Background: Social adversities are prevalent among those with psychiatric disorders and may be involved in poor outcomes among patients receiving treatment. Identification of social risk factors influencing outcomes will help provide targeted interventions for at-risk patients. This thesis explored the role of social and behavioural factors in relation to adverse psychiatric outcomes, specifically relapse to substance use and attempted suicide. Methods: We used scoping study methodology to perform a comprehensive review to identify the gaps in the literature examining social functioning and MMT outcomes. This review informed our primary cohort study examining the association between social factors and continued opioid use in MMT. Lastly, we conducted a case-control study to identify risk factors for suicide attempts by comparing psychiatric patients with and without suicide attempt history (cases and controls, respectively). Multivariable logistic regression analyses were conducted in both primary studies to examine the association between predictors and outcomes. Results: The review included 101 observational studies and determined the need for further research on social factors and MMT outcomes among a current sample of Canadian patients. Our cohort study included 1043 participants (mean age=38.4 years, standard deviation [SD]=11.06); 45.8% women) to investigate this and found that unemployment, criminal activity and interpersonal conflict with friends significantly increased odds of illicit opioid use. In examining risk factors for suicide attempts, we recruited 146 cases (mean age=45.18 years, SD=14.70 years; 55% female) and 104 control participants (mean age=45.01 years, SD=14.23 years; 50% female). No sociodemographic differences existed between groups, however higher impulsivity and borderline personality symptoms significantly increased odds of attempted suicide. Conclusions: Findings from these studies may indicate the need for structured monitoring of at-risk psychiatric patients. It may be important to develop tools to measure social and behavioural factors in clinical settings and promote further integration of social services in treatment settings. / Thesis / Master of Science (MSc)

Through changes in the code of statutes, SOSFS 2009:27 (M), opioid addicts are excluded since March 1 2010 from possibilities to be accepted for substitution treatment. Opiate addicts are solitary admitted for substitution treatment from that date. Opioid addicts are excluded admission for treatment regardless of the fact that they fulfil the ICD-10 diagnosis F.11.2, i.e. opioid/opiate addictive criteria. The alteration in the statutes was carried out in reference to the fact that evidence for this kind of treatment intended for opioid addicts was missing. Both groups i.e. opiate – and opioid addicts, are nevertheless experienced in clinical work , to have extensive problems with addiction, health, social situation along with the risk of premature death.     The purpose with this study is to identify what differences and/or similarities there are in background varieties and the severity of the problems  between the groups. This is conducted with the use of a population (n=127) with comparable background material, e.g. collected Addictions Severe Index- interviews, scientifically survey and compare background factors and the severity of the problems.      The main discovery in this study is that one can demonstrate great similarities between the groups regarding background as well as the severity of the problems. It is therefore of great interest, on a individual as well as a social oriented level, that pursued studies regarding diagnostic safety and on processes in substitution program are needed to generate further knowledge as a foundation for development of future care and changes in the code of statutes.

Drug abusers in Taiwan are infected with HIV(Human Immunodeficiency Virus) seriously day by day in recent years. In view of this, since Aug.1,2005, C.D.C.(Center for Disease Control, R.O.C.(Taiwan)) has promoted Harm Reduction Program for drug abuse patients in control of spurting question of drug abuse/AIDS overflowing. We adopt the analysis frame of social marketing in this research to inspect the promotion of Harm Reduction Program at present government. Through questionnaire survey, we in death understand their contact situation and views of Harm Reduction Program from the mass population and the stakeholders(drug abusers). We visit 311 effective samples of opium-smoking prisoners(as drug group) to find out 84.9%(258) respondents has participated the declaration of health education of Harm Reduction Program during serving a sentence, 91.6%(282) has received information through newspaper, TV, broadcast, and brochure during serving a sentence, 89%(277) has got impression on C.D.C. slogans of ¡§Injecting drug, infecting AIDS¡¨, and the measure of offering needle and syringes exchange, methadone maintenance treatment, health education, and transferring/consulting service has accorded with the demand of drug abusers. In addition, we visit 289 effective samples of the public (as general group) to find out only 12.5% (36 ) respondents has participated the declaration of health education of Harm Reduction Program during in the past year, 53.5%(153) has received information through newspaper, TV, broadcast, and brochure during in the past year, and 55%(159) has got impression on C.D.C. slogans of ¡§Injecting drug, infecting AIDS¡¨. Both the public and opium-smoking prisoners have affirmed the promotion of Harm Reduction Program, and most has identified with the importance of the execution of Harm Reduction Program. We also find out 34%(99) respondents of the public has regarded famous actor as anti-drug spokesman can bring his attention and identification mostly, and moreover, 41%(128) respondents of opium-smoking prisoners has believed the declaration of acting as an example to others by the drug abstinence successfully is convincing most.

A. Marudinaite. The evaluation of metadone maintenance treatment program process in Lithuania: Master Thesis // supervisor prof. Žilvinas Padaiga; Department of Social Medicine, Kaunas University of Medicine. – Kaunas, 2005 – 59 p. Objective: To evaluate methadone maintenance treatment program process in Lithuania. Methods: The analysis was based on instruments developed or adapted by the World Health Organization (WHO): Treatment services review, Checklist for Service Description, Checklist on service quality, Staff attitude and Satisfaction Questionnaire, Schedules for the Assessment of Standards of Care, and Treatment Perception Questionnaire. 50 patients from Vilnius, 20 from Kaunas and 30 from Klaipeda Centers for Addictive Disorders have been questioned, as well as focus groups, comprised of program personnel, patients, external experts, and community representatives. Results: the literature review revealed the factors influencing the process of methadone maintenance treatment (MMT) program: quantity and quality of services; consultations of psychologists to both patients, their relatives and social workers, as well as medical help; adequate methadone dose (it is usually 60 – 100 mg/day); take home privileges, which improve patients motivation; control urine tests, which deter patients from drug usage. The MMT in Lithuania review indicates that treatment accessibility for drug users is very limited geographically. MMT is run only in five largest Lithuanian cities:... [to full text]

Opioid drug related death is the topic of this thesis. Each of the published works submitted in this volume has investigated an aspect of opioid drug related death. The publications have been grouped into three sub-themes: i. Characteristics of opioid drug related deaths ii. Methadone-related deaths in and out of treatment iii. Improving the quality of treatment for opioid drug dependence: a focus on injectable opioid treatment The introduction and background (Chapter1) will briefly review-the-relevant literature on opioid drug death predating my own contribution to the field. The next chapter of the thesis, 'Publications' (Chapter 2), will comprise the body of published work being submitted for the degree of Doctor of Medicine. Each article is accompanied by text on the preceding page outlining my individual contribution to that research study. The thesis will conclude with a discussion of the published works (Discussion, Chapter 3) which summarises the chief findings and reflects on the international significance and impact of the work. Finally, the Conclusion (Chapter 4) will submit suggestions for areas of future research into opioid drug related death.

<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.

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.