screening for and counseling about HCV infection status, on-site HCV treatment and outcomes, and demographic and substance abuse data. Results: Two hundred ninety-one patient charts were reviewed. Two hundred eighty-one (99%) patients were screened for HCV antibody (HCV-Ab), and 188 (65%) were positive. Forty-nine (17%) patients were HIV/HCV coinfected. Ninety-eight percent of the HCV-Ab-positive patients received HCV counseling. Hundred fifty-nine (85%) of the HCV-Ab-positive patients were eligible to receive further evaluation and treatment for HCV on site, and 125 (78%) accepted. Hundred eighteen (94%) patients were tested for chronic HCV, and 83 were determined to have chronic HCV. Twenty-five patients received liver biopsy; low-stage disease was found in 7 patients. Twenty-one patients initiated HCV treatment. Sustained viral response was achieved in 8 patients. Seventeen patients had contraindications to HCV treatment. Further workup was prevented or delayed in 45 patients for various reasons, most commonly due to personal choice (29 patients). Conclusions: This study demonstrates that current and former injection drug users can be engaged successfully in evaluation and treatment of HCV infection when these services are collocated with MMT.

Heinz AJ; Disney ER; Epstein DH; Glezen LA; Clark PI; Preston KL. A focus-group study on spirituality and substance-user treatment. Substance Use & Misuse 45(1/2): 134-153, 2010. (52 refs.)

Focus groups were conducted in 2005-2006 with 25 urban methadone-maintained outpatients to examine beliefs about the role of spirituality in addiction and its appropriateness informal treatment. Thematic analyses suggested that spirituality and religious practices suffered in complex ways during active addiction, but went "hand in hand" with recovery. Participants agreed that integration of a voluntary spiritual discussion group into formal treatment would be preferable to currently available alternatives. One limitation was that all participants identified as strongly spiritual. Studies of more diverse samples will help guide the development and evaluation of spiritually based interventions in formal treatment.

Igboekwu J; Wolff K. Methadone maintenance therapy and feto-maternal outcomes of pregnancy. Heroin Addiction and Related Clinical Problems 12(4): 17-21, 2010. (25 refs.)

We studied a cohort of pregnant opioid dependent women (n = 30) on methadone maintenance therapy aiming to identify obstetrics, neonatal and pregnancy outcomes and characteristics including the level of antenatal contact and its effect. There were statistical significant associations between birth weight and use of illicit drug and between use of illicit drugs and gestational age (crack use and length of labour r2 = .57 and r2 = .012. P = 0.05; Cocaine use and type of delivery r2 = .515 and r2 = .006. P = 0.05; Birth weight and length of gestation r2.429 and r2 = .041. p = 0.05).

Jariani M; Saaki M; Nazari H; Birjandi M. The effect of olanzapine and sertraline on personality disorder in patients with methadone maintenance therapy. Psychiatria Danubina 22(4): 544-547, 2010. (19 refs.)

Background: Various drugs have been suggested for treatment of Borderline Personality Disorder (BPD)-a disabling disease affecting two percent of the general population. If a drug could alleviate a wide range of symptoms, it would be more suitable. In these disorders drug addiction is very common. This fact makes the symptoms complicated and the treatment more difficult. Subjects and methods: This study is designed to evaluate the effect of Olanzapine and Sertraline in patients suffering from personality disorders who are on methadone maintenance therapy. This study is a clinical trial. 120 males and females were chosen for methadone maintenance therapy through interview by a psychiatrist based on DSM-IV-TR diagnostic criteria for BPD. Afterwards they were randomly divided into two groups. These groups separately received Olanzapine (5-10 mg daily) and Sertraline (50-100 mg daily) therapy. The SCL-90 questionnaire was filled by all participants before treatment and at the 4(th), 8(th) and 12(th) weeks of treatment. Results: According to this clinical trial, Olanzapine and Sertraline are effective in ameliorating symptoms of depression, anxiety and aggression, reducing sensitivity in interpersonal relationships and alleviating obsessive symptoms, pessimistic behaviors and somatization disorders in patients with personality disorders on methadone maintenance therapy. Conclusion: As result of this study it appears that Olanzapine and Sertraline are definitely effective in alleviating symptoms of patients with personality disorder, prescribing theses drugs are recommended for these patients.

Jarvinen M; Miller G. Methadone maintenance as last resort: A social phenomenology of a drug policy. Sociological Forum 25(4): 804-823, 2010. (42 refs.)

Drawing on qualitative interviews with drug addicts in Copenhagen, Denmark, this article offers a phenomenological reading of a methadone maintenance program. The program is set within the principles of harm reduction, meaning that its aim is not to cure the participants' addiction but to keep them stable on substitution medicine and slow the deterioration of their lives. We analyze the program's implications for participants' sense of agency and constraint and for their orientations toward the past, present, and future. A major concern is with the program as a last resort policy that challenges neoliberal ideals of self-governance and self-development. While the program increases the participants' sense of stability by providing them with methadone and by allowing them to better address their economic, housing, and other needs of everyday life, it also represents a context of physical, emotional, and social dependence. The interviews cast the program as a paradox that simultaneously increases participants' sense of stability and vulnerability. In essence, the Danish methadone program has the effect of both helping the participants by reducing the drug-related harm in their lives and of fostering conditions of inferiorization and enduring nonbecoming.

Jiao MD; Greanya ED; Haque M; Yoshida EM; Soos JG. Methadone maintenance therapy in liver transplantation. Progress In Transplantation 20(3): 209-214, 2010. (41 refs.)

Cirrhosis due to chronic infection with hepatitis C virus remains by far the most common reason for liver transplantation in North America. Currently, parenteral use of street drugs is the most common means of acquiring hepatitis C. Methadone maintenance therapy is an accepted form of treatment for chronic opiate (eg, heroin) addiction and, not surprisingly, a significant proportion of methadone-treated patients have chronic hepatitis C. The feasibility of liver transplant candidacy in hepatitis patients who require methadone maintenance therapy is controversial, and some transplant centers require patients to withdraw from such therapy in order for the transplant process to move forward. Thus stable patients with end-stage cirrhosis who are receiving methadone maintenance are left in a most difficult situation: discontinue methadone and accept the side effects of withdrawal with the risk of recidivism to use of street opiates, an absolute contraindication for transplantation, or continue methadone therapy and risk exclusion from the transplant process. The issue of methadone replacement therapy in end-stage cirrhosis and the posttransplant literature on the subject are explored in this paper.

Judson G; Bird R; O'Connor P; Bevin T; Loan R; Schroder M et al. Drug injecting in patients in New Zealand Methadone Maintenance Treatment programs: An anonymous survey. Drug and Alcohol Review 29(1): 41-46, 2010. (25 refs.)

Introduction and Aims. To investigate the prevalence and nature of injecting behaviour among patients on Methadone Maintenance Treatment (MMT) programs. Design and Methods. A self-reported questionnaire was handed to 423 patients enrolled in MMT across six clinics in the lower North Island of New Zealand. Results. A total of 151 patients responded, giving a 35.6% response rate. One hundred and twenty (79.5%) respondents reported they had injected methadone while enrolled in MMT, 84 (55.6%) had injected methadone in the last year and of those 43 (35.8%) had injected methadone in the last week. Reasons given for injecting of methadone included: rapid onset of effect, needle fixation and euphoria. Time on the methadone programme was negatively associated with ever injecting methadone [odds ratio (95% CI) 0.92 (0.85-0.99), P = 0.029] and injecting other substances [odds ratio (95% CI) 0.93(0.87-1.0), P = 0.046]. More frequent pharmacy-observed consumption was associated with increased injecting of other substances [odds ratio (95% CI) 1.32 (1.09-1.59), P = 0.005] but not methadone. The time a person had been enrolled on the methadone programme was associated with decreased use of other substances [odds ratio (95% CI) 0.93 (0.87-1.0), P = 0.046]. Discussion and Conclusions. Many individuals on MMT continue to inject their methadone. In this sample, the frequency of injection of methadone did not correlate with prescribed dose or takeaway arrangements. The beneficial impact of time on the programme emphasises the importance of retention in treatment. It is suggested that these results also indicate a need for routine education concerning safe injecting

Kahan M; Srivastava A; Conway B. Is there a need for heroin substitution treatment in Vancouver's downtown eastside? Canadian Journal of Public Health 102(2): 84- 86, 2011. (17 refs.)

The North American Opiate Medication Initiative (NAOMI) was a randomized controlled trial conducted in Vancouver and Montreal comparing heroin substitution treatment (HST) to methadone treatment (MT) for heroin addicts. The HST group had a higher treatment retention rate and lower illicit heroin use than the MT group. Despite the rigour with which the study was designed, systematic flaws have affected the interpretation of the results. In the MT arm, the dose was titrated slowly, contributing to the high early dropout rate. The mean maintenance dose was suboptimal. The investigators did not calculate on-treatment retention rates; by the end of the trial, more subjects were on MT than HST. Life-threatening events were more common in the HST than the MT group. Overall, the only clear advantage of HST over MT was its greater initial treatment attractiveness, resulting in more early drop-outs in the MT group. HST is intended for treatment-refractory addicts who have no other option but to use street heroin. Yet for most NAOMI subjects, the safest and most cost-effective approach is comprehensive MT or buprenorphine with optimal dosing, flexible program policies, and the provision of integrated primary care and social services. These proven strategies, currently lacking in Vancouver's Downtown Eastside, should be implemented before diverting already insufficient resources to HST, given its risks, cost and uncertain efficacy.

Karow A; Reimer J; Schafer I; Krausz M; Haasen C; Verthein U. Quality of life under maintenance treatment with heroin versus methadone in patients with opioid dependence. Drug and Alcohol Dependence 112(3): 209-215, 2010. (46 refs.)

Background: There is increasing evidence that health-related quality of life (HRQOL) is associated with a successful treatment and better outcome in opioid addiction. The aim of the present study was the longitudinal investigation of HRQOL in patients with severe dependence who were randomly assigned to four groups of medical and psychosocial treatment heroin (diacetylmorphine) versus methadone and case management (CM) versus psychoeducation (PSE) respectively. Methods: HRQOL (MSQoL) and physical health (OTI) were Investigated in 938 subjects who participated in the German multi-centre study examining the effects of heroin-assisted treatment in patients with severe opioid dependence. Data for the present analysis were taken from baseline and 12-month follow up. Results: Under both forms of maintenance and psychosocial treatment HRQOL improved significantly during the observation period. HRQOL improvement under maintenance with heroin exceeded improvement under methadone especially with regard to subjective physical health HRQOL improvement was significantly associated with better expert-rated physical health. Further analyses showed significant better improvement of HRQOL in subjects treated with PSE compared with CM. Conclusions: The advantage of heroin with regard to the improvement of HRQOL may be partially explained by a better Improvement of physical health under maintenance with heroin compared with methadone which highlights the importance of a comprehensive model of health care for patients with severe opioid dependence. Future studies need to investigate the benefits of PSE for patients in maintenance therapy.

King A. Service user involvement in methadone maintenance programmes: The 'philosophy, the ideal and the reality'. Drugs: Education, Prevention and Policy 18(4): 276-284, 2011. (30 refs.)

Internationally, service user involvement has become a common feature of public policy and more specifically public health policy in the recent decades. In a general context, the involvement of service users in health services has been well documented; however, less evidence is available within the area of drug treatment service provision. This study, which was conducted in Ireland, sought to address this gap in the knowledge and understanding of service user involvement within this setting. Qualitative in-depth interviews were undertaken with a broad range of participants. The sample, which totalled 20 individuals, comprised both service users and service providers. Meanings, and mechanisms of and limits to user involvement were explored. This study highlights the ambiguity that exists between policy recommendations on service user involvement and actual practice within treatment services. Although, participants acknowledged that services could and should learn from the individual and collective experiences of service users, they were found to be passive players in planning, developing, evaluating and delivering the services they received. The study suggests that in order to change the rhetoric of policy recommendations into a reality within this context, a much more committed approach which includes the education and training of all involved in drug treatment services is required.

Li L; Sangthong R; Chongsuvivatwong V; McNeil E; Li JH. Multiple substance use among heroin-dependent patients before and during attendance at methadone maintenance treatment program, Yunnan, China. Drug and Alcohol Dependence 116(1-3): 246-249, 2011. (24 refs.)

Background: Multiple substance use is a common problem among heroin users. This study aims to describe patterns of multiple substance use one year before and during attendance at methadone maintenance treatment (MMT) programs and associated variables of continued heroin use in MMT clinics in Yunnan, China. Methods: The study was conducted among 168 heroin addicts who had received treatment for at least one year at two MMT clinics in Kunming city. A structured questionnaire, a medical record, and computer database were used to obtain history of substances use, significant clinical information, and treatment details, respectively. Results: Heroin, tobacco, and alcohol were the most commonly used substances both before and during MMT. After one year in MMT, use of heroin, alcohol, tramadol, and triazolam significantly decreased whereas use of ephedrine increased. Simultaneous substance use was halved but the decrease was not statistically significant. The proportion of injecting users was reduced from 61% to 43%. History of heroin use in the preceding 6 months during MMT increased the odds of continued heroin use (OR = 5.8, 95% Cl =12.9-11.3]). An average 10 mg higher methadone dose increment was associated with a reduced odds of heroin use by 10%. Conclusion: MMT did not reduce the number of substances used, but the number of injecting heroin users after the first year of treatment decreased. Heroin use in the preceding.6 months during MMT treatment and lower methadone dose were associated with continued heroin use in MMT.

Li LH; Liu Y; Zhang YH; Beveridge TJR; Zhou WH. Temporal changes of smoking status and motivation among Chinese heroin-dependent, methadone-maintained smokers. Addictive Behaviors 35(10): 861-865, 2010. (36 refs.)

Introduction: The rates of cigarette smoking remain extremely high in active heroin users and methadone-maintained patients. It remains undetermined whether smoking status and motivation would be differentially affected by heroin and methadone administration. Methods: Heroin-dependent, methadone-maintained patients were recruited in the present studies. A battery of self-report questionnaires was used in the current study, in order to assess smoking status and motivations before first heroin use, during active heroin use and after Methadone Maintenance Treatment (MMT) admission. Results: An extremely high portion of participants started smoking before first heroin use. The highest level of cigarette smoking was found during the period of active heroin use, and cigarette consumption was reported to decrease after MMT admission. A wide range of smoking motivations were found before first heroin use. Moreover, "maintaining heroin pleasure" was the primary motivation for the increase in cigarette consumption during the period of active heroin use and 1 h after heroin administration, while "habitual smoking" was the primary smoking motivation before first heroin use and after MMT admission respectively. Conclusions: The present study first demonstrated that the prolonged rewarding effect of heroin following cigarette smoking may account for the increase of nicotine consumption found in the heroin-dependent patients. It appears that heroin and methadone differentially influenced smoking status and motivation among heroin-dependent, methadone-maintained patients.

Lin C; Wu Z; Detels R. Family support, quality of life and concurrent substance use among methadone maintenance therapy clients in China. Public Health 125(5): 269-274, 2011. (23 refs.)

Objectives: The methadone maintenance therapy (MMT) programme has been scaled up rapidly in China. This study explored the family support perceived by MMT clients and its association with their quality of life and concurrent illicit drug use. Study design: Cross-sectional study. Methods: Five hundred and sixty MMT clients were selected at random from 28 MMT clinics and services in Zhejiang and Jiangxi Provinces, China for participation in a face-to-face interview study. The participants' perceived family support and quality of life were measured through face-to-face structured interviews conducted by trained interviewers. Self-reported information about illicit drug use was obtained from clients. Urine specimens were collected from the participants to test for heroin use. Results: Among the 560 participants, 471 (84.1%) were male and 168 (30.0%) were unemployed at the time of the study. In total, 398 (71.1%) were injecting drug users and 309 (55.2%) had a history of drug use of more than 10 years. Around one-third (n = 211, 37.7%) of the participants reported concurrent illicit drug use or had a positive urine test. Perceived family support was associated with increased physical health, psychological health, environmental health and social health. In addition, perceived family support was negatively correlated with concurrent substance use. Conclusions: Drug use and MMT is a family issue in China. Based on the findings of this study, it is suggested that involving family members in recruitment and interventions of the MMT programme will achieve higher rates of participation and compliance.

Lin CQ; Wu ZY; Rou KM; Yin WY; Wang CH; Shoptaw S et al. Structural-level factors affecting implementation of the methadone maintenance therapy program in China. Journal of Substance Abuse Treatment 38(2): 119-127, 2010. (47 refs.)

This study identifies structural-level factors influencing methadone maintenance therapy (MMT) program implementation in China. Twenty-eight service providers and 560 randomly selected clients from 28 MMT clinics in the study area underwent face-to-face interviews. Number of clients, retention rate, coverage, and structural-level factors were collected from a survey of service providers. Individual-level factors and self-reported illicit drug use information were obtained from clients. Urine specimens were collected from the client participants to test for heroin use. Clinics affiliated with the local Centers for Disease Control and Prevention (CDC) had more clients, higher retention rates, and broader coverage than those not affiliated with the CDC. Longer operating hours, incentive for compliant clients, and comprehensive services were positively associated with client recruitment and coverage. Comprehensive services and incentives for compliant clients were negatively associated with concurrent illicit drug use. Comprehensive services should be incorporated into the MMT program. Extended operating hours and incentives for compliant clients should be implemented.

Liu AJW; Jones MP; Murray H; Cook CM; Nanan R. Perinatal risk factors for the neonatal abstinence syndrome in infants born to women on methadone maintenance therapy. Australian & New Zealand Journal of Obstetrics & Gynaecology 50(3): 253-258, 2010. (31 refs.)

Background: Neonatal abstinence syndrome (NAS) occurs in more than 50% of infants exposed to intrauterine opiates. Maternal opiate dosing has been investigated with conflicting results. Aims: The aims of this study were to correlate maternal methadone dose and other risk factors with the development of NAS requiring pharmacological treatment by using easily accessible clinical parameters. Methods: Retrospective medical record review of data from 228 opioid dependent pregnant women who delivered 232 live-born infants. Logistic regression analysis was performed on maternal, perinatal and neonatal parameters to identify risk factors for NAS requiring treatment. A prediction model was developed and validated on a separate independent cohort of 188 infants. Results: Of the 232 infants, 172 (74%) infants were treated for NAS. The risk of withdrawal increased by 17% per 5 mg increment of the last maternal methadone dose. The risk was lower for younger gestational ages and for those delivered by Caesarean section compared to those delivered by normal vaginal delivery. Through predictive modeling, gestational age, mode of delivery and last methadone dose were established as risk factors for withdrawal. The model was validated by other statistical measures and its diagnostic performance confirmed on the separate independent cohort. Conclusions: Our data suggests that timing and mode of delivery as well as last maternal methadone dose are significant risk factors for the development of NAS requiring treatment. Based on these clinical parameters, risk stratification for perinatal management of pregnancies associated with opioid dependency and risk prediction for the neonate might now be possible.

Lobmaier PP; Kunoe N; Waal H. Treatment research in prison: Problems and solutions in a randomized trial. Addiction Research & Theory 18(1): 1-13, 2010. (60 refs.)

Opioid-dependent individuals are frequently incarcerated and relapse rates following their release are high. Evidence of the effectiveness of prison-based treatments and community aftercare is limited. We report the preliminary findings of a randomized controlled trial that encountered specific challenges inherent in prison research. Naltrexone implants were compared with methadone maintenance treatment among pre-release inmates. Naltrexone implants have not previously been evaluated in prison settings. Approximately 41% of eligible inmates volunteered to participate; 27 of the total 46 participants commenced treatment according to the protocol. Although most inmates intended to remain abstinent from heroin after their release, the relapse rates among individuals who had not commenced treatment were high. Naltrexone implants were regarded as a valuable treatment option. During the study, several problems were encountered regarding enrollment, treatment initiation and aftercare. These findings have important implications for future prison research. Random allocation to the fixed interventions was inefficient in limiting the risk of selection bias. Alternative approaches should be considered, such as sequential multiple assignment randomized trials.

Madden ME; Shapiro SL. The methadone epidemic: Methadone-related deaths on the rise in Vermont. American Journal of Forensic Medicine and Pathology 32(2): 131- 135, 2011. (29 refs.)

The prevalence of methadone-related overdose deaths is increasing worldwide and has been a topic of recent debate. Methadone-related deaths, to this point, have not been systematically reviewed in the state of Vermont. All of the methadone-related fatalities from 2001 to 2006 (total, 76 cases), which were examined by the Vermont Office of the Chief Medical Examiner were retrospectively reviewed. The mean age of the decedents was 36 years (range, 16-74 years), and 72% were male. The manners of death were classified as follows: 84% accident, 12% undetermined, and 4% suicide. The mean level of methadone was 457 ng/mL (range, 50-3793 ng/mL). The substances causing death were determined to be methadone alone in 26 (34%), methadone with only other prescribed medications in 29 (38%), methadone with only illicit drugs (excluding tetrahydrocannabinol) in 13 (17%), methadone with both illicit and prescribed medications in 5 (7%), and methadone with ethanol in 3 (4%). The methadone was obtained by illegal diversion (sale, gift, or theft) in 67% of cases. In the remaining cases (33%), the methadone was obtained by physician's prescription for chronic pain (60%), acute pain or injury (8%), methadone maintenance therapy for heroin dependence (8%), and unknown reasons (24%). The number of overdose deaths has increased 4-fold from 2001 (17 deaths) to 2006 (79 deaths). The proportion of methadone-related deaths has increased by 300% from 2001 (0.6% of reported deaths, 12% of overdose deaths) to 2006 (3% of reported deaths, 37% of overdose deaths). Methadone maintenance therapy for heroin dependence in our population comprises an insignificant number of the methadone-related deaths (3% of the decedents). In Vermont, the populations most at risk are those taking methadone for chronic pain and those obtaining diverted methadone for abuse. Education of clinicians regarding the increasing number of methadone-related deaths, the potential for abuse and diversion, and the pharmacokinetics of methadone may help halt this epidemic and reduce the number of fatalities from this drug.

McCarty D; Perrin NA; Green CA; Polen MR; Leo MC; Lynch F. Methadone maintenance and the cost and utilization of health care among individuals dependent on opioids in a commercial health plan. Drug and Alcohol Dependence 111(3): 235-240, 2010. (18 refs.)

Background: Few health plans provide maintenance medication for opioid dependence. This study assessed the cost of treating opioid-dependent members in a commercial health plan and the impacts of methadone maintenance on costs of care. Methods: Individuals with diagnoses of opioid dependence (two or more diagnoses per year) and at least 9 months of health plan eligibility each year were extracted from electronic health records for the years 2000 through 2004 (1,518 individuals and 2,523 observations across the study period-some individuals were in multiple years) Analyses examined the patterns and costs of health care for three groups of patients (1) one or more methadone visits during the year (n = 1 298; 51%) (2) no methadone visits and 0 or 1 visits in the Addiction Medicine Department (n = 370 15%) (3) no methadone visits and 2 or more visits in addiction medicine (n = 855, 34%) Results: Primary care (86%) emergency department (48%) and inpatient (24%) visits were common. Mean total annual costs to the health plan were $11,200 (2004 dollars) per member per year. The health plan's costs for members receiving methadone maintenance were 50% lower ($7,163) when compared to those with two or more outpatient addiction treatment visits but no methadone ($14,157) and 62% lower than those with one or zero outpatient addiction treatment visits and no methadone treatment ($18, 694) Conclusions: Use of opioid maintenance services was associated with lower total costs of care for opioid-dependent members in a commercial health plan.

Mitchell SG; Morioka R; Reisinger HS; Peterson JA; Kelly SM; Agar MH et al. Redefining retention: Recovery from the patient's perspective. Journal of Psychoactive Drugs 43(2): 99-107, 2011. (34 refs.)

This study examines the process of discharge and treatment reentry for six participants who entered treatment voluntarily but were administratively discharged from methadone treatment programs. The participants completed semistructured interviews at treatment entry and at four, eight and 12 months post-treatment entry. Grounded theory methodology was used to examine the phenomenon of treatment reentry from the perspective of the patients, who often viewed their recovery as an accumulation of positive changes. Differences in terms of the patients' goals and motivations for seeking treatment from those of the treatment programs, combined with difficulties encountered during the treatment process eventually led to discharge. However, these patients were then able to navigate their way through the treatment system in different ways in order to remain in treatment. The authors conclude that failure to abide by treatment clinic rules do not necessary constitute "treatment failure" from the perspective of patients, who often wish to remain in treatment even if it is not progressing optimally from the program's perspective. As a result, the recovery process can be more fragmented and is often characterized by a series of cyclical treatment episodes rather than continuous time in treatment, thereby impeding their progress towards recovery.

Mohamad N; Abu Bakar NH; Musa N; Talib N; Ismail R. Better retention of Malaysian opiate dependents treated with high dose methadone in methadone maintenance therapy. Harm Reduction Journal 7: e-article 30, 2010. (43 refs.)

Background: Methadone is a synthetic opiate mu receptor agonist that is widely used to substitute for illicit opiates in the management of opiate dependence. It helps prevent opiate users from injecting and sharing needles which are vehicles for the spread of HIV and other blood borne viruses. This study has the objective of determining the utility of daily methadone dose to predict retention rates and re-injecting behaviour among opiate dependents. Methods: Subjects comprised opiate dependent individuals who met study criteria. They took methadone based on the Malaysian guidelines and were monitored according to the study protocols. At six months, data was collected for analyses. The sensitivity and specificity daily methadone doses to predict retention rates and reinjecting behaviour were evaluated. Results: Sixty-four patients volunteered to participate but only 35 (54.69%) remained active and 29 (45.31%) were inactive at 6 months of treatment. Higher doses were significantly correlated with retention rate (p < 0.0001) and re-injecting behaviour (p < 0.001). Of those retained, 80.0% were on 80 mg or more methadone per day doses with 20.0% on receiving 40 mg -79 mg. Conclusions: We concluded that a daily dose of at least 40 mg was required to retain patients in treatment and to prevent re-injecting behaviour. A dose of at least 80 mg per day was associated with best results.

Nakchbandi IA. Commentary on Grey et al. (2011): Does methadone maintenance therapy adversely affect bone mass? (commentary). Addiction 106(2): 355-356, 2011. (16 refs.)

Neufeld K; Kidorf M; King V; Stoller K; Clark M; Peirce J et al. Using enhanced and integrated services to improve response to standard methadone treatment: Changing the clinical infrastructure of treatment networks. Journal of Substance Abuse Treatment 38(2): 170-177, 2010. (24 refs.)

Outcomes are presented from opioid-dependent outpatients (N = 81) participating in a new community-based initiative designed to improve access to enhanced substance abuse and psychiatric services in a publicly supported methadone maintenance treatment network in Baltimore, MD. The initiative, entitled Community Access to Specialized Treatment (CAST), is located at the Addiction Treatment Services, a program within this network. Network programs referred patients engaged in unremitting drug use who are at risk for discharge to CAST, where they received methadone substitution, individual and group counseling within an adaptive platform, behavioral contingencies to reinforce adherence, and on-site psychiatric evaluation and care. Patients returned to their referring program after producing at least two consecutive weeks of drug-negative urine samples and full counseling adherence. CAST was well utilized by the community. Patients had high rates of adherence to scheduled individual and group counseling services (93% and 73%, respectively); 43% of referrals successfully completed the program in an average of 101 days. This community-wide service delivery approach is a novel alternative to integrating intensive substance abuse and psychiatric care at each program within a treatment network.

Nyamathi A; Tyler D; Sinha K; Marfisee M; Cohen A; Greengold B. Predictors of hepatitis knowledge improvement among methadone maintained clients enrolled in a hepatitis intervention program. Journal of Community Health 35(4): 423-432, 2010. (44 refs.)

This randomized, controlled study (n = 256) was conducted to compare three interventions designed to promote hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination completion, among clients undergoing methadone maintenance treatment (MMT) in Los Angeles and Santa Monica. The participants were randomized into three groups: Motivational Interviewing-Single Session (MI-Single), Motivational Interviewing-Group (MI-Group), or Nurse-Led Hepatitis Health Promotion (HHP). All three treatment groups received the 3-series HAV/HBV vaccine. The MI sessions were provided by trained therapists, the Nurse-Led HHP sessions were delivered by a research nurse. The main outcome variable of interest was improvement in HBV and HCV knowledge, measured by a 6-item HBV and a 7-item HCV knowledge and attitude tool that was administered at baseline and at 6-month follow-up. The study results showed that there was a significant increase in HBV- and HCV-related knowledge across all three groups (p < 0.0001). There were no significant differences found with respect to knowledge acquisition among the groups. Irrespective of treatment group, gender (P = 0.008), study site (P < 0.0001) and whether a participant was abused as a child (P = 0.017) were all found to be predictors of HCV knowledge improvement; only recruitment site (P < 0.0001) was found to be a predictor of HBV knowledge. The authors concluded that, although MI-Single, MI-Group and Nurse-Led HHP are all effective in promoting HBV and HCV knowledge acquisition among MMT clients, Nurse-Led HHP may be the method of choice for this population as it may be easier to integrate and with additional investigation may prove to be more cost efficient.

Nyamathi AM; Nandy K; Greengold B; Marfisee M; Khalilifard F; Cohen A et al. Effectiveness of intervention on improvement of drug use among methadone maintained adults. Journal of Addictive Diseases 30(1): 6-16, 2011. (45 refs.)

The purpose of this study is to evaluate the effectiveness of three interventions (individual motivational interviewing, group motivational interviewing, or nurse-led hepatitis health promotion) in reducing drug use. A randomized, controlled trial was conducted with 256 methadone maintained moderate-to-heavy alcohol-using adults attending one of five MM outpatient clinics. Drug use in the overall sample was significantly reduced from baseline to 6-month follow-up, as assessed by a 30-day recall (p 0.0001), with a trend apparent for 6-month recall (p = 0.09). The group and individual programs revealed significant decreases in drug use at the 30-day recall.

Okoli CTC; Khara M; Procyshyn RM; Johnson JL; Barr AM; Greaves L. Smoking cessation interventions among individuals in methadone maintenance: A brief review. (review). Journal of Substance Abuse Treatment 38(2): 191-199, 2010. (47 refs.)

Background: Individuals in methadone maintenance treatment are motivated to quit smoking and are interested in smoking cessation treatment. However, few studies have assessed the efficacy of smoking cessation treatment for individuals undergoing methadone maintenance. The purpose of this article is to review interventions for tobacco use cessation among individuals in methadone maintenance with a particular emphasis on the components of such interventions and their effect on smoking cessation/reduction and drug use. Methods: A comprehensive search of six databases in June 2008 retrieved 584 research studies, which addressed smoking cessation interventions among individuals in substance use treatment. Of the retrieved articles, eight studies addressed smoking cessation among individuals undergoing methadone maintenance treatment. These studies were examined for effect of intervention on smoking cessation/reduction, gender differences in treatment outcomes, and the effect of the smoking cessation intervention on substance use behaviors. Results: Few studies demonstrated successful smoking abstinence among individuals in methadone maintenance treatment. Most interventions were associated with significant smoking reduction from baseline. Few studies assessed differences between men and women in smoking cessation treatment outcome. Smoking cessation treatment was not associated with increased substance use. Conclusions: To date, interventions among individuals in methadone treatment have been largely unsuccessful in achieving sustained smoking abstinence. However, smoking cessation treatment does not worsen substance use. Future studies are necessary to determine intervention designs and components that can enhance smoking cessation among individuals in methadone maintenance.

Oliver P; Keen J; Rowse G; Ewins E; Griffiths L; Mathers N. The effect of time spent in treatment and dropout status on rates of convictions, cautions and imprisonment over 5 years in a primary care-led methadone maintenance service. Addiction 105(4): 732-739, 2010. (21 refs.)

Background: Methadone maintenance treatment (MMT) in primary care settings is used increasingly as a standard method of delivering treatment for heroin users. It has been shown to reduce criminal activity and incarceration over periods of periods of 12 months or less; however, little is known about the effect of this treatment over longer durations. Aims To examine the association between treatment status and rates of convictions and cautions (judicial disposals) over a 5-year period in a cohort of heroin users treated in a general practitioner (GP)-led MMT service. Design: Cohort study. Setting: The primary care clinic for drug dependence, Sheffield, 1999-2005. Participants: The cohort comprised 108 consecutive patients who were eligible and entered treatment. Ninety were followed-up for the full 5 years. Intervention The intervention consisted of MMT provided by GPs in a primary care clinic setting. Measurements: Criminal conviction and caution rates and time spent in prison, derived from Police National Computer (PNC) criminal records. Findings: The overall reduction in the number of convictions and cautions expected for patients entering MMT in similar primary care settings is 10% for each 6 months retained in treatment. Patients in continuous treatment had the greatest reduction in judicial disposal rates, similar to those who were discharged for positive reasons (e.g. drug free). Patients who had more than one treatment episode over the observation period did no better than those who dropped out of treatment. Conclusions: MMT delivered in a primary care clinic setting is effective in reducing convictions and cautions and incarceration over an extended period. Continuous treatment is associated with the greatest reductions.

Pani PP; Maremmani I; Pacini M; Lamanna F; Maremmani AGI; dell'Osso L. Effect of psychiatric severity on the outcome of methadone maintenance treatment. European Addiction Research 17(2): 80-89, 2011. (67 refs.)

While psychiatric comorbidity has been shown to produce a negative impact on the outcome of opioid use disorders, longitudinal studies carried out in the context of methadone maintenance treatment programs (MMTP) to evaluate outcomes strictly linked to methadone efficacy have not demonstrated a similar negative influence. To verify whether results obtained considering psychopathology in terms of formal psychiatric diagnoses were replicated when assessing psychopathology in terms of global psychiatric severity, a retrospective cohort study was designed. 259 patients commencing methadone maintenance treatment were divided into two groups on the basis of SCL-90 severity score and compared for retention in treatment, toxicological urine test results and psychological/psychiatric status throughout a one year period of observation. The results of the study suggest that patients in MMTP with high psychiatric severity are not characterized by a lower retention in treatment or higher substance use than those with low psychiatric severity. Moreover, during treatment high severe psychiatric patient status appears to improve significantly for all psychological/ psychiatric dimensions explored by SCL-90. These results are consistent with those obtained in previous studies on the efficacy of MMTP, comprehensive of psychiatric care, irrespective of the severity of psychopathology exhibited by patients at the beginning of treatment.

Peles E; Schreiber S; Bar Hamburger R; Adelson M. No change of sleep after 6 and 12 months of methadone maintenance treatment. Journal of Addiction Medicine 5(2): 141- 147, 2011. (37 refs.)

Objective: To determine whether the methadone maintenance treatment (MMT) affects sleep. Methods: We prospectively followed up the sleep pattern of 23 opiate addicts when admitted to MMT and after 6 and 12 months of treatment. Pittsburgh Sleep Quality Index, pain self-report questionnaires, urine for drug abuse, and one-night sleep polysomnography were assessed. Results: The baseline sleep indices (sleep time [5.5 +/- 1.1 hours], sleep efficiency [80.6% +/- 10.5%], rapid eye movement [REM] stage percent of sleep [14.3% +/- 8.4%], percent of non-REM stage 3-4 [6.7% +/- 8.6%], and Pittsburgh Sleep Quality Index Scores [11.4 +/- 4.8]) did not change at 6 and 12 months. Proportion of patients with absent non-REM stage 3-4 reduced (47.8%, 34.8%, 13%, P = 0.03), and mean REM density increased (P = 0.04). Body mass index increased (24 +/- 4.2 kg/m(2), 25.7 +/- 4 kg/m(2), 27.1 +/- 4.8 kg/m(2), P < 0.0005) with no change in the rate of benzodiazepine abuse or chronic pain. No patient had central sleep apnea. The Respiratory Disturbance Index (apnea or hypopnea numbers/sleep hr) increased among 5 patients who increased >= 25% of their entry weight (3.4 +/- 4.1, 11.8 +/- 10.1, 29.6 +/- 30.4 Respiratory Disturbance Index's) but not with the other 18 (3.9 +/- 4.8, 6.2 +/- 6.2, 7.8 +/- 7.4). Conclusions: We conclude that MMT did not negatively affect the opiate addicts' baseline poor perceived and objective sleep. Only extensive weight gain (evident in a minority of patients) was associated with obstructive sleep apnea.

Peles E; Schreiber S; Hetzroni T; Adelson M; Defrin R. The differential effect of methadone dose and of chronic pain on pain perception of former heroin addicts receiving methadone maintenance treatment. Journal of Pain 12(1): 41-50, 2011. (54 refs.)

The reports on pain perception among former heroin addicts receiving methadone maintenance treatment (MMT) vary with regard to pain and intolerance threshold, and perception of suprathreshold stimuli has not been previously evaluated. Our aim was to systematically assess perception of threshold and suprathreshold noxious and innocuous stimuli with special attention to the effect of MMT dose and the presence of chronic pain. Noxious and innocuous, thermal and mechanical thresholds and ratings of suprathreshold heat-pain stimuli were measured among 31 MMT subjects receiving high and low MMT dose, with and without chronic pain, and in 17 healthy controls. The characteristics of chronic pain were also evaluated. MMT dose and chronic pain differentially affected pain perception. Whereas MMT dose did not affect thresholds, chronic pain MMT subjects exhibited increased pain threshold and pain-free MMT subjects exhibited decreased pain threshold compared with controls. MMT in general was associated with decreased perception of suprathreshold pain; however, MMT subjects with chronic pain exhibited increased suprathreshold pain ratings. It appears that subjects receiving MMT are hyperalgesic but that chronic pain in these subjects interferes with threshold measurements, inducing an apparent hypoalgesia. On the other hand, chronic pain reduces the analgesic effect of methadone seen in pain-free MMT subjects, amplifying suprathreshold pain perception. Factors such as chronic pain and MMT dose should be taken into account in future studies on pain perception in this population. Perspective: We show that the presence of chronic pain and methadone dose significantly affects perception of pain in former heroin addicts receiving MMT. Studying the alteration in pain perception in these subjects may contribute to understanding the high rates of chronic pain among them and may promote better treatment

Peles E; Schreiber S; Linzy S; Adelson M. Pathological gambling in methadone maintenance clinics where gambling is legal versus illegal. American Journal of Orthopsychiatry 80(3): 311-316, 2010. (22 refs.)

Lifetime potential and probable pathological gambling (PG) were assessed using the South Oaks Gambling Screen (SOGS) questionnaire. The prevalence between patients in methadone maintenance treatment (MMT) in Tel Aviv (Israel, gambling is illegal) and MMT patients in Las Vegas (NV, USA, gambling is legal) was compared. Urine toxicology and substance use was assessed as well. PG at MMT admission was higher in Tel Aviv (48/178, 27%) than in Las Vegas (19/113, 16.8%; p = .05). In Tel Aviv gambling mostly preceded opiate abuse (58.3%), while it followed opiate abuse in Las Vegas (66.7%, p < .001). Only 20.8% in Tel Aviv and 21.1% in Las Vegas were currently gambling. Multivariate analyses found older age on admission to MMT odds ratio (OR) = 1.05 (95% confidence interval [CI] 1.01-1.08), being male OR = 2.6 (95% CI 1.3-5.3) and being from the Tel Aviv MMT clinic OR = 2.5 (95% CI 1.3-4.9) to characterize PG. Detection of any drug in MMT admission urine specimens was unrelated to PG. Older age on admission to MMT, and male gender characterized PG in different MMT clinics, independent of the legal status of gambling. Low current PG rates for patients in both MMT clinics suggest that legality may not be relevant.

Peles E; Schreiber S; Rados V; Adelson M. Low risk for hepatitis C seroconversion in methadone maintenance treatment. Journal of Addiction Medicine 5(3): 214-220, 2011. (30 refs.)

Objectives: To study the risk factors for seroconversion to hepatitis C virus (HCV) infection since admission to methadone maintenance treatment (MMT) and to characterize the seronegative admitted group. Methods: All 657 patients admitted to our MMT clinic in Tel Aviv, Israel, between 1993 and 2008 were prospectively followed up. Those who were HCV negative (n = 271) with >1 HCV tests (n = 207) were included for seroconversion analyses. Results: Proportions of ever drug injectors, benzodiazepine abuse, and former USSR immigrants were higher among HCV sera-positive versus sera-negative patients on admission to MMT. The incidence of HCV seroconversion in MMT was 2/100 person years [py] (25 seroconversions, 1133.9 py). Seroconversion rates were higher among 44 younger patients (<30 years: 9.6/100 vs 1.4/100 py, P < 0.0005), among 103 patients with positive urine results to benzodiazepines (3.6/100 vs 1/100 py, P = 0.005), among 118 patients who injected the drugs (3.9/100 vs 1/100 py, P = 0.003), and among 43 patients who dropped out and were readmitted to the MMT(4.3/100 vs 1.7/100 py, P = 0.04). There was a trend of higher seroconversion among 61 females (P = 0.1), among 62 patients with no children (P = 0.1), and among those having hepatitis B antigen (n = 7; P = 0.09). Variables that predicted seroconversion were drug injection, benzodiazepine abuse, and being younger at admission to MMT. Being a former USSR immigrant did not predict seroconversion. Conclusions: The HCV seroconversion rate of patients in MMT is low, also, for former USSR immigrants. The predictors for seroconversion were only admission variables (younger age at admission to MMT, ever drug injector, and having positive urine to benzodiazepines at MMT admission). Specific intervention to eliminate seroconversion is needed for these high-risk groups.

Peles E; Schreiber S; Sason A; Adelson M. Earning "take-home" privileges and long-term outcome in a methadone maintenance treatment program. Journal of Addiction Medicine 5(2): 92- 98, 2011. (13 refs.)

Objectives: This observational prospective study aimed to determine whether duration to the earning of privileges of "take-home" methadone doses (as a part of behavioral enforcement) reflects long-term outcome of patients in methadone maintenance treatment (MMT). Methods: All 657 former heroin addicts admitted to our MMT clinic between June 1993 and June 2008 were prospectively studied and followed up. Duration from admission to first take-home dose (until October 2008), to leaving (retention, until June 2009), and to dying (survival, until June 2008) was calculated. Results: Most patients (n = 435; 66.2%) ever achieved take-home privileges. Retention was longest (10 years, 95% confidence interval [CI]: 8.8 to 11.2) for 110 patients who achieved their first take-home dose after 3 to 6 months, followed by 9 years (95% CI: 7.7 to 10.3) for 98 patients who achieved it after >6 months and <= 1 year, and 8.3 years (95% CI: 7.2 to 9.4) for 127 patients who managed to achieve it only after >1 year. Retention was lower among patients who were given exceptional take-home doses (not respecting policy regulations) <3 months since admission: 5.1 years (95% CI: 3.4 to 7.8) for 30 patients (who got it for medical reasons), 9 years (95% CI: 6.7 to 11.3) for 14 patients admitted from another MMT, and 6.3 years (95% CI: 5 to 7.6) for 56 patients who got it for unjustified (mistakes) reasons. The shortest retention in MMT was 2.2 years (95% CI: 1.8 to 2.7, P < 0.0005) for 222 patients who never managed to achieve any take-home privileges. Survival was longer among patients who ever versus never received take-home privileges (13.2 years [95% CI: 12.8 to 13.6] vs 12.3 years [95% CI: 11.5 to 13.1], respectively; P = 0.04) and longest (14.1 years [95% CI: 13.4 to 14.7]) among those who received take-home privileges after 3 to 6 months. Conclusions: The group with the shortest time (3 to 6 months) to the achievement of first take-home dose had the best outcome. Further studies are needed to characterize this group.

Peterson JA; Schwartz RP; Mitchell SG; Reisinger HS; Kelly SM; O'Grady KE et al. Why don't out-of-treatment individuals enter methadone treatment programmes? International Journal of Drug Policy 21(1): 36-42, 2010. (54 refs.)

Background: Despite the proven effectiveness of methadone treatment, the majority of hero in-dependent individuals are out-of-treatment. Methods: Twenty-six opioid-dependent adults who met the criteria for methadone maintenance who were neither seeking methadone treatment at the time of study enrollment, nor had participated in such treatment during the past 12 months, were recruited from the streets of Baltimore, Maryland through targeted sampling. Ethnographic interviews were conducted to ascertain participants' attitudes toward methadone treatment and their reasons for not seeking treatment. Results: Barriers to treatment entry included: waiting lists, lack of money or health insurance, and requirements to possess a photo identification card. For some participants, beliefs about methadone such as real or rumored side effects, fear of withdrawal from methadone during an incarceration, or disinterest in adhering to the structure of treatment programmes kept them from applying. In addition, other participants were not willing to commit to indefinite "maintenance" but would have accepted shorter time-limited methadone treatment. Conclusion: Barriers to treatment entry could be overcome by an infusion of public financial support to expand treatment access, which would reduce or eliminate waiting lists, waive treatment-related fees, and/or provide health insurance coverage for treatment. Treatment programmes could overcome some of the barriers by waiving their photo I.D. requirements, permitting time-limited treatment with the option to extend such treatment upon request,and working with corrections agencies to ensure continued methadone treatment upon incarceration.

Pieper B; Templin TN; Kirsner RS; Birk TJ. The impact of vascular leg disorders on physical activity in methadone-maintained adults. Research In Nursing & Health 33(5): 426-440, 2010. (51 refs.)

Chronic venous disorders (CVD) and peripheral arterial disease (PAD) may affect diverse physical activity domains. How CVD and PAD and other relevant variables affect physical activity was examined in 569 opioid-addicted adults. Both CVD and PAD were significantly inversely related to daily walking, sports, and active living. Effects remained significant in the latent variable regression after controlling covariates. Overall activity was very low; most participants walked less than a half mile daily and rarely engaged in sports. Motivation for physical activity was the strongest predictor (beta=.55) of daily physical activity. Health-care professionals promoting physical activity for iniection users should consider the vascular health of their legs and motivational variables in addition to general health.

Ramasamy P; Lintzeris N; Sutton Y; Taylor H; Day CA; Haber PS. The outcome of a rapid hepatitis B vaccination programme in a methadone treatment clinic. Addiction 105(2): 329-334, 2010. (24 refs.)

Aim: Injecting drug users are a high-risk population for hepatitis B (HBV), but are difficult to engage in vaccination programmes. This study examines the completion rates of a HBV vaccination schedule and seroconversion in a group of patients in methadone maintenance treatment. Methods: Patients at a public methadone maintenance programme in Sydney, Australia, were screened for viral hepatitis (hepatitis A, B and C) and offered a rapid HBV vaccination schedule (0, 1 and 2 months). Hepatitis B surface antibody (antiHBs) was retested on completion of the vaccination schedule. Results: A total of 143 patients [71.3% male, mean age 33.1 (standard deviation +/- 8.3)] enrolled in the project. Forty-nine per cent of patients were HAV antibody (Ab) positive, 81.1% hepatitis C virus (HCV) antibody (Ab) positive and 38.9% antiHBs positive. Exposure to multiple hepatitis viruses was common, with 24.5% testing positive for all three viruses. Seventy-three (83%) of the 88 antiHBs negative patients completed the vaccination schedule. Post-vaccination serology indicated a seroconversion rate of 75.4% (55 of 73) of completors, or 62.5% of eligible participants (55 of 88). Conclusion: While there was a high rate of completion of the rapid vaccination schedule in this population, a moderate seroconversion rate was achieved. Further work is required to identify an optimal vaccination schedule in opioid substitution patients.

Rosen D; Morse JQ; Reynolds CF. Adapting problem-solving therapy for depressed older adults in methadone maintenance treatment. Journal of Substance Abuse Treatment 40(2): 132-141, 2011. (77 refs.)

Late-life depression is prevalent in older adults who are dependent on opiates. Depressive disorders among opiate abusers have detrimental effects on their well-being and ability to refrain from illegal drugs. There are numerous barriers to the provision of appropriate mental health care to older adults receiving methadone maintenance treatment. This article focuses on problem-solving therapy (PST) and presents evidence that PST may be a promising nonpharmacological treatment for older methadone clients with comorbid depressive disorders that can be applied within the staffing and resource limits of methadone maintenance treatment facilities. The advantages of PST relative to other behavioral therapies for this population are based on evidence that PST is less cognitively demanding for an older adult population with mood and substance use disorders. A properly modified PST for an older adult substance-dependent population with subsyndromal or diagnosed depression may be a viable option for methadone maintenance programs with limited resources.

Salsitz EA; Holden CC; Tross S; Nugent A. Transitioning stable methadone maintenance patients to buprenorphine maintenance. Journal of Addiction Medicine 4(2): 88-92, 2010. (15 refs.)

Objectives: Little data exists on psychosocially stable patients maintained long term on methadone maintenance treatment who attempt to transition their maintenance treatment to buprenorphine. The aims of this study were (1) to determine whether there is a correlation between baseline methadone maintenance dose and final buprenorphine maintenance dose, (2) to investigate subjective and objective outcomes over time in psychosocially stable opioid-dependent patients who transitioned their long-term maintenance treatment from methadone to buprenorphine. Methods: In this retrospective study, 104 such patients on dosages of methadone 5 to 80 mg/d were offered the opportunity to convert their maintenance treatment to buprenorphine, of which 25 accepted. Results: All patients (n = 25, 100%) who readily attempted transition to buprenorphine succeeded. A low-moderate association was found between patients' pretransfer methadone dose and posttransfer buprenorphine dose (Spearman correlation coefficient rho = 0.46, P = 0.02). At a mean 30.3 months duration(SD 16.5), 22 patients (88%) remained on buprenorphine maintenance, 1 patient (4%) tapered off buprenorphine under clinician supervision, 1 patient (4%) died of hepatitis C, and 1 patient (4%) relapsed to cocaine and was lost to follow-up. Conclusions: The results demonstrate a low to moderate association between methadone and buprenorphine maintenance doses, and that buprenorphine is a viable maintenance treatment for opioid dependence for psychosocially stable patients on long-term methadone maintenance dosages up to 80 mg/d.

Schafer I; Eiroa-Orosa FJ; Verthein U; Dilg C; Haasen C; Reimer J et al. Effects of psychiatric comorbidity on treatment outcome in patients undergoing diamorphine or methadone maintenance treatment. Psychopathology 43(2): 88-95, 2010. (24 refs.)

Background: Comorbid psychiatric disorders among opioid-dependent patients are associated with several negative outcome factors. However, outcomes of maintenance treatment have not been sufficiently established, and no evidence is available with respect to heroin-assisted treatment (HAT). Methods: For patients in the German heroin trial outcome measures were analyzed for HAT versus methadone maintenance treatment (MMT) both for patients with and without a comorbid diagnosis according to CIDI. Results: 47.2% of the sample had at least one comorbid psychiatric diagnosis, mainly neurotic, stress-related or somatoform (F4) or affective (F3) disorders. HAT had a better outcome than MMT concerning improvement of health and reduction of illicit drug use in both comorbid and non-comorbid patients, but weaker effects were found in the comorbid group. Conclusions: The better outcome of HAT also in comorbid patients suggests that psychiatric comorbidity should be an inclusion criterion for HAT. The weaker advantage of HAT may be due to pharmacological or methodological reasons.

Schiff M; Levit S. Correlates of therapeutic alliance and treatment outcomes among Israeli female methadone patients. Research on Social Work Practice 20(4): 380-390, 2010. (61 refs.)

Objectives: This study examines potential predictors (e.g., attachment style, frequency of therapeutic treatment sessions) of client-rated therapeutic alliance between the social worker and client. The relationship between therapeutic alliance and client's psychological outcomes (hope and posttraumatic stress symptoms [PTS's]) was also assessed. Methods: The study sample included 95 of 193 female clients (average age 39.35, SD 8.66) at four methadone clinics in Israel. Results: Clients reported a strong therapeutic alliance with their social workers. Stepwise hierarchical multiple regression analyses revealed that only the frequency of treatment sessions, the avoidance dimension of attachment, and less frequent opiate use were significant predictors of therapeutic alliance. Therapeutic alliance significantly predicted hope but did not predict reduced PTS. Conclusions: Implications for social work practice and future research are discussed.

Shirinbayan P; Rafiey H; Roshan AV; Narenjiha H; Farhoudian A. Predictors of retention in methadone maintenance therapy: A prospective multi-center study. Scientific Research and Essays 5(21): 3231-3236, 2010. (25 refs.)

In the methadone maintenance therapy (MMT) as the treatment of choice in opiate dependency, retention is considered as a target. Given the paucity of data regarding factors affecting retention in MMT in Iran, we sought to determine the predictors of duration of retention. This multi-center prospective study was conducted at 7 outpatient treatment facilities in 4 cities in Iran, in 2007. 282 consecutive opiate dependent people were followed for 6 months, following their entry to MMT. Independent data were registered at baseline and included socio-demographic, social, psychological, drug related and legal data. Length of retention in MMT (0 - 6) considered as dependent variable. Predictors of length of retention were determined using a backward linear regression model. Retention was 0 months in 17.7% (n = 50), 1 months in 19.8% (n = 56), 2 months in 9.2% (n = 26), 3 months in 3.5% (n = 10), 4 months in 8.2% (n = 23), 5 months in 18.8% (n = 53) and 6 months in 22.7% (n = 64). According to the backward linear regression, the only predictors of remission were city (B=0.427, p < 0.001, CI = 0.339 - 0.514), perceived importance of distance to clinic (B = -0.008, p = 0.085, CI = -0.018 - 0.001), perceived social support (B = 0.006, p= 0.069, CI = 0.000 - 0.013), and perceived pleasure with drug use (B = 0.010, p = 0.007, CI = 0.003 - 0.017). This study shed light on factors that may serve as barriers for remaining in MMT for opiate dependence, in Iran. Some variables should be considered in programs developed by Iranian authorities to increase retention rate in MMT.

Skinner ML; Haggerty KP; Fleming CB; Catalano RF; Gainey RR. Opiate-addicted parents in methadone treatment: Long-term recovery, health, and family relationships. Journal of Addictive Diseases 30(1): 17-26, 2011. (35 refs.)

Few studies follow the lives of opiate-addicted parents. The authors examined a 12-year follow-up of 144 parents in methadone treatment and their 3- to 14-year-old children. Parent mortality was high. Among survivors, drug use and treatment, incarceration, residential and family disruptions, and health problems were common. Moderate and long-term recovery were associated with consistent methadone treatment, further education, employment, and fewer relationship disruptions. Earlier depression, deviant friends, and poor coping skills predicted continued drug problems. Thus, interventions should include treatment for depression and build skills for avoiding and refusing drugs, coping with stress, and maintaining recovery-supportive friendships.

Smye V; Browne AJ; Varcoe C; Josewski V. Harm reduction, methadone maintenance treatment and the root causes of health and social inequities: An intersectional lens in the Canadian context. Harm Reduction Journal 8(17), 2011. (79 refs.)

Background: Using our research findings, we explore Harm Reduction and Methadone Maintenance Treatment (MMT) using an intersectional lens to provide a more complex understanding of Harm Reduction and MMT, particularly how Harm Reduction and MMT are experienced differently by people dependent on how they are positioned. Using the lens of intersectionality, we refine the notion of Harm Reduction by specifying the conditions in which both harm and benefit arise and how experiences of harm are continuous with wider experiences of domination and oppression. Methods: A qualitative design that uses ethnographic methods of in-depth individual and focus group interviews and naturalistic observation was conducted in a large city in Canada. Participants included Aboriginal clients accessing mainstream mental health and addictions care and primary health care settings and healthcare providers; Results: All client-participants had profound histories of abuse and violence, most often connected to the legacy of colonialism (e. g., residential schooling) and ongoing colonial practices (e. g., stigma & everyday racism). Participants lived with co-occurring illness (e. g., HIV/AIDS, Hepatitis C, PTSD, depression, diabetes and substance use) and most lived in poverty. Many participants expressed mistrust with the healthcare system due to everyday experiences both within and outside the system that further marginalize them. In this paper, we focus on three intersecting issues that impact access to MMT: stigma and prejudice, social and structural constraints influencing enactment of peoples' agency, and homelessness; Conclusions: Harm reduction must move beyond a narrow concern with the harms directly related to drugs and drug use practices to address the harms associated with the determinants of drug use and drug and health policy. An intersectional lens elucidates the need for harm reduction approaches that reflect an understanding of and commitment to addressing the historical, socio-cultural and political forces that shape responses to mental illness/health, addictions, including harm reduction and methadone maintenance treatment.

Soyka M; Zingg C; Koller G; Hennig-Fast K. Cognitive function in short- and long-term substitution treatment: Are there differences? World Journal of Biological Psychiatry 11(2, Part 2): 400-408, 2010. (44 refs.)

Cognitive impairment in drug-dependent patients receiving methadone maintenance treatment has been reported previously, although the literature is limited and results remain controversial. Long-term effects under stable methadone maintenance treatment (MMT) and the possibility of improvement in cognitive performance during long-term substitution treatment have rarely been investigated. We performed a comparative study investigating differences in cognitive functions under short-and long-term methadone treatment to test the hypothesis that patients perform better under long-than under short-term MMT. Seventy-seven patients were assessed cross-sectional either at least 30 days after the start of MMT (short-term group, n = 35) or after at least 6 months of MMT (long-term group, n = 42) with a comprehensive neuropsychological test battery on intelligence, learning and memory, attention and executive functions. Urine screenings were performed immediately before neuropsychological testing to check for concomitant drug use. Our findings may suggest, with all due caution, a slightly better performance of the long-term group in executive functions and visuo-construction. No group differences were found in attentional functions and learning and memory. More longitudinal research and studies controlling for the effects of dosage and duration of opioid addiction are necessary.

Strike C; Rufo C. Embarrassing, degrading, or beneficial: Patient and staff perspectives on urine drug testing in methadone maintenance treatment18. Journal of Substance Use 15(5): 303-312, 2010. (18 refs.)

Urine drug testing is a routine, but debated and contentious procedure in methadone maintenance treatment (MMT). Largely overlooked in the debate are the perspectives of patients and clinical staff about this procedure. Using semi-structured interviews (n = 64) with MMT patients and clinical staff at four programmes, we explore their attitudes and perceived implications for treatment. We documented varied urinalysis practices by site and with considerable disagreement regarding its emotional impact and therapeutic value. Among patients, comments about urine drug testing varied from degrading to ambivalence to acceptance as a necessary component of treatment. Staff members who supported urinalysis and described it as beneficial stated that it provided a point of entry into patients' lives and helped to identify possible barriers to recovery. Others believed urinalysis impeded the development and maintenance of an effective therapeutic alliance. Lack of strong empirical evidence demonstrating improved patient outcome related to urine drug testing suggests that this procedure should be determined based on individual patient goals.

Sullivan LE; Moore BA; O'Connor PG; Barry DT; Chawarski MC; Schottenfeld RS et al. The association between cocaine use and treatment outcomes in patients receiving office-based buprenorphine/naloxone for the treatment of opioid dependence. American Journal on Addictions 19(1): 53-58, 2010. (23 refs.)

Cocaine use in patients receiving methadone is associated with worse treatment outcomes. The association between cocaine use and office-based buprenorphine/naloxone treatment outcomes is not known. We evaluated the association between baseline and in-treatment cocaine use, treatment retention, and urine toxicology results in 162 patients enrolled in a 24-week trial of primary care office-based buprenorphine/naloxone maintenance. Patients with baseline cocaine metabolite-negative urine toxicology tests compared with those with cocaine metabolite-positive tests had more mean weeks of treatment retention (18.3 vs. 15.8, p = .04), a greater percentage completed 24 weeks of treatment (50% vs. 33%, p = .04) and had a greater percentage of opioid-negative urines (47% vs. 34%, p = .02). Patients with in-treatment cocaine metabolite-negative urine toxicology tests compared with cocaine metabolite-positive patients had more mean weeks of treatment retention (19.0 vs. 16.5, p = .003), a greater percentage completed 24 weeks of treatment (60% vs. 30%, p < .001), and had a greater percentage of opioid-negative urines (51% vs. 35%, p = .001). We conclude that both baseline and in-treatment cocaine use is associated with worse treatment outcomes in patients receiving office-based buprenorphine/naloxone and may benefit from targeted interventions.

Taylor LE; Bowman SE; Chapman S; Zaller N; Stein MD; Cioe PA et al. Treatment for hepatitis C virus genotype 1 infection in HIV-infected individuals on methadone maintenance therapy. Drug and Alcohol Dependence 116(1-3): 233-237, 2011. (45 refs.)

Background: A minority of HIV/HCV coinfected patients with opiate addiction undergo HCV treatment. HCV therapy for HCV-monoinfected methadone maintenance (MM) recipients is safe and effective. We evaluated treatment efficacy and adherence to pegylated interferon (pegIFN) among HIV/HCV coinfected MM recipients. Methods: HCV treatment-naive, HIV-infected persons 18-65 years with chronic HCV genotype 1 on MM were prospectively enrolled in an HCV treatment study at two HIV clinics. At weekly visits pegIFN alfa-2a injections were directly administered. Daily MM recipients had morning ribavirin delivered with methadone at off-site methadone clinics. Weekly take-home MM recipients took ribavirin unsupervised. Target enrollment was 30 participants. Results: During 18 recruitment months, 11 participants were enrolled, 6 of whom received daily methadone. Mean age was 46, 64% were female, 5 were Caucasian, 4 Black and 2 Hispanic. At baseline, 82% had high HCV RNA and 55% had stage 2 fibrosis or greater. The majority (91%) were on HAART, and 82% had undetectable HIV RNA with a median CD4(+) of 508 Cells/mu L. All had polysubstance use history, non-substance-based psychiatric diagnoses and were on psychotropic medications pre-enrollment. Two (18%) participants achieved a Sustained Virologic Response (SVR). Two completed 48 treatment weeks, 5 were withdrawn due to adverse events, 2 dropped out prematurely and 2 had treatment discontinued for virologic non-response. Of on-treatment weeks, adherence to pegIFN was >99%. Conclusions: SVR rate was comparable to historic controls for coinfected genotype 1 patients, with optimal pegIFN adherence. Adverse effects often prevented therapy completion in this population.

Trksak GH; Jensen JE; Plante DT; Penetar DM; Tartarini WL; Maywalt MA et al. Effects of sleep deprivation on sleep homeostasis and restoration during methadone-maintenance: A P-[31] MRS brain imaging study. Drug and Alcohol Dependence 106(2): 79-91, 2010. (111 refs.)

Insomnia afflicts many individuals, but particularly those in chronic methadone treatment. Studies examining sleep deprivation (SD) have begun to identify sleep restoration processes involving brain bioenergetics. The technique P-[31] magnetic resonance spectroscopy (MRS) can measure brain changes in the high-energy phosphates: alpha-, beta-, and gamma-nucleoside triphosphate (NTP). In the present study, 21 methadone-maintained (MM) and 16 control participants underwent baseline (BL), SD (40 wakeful hours), recovery1 (RE1), and recovery2 (RE2) study nights. Polysomnographic sleep was recorded each night and P-[31] MRS brain scanning conducted each morning using a 4T MR scanner (dual-tuned proton/phosphorus head-coil). Interestingly, increases in total sleep time (TST) and sleep efficiency index (SEI) commonly associated with RE sleep were not apparent in MM participants. Analysis of methadone treatment duration revealed that the lack of RE sleep increases in TST and SEI was primarily exhibited by short-term MM participants (methadone <12 months), while RE sleep in long-term MM (methadone >12 months) participants was more comparable to control participants. Slow wave sleep increased during RE1, but there was no difference between MM and control participants. Spectral power analysis revealed that compared to control participants; MM participants had greater delta, theta, and alpha spectral power during BL and RE sleep. P-[31] MRS revealed that elevations in brain beta-NTP (a direct measure of ATP) following RE sleep were greater in MM compared to control participants. Results suggest that differences in sleep and brain chemistry during RE in MM participants may be reflective of a disruption in homeostatic sleep function.

Uhlmann S; Milloy MJ; Kerr T; Zhang R; Guillemi S; Marsh D et al. Methadone maintenance therapy promotes initiation of antiretroviral therapy among injection drug users. Addiction 105(5): 907-913, 2010. (46 refs.)

Aims: Despite proven benefits of antiretroviral therapy (ART), many human immunodeficiency virus (HIV)-infected injection drug users (IDU) do not access treatment even in settings with free health care. We examined whether methadone maintenance therapy (MMT) increased initiation and adherence to ART among an IDU population with free health care. Design: We examined prospectively a cohort of opioid-using antiretroviral-naive HIV-infected IDU and investigated factors associated with initiation of antiretroviral therapy as well as subsequent adherence. Factors associated independently with time to first initiation of antiretroviral therapy were modelled using Cox proportional hazards regression. Findings: Between May 1996 and April 2008, 231 antiretroviral-naive HIV-infected opioid-using IDU were enrolled, among whom 152 (65.8%) initiated ART, for an incidence density of 30.5 [95% confidence interval (CI): 25.9-35.6] per 100 person-years. After adjustment for time-updated clinical characteristics and other potential confounders, use of MMT was associated independently with more rapid uptake of antiretroviral therapy [relative hazard = 1.62 (95% CI: 1.15-2.28); P = 0.006]. Those prescribed methadone also had higher rates of ART adherence after first antiretroviral initiation [odds ratio = 1.49 (95% CI: 1.07-2.08); P = 0.019]. Conclusion: These results demonstrate that MMT contributes to more rapid initiation and subsequent adherence to ART among opioid-using HIV-infected IDU. Addressing international barriers to the use and availability of methadone may increase dramatically uptake of HIV treatment among this population.

Vanagas G; Padaiga Z; Bagdonas E. Cost-utility analysis of methadone maintenance treatment in Lithuania. Medicina-Lithuania 46(4): 286-292, 2010. (30 refs.)

Background. Economic evaluations in health care involve the identification, measurement, valuation, and then comparison of the costs (inputs) and outcomes of treatments or preventive activities. The aim was to analyze the cost-utility of six-month methadone maintenance treatment program in a Lithuanian primary health care setting. Methods. A prospective study design was used. All the information was obtained through the validated questionnaires at the baseline and 3- and 6-month follow-ups. WHOQOL-BREF was used to assess the quality of life; the costs were assessed using the DATCAP methodology from the perspective of a patient and outpatient clinic during follow-up period. Results. A total of 102 opioid-dependent patients were recruited in the study; 512 follow-up patient-months were obtained. The methadone maintenance treatment has significantly improved physical, psychological, and environmental components of quality of life during follow-up. Total program costs were 61 288.87 EUR. Cost paid by a patient comprised about 31% of total program costs. Cost per quality-adjusted life-month (QALM) for physical domain was 2227.55 EUR; for psychological domain, 1879.50 EUR; for social domain, 5467.64 EUR; and for environmental domain, 4626.47 EUR. Costs per QALM and quality-adjusted life-year (QALY) for total quality of life in the maintenance program were 2864.00 EUR and 34 368.00 EUR, respectively. Conclusions. Our results showed that 6-month methadone maintenance program was effective in the terms of quality-of-life improvement. Methadone maintenance treatment program was less effective in terms of cost per QALY.

Versek BE; Carpenedo CM; Rosenwasser BJ; Dugosh KL; Bresani E; Kirby KC. Resets do not appear to increase the rate of adverse events or prolong relapse in voucher-based reinforcement therapy. Journal of Substance Abuse Treatment 39(2): 167-173, 2010. (32 refs.)

Voucher-based reinforcement therapy (VBRT) is an efficacious contingency management intervention for substance use disorders that provides escalating voucher values to reinforce continuous abstinence and typically resets escalated values to the initial low level upon detection of drug use. The objective of this study involving 130 methadone-maintained outpatients receiving VBRT was to investigate whether resets (a) increase risk for adverse events (AEs) and (b) delay return to abstinence in relation to magnitude of voucher reset. Weeks following resets were examined for increased likelihood of AEs using a Poisson regression. A Cox proportional hazards model was used to determine if higher resets increased the number of days until a negative urine specimen. Results showed that resets did not increase the likelihood of AEs nor were higher resets related to an increased delay to abstinence. Research involving larger samples is needed to produce sufficient data directly addressing safety concerns of various treatment stakeholders.

Villagonzalo KA; Dodd S; Ng F; Mihaly S; Langbein A; Berk M. The utility of the Mood Disorders Questionnaire as a screening tool in a methadone maintenance treatment program. International Journal of Psychiatry in Clinical Practice 14(2): 150-153, 2010. (12 refs.)

Objective. Comorbid mental illness amongst methadone maintenance therapy clients may be common and screening may be warranted. The Mood Disorders Questionnaire (MDQ) is a screening tool for bipolar disorder that has been validated in other treatment settings. Its utility for patients with substance use disorders is assessed in this study. Methods. Clients of a methadone maintenance program were invited to complete the MDQ when they attended a public Drug and Alcohol Service for their regular scheduled appointments. Information about their history of substance use was also collected. Results. Eighty clients (43 females, 37 males) aged 35 +/- 8.0 years (mean +/- SD) participated in the study. Seventy-four clients completed the MDQ of which 36 (48.6%) obtained a positive screen. A check of client files suggested that only three of the 74 participants had a current working diagnosis of bipolar disorder. These three participants had screened positive on the MDQ. Conclusions. There was a high prevalence of manic symptoms reported by participants, suggesting that screening for bipolar disorder in this population may be warranted. However, there is a risk of false positives with the MDQ, as it does not clearly differentiate between symptoms of mania and drug intoxication.

Wilson ME; Schwartz RP; O'Grady KE; Jaffe JH. Impact of interim methadone maintenance on HIV risk behaviors. Journal of Urban Health. Bulletin of the New York Academy Of Medicine 87(4): 586-591, 2010. (14 refs.)

The extent to which interim methadone (IM) without counseling reduces HIV risk behavior has not been reported. The AIDS Risk Assessment scale was administered at baseline and 4-month follow-up to 319 adult heroin-dependent participants randomly assigned to IM or waiting list. On an intent-to-treat basis, there was a significantly greater reduction in drug injection and unprotected sex while high from baseline to follow-up, favoring the IM condition. Remedying the shortage of methadone capacity through the expansion of IM would be a worthwhile approach to reducing the spread of HIV infection.

Wu E; El-Bassel N; Gilbert L; Chang M; Sanders G. Effects of receiving additional off-site services on abstinence from illicit drug use among men on methadone: A longitudinal study. Evaluation and Program Planning 33(4): 403-409, 2010. (56 refs.)

Health and psychosocial service needs that may be co-morbid with opioid addiction may impede the success of drug treatment among patients attending methadone maintenance treatment programs (MMTPs). This longitudinal panel study investigates whether receipt of services from one or more helping professionals outside of the MMTP confers a benefit for drug treatment outcomes among a random sample of male MMTP patients (N = 356). Each participant was interviewed 3 times, with 6 months between each interview. Since this observational study did not employ random assignment, propensity score matching was employed to strengthen causal validity of effect estimates. Results support hypotheses that receiving additional off-site services has significant beneficial effects in increasing the likelihood of abstaining from cocaine, heroin, and any illicit drug use over both the ensuing 6- and 12-month time periods. These findings indicate that receipt of additional medical and/or psychosocial services enhances the efficacy of methadone treatment in increasing abstinence from illicit drug use.

Xiao L; Wu ZY; Luo W; Wei XL. Quality of life of outpatients in methadone maintenance treatment clinics. Journal of Acquired Immune Deficiency Syndromes 53(Supplement 1): S116-S120, 2010. (30 refs.)

Objective: To explore the quality of life (QOL) changes in methadone maintenance treatment (MMT) clinic outpatients in the first 3 months of treatment. Methods: A cohort study was conducted in 5 MMT clinics for more than 3 months, and the QOL of outpatients was measured by the QOL instrument for drug addicts at days 1, 30, and 90 to explore QOL changes. Repeated measurement analysis method was used for data analysis. Results: One hundred seventy-two outpatients in 5 MMT clinics were recruited, and 142 (82.65%) remained in treatment at day 90. The Cronbach alpha coefficient of the QOL instrument for drug addicts used in our Study is 0.96, with a range of 0.74-0.94 for all subscales. The QOL scores of drug addicts improved from day I to day 30 ((X) over bar (beginning) 51.92, (X) over bar (first) (month) = 74.83, P < 0.01), and all subscale scores improved significantly (P < 0.01). However, QOL improved little from day 30 to day 90, ((X) over bar (first) (month) 74.83, (X) over bar (third) (month) = 75.99, P < 0.01). Physical health and mental health improved significantly during the second and third month, whereas all other subscale scores did not (P > 0.05). Conclusions: MMT is helpful in improving the QOL of outpatients in MMT clinics in China.

Yin WY; Hao Y; Sun XH; Gong XL; Li F; Li JH; Rou KM et al. Scaling up the national methadone maintenance treatment program in China: Achievements and challenges. International Journal of Epidemiology 39(Suppl. 2): II29-II37, 2010. (34 refs.)

China's methadone maintenance treatment program was initiated in 2004 as a small pilot project in just eight sites. It has since expanded into a nationwide program encompassing more than 680 clinics covering 27 provinces and serving some 242 000 heroin users by the end of 2009. The agencies that were tasked with the program's expansion have been confronted with many challenges, including high drop-out rates, poor cooperation between local governing authorities and poor service quality at the counter. In spite of these difficulties, ongoing evaluation has suggested reductions in heroin use, risky injection practices and, importantly, criminal behaviours among clients, which has thus provided the impetus for further expansion. Clinic services have been extended to offer clients a range of ancillary services, including HIV, syphilis and hepatitis C testing, information, education and communication, psychosocial support services and referrals for treatment of HIV, tuberculosis and sexually transmitted diseases. Cooperation between health and public security officials has improved through regular meetings and dialogue. However, institutional capacity building is still needed to deliver sustainable and standardized services that will ultimately improve retention rates. This article documents the steps China made in overcoming the many barriers to success of its methadone program. These lessons might be useful for other countries in the region that are scaling-up their methadone programs.

Zeiler I; Langlands T; Murray JM; Ritter A. Optimal targeting of Hepatitis C virus treatment among injecting drug users to those not enrolled in methadone maintenance programs. Drug and Alcohol Dependence 110(3): 228-233, 2010. (32 refs.)

Background: This work used mathematical modelling to explore effective policy for Hepatitis C virus (HCV) treatment in Australia in the context of methadone maintenance treatment (MMT). Method: We consider two models to depict HCV in the population of injecting drug users (IDU) within Australia. The first model considers the IDU population as a whole. The second model includes separate components for those that are or are not enrolled in MMT. The impact of different levels of HCV treatment and its allocation dependent on MMT status were then determined in terms of the steady state levels of each of these models. Results: Although increasing levels of HCV treatment decrease chronic infection prevalence, initially numbers of acutely infected can rise. This is caused by the high rate of reinfection. We find that no matter the extent of HCV treatment, HCV prevalence cannot be eliminated without limiting risk behaviour. Assuming equal adherence to HCV therapy between MMT and non-MMT, over 84% of HCV treatment should be allocated to those not in MMT. Only if adherence to HCV therapy in non-MMT patients falls below 44% of that in MMT then treatment should be preferentially directed to those in MMT. Conclusions: Contrary to generally held beliefs regarding HCV treatment the majority of therapy should be allocated to those that are still actively injecting. This is due to rates of reinfection and to the high turnover of individuals in MMT. Higher adherence to HCV therapy in MMT would need to be achieved before this changed.