Thesis (M. Sc.)--University of Canterbury, 2009. / Typescript (photocopy). Includes bibliographical references (leaves 102-122). Also available via the World Wide Web.

Methadone treatment continues to be the most widely used treatment modality for heroin addiction despite continued controversy. The efficacy of methadone treatment has been determined primarily by statistical research of program outcomes. This study explored heroin addicts' perceptions of methadone treatment.

Tho present thesis represents a summary or research done by the author (and others) that was conducted with heroin addicts and drug abusers undergoing behavioral and pharmacological therapy at Stockton State Hospital, Stockton, California. From June 1970 to December 1970 the Research Department of Stockton State Hospital, in conjunction with the Drug Abuse Program at Stockton State Hospital, conducted research investigating a number of difference facets relating to inpatient programs for heroin addicts undergoing methadone maintenance and drug abusers. These facets included the investigation and evaluation of (a) motivational factors; affecting the voluntary participation of inpatient heroin addicts and drug abusers in behavioral and pharmacological therapy, (b) the effectiveness of the synthetic narcotic methadone hydrocloride as a primary reinforcing technique for appropriate behavior, (c) the effectiveness of various therapeutic approaches used in conjunction with behavioral modification techniques, and (d) the effect of methadone on perceptual and motor functioning in the heroin addict under-going methadone maintenance. The present thesis is a compilation cf these research projects.

It is well established that methadone maintenance (MM) reduces but does not eliminate the self-administration of other illicit drugs. For those on MM, there is considerable variation in consumption patterns, route of heroin administration, additional non-opioid substances routinely administered and the clinical disorders associated with these patterns of use. While there is a large literature base documenting these phenomena, studies have been almost exclusively descriptive in nature, with little attempt to develop a theoretical model in which to understand such use. In the following thesis, a model proposed by Gray was tested, the Reinforcement Sensitivity Theory (RST). This biopsychosocial model broadly describes two action tendencies; approach (Behavioural Activation System) and avoidance or withdrawal (Flight Fight Freeze System and the Behavioural Inhibition System). The model proposes that a heightened sensitivity to punishment underlies anxiety disorders. Conversely, a heightened sensitivity to rewarding stimuli may predispose some individuals to engage in highly rewarding behaviour and is associated with conduct disorder and antisocial personality disorder. According to the Joint Subsystems Hypothesis, these personality styles are mutually dependent, whereby BIS and BAS interact to influence reward mediated and punishment mediated behaviours. Based on Gray's model, this thesis tests whether opiate dependent individuals with heightened sensitivity to punishment are more likely to use anxiolytic drugs (such as benzodiazepines), and individuals with heightened reward sensitivity will show a preference for substances that have high reward potential (such as stimulants). At time one, the participant sample (N= 120) comprised 71 males (59%) and 49 females who were opioid dependent and recruitment took place over an eight-month period in two city opioid replacement clinics. A range of measures was administered to assess substance use, mood, anxiety and the personality dimensions of reward sensitivity and punishment sensitivity, with substance use again measured at three months. Results of the first study suggested that a large proportion of the variance was accounted for by personality within the models. A total of 98 participants (81%) participated in the 12-week follow-up study. Sensitivity to punishment and reward significantly predicted drug preference. Although psychopathology symptoms were not able to moderate the relationship between personality and drug use, anxiety symptoms negatively mediated the relationship between punishment sensitivity and anxiolytic use, whereby the relationship became non-significant. In contrast, sensitivity to reward remained the strongest predictor of amphetamine use over antisocial characteristics. Individual differences were not able to predict treatment retention nor susceptibility to relapse during a 12-week initiation to a MM programme.

<p>Methadone Maintenance treatment of compulsive opioid addiction was started by the study of Dole and Nyswander (1965) and has subsequently been replicated in programs throughout the world. Methadone treatment has become the most effective modality for the treatment of chronic heroin addiction. </p><p>In 1966 a Swedish National methadone maintenance program was opened at the Psychiatric Research Center, Ulleråker hospital at Uppsala.</p><p>The aim of this thesis was to study the outcome of methadone treatment along various lines:</p><p>• An open randomised controlled study comparing the efficacy of methadone treatment and drug free treatment in 34 heroin addicts, 20-24 years of age. </p><p>• Before/after comparisons of rehabilitation among 345 heroin addicts admitted during the 23 years when this was a centralised National program.</p><p>• Retention in treatment.</p><p><b>Study subjects, methods and treatment goals: </b>Subjects underwent an admission procedure when background data was collected through hospital records, and personal interviews. Therapeutic efforts focused on vocational rehabilitation, i.e. a return to full-time work or studies, hoping to make patients abandon their drug addict’s life-style and make them socially accepted and self-supporting. </p><p><b>Results: </b>Thirty-four heroin addicts with a history of 4-8 years of heroin use were randomly assigned either to methadone treatment (17) or an untreated control group (17). The controls could not apply for methadone treatment until two years later. Outcome after six years observation showed that 81% became free of drug abuse, while the corresponding figure for the controls was only 1/17 (6%). The mean yearly death rate for the controls was 7.2%. Likewise, among the total material of 345 heroin addicts, 70-80% of the patients became engaged in work or studies, a significant increase compared with the situation before treatment (1.7%). The program was an effective reducer of illicit heroin use and criminality among its patients and prevented the occurrence of HIV infection among patients in long-term methadone treatment. The average one-year retention during 1967-1989 was 90% and cumulative retention showed that 29% were still in treatment 10 years after admission.</p><p><b>Conclusion: </b>The present results emphasise the importance of vocational rehabilitation and support in a treatment strategy based on long-term maintenance therapy.</p>

Methadone Maintenance treatment of compulsive opioid addiction was started by the study of Dole and Nyswander (1965) and has subsequently been replicated in programs throughout the world. Methadone treatment has become the most effective modality for the treatment of chronic heroin addiction. In 1966 a Swedish National methadone maintenance program was opened at the Psychiatric Research Center, Ulleråker hospital at Uppsala. The aim of this thesis was to study the outcome of methadone treatment along various lines: • An open randomised controlled study comparing the efficacy of methadone treatment and drug free treatment in 34 heroin addicts, 20-24 years of age. • Before/after comparisons of rehabilitation among 345 heroin addicts admitted during the 23 years when this was a centralised National program. • Retention in treatment. <b>Study subjects, methods and treatment goals: </b>Subjects underwent an admission procedure when background data was collected through hospital records, and personal interviews. Therapeutic efforts focused on vocational rehabilitation, i.e. a return to full-time work or studies, hoping to make patients abandon their drug addict’s life-style and make them socially accepted and self-supporting. <b>Results: </b>Thirty-four heroin addicts with a history of 4-8 years of heroin use were randomly assigned either to methadone treatment (17) or an untreated control group (17). The controls could not apply for methadone treatment until two years later. Outcome after six years observation showed that 81% became free of drug abuse, while the corresponding figure for the controls was only 1/17 (6%). The mean yearly death rate for the controls was 7.2%. Likewise, among the total material of 345 heroin addicts, 70-80% of the patients became engaged in work or studies, a significant increase compared with the situation before treatment (1.7%). The program was an effective reducer of illicit heroin use and criminality among its patients and prevented the occurrence of HIV infection among patients in long-term methadone treatment. The average one-year retention during 1967-1989 was 90% and cumulative retention showed that 29% were still in treatment 10 years after admission. <b>Conclusion: </b>The present results emphasise the importance of vocational rehabilitation and support in a treatment strategy based on long-term maintenance therapy.

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.

No description available.

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.