Lessons Learned in OBOT: 3 Case Studies of Women who did not Succeed in Pharmacy-based Methadone Treatment

This brief report describes how a family medicine residency practice (FMRP) leveraged a resident-led quality improvement project and a grant-funded Addiction Integrated Care Team (AICT) to initiate an office-based opioid treatment (OBOT) program to provide medications for opioid use disorder during the COVID-19 pandemic. In 2020, the practice experienced four disruptors that shifted motivation for practice development: (a) The COVID-19 pandemic demanded rapid change in primary care processes/staffing, including pivoting to telehealth/remote practice. (b) The practice's transition to a federally qualified community health center model meant a shift in organizational priorities that required offering OBOT services. (c) External grant resources became available through the AICT program to support practice core for OBOT, and 10 implementation strategies were utilized. (d) A resident champion implemented an OBOT quality improvement project. These efforts resulted in the practice offering the OBOT program and 18 patients receiving OBOT from January 2020 to February 2021, with 10 of 18 patients engaged for 12 months or longer. Further, the cumulative adoption and reach from January 2020 through September 2022 was 15 faculty and 14 residents becoming prescribers and 101 patients served within the OBOT program, respectively. FMRPs striving for significant practice transformation, such as implementing an OBOT program during a pandemic, may benefit from synergistic guidance and resources including established theory, strategies from the implementation science literature, and resident-led quality improvement efforts. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Drug abuse has a long, but also different history in Germany and China. The Opium War largely influenced the history of China in 19th century; however, China was once recognized as a drug-free nation for 3 decades from the 1950s to the 1980s. Drug abuse has spread quickly since re-emerging as a national problem in China in the late 1980s. The number of registered drug abusers increased from 70 000 in 1990 to more than 1 million by the end of 2005. In past decades, illicit drug trafficking and production have swept most provinces in China, and drug abuse has caused many problems for both abusers and the community. One major drug-related problem is the spread of HIV, which has caused major social and economic damage in China. Germany, the largest developed European country, also faces the drug and addiction problem. Germany has about 150 000 heroin addicts, for whom HIV/AIDS has become a serious threat since the mid 1980s. To control the drug problem, the German Government adopted the “Action Plan on Drugs and Addiction” in 2003; the China Central Government approved a similar regulation in the antidrug campaign in 2005. Germany has experience in reducing drug-related harm. The methadone maintenance treatment (MMT) program has run for more than 20 years and the public has become more tolerant of addicts. In 2003, China began the MMT program for controlling the spread of HIV/AIDS. It is necessary for China to learn from developed countries to acquire success in its antidrug campaign. In this review, we will go over the differences and similarities in drug abuse between Germany and China. The differences are related to history, population and economics, drug policy context, drug laws, HIV/hepatitis C virus infection, the MMT program and so on. These 2 nations have drug abuse problems with different histories and currently use different approaches to handle illicit drug marketing and use. The legal penalties for illicit drug offences reflect the social differences of these 2 nations with respect to the seriousness of particular types of crimes. The characteristics of the MMT program may also influence patterns of drug abuse in these 2 nations and China should improve the MMT program based on the successful model in Europe, the USA, and Australia. We recommend more dialogue and collaboration between Germany and China.

This 18-month follow-up study examined the predictors of the severity of depressive symptoms among intravenous heroin users receiving methadone maintenance treatment (MMT) in Taiwan. The severity of depressive symptoms in 368 intravenous heroin users receiving MMT in southern Taiwan was assessed using the Center for Epidemiological Studies Depression scale at baseline and at 3, 6, 9, 12, 15, and 18 months of treatment. Demographic and substance-using characteristics, severity of heroin use, HIV serostatus, criminal record, and family function were collected during baseline interviews. Data on methadone dosage at each follow-up interview and the duration of retention in the MMT program were also collected. A generalized estimating equation was used to determine independent predictors of depressive symptoms during the 18-month period of MMT. Female gender, lack of fixed employment, severe heroin use, concurrent methamphetamine use, low family function at baseline, heroin use during the MMT, low methadone dosage, and short duration of participation in MMT predicted more severe depressive symptoms during the 18-month MMT. This study found that sociodemographic and substance-using characteristics at baseline predicted the severity of depressive symptoms among heroin users receiving MMT. Methadone dosage and MMT duration were also predictive of depression severity. The predictors found in this study can be used to identify heroin users who are at risk for depressive symptoms in the MMT program.

ContextAlthough office-based opioid treatment with buprenorphine (OBOT-B) has been successfully implemented in primary care settings in the US, its use has not been reported in homeless patients.ObjectiveTo characterize the feasibility of OBOT-B in homeless relative to housed patients.DesignA retrospective record review examining treatment failure, drug use, utilization of substance abuse treatment services, and intensity of clinical support by a nurse care manager (NCM) among homeless and housed patients in an OBOT-B program between August 2003 and October 2004. Treatment failure was defined as elopement before completing medication induction, discharge after medication induction due to ongoing drug use with concurrent nonadherence with intensified treatment, or discharge due to disruptive behavior.ResultsOf 44 homeless and 41 housed patients enrolled over 12 months, homeless patients were more likely to be older, nonwhite, unemployed, infected with HIV and hepatitis C, and report a psychiatric illness. Homeless patients had fewer social supports and more chronic substance abuse histories with a 3- to 6-fold greater number of years of drug use, number of detoxification attempts and percentage with a history of methadone maintenance treatment. The proportion of subjects with treatment failure for the homeless (21%) and housed (22%) did not differ (P = .94). At 12 months, both groups had similar proportions with illicit opioid use [Odds ratio (OR), 0.9 (95% CI, 0.5–1.7) P = .8], utilization of counseling (homeless, 46%; housed, 49%; P = .95), and participation in mutual-help groups (homeless, 25%; housed, 29%; P = .96). At 12 months, 36% of the homeless group was no longer homeless. During the first month of treatment, homeless patients required more clinical support from the NCM than housed patients.ConclusionsDespite homeless opioid dependent patients’ social instability, greater comorbidities, and more chronic drug use, office-based opioid treatment with buprenorphine was effectively implemented in this population comparable to outcomes in housed patients with respect to treatment failure, illicit opioid use, and utilization of substance abuse treatment.

Methadone is a controlled drug and can be prescribed by an authorized person in charge, under the direction of medical practitioners, for particular patients, to cure their addiction to opioid substances. The development and evaluation of a methadone dispenser present a prototype solution for solving the current manual methadone dispensing problems, which are prone to human error, with the implementation of the methadone maintenance treatment (MMT) program at the same time to increase public awareness about this program. In the current study, the performance of a methadone dispenser is evaluated by investigating the simulation analysis, feasibility, and efficiency of the device as compared to the manual technique. For testing purposes, methadone syrup was replicated with sugar solution of 66.6 g/50 mL at 25°C with a dynamic viscosity of 36.680 mPa.s. Thus, it was quantified that the time taken to dispense the sugar solution by using the methadone dispenser has shown a significant improvement of 81.40 % time reductions as compared to the manual technique. The low repeatability percentage of the methadone dispenser by 1.64 % contributes to a high precision device that is reliable enough to be implemented in the MMT program with a dispensing accuracy increment of 3.87 %, as compared to the manual technique. The findings suggest that the methadone dispenser is reliable and feasible and contributes to error reduction for implementation in the MMT program with approximately ≈ 97 % efficiency.

For people seeking treatment, the course of heroin addiction tends to be chronic and relapsing, and longer duration of treatment is associated with better outcomes. Heroin addiction is strongly associated with deviant behaviour and crime, and the objectives in treating heroin addiction have been a blend of humane support, rehabilitation, public health intervention and crime control. Reduction in street heroin use is the foundation on which all these outcomes are based. The pharmacological basis of maintenance treatment of dependent individuals is to minimize withdrawal symptoms and attenuate the reinforcing effects of street heroin, leading to reduction or cessation of street heroin use. Opioid maintenance treatment can be moderately effective in suppressing heroin use, although deviations from evidence-based approaches, particularly the use of suboptimal doses, have meant that treatment as delivered in practice may have resulted in poorer outcomes than predicted by research. Methadone treatment has been 'programmatic', with a one-size-fits-all approach that in part reflects the perceived need to impose discipline on deviant individuals. However, differences in pharmacokinetics and in side-effects mean that many patients do not respond optimally to methadone. Injectable diamorphine (heroin) provides a more reinforcing medication for some 'nonresponders' and can be a valuable option in the rehabilitation of demoralized, socially excluded individuals. Buprenorphine, a partial agonist, is a less reinforcing medication with different side-effects and less risk of overdose. Not only is it a different medication, but also it can be used in a different paradigm of treatment, office-based opioid treatment, with less structure and offering greater patient autonomy.

Evidence-based treatment for opioid use disorders: A national study of methadone dose levels, 2011–2017

To determine the proportion of heroin use among patients who were involved in community-based methadone maintenance treatment (MMT) program and to identify the risk factors associated with heroin use. This study was conducted in 9 MMT clinics within 3 provinces. Thirteen hundred and one patients who met the study criteria were selected from each of the five groups with different dosages of methadone users. An administrative questionnaire was applied to explore the demographics, drug abuse-related behaviors and MMT services received by the clients, etc. The prevalence of depression and anxiety among the clients were also collected by SAS and SDS. Urine samples were collected as a biological marker to indicate if heroin had been used. Of the 1301 patients, 76.2% were males. The mean age was (34.6 +/- 6.5) years while 71.7% had an education level of primary school or below. The average daily dosage of methadone was (48.1 +/- 29.4) mg and self-satisfied evaluation score on treatment was 8.6. On average, 27.7% urine samples showed positive opiate evidence. Marital status, employment status, treatment retention, self-satisfied evaluation score on dosage and dropout history were found to be significantly associated with heroin use, while gender, education level and dosage had no significant association with heroin use. It seemed that risk factors that associated with heroin use were different from areas to areas. High quality MMT clinic services, high self-satisfied score, longer treatment retention and low dropout rate seemed to have the effects of reducing the risk of ongoing heroin abuse under the methadone maintenance treatment program.

To understand the situation of client-retention to methadone maintenance treatment (MMT) program and related factors. A cohort study was adopted. In total, 1003 heroin addicts who were treated at 8 local MMT clinics with less than one month period, were recruited under nominal informed consent from Guizhou province, southwest part of China, during June to October 2006. Face-to-face interview and questionnaire administered to collect relevant information from the clients who were also followed until June 2007 to understand the situation on retention. Data were analyzed with Kaplan-Meier method to estimate the retention rate at different time spans while factors related to retention were analyzed with Cox proportional hazard regression model. All the clients were followed-up for 14 months, with an average retention of ten months. The retention rates of the clients were 68.8% and 57.4% at 6th-month and 12th-month of the treatment program, estimated by Kaplan-Meier method. Results of Cox regression analysis showed that factors influencing retention rate on MMT among the clients, including their awareness on MMT, daily dose of methadone intake, and different MMT clinics which they were attached to. Risk influencing the withdrawal from MMT had a 20% decrease along with the increase when the daily dose of methadone intake reached 25 mg, with a hazard ratio of 0.80 (P < 0.01). If the clients were aware that methadone was a life-time treatment when they began the MMT program, the risk for withdrawal would be lower than those who were not and the hazard ratio became 0.66 (P < 0.05). Our data showed that about half of the clients who were at the MMT program would still stick to it after 12-months, suggesting that the retention rate was not satisfactory and need to be improved. Factors as the MMT clinics themselves that the clients visited, daily methadone dosage they took, and the awareness on MMT etc. were important predictors to the rate of retention on MMT program.

Background Recurrent dropout often occurs among participants receiving methadone maintenance treatment (MMT), which negatively affects treatment effectiveness. However, few researchers focused on this phenomenon including those in China. This study examined systematically factors associated with dropout based on recurrent events analysis among Chinese MMT participants. Methods This retrospective study involved participants who firstly enrolled in MMT program between 2006 and 2017 of nine clinics in the Guangdong Province. The factors influencing recurrent dropout were identified using Prentice-Williams-Peterson model with total time (PWP-TT), then a comparison with Cox proportional hazards model was conducted. Results Among a total of 1,319 participants, 1,922 treatment episodes were identified. There were 366 (27.7%) participants remained in MMT at one year follow-up. There was a progressive shortening of the treatment episode duration among participants with multiple treatment episodes. Protective factors included higher average age (≥50 years) before attending MMT, the higher last methadone dosage before each dropout (≥50ml) and higher average dosage (≥60ml) in each episode, while being divorced, arrested in the past 3 months, having contact with drug-using friends more than once per day, and being positive for the first morphine urine test were risk factors. Additionally, higher average dosage (≥60ml) had constant protective effects on subsequential treatment episodes. Conclusions The risk of dropout increased as participants experienced multiple treatment episodes in MMT. The influencing factors for recurrent dropout were variable across all treatment episodes. Greater efforts are needed to provide sufficient methadone dosage for the participants to decrease dropout rate.

Little is known about mortality of opiate users attending methadone maintenance treatment (MMT) clinics. We sought to investigate mortality and its predictors among human immunodeficiency virus (HIV)-positive MMT clients. Records of 306 786 clients enrolled in China's MMT program from 24 March 2004 to 30 April 2011 were abstracted. Mortality rates were calculated for all HIV-positive antiretroviral treatment (ART)-naive and ART-experienced clients. Risk factors were examined using stratified proportional hazard ratios (HRs). The observed mortality rate for all clients was 11.8/1000 person-years (PY, 95% confidence interval [CI], 11.5-12.1) and 57.2/1000 PY (CI, 54.9-59.4) for HIV-positive clients (n = 18 193). An increase in average methadone doses to >75 mg/day was associated with a 24% reduction in mortality (HR = 0.76, CI, .70-.82), a 48% reduction for ART-naive HIV-positive clients (HR = 0.52, CI, .42-.65), and a 47% reduction for ART-experienced HIV-positive clients (HR = 0.53, CI, .46-.62). Among ART-experienced clients, initiation of ART when the CD4(+) T-cell count was >300 cells/mm(3) (HR = 0.64, CI, .43-.94) was also associated with decreased risk of death. We found high mortality rates among HIV-positive MMT clients, yet decreased risk of death, with earlier ART initiation and higher methadone doses. A higher daily methadone dose was associated with reduced mortality in both HIV-infected and HIV-uninfected clients, independent of ART.

To describe the characteristics and factors associated with long-term retention for methadone maintenance treatment (MMT) patients. This study was conducted in eight MMT clinics located in Sichuan, Yunnan, Guangxi, Guizhou and Zhejiang provinces. Five hundred and thirty-nine MMT patients who enrolled in MMT clinics in 2004 and retained in treatment by June 2010 were selected as study subjects. Chi-square tests were used to compare the demographics and drug abuse history at enrollment and treatment characteristics during the follow-up period between continuous treatment patients and discontinuous treatment patients. Of the 539 patients, 110 (20.4%) were continuous treatment patients whereas 429 (79.6%) were discontinuous treatment patients. Of these 429 discontinuous treatment patients, 84.1% (361/429) had 2-4 treatment episodes whereas 15.9% (68/429) had 5 or more episodes during follow-up period. When continuous treatment patients were compared with discontinuous treatment patients, living with family members or friends (88.2% (97/110), 78.5% (337/429)), age of first drug use under 25 (61.8% (68/110), 71.3% (306/429)), low urine morphine positive test results (67.3% (74/110), 38.2% (164/429)) and living within 5 kilometers of the MMT clinic (72.7% (80/110), 61.3% (263/429)) were positively associated with higher possibility of continuous treat retention (P < 0.05). Demographics and drug abuse characteristics at enrollment, including gender, age, employment status, family relationship, injection, needle sharing, criminal behavior, contacts with drug users, MMT daily dosage and family members receiving MMT were not significantly associated with treatment retention (P > 0.05). Illicit drug use during the treatment and longer distance travelling to MMT clinic might have negative impact on patients' continuous treatment retention. Mobile MMT vehicles and expanded MMT service sites could be introduced to improve compliance of treatment retention of MMT patients.

ImportanceIllicit and nonmedical (use in ways other than instructed) drug use is common in adolescents and young adults and increases the risk of harmful outcomes such as injuries, violence, and poorer academic performance.ObjectiveTo review the benefits and harms of interventions to prevent illicit and nonmedical drug use in children, adolescents, and young adults to inform the US Preventive Services Task Force.Data SourcesMEDLINE, PubMED, PsycINFO, and the Cochrane Central Register of Controlled Trials (January 1, 2013, to January 31, 2019 [children and adolescents]; January 1, 1992, to January 31, 2019 [young adults <25 years]); surveillance through March 20, 2020.Study SelectionClinical trials of behavioral counseling interventions to prevent initiation of illicit and nonmedical drug use among young people.Data Extraction and SynthesisCritical appraisal was completed independently by 2 investigators. Data were extracted by 1 reviewer and checked by a second. Random-effects meta-analysis was used to estimate the effect sizes associated with the interventions.Main Outcomes and MeasuresNumber of times illicit drugs were used; any illicit drug or any cannabis use.ResultsTwenty-nine trials (N = 18 353) met inclusion criteria. Health, social, or legal outcomes such as mental health symptoms, family functioning, consequences of drug use, and arrests were reported in 19 trials and most showed no group differences. The effects on illicit drug use in 26 trials among nonpregnant youth (n = 17 811) were highly variable; the pooled result did not show a clinically important or statistically significant association with illicit drug use (standardized mean difference, −0.08 [95% CI, −0.16 to 0.001]; 24 effects [from 23 studies]; n = 12 801; I2 = 57.0%). The percentage of participants using illicit drugs ranged from 2.3% to 38.6% in the control groups and 2.4% to 33.7% in the intervention groups at 3 to 32 months’ follow-up. The median absolute risk difference between groups was –2.8%, favoring the intervention group (range, –11.5% to 14.8%). The remaining 3 trials provided a perinatal home-visiting intervention to pregnant Native American youth. One trial (n=322) found a reduction in illicit drug use at 38 months (eg, cannabis use in the previous month, 10.7% in the intervention group and 15.6% in the control group) but not at earlier follow-up assessments. Across all 29 trials, only 1 trial reported on harms and found no statistically significant group differences.Conclusions and RelevanceThe evidence for behavioral counseling interventions to prevent initiation of illicit and nonmedical drug use among adolescents and young adults was inconsistent and imprecise, with some interventions associated with reduction in use and others associated with no benefit or increased use. Health, social, and legal outcomes were sparsely reported, and few showed improvements.

Methadone maintenance treatment (MMT) effectively reduces illicit opioid use and its negative consequences when patients participate in and adhere to treatment. Patients' participation and adherence may relate to their perceptions about methadone doses and dose adjustments and the meanings that patients associate with treatment. This study assessed patient perceptions about methadone dosing and the meanings associated with methadone treatment to better support patient adherence to and success in MMT. We conducted semistructured interviews with 19 patients in an urban MMT program. Interviews were transcribed verbatim and analyzed through an iterative process. Participants' expressed perceptions about methadone doses related to ideas of "comfort" and "function," suggesting a model for determining dose appropriateness and "ideal" methadone dose based on various factors both intrinsic and extrinsic to MMT. Intrinsic factors included those exerting downward pressure on "ideal" methadone dose such as lack of control in treatment, disdain for getting "high," concerns about methadone dependence, and desire to avoid adverse effects; those exerting upward pressure such as concern about withdrawal; and those exerting mixed pressures such as methadone formulations. Extrinsic factors included those exerting downward pressure such as shame about and stigma around MMT; those exerting upward pressure such as medical conditions and medication interactions; and those exerting mixed pressures such as family and peer relationships. Participants held perceptions about methadone dosing that included considerations beyond typical medical parameters used by physicians and other MMT providers to determine appropriate methadone doses. The model that emerged from our data could help inform MMT providers to support greater patient comfort with methadone doses and dose changes, as well as adherence to and success in MMT.

The authors evaluated the effects on retention and other outcomes of three approaches in a methadone maintenance program. At the time of admission, 300 chronic opioid users were randomly assigned to standard treatment, patient‐regulated dose, or optional counseling. Retention of the optional counseling group exceeded that of the other two groups, but the difference was only of borderline significance. Allowing patients to regulate their methadone dose did not lead to a general escalation of dose. Subjects in optional counseling saw their counselors less than half as often as those in the standard treatment with two mandatory sessions per month. Illicit drug use and social performance in the twelfth month did not differ significantly among the three subgroups that remained in treatment. The findings support patient participation in decisions about methadone dose and the frequency of counseling.