The purpose of this study is to describe and analyze how health care providers, working at care facilities providing maintenance treatment programs for opiate dependence, perceive and manage the legal framework governing the treatment. The study is limited to a few particular rules within this framework which over the recent decade have been the subject matter of debate regarding i.a. their alleged lack of relation to scientific research and their frequently disastrous implications for program participants. The empirical material consists of interviews with five respondents working at four different care facilities and has been analyzed by using Lipskys theory on street-level bureaucrats as policymaking agents. The results of the study show that the rules are looked upon and dealt with in a liberal fashion and that the primary loyalty of the maintenance treatment staff is clearly directed towards promoting the well-being of their patients and helping them reach their treatment goals rather than strictly following the rules.

Denna studie syftar till att beskriva patienters upplevelse av läkemedelsassisterad behandling för opiatberoende (LARO), även kallad underhållsbehandling. I studien undersöks hur upplevelsen av LARO är och hur den beskrivs utifrån två olika patientgrupper; de patienter med en mindre välfungerande behandling som dagligen går till mottagningen för att ta medicin övervakat och som lämnar urinprov två gånger i veckan, samt de patienter med en välfungerande behandling som går till mottagningen två gånger i veckan för att lämna urinprov men hämtar medicin på apoteket. I uppsatsen har sex patienter intervjuats om hur de upplever LARO. Uppsatsens resultat illustrerar bland annat upplevd brist på delaktighet och empowerment i behandlingen samt vikten av en god relation mellan patienter och personal på LARO-mottagningen. Studiens slutsats är att Patient empowerment bör vara grundstenen i all arbete med omvårdnad och behandling. / This study aims to describe patients' experiences of medication-assisted treatment for opioid dependence (LARO), also called maintenance therapy. The study examines how the patients experience LARO is and how the experience is percieved among the two patient groups: those patients with a less well functioning treatment that daily goes to the clinic to take medication supervised, and submit urine samples twice a week, as well as those patients with a functioning treatment that goes to the clinic twice a week to provide a urine sample but retrieves medicine from the pharmacy.In the paper, six patients were interviewed about how they experience LARO. Results of the thesis illustrate, among other things, the experienced lack of participation and empowerment in the treatment and the importance of a good relationship between patients and staff at LARO reception. The study concludes that patient empowerment should be the cornerstone of all the work with care and treatment.

Background: The consequences of continued opioid abuse among patients treated with opioid substitution therapy (OST) are serious and can result in abnormal cardiovascular function, overdose, and mortality. Conflicting evidence exists that both implicates and refutes the role of chronic non-cancer pain (CNCP) as a major risk factor for continued opioid abuse within the addiction treatment setting. This thesis aims to 1) evaluate the impact of chronic pain on the treatment outcomes of patients with opioid addiction receiving OST, 2) determine whether a clinical or inflammatory profile exists to distinguish pain in this population, 3) explore the sources of heterogeneity in previous studies examining this question, 4) determine the best therapy for patients with chronic pain, and 5) evaluate the most effective treatment for opioid addiction. We anticipate chronic pain to be an important predictor of continued opioid abuse such that patients with comorbid pain will require careful consideration when managed on OST. Methods: We systematically reviewed the literature to determine the impact of pain in opioid addiction patients receiving methadone maintenance treatment (MMT). We determined the clinical and inflammatory profile of MMT patients using data from the Genetics of Opioid Addiction (GENOA) research collaborative between the Canadian Addiction Treatment Centres (CATC) and the Population Genomic Program. GENOA is a prospective cohort study aimed to determine the genetic, biological, and psychosocial determinants of treatment prognosis for opioid addiction patients receiving MMT. GENOA recruits patients ≥ 18 years of age meeting the DSM-IV criteria for opioid dependence. All GENOA participants are receiving MMT for the management of opioid addiction. Baseline data from the GENOA pilot study (n=235) were used to evaluate the impact of pain on illict opioid use behaviour and determine the clinical and inflammatory profile of patients with comorbid pain. We explored sources of heterogeneity in previous studies using data from the full-phase GENOA study (n=444), examining the prognostic value of different pain measures for predicting illicit opioid use. We then performed a multiple treatment comparison of all opioid substitution and antagonist therapies in efforts to determine the best intervention for improving treatment outcomes for patients with comorbid pain. We lastly determined the most effective treatment for opioid addiction by performing a network meta-analysis using data from a systematic review of opioid maintenance therapy trials. Results: Our initial systematic review confirmed a lack of consensus in the literature, whereby some studies suggest pain increases risk for illicit opioid use and other studies suggest pain has no effect on substance use behaviour. Findings from the analysis of GENOA pilot data confirmed chronic pain to be an important predictor of sustained opioid abuse and also showed patients with pain to have elevated Interferon-Gamma. Using data from the GENOA prospective cohort study we determined the Brief Pain Inventory (a commonly used pain measurement in pervious studies) to be highly sensitive with poor prognostic value. Our final reviews propose 1) there is limited evidence to suggest any OST is superior for managing patients with comorbid pain, and 2) heroin and high-dose methadone are the most effective treatments for improving treatment retention. The final systematic review and network meta-analysis in this thesis also highlights a major problem in the treatment of opioid use disorders, primarily the lack of consensus as to what outcomes matter for determining success in patients with addiction. Conclusion: Patients with comorbid pain and addiction are at high-risk for continued opioid abuse and should be managed closely by clinicians administering OST. Contention in the previous literature likely resulted from the use of pain measurements with poor prognostic value. No OST demonstrated superiority for managing patients with chronic pain. While our findings indicate heroin is the most effective treatment across multiple endpoints, we use this thesis to provide readers with 1) a sense of the feasibility issues associated with heroin administration, 2) a summary of the limitations of this evidence base, and 3) recommendations for how to improve the addiction trials’ design for future research. / Thesis / Doctor of Philosophy (PhD)

Deux paradigmes se côtoient dans le traitement de la dépendance au Québec. Tout d’abord, il y a le paradigme de l’abstinence avec un modèle d’intervention souvent basé sur les Alcooliques Anonymes. Avec ce modèle, l’alcoolisme (ou la toxicomanie) est défini comme une maladie. En ce qui a trait à la réduction des méfaits, cette dernière vise la réduction des effets néfastes de l’usage de drogues plutôt que l’élimination de leur usage (Brisson, 1997). Nous nous sommes intéressés à une intervention inscrite dans ce paradigme soit le programme de substitution à la méthadone. Cette étude avait comme but de connaître les perceptions de personnes inscrites à ce programme, comprendre comment est vécu le rétablissement à travers la participation au programme et connaître les perceptions de ces personnes en ce qui a trait aux conséquences de la dépendance. Un cadre théorique s’inscrivant dans la perspective de l’interactionnisme symbolique a été choisi. Plus précisément, les processus de transformations normatives de Maria Caiata Zufferey, la théorie de l’étiquetage d’Howard Becker et le concept de stigmate d’Erving Goffman ont été retenus. Ensuite, dix entrevues semi-dirigées auprès d’hommes et de femmes majeures inscrites à un programme de substitution à la méthadone ont été réalisées. En ce qui a trait au chapitre portant sur les résultats, il a mis en lumière différents rapports à la méthadone vécus par les participants. Pour ce faire, trois figures construites à l’aide de l’analyse typologique ont été développées. Il ressort que pour certaines personnes, la méthadone fut décrite comme un substitut nécessaire, pour d’autres, elle correspondait à une aide dont ils veulent se débarrasser et pour une minorité, elle suscitait de l’ambivalence. En définitive, bien que la substitution demeure le traitement de choix pour la dépendance aux opioïdes, il est difficile de parler de sortie du monde de la drogue à l’aide de la méthadone puisque ce traitement apparaît comme étant presque aussi stigmatisé que la dépendance à l’héroïne (Lauzon, 2011). À première vue, la méthadone permet de prendre une distance avec le monde de la drogue (l’argent facile, les vols, la prostitution) et permet de se reconstruire une existence sur la base de repères stables, mais à bien considérer les choses, elle confine les personnes interrogées dans une situation d’ambivalence puisqu’elle les rattache à une identité de toxicomane. Mots-clés : dépendance, programme de substitution à la méthadone, perception, participant, réduction des méfaits, stigmatisation. / Two paradigms are frequent when treating addiction in Quebec. First, there is the paradigm of abstinence with an intervention model often based on Alcoholics Anonymous. With this model, alcoholism (or addiction) is defined as a disease. The second paradigm, harm reduction, is aimed to reduce the harmful effects of drug use rather than eliminating their use (Brisson, 1997). We are particularly interested in an intervention found in this paradigm named methadone maintenance treatment. This research was aimed to identify the perceptions of people enrolled in this treatment, understand their recovery process while participation in this treatment and understanding the perceptions of users of methadone in regards to the consequences of addiction. A theoretical framework found in the symbolic interactionist perspective was selected. More specifically, the process of normative transformations of Maria Caiata Zufferey, the labelling theory of Howard Becker and the stigma theory of Erving Goffman were selected. A qualitative methodology was retained. Ten semi-structured interviews with men and women enrolled in a methadone maintenance treatment were conducted. The chapter that focussed on the results highlighted various reports on how methadone maintenance treatment was experienced by the participants. To do this, three figures constructed using typology analysis were developed. For some people, methadone was described as a necessary substitute, for others, it corresponded to a help that they wanted to eliminate and for a minority, it aroused ambivalence. One thing is certain, although the substitution remains the treatment of choice for opioid dependence, it is difficult to speak of the output of the drug world with the help of methadone because this treatment appears to be almost as stigmatized as the dependence on heroine (Lauzon, 2011). At first glance, the use of methadone can help distance a person from the world of drugs (easy money, theft, prostitution) and can help rebuild their lives on a basis of landmark stability, but to carefully consider, it confines the respondents in a state of ambivalence as it relates to the identity of an addict. Keywords : harm reduction, methadone maintenance treatment, perception, participant, stigma, dependency.

Background Heroin dependence is associated with increased risk of the transmission of blood-borne viral (BBV) infections such as HIV, as a result of unsafe injecting practices. Opioid Substitution Treatment (OST) Programmes including Methadone Maintenance Treatment (MMT) programmes are a recommended way of addressing heroin dependence with the dual aims of reducing both heroin use and associated harms. However, OST programmes, particularly in prison settings, are often unavailable, in spite of large numbers of prisoners with heroin dependence and the high risk of HIV transmission in the prison setting. Little is currently known about the delivery of OST programmes within prison settings. A systematic literature review conducted within this study revealed that there are only a small number of studies from middle and lower-income countries and the perspectives of the range of stakeholders are often underrepresented. Aim and setting of this study This aim of this study was to understand the role of Methadone Maintenance Treatment (MMT) programmes within the context of HIV prevention programmes and to identify barriers and facilitators that influence the implementation, routine delivery and sustainability of methadone programmes in Indonesian prisons. Study design Three prison settings were selected as part of a qualitative case study. These comprised: a narcotics prison that provided methadone, a general prison that provided methadone, and a general prison, where there was no methadone programme. This allowed the exploration of multiple perspectives of prisoners and the diverse range of staff involved in the implementation of programmes. Interview and observational data were supplemented by data from medical case notes. Qualitative data underwent thematic analysis, with the help of framework analysis for data management. Principal findings This study found that there were many misconceptions about methadone programmes. HIV infection was not recognised as a problem and prison staff, healthcare staff and prisoners alike lacked understanding of the roles of methadone programmes. Prisoners participating in programmes were often stigmatised, while many prisoners believed methadone withdrawal was dangerous and could lead to death. These factors all contributed to low level participation, observed in both prisons with methadone programmes. Lack of confidentiality and associated stigmatisation as well as inappropriate assessment criteria also contributed to this, as did a lack of support systems. A reduction in international funding and a shift in national drug policy priorities away from the provision of methadone to drug-free Therapeutic Community (TC) programmes, together with a failure to embed methadone programmes within the daily prison routine currently pose challenges to effective implementation, delivery and programme sustainability. Conclusion Educating policy makers and practitioners could improve understanding of the roles of methadone programmes and increase support for programme delivery within prisons. It is therefore recommended that Indonesian government and prison policy focuses on ensuring effective delivery and sustainability of methadone programmes for people with heroin dependence in the prison setting.

Bakgrund: Personer med opioidberoende är till sin omfattning mer än 26 miljoner människor världen över. Läkemedelsassisterad rehabilitering av opioidberoende (LARO) i kombination med omvårdnad och psykosocial behandling är en effektiv behandlingsmetod vid opioidberoende. Målen med LARO-behandling är utöver att minska dödligheten att personer med opioidberoende ska få ökad psykisk och fysisk hälsa samt få ett socialt fungerande liv. Klinisk erfarenhet visar dock att det finns svårigheter med att kvarhålla personer i LARO-behandling, vilket ofta leder till att personer i stället avlider. Sjuksköterskan har ett ansvar att ge omvårdnad på ett personcentrerat tillvägagångssätt i samband med behandling och kunskap som en sjuksköterska besitter kan hjälpa till att förbättra vårdresultaten i en LARO-behandling. Syfte: Syftet med studien var att belysa hur vuxna patienter med opioidberoende upplever omvårdnad vid LARO-behandling (läkemedelsassisterad rehabilitering vid opioidberoende). Metod: En allmän litteraturöversikt genomfördes där resultatet baserades på nio vetenskapliga artiklar med kvalitativ ansats som inhämtats genom systematiska sökningar i databaserna PubMed och CHINAL. Data analyserades i enlighet med Fribergs analys bestående av fem steg. Resultat: Analysen resulterade i tre huvudkategorier med sex tillhörande subkategorier. Huvudkategorierna var: Sjuksköterskan villkorar LARO-behandlingen, Vårdrelationen med sjuksköterskan och Utmaningar i tillgängligheten. Subkategorierna var: Begränsad delaktighet, Stigmatisering, Vikten av en god relation, Brister med informationen, Begränsad tillgänglighet och Avsaknaden av omvårdnadsutbud. Slutsats: Patienter med opioidberoende upplevde LARO-behandlingen som villkorad. Patienter upplevde bristande delaktighet gällande omvårdnaden. Upplevelse av stigmatisering kopplat till omvårdnaden framkom även. Patienter upplevde att de misstänkliggjordes efter flertalet år i behandling. Brister avseende tillgänglighet kopplat till LARO-behandlingen identifierades. Relationen till sjuksköterskan upplevdes vara en viktig del i behandlingen. Relationen skulle bidra till att bygga förtroende, reducera stigma och upplevas accepterande. Rådgivande samtal tillsammans med medicinering ansågs vara den viktigaste aspekten i behandlingen. / Background: People with substance use disorder are to its extent more than 26 million people worldwide. LARO treatment (drug-assisted rehabilitation in opioid dependence) for people with substance use disorder in combination with other nursing care and psychosocial treatment is an effective treatment for people with substance use disorder. The goals of LARO treatment are for people with opioid dependence to have increased mental and physical health, have a socially functioning life and a reduced mortality. However, clinical experience shows that there are difficulties in retaining people in LARO treatment, which often leads to people dying instead. The nurse has a responsibility to provide nursing in a person-centered approach. Knowledge that a nurse possesses can help improve care outcomes in a LARO treatment. Aim: The purpose of the study was to highlight how adult patients with opioid dependence experience nursing care during LARO treatment. Method: A literature review was conducted where the results were based on nine scientific articles with qualitative approaches obtained through systematic searches in the databases PubMed and CINAHL. The data was analyzed in accordance with Friberg's analysis that consists of five steps. Results: The analysis led to three main categories with six associated subcategories. The main categories were following: The nurse conditions the treatment, The care relationship and Accessibility challenges. The associated categories were: Limited participation, Stigma, The imprtance of a good relationship, Deficiencies with the information, Limited availability and Lack of nursing services. Conclusion: Patients with opioid dependence experienced LARO treatment as conditional and experienced a lack of participation. Experiences of stigma linked to nursing emerged. Deficiencies regarding accessibility linked to the LARO treatment were identified. The relationship with the nurse was perceived to be an important part of the treatment. The relationship would help build trust, reduce stigma, and be perceived as accepting. Counseling along with medication was considered the most important aspect of treatment.

毒品濫用問題乃世界各國共通之施政難題，我國政府於1993年宣布向毒品宣戰，並在2005年8月引進美沙酮替代療法（Methadone Maintenance Treatment，MMT），於全國各縣市推動毒品減害計畫。但歷經十餘年之努力，毒品人口與整體毒品再犯率截至2010年底並未明顯降低，足見毒品防制政策有全面檢視問題癥結，重新調整執行策略之必要。本研究就此現象探討三項議題：1.毒品防制領域，IT有無著力之空間？ 2.以美沙酮替代療法為主之毒品防制策略在台灣地區推行是否發揮預期的效果？現行做法有無改善空間？ 3.出監毒癮者復歸社會後再犯率高，其最需要政府的幫助為何，方能有效降低再犯毒品罪之誘因？。三項議題互為關聯。 本研究探訪毒品防制第一線工作人員，並參考國內外毒品減害文獻，歸納目前毒品危害防制工作推動上的困境，探究IT可出力之空間，並提出“毒品成癮者資訊總歸戶”的概念。整合法務、警政、衛生醫療等毒品防制資訊，建立跨部會即時歸戶資料庫並建立部會間協同作業之標準作業程序（SOP），以提升毒品防制工作之效率。進而運用歸戶系統之客觀數據，評量毒品替代療法政策之推行成效，並實際訪問領域專家及調查毒品犯社會適應之困難與需求，以歸納具體、可行之解決方案。 研究發現資訊系統可改善毒品危害防制中心效率，但不能單獨讓毒品防制工作之網絡有效運轉，現行毒品防制組織、制度問題之發現與解決更是關鍵。本文並依客觀數據之分析及實地訪問、調查結果，提出多項制度變革之建議，以供政府權責機關參採。 / Background:Drug abuse problems have been a global concern issue. Taiwan’s government introduced Methadone Maintenance Treatment (MMT) in Aug. 2005, now it has become one of the major strategies in fighting drug abuse. Whereas, up to 2010 MMT strategy still not shows effectiveness in reduce drug population and recidivism. The aim of this study is to: Provide the value to the Drug Abuse Provention System in R.O.C.through IT approach,and to evaluate whether MMT is performed adequately in Taiwan.If not,what are the key factors? The study will provide objective evidence and suggestions to authorities for better decision making. Methods: This study used Prove of Concept (POC) and experiment approachs. Build software system and SOP to prove the concept of “National Drug Addicts Supporting and Monitoring System (NDASMS)” can enhance the efficiency of Information Intergration among government agencies of drug prevention effectively. The study also used the data of NDASMS to evaluate the efficacy of MMT implementation in Taiwan, and find the reasons why MMT dose not work as expected. Result: The IT approach have been proved that enhance the infromation integration effectively among agencies, but IT can,t make the Chain of National Drug Provention Mechanism improve alone.The adequacy of MMT implementation and its supporting measures in Taiwan need to be further examined.

No description available.

The thesis focuses on the subjectively perceived changes in the lives of persons in the methadone maintenance treatment program, on their experiencing of the changes and subjective judgment of the treatment. The topic is treated according to the Bio-Psycho-Socio-Spiritual Model of Addiction. The theoretical part deals with the quality of life and the subjectively perceived well-being and defines six dimensions of well-being on which the practical part of the thesis is based. It also elaborates on the Bio-Psycho-Socio-Spiritual Model of Addiction in the context of the methadone maintenance treatment. Moreover, it describes the factors in life change and the motivation to change. The last theoretical chapter focuses on the opioid substitution treatment as such and more specifically on the methadone maintenance treatment. The practical part presents the results of the research. The aim of the thesis is to analyse how the persons in the methadone maintenance treatment program in České Budějovice perceive life changes. A qualitative research was chosen for that purpose. The data were obtained through the technique of narrative interview. The research group consisted of four respondents who were on the methadone maintenance treatment program. The results show that the subjectively perceived changes in the lives of the persons in the methadone maintenance treatment program relate to five out of six dimensions of well-being. No changes were recorded in the dimension concerning the sense of life, in other words, even after a several month methadone maintenance treatment these persons perceive no goal of their lives. Important consequences for work with these persons can be drawn from that, especially for therapists in opioid substitution centres, who should develop spirituality aspects of persons.

This was a retrospective study of a community-based methadone maintenance treatment (MMT) program in Toronto. Participants (N = 170) were federally sentenced adult male offenders admitted to this voluntary program between 1997 and 2009 while subject to community supervision following incarceration. The primary investigation examined correlates of treatment responsivity, with principal outcome measures including MMT clients’ rates of: (i) illicit drug use; and (ii) completion of conditional (parole) or statutory release (SR). For a subset (n = 74), recidivism rates were examined after a 9-year interval. Findings included strong convergent evidence from logistic regression and ROC analyses that an empirically and theoretically derived set of five variables was a stable and highly significant (p <.001) predictor of release outcome. Using five factors related to risk (work/school status, security level of releasing institution, total PCL-R score, history of institutional drug use, and days at risk), release outcome was predicted with an overall classification accuracy of 88%, with high specificity (86%) and sensitivity (89%). The logistic regression model generated an R2 of .55 and the accompanying AUC was .89, both substantial. Work/school status had an extremely large positive association with successful completion of community supervision, accounting for > half of the total variance explained by the five-factor model and increasing the estimated odds of successful release outcome by > 15-fold. Also, when in the MMT program, clients' risk taking behaviour was significantly moderated, with low overall base rates of illicit drug use, yet the rate of parole/SR revocation (71%) was high. The 9-year follow-up showed a high mortality rate (15%) overall. Revocation of release while in the MMT program was associated with a significantly higher rate and more violent recidivism at follow-up. Results are discussed within the context of: (a) Andrews' and Bonta's psychology of criminal conduct; (b) the incompatibility of a harm reduction treatment model with an abstinence-based parole decision-making model; (c) changing drug use profiles among MMT clients; (d) a strength-based approach to correctional intervention focusing on educational and vocational retraining initiatives; and (e) creation of a user friendly case-based screening algorithm for prediction of release outcome for new releases.