Thesis (Ph.D.)--York University, 2008. Graduate Programme in Communication and Culture. / Typescript. Includes bibliographical references (leaves 261-277). Also available on the Internet. MODE OF ACCESS via web browser by entering the following URL: http://gateway.proquest.com/openurl?url_ver=Z39.88-2004&res_dat=xri:pqdiss&rft_val_fmt=info:ofi/fmt:kev:mtx:dissertation&rft_dat=xri:pqdiss:NR51780

PURPOSE: This qualitative study explores the perceptions of women diagnosed with Opiate Use Disorder enrolled in Methadone Maintenance Treatment (MMT). The purpose is to gain an understanding of the women’s perceptions of their treatment and recovery. RESEARCH QUESTIONS: Research questions explored: the women’s experiences and perceptions related to recovery on dimensions such as family, social network, sense of identity, motivations for continued recovery, and relapse prevention methods; their belief in their ability to succeed; changes in personal identity from a drug user to a non-drug-user; and the role of the methadone medication in their recovery. SAMPLE: Criteria included women 35-50 years of age with a history of opioid addiction for at least 5 years; regular attendance at the Methadone program; abstinent from alcohol and illicit drugs for 12- 18 months. RESEARCH DESIGN: A convenience sample of thirty-one women was interviewed using semi-structured interviews, conducted by the PI. Open-ended questions were asked to elicit the women’s views. The PI conducted a record review to verify that the women had a history of opioid addiction, were regular attendees of the MMT program, and had maintained the period of abstinence that they reported. Methods included Thematic Analysis. THEORETICAL FRAMEWORKS: Guiding frameworks were the Developmental Model of Recovery (Brown, 1985), describing healthy adaptation following a period of debilitation, and Symbolic Interactionism (Blumer, 1969), describing social interactions as mutually developed exchanges to which individuals bring their own symbolic meanings. FINDINGS: These women had positive perceptions of their recovery and changes in themselves including becoming more responsible, reuniting with their families and developing personal insight. They saw methadone as crucial to their recovery. Although they saw themselves as fairly well along in recovery, they believed they could not be fully recovered until they were off methadone. IMPLICATIONS: Findings help us understand the women’s perception of how MMT and behavioral and personal changes contributed to their recovery. Although these women, who were abstinent and treatment-compliant for at least one year, were able to ignore or reframe their experiences of methadone stigma, the stigma may contribute to treatment drop out for some women, especially early in treatment

Background and Objectives: Opioid addiction is a major contributor to the global burden of disease and carries a significant risk of morbidity and mortality. Individuals with opioid addiction are subject to numerous adverse consequences including infectious diseases, medical complications, psychiatric disorders, and social disintegration. Women especially experience a heightened vulnerability to the adverse medical and social consequences of opioid addiction as a result of biological sex characteristics and socially-defined gender roles, which increases their risk for poor treatment outcomes. The general objective of this thesis if to investigate sex and gender differences in the management and treatment of opioid addiction with a focus on hormonal influences, genetic variation, and sociobehavioral characteristics including substance use behavior, health status, and social functioning. Methods: Using various methodologies, we compared the biological and social characteristics of men and women with opioid addiction in the context of methadone treatment. We assessed sex and gender differences in methadone treatment outcomes using a systematic review of the literature and a meta-analysis, which was developed based on published protocol. Next, we used data from the multi-centre GENOA cross-sectional study including 250 patients with opioid addiction recruited from Ontario methadone clinics to measure testosterone levels among men and women compared to non-opioid using controls; total serum testosterone was assayed using ELISA and RIA techniques. Following this study, we conducted a systematic review and meta-analysis to test the effect of opioid use on testosterone levels, performing subgroup analyses by sex and type of opioid used. Using the previous GENOA sample, we then completed genotype analysis on variants of BDNF and DRD2 genes to test the genetic effect on continued opioid use, measured through urine drug screening. Finally, we recruited an additional 503 participants meeting criteria for opioid use disorder who were receiving treatment with methadone, from which we obtained information on drug use patterns and addiction severity using the Maudsley Addiction Profile (MAP) tool to evaluate sex and gender differences. Results: In our initial systematic review, we found 20 studies collectively showing that women were less likely than men to report alcohol use, employment, or legal involvement, but were more likely to misuse amphetamines. Using the GENOA dataset of methadone patients, we found a significant reduction in testosterone level among men but not women, which was associated with methadone dose. We also determined that testosterone did not fluctuate significantly between menstrual cycle phases. In line with these findings, our systematic review showed a significant suppression in mean testosterone level among men that use opioids compared to controls, but not in women. Our results also showed that methadone did not affect testosterone differently than other opioids. Among GENOA participants, BDNF rs6265 and DRD2 rs1799978 genetic variants were not significantly associated with continued opioid use while in methadone maintenance treatment. Our final study identified sex and gender differences in substance use, health status, and social functioning. Women were younger, had children, were current smokers, had higher rates of benzodiazepine use, more frequent physical and psychological health problems, family history of psychiatric disorders, more partner conflict, and began regular use of opioids through a physician prescription. In comparison, men were more likely to be employed and to report cannabis and amphetamine use. Conclusions: This thesis has demonstrated that men and women are differentially affected by opioid addiction and experience sex- and gender-specific challenges throughout the course of methadone treatment that are likely to impact treatment outcomes. The identification of clinically-relevant sex and gender differences is important to our understanding of the addiction profile, and can therefore be used to promote strategies for effective treatment and management of opioid addiction among men and women incorporating both biological and social perspectives. / Thesis / Doctor of Philosophy (PhD)

The United States is in the midst of an opioid crisis. Fortunately, effective treatments for opioid use disorder exist (OUD); however, they are underutilized. Medications for opioid use disorder (MOUDs) decrease death by 50 %. These MOUDs are particularly relevant in the criminal justice population given that this population has a higher OUD disease burden but is less likely than the general population to receive this life-saving treatment. Research has identified negative attitudes toward MOUDs among corrections staff as a barrier to utilizing MOUDs. This thesis examines the relationships between community correction staff familiarity with methadone, one type of MOUD, and their opinions toward methadone using extant data from the Criminal Justice Drug Abuse Treatment Studies 2 (CJ-DATS 2) series. These data were collected between 2010-2012. The study was guided by the Knowledge-Attitude Behavior (KAB) model. The data are described using descriptive statistics, and I estimate logistic regressions to examine the relationship between respondent familiarity with methadone and their attitude toward methadone while controlling for other covariates. With a sample of 167 corrections employees, I found that corrections staff who agreed or strongly agreed with the statement that they were familiar with methadone had more positive methadone attitudes. Future research should examine the relationship between familiarity/knowledge, attitudes, and behaviors in other criminal justice settings and for other MOUDs (i.e., buprenorphine and naltrexone).

Aims and objectives Substance misuse is a chronic relapsing condition associated with high morbidity and mortality. Treatment attempts to reduce harms associated with drug use and to promote recovery and has developed considerably in the last 30 years. Opioid substitution therapy using methadone (OST-M) is an effective treatment for opioid dependency. Though the effectiveness of OST-M in delivering harm-reduction is well evidenced, evidence demonstrating recovery is limited as is understanding of those factors influencing progress. In this context, national policy makers and stakeholders have repeatedly questioned the value of OST-M as a substance misuse treatment and, at times, have sought to limit its use. Rigorous, long term outcome studies of UK subjects are required to improve clinical outcomes in OST-M subjects and to ensure ongoing availability of evidence-based treatments. In this context, the study had two main objectives: to demonstrate that standard clinical information systems can deliver rich, valid datasets to support outcome research; to use these data to explore the relationships between a selection of baseline variables (patient characteristics, comorbid conditions, the nature of substance misuse and the treatment received), the clinical process and long term outcomes achieved in a large cohort of OST-M patients in a standard NHS treatment setting. Methods and materials Standard clinical information, collected over 7 years, was linked with validated data from a range of databases. A large representative sample (76% of the OST-M treatment population in a region) was described in detail. Follow-up data were retrieved from clinical casenotes (4 years) and linked datasets (4-7 years) and collated to create a database for analysis. Variables for analysis were selected following a review of the published literature. Univariate analyses were undertaken to demonstrate statistically significant associations between baseline and follow-up variables. Significant variables were then entered into multiple regression analyses to develop predictive models for selected outcomes. Any predictive models were then subjected to cross-validation to determine their predictive power in novel datasets. Key results Many highly significant associations were shown. Significant personal (demographic) factors included: age, gender, having children, having conflict in personal relationships, educational level achieved and being in employment. It was notable that the area lived in (of three districts) was strongly associated with a wide variation in clinical process and outcomes achieved. Whether treated in primary care or specialist services, the medical treatments received, the level of non-NHS support and patient satisfaction showed strong associations with outcome. Baseline illicit drug use was also strongly associated with outcome. Multiple regression analyses found that despite these highly significant associations, strong predictive models of long terms outcome could not be demonstrated. Where weak models were created - predicting drug use (by self - report); drug use (positive tests); family stability - cross validation showed these had no predictive value in novel datasets. Conclusions Standard clinical information, linked with relevant NHS datasets can give rich and comprehensive data suitable for research of large representative samples over long time periods. This study represents one of the largest OST-M populations ever described in the UK with longer follow-up periods than most of the published literature. In this study strong associations were found between a range of independent and dependent variables over 4-7 years. These findings broadly reflected the evidence base. However, the associated variables could not generate strong useful predictive models of long term outcome. This could reflect issues of study design or data quality. This type of approach should be further developed in the field of substance misuse research. Issues of data quality would require to be addressed to maximize the value of these datasets. Further research is required to develop better understanding into key factors influencing long term outcomes of treatment in substance misuse.

Today's methadone patients differ from those of the past due to increases in polydrug use, mental health issues, and medical needs. Patients requiring methadone treatment for their opiate addiction are now older than those who initially presented for treatment when methadone treatment first started. The number of older opiate users will continue to grow as the population continues to age. Although previous studies on opiate addiction focused on using methadone in treatment of younger adults, this study used phenomenological methodology to explore the lived experiences of opiate addicted methadone users between the ages of 50 to 55, an understudied population. A sample of 8 older addicts from the Midwest, using methadone in their treatment, provided data collected in face-to-face interviews for this study. Content analysis of the data was conducted with the assistance of NVivo 11 to code and identify categories and themes. Emergent themes included: the impact of methadone use on participants' relationship with others, participants' attitude of being an older methadone user, mental health stressors related to being an older methadone user, struggles in attending the methadone clinic daily, and needing other treatment besides treatment for methadone use. The study impacts social change by informing addiction professionals who may want to develop appropriate treatment interventions for this population.

Opioid dependence is a chronic relapsing condition resulting in significant individual and community harms, for which the most effective treatment is long term opioid pharmacotherapy (OP). In contrast to other Australian states and territories, in Victoria, 80-85 % of OP prescribing is undertaken by GPs, and while demand for this treatment is difficult to estimate, all evidence indicates that the current and future GP workforce is inadequate to meet projected need. / GPs have shown a reluctance to become actively involved in the treatment of patients with drug dependence, especially where illicit drugs are involved. In order to prescribe OP, Australian medical practitioners are required to complete a specific training program. Little is known of the reasons why GPs decline to undertake this training, and why the majority who complete training, subsequently prescribe to very few or no patients. / Using in-depth interviews and an analysis of existing data from the Victorian Department of Human Services, this thesis not only explores why GPs are unwilling to complete OP training, and why many subsequently fail to prescribe, but also identifies both barriers and facilitators which influence GPs in their decisions regarding these issues. The results have not only provided new information on the reasons GPs decline the offer of training but also supported existing research.

Introduction. There is clear evidence that children raised in families affected by parental drug use are at high risk for a wide range of adverse outcomes, including; early cognitive and language delay (van Baar & de Graaff, 1994); poor school attendance and educational under-achievement (Hogan & Higgins, 2001; Steinhausen, Blattmann, & Pfund, 2007); substance abuse and psychological problems (Keller, Catalano, Haggerty, & Fleming, 2002; Kilpatrick, Acierno, Saunders, Resnick, Best, & Schnurr, 2000; Kolar, 1994; Lagasse, Hammond, Liu, Lester, Shankaran, Bada et al., 2006; Merikangas, Dierker, & Szatmari, 1998; Moss, Vanyukov, Majumder, Kirisci, & Tarter, 1995; Nunes, Weissman, Goldstein, McAvay, Beckford, Seracini et al., 2000; Nunes, Weissman, Goldstein, McAvay, Seracini, Verdeli et al., 1998; Stanger, Higgins, Bickel, Elk, Grabowski, Schmitz et al., 1999). Careful examination of the impact of parental drug use on children and the developmental mechanisms associated with risk and resilience is central to the establishment of appropriate intervention. Children born to mothers who are drug dependent and enrolled in methadone maintenance treatment during pregnancy face the “double jeopardy” of prenatal drug exposure and post-natal environmental disadvantage (Zuckerman & Brown, 1993). This research aimed to identify early developmental difficulties or differences in communicative and cognitive development, and in particular the joint attention skills, of young children born to mothers engaged in methadone maintenance treatment. Of particular interest was the way in which pre- and postnatal factors combined to influence developmental outcome at age 2 years. This prospective, longitudinal study offered the opportunity to indentify early indicators of developmental differences in this group and thus, contribute to a better understanding of the long-term mechanisms of risk. Research Methods. Sixty children born to mothers engaged in methadone maintenance treatment and 60 randomly-selected, non-exposed comparison children were followed prospectively from birth to age 2 years. During the third trimester of pregnancy, mothers completed a comprehensive maternal interview. At 18 months, children were visited at home and evaluations of the social background, family and childrearing context were completed. At age 2 years, all children underwent a developmental assessment that included the Early Social Communication Scales (ESCS) (Mundy, Hogan, & Doehring, 1996). The ESCS consists of a semi-structured series of activities, which assess the joint attention abilities, social skills and interactive behaviour of infants aged 8 to 30 months. The focus of this study was on children’s use of two types of communicative behaviour – requesting and affect-sharing communications. Alongside the ESCS, the Mental Development Index (MDI) and language items from the Bayley Scales of Infant Development (BSID-II) (Bayley, 1993) and the Communication and Symbolic Behaviour Scales– Developmental Profile (CSBS-DP) (Wetherby & Prizant, 1998), were used to assess concurrent cognitive and language skills. Results. The results of this study indicated that children born to mothers engaged in methadone maintenance treatment were typically growing up in single-parent families (p=<.0001) and in welfare-dependent households (p=<.0001). Methadone-exposed children were also more likely to be living in out-of-home care placements at age 18months than comparison group children (p=<.0001). Their caregivers were less likely to be accepting of (p=<.01) and responsive to their needs (p=.008) compared to parents of comparison children. At home, methadone-exposed children had fewer learning opportunities (p=<.0001) and were more likely to live in houses where the television was on for longer, compared to non-exposed children (p=<.001). Caregivers of methadone-exposed toddlers reported more depression (p=<.0001), more illicit substance use (p=<.0001) and more family stress (p=.004) than comparison caregivers. They were also more often victims of psychological aggression (p=.002) and violence from others (p=<.0001), but they also reported that they were more likely to use psychological aggression (p=<.001) and physical punishment (p=<.03) in managing their children’s behaviour than comparison caregivers. The developmental assessment at age 2 years suggested that methadone-exposed children were significantly more likely to engage in communicative behaviour, which expressed a request, than non-exposed, comparison children (p=.03). On the other hand, analysis suggested that whilst methadone-exposed children were less likely than comparison children to engage in communication, which had the goal of affect sharing, this difference did not reach significance (p=.27). Previous research links greater use of requesting behaviours with later behaviour problems (Sheinkopf, Mundy, Claussen, & Willoughby, 2004). The MDI, BSID language measure and CSBS results further indicated significant delay in both cognitive (p =<.0001) and language development (p =<.0001) in the methadone-exposed group, compared to the comparison group. Between group differences were attenuated by control for confounding social background and prenatal factors, including maternal education, gestational age, other drug exposures during pregnancy and gender, but significant differences remained. Further analysis suggested that parenting practices and family environment factors were important intervening influences on the relationship between being born to a mother engaged in methadone maintenance treatment and poorer outcomes. More specifically, the association between methadone-exposure and differences in joint attention behaviours, were explained by caregiver use of psychological aggression (p=.01), caregiver disruption (p=.07) and caregiver stress (p=.01). On the other hand, poorer cognitive and language outcomes were explained by family contextual factors, including a less child-centered home environment (p=.008), caregiver disruption (p=.001), increased use of background TV (p=.02) and fewer stimulating activities (p=.06) Discussion. The family circumstances of children born to mothers engaged in methadone maintenance treatment during pregnancy, when compared with a group of randomly-selected comparison children, showed pervasive differences and multiple disadvantage. Findings suggest that these differences in family disruption, family functioning and parenting practices explain the negative outcomes of methadone-exposed children in early cognitive and communication skills at age 2 years. These results raise concerns for the later functioning of methadone-exposed children and emphasise the key importance of early intervention for children and families affected by parental drug use.

Context: Modifiable risk factors in older methadone maintenance treatment (MMT) patients may put them at a greater risk of acquiring chronic diseases. The paucity of literature regarding the well-being and service needs of older MMT patients required investigation to determine whether these patients are treated for and adhere to chronic disease medications(s) comparably to those not on MMT. Objective: This study compared the proportion of MMT patients to a matched control group treated with first-line medications for four chronic diseases: hypertension, chronic obstructive pulmonary disease (COPD), diabetes mellitus and depression. As a secondary outcome measure, this study also examined the adherence comparability between the two groups. Method: This case control study used prescription claims data from the BC Ministry of Health’s PharmaNet database from October 1, 2008 to December 31, 2009. Each MMT patient was individually matched with a control subject in terms of age, sex, social assistance coverage and local health area. Both groups consisted of 143 men and 56 women for a total of 400 participants. Persons 50 years of age and older, residents of BC, and had prescriptions filled during October 1, 2008 to December 31, 2009, were randomly selected from the PharmaNet database. Results: Odds ratios (ORs) were calculated to compare the odds of MMT patients to non-MMT patients on a first-line medication for each chronic disease under investigation. ORs were 0.865 for hypertension (ns), 0.738 for diabetes (ns) and 4.176 for depression (p <0.001). For COPD the OR could not be calculated as no controls were treated for COPD; however, 11.6% of the MMT group were prescribed COPD medications which was significantly higher than the controls (p<.001). Adherence was calculated using continuous measures of medication availability (CMA) “by patient” and “by medication class” during patients’ persistent periods (continuous use periods) CMA(1), as well as the entire study period CMA(2). By patient, the mean CMA(1) showed no difference between the groups (non-MMT group: 91.9%, SD=15.8, CI=95% vs MMT group: 89.7%, SD=22.2, CI=95%). The mean CMA(2) was statistically different (p<0.05) between the groups (non-MMT group: 70.5%, SD=25.3, CI=95% vs MMT group: 60.8%, SD=29.1, CI=95%). By medication class, CMA(1) was 80-100% for most medication classes for both groups except for insulins and inhalers in the MMT group which fell between 40-79%. The CMA(2) for most medication classes was 60-86% in the non-MMT group and 30-76% in the MMT group. However, the differences between the groups were not statistically significant. Conclusion: Odds ratios for the treatment of all four chronic diseases differed. Therefore, looking at each chronic disease separately may be worthwhile to suggest potential targets for intervention. Disease-specific tailored interventions related to lifestyle risk factors, comorbid medical conditions, and adherence to chronic medications could potentially improve the overall health of older MMT patients. However, development of appropriate interventions and treatments requires research that properly recognizes the physical and mental health problems faced by older MMT patients (Rosen, Hunsaker, Albert, Cornelius, & Reynolds III, 2010). / Graduate

Indonesia has been implementing methadone maintenance treatment (MMT) since January 2003 as a strategy to minimize HIV transmission among injecting drug users (IDU). Previous studies have shown the effectiveness of the program and also showed that the program had attracted many IDU to participate. However, the dropout rate, particularly in Jakarta clinics, was relatively high. The first aim of this study was to investigate the MMT retention rate and its predictive variables. The second aim was to examine the effects of remaining in the program on treatment outcomes. A six-month longitudinal prospective cohort study was conducted at the client level and a cross-sectional survey was carried out at the clinic level. Information from this study provides significant inputs for developing drug treatment policy and improving its quality of service in Indonesia. It also contributes to a better understanding of the substitution treatment implementation in Indonesia. The average 3-month treatment retention rate was 74.2 percent and the 6-month retention rate was 61.3 percent. There was no significant difference in retention rates between clinics. Significant predictors of treatment retention in MMT in Indonesia were size of dose, the interaction between take-home dose and clinic experience, age of participant, participant’s belief towards the program and perceived accessibility, while a variable representing perceived peer support unexpectedly predicted an increased likelihood of prematurely leaving the treatment. This study showed a marked reduction in the use of heroin and depression status and a significant improvement of self-efficacy at the follow up times among participants who continued in treatment. There were no significant differences in criminal involvement and physical health status between those who remained in treatment and the treatment dropouts in both follow-up interviews. Nevertheless, there was a significant improvement in physical health from baseline to follow-up in both groups. The study concluded that retention rates of MMT in Indonesia were comparable to those of similar programs in other countries. As previously reported in other settings, dose was the primary predictor of treatment retention in Indonesia. A policy of providing take-home doses, prescribed in experienced clinics,was also found to be a significant predictor of remaining in treatment. Further research, however, is still needed to explain some of the unexpected observations. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1522114 / Thesis (Ph.D.) -- University of Adelaide, School of Medical Sciences, 2010