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

Background: Methadone maintenance treatment (MMT) is a commonly prescribed therapy for patients with opioid use disorder, yet inter-individual variability in terms of treatment response is evident. Given the high prevalence of cannabis use in this population, this thesis aims to elucidate the association between cannabis use and MMT outcomes. Methods: We conducted a systematic review and meta-analysis to comprehensively evaluate the literature and quality of evidence, as well as to identify gaps in the literature to inform future research. We then conducted a cross-sectional study investigating sex differences in the association between cannabis use and illicit opioid use in MMT patients. We employed a multivariable logistic regression analysis to assess the influence of any cannabis use as well as heaviness of cannabis use within men and women. Results: The systematic review included 22 observational studies. Results revealed the low quality of available evidence as well as substantial heterogeneity among studies. We identified several limitations in the evidence base including reliance on crude measures of cannabis use and inadequate consideration of confounding variables. Our cross-sectional study included a sample of 777 patients on MMT. Consistent with previous research, we found cannabis use to be unrelated to illicit opioid use in the entire sample. However when we stratified the analysis by sex, we found cannabis use was associated with increased odds of having concurrent illicit opioid use. Conclusion: Results of this thesis suggest certain populations within MMT patients may be at higher risk of experiencing adverse effects of cannabis in terms of treatment outcomes. Future work can build on the results of these studies to identify unique risk factors for patients in order to inform the use of tailored treatment options to improve MMT effectiveness. / Thesis / Master of Science (MSc)

Background: The theme of the position and experiences of pregnant women in the context of methadone maintenance treatment has not yet been thoroughly examined, the aim was to contribute to break the taboo concerning this topic and help to destigmatize these women. Goals: To map the situation of pregnant women in MMT and to alert to therapeutic specificity of these women. Methods: Semi-structured interview and analysis of the medical documentation were used to obtain the data, observation method, qualified estimate and clinical case reports. Data were processed through content analysis. File: The research group consists of 7 patients who were treated in the Department of Adictology 1st Faculty of Medicine, Charles University and General University Hospital in Prague, who gave birth to at least one child between 2004 and 2014. Results: The analysis shows that during their pregnancy women reduce the use of illicit drugs and tobacco. Despite these pregnancies are usually not planned, it was observed that in these women the pregnancy occured in a situation when the respondents were stabilized in both the treatment and in their social situation. The experience of pregnancy played a stimulating role for dose reduction or direction to abstinence. The reasons are usually the confrontation with the NAS of their child...

Addiction to opiates is a complex public health issue affecting thousands of Canadians. Methadone Maintenance Treatment (MMT) is considered the gold standard in Canada, and the world, for treating opiate dependence. In the past, Canadian research into opiate addiction and the effectiveness of MMT has mostly focused on larger cities: Toronto, Montreal, and Vancouver. This community based research study employed a mixed method approach to gain understanding of the experiences and satisfaction with MMT and other health services available to opiate users in Belleville, Ontario (population 48,000). Surveys (N = 53), focus groups, participant-observation methods and key informant interviews were used to gather data. The results provide an overall picture of the quality of life for opiate users and MMT clients, the quality of care clients receive, and the perceptions of community members regarding MMT. Challenges related to smaller locales are identified along with recommendations for improving MMT health services. / UOIT

The methadone maintenance treatment population suffers from high rates of comorbid psychiatric and substance use disorders. Despite a more than 40-year treatment history, not all patients are satisfied with methadone treatment and more than half of the patients complain of significant inter-dose withdrawal at least some of the time. The objectives of this research were to investigate the pharmacological response to methadone under the influence of comorbid major depressive disorder and smoking; and to identify factors other than physical withdrawal symptoms that can differentiate patients based on their complaints of dissatisfaction with treatment. In Study 1, seven depressed methadone maintenance patients experienced more opioid withdrawal symptomatology over a 24-hour methadone-dosing interval than 10 nondepressed methadone patients. Depression severity was significantly correlated with trough opioid withdrawal severity. This suggests that depression or depressive symptoms are related to reported opioid withdrawal. In Study 2, many factors other than physical opioid withdrawal symptoms were able to differentiate patients who were satisfied with treatment (holders, n=25), partially satisfied with treatment (partial holders, n=35), and not satisfied with treatment(nonholders, n=30). Results suggested that these patient satisfaction groups cluster differently depending on physical opioid withdrawal, mood, psychological distress, and personality. Nonholders experienced more physical withdrawal symptoms, craving for opioids, and negative drug effects. Holders had less psychological distress and experienced less negative mood states than the other groups. Partial holders had less agreeable personalities compared to patients in the other groups. In Study 3, opioid and nicotine withdrawal symptoms and effects were measured in 40 methadone-maintained patients who were current smokers during trough and peak methadone effects, both pre and post-nicotine administration. Cigarette smoking enhanced opioid withdrawal suppression during the peak methadone condition, methadone attenuated nicotine withdrawal, and methadone and nicotine shared many of the same main effects, suggesting that smoking and methadone effects may be inseparable dimensions. In summary, the results of these studies suggest that in addition to physical symptoms, mood related factors are important to opioid withdrawal perception and that the mood factors and drug interactions can impact on a patient’s perception of satisfaction with methadone treatment.

The methadone maintenance treatment population suffers from high rates of comorbid psychiatric and substance use disorders. Despite a more than 40-year treatment history, not all patients are satisfied with methadone treatment and more than half of the patients complain of significant inter-dose withdrawal at least some of the time. The objectives of this research were to investigate the pharmacological response to methadone under the influence of comorbid major depressive disorder and smoking; and to identify factors other than physical withdrawal symptoms that can differentiate patients based on their complaints of dissatisfaction with treatment. In Study 1, seven depressed methadone maintenance patients experienced more opioid withdrawal symptomatology over a 24-hour methadone-dosing interval than 10 nondepressed methadone patients. Depression severity was significantly correlated with trough opioid withdrawal severity. This suggests that depression or depressive symptoms are related to reported opioid withdrawal. In Study 2, many factors other than physical opioid withdrawal symptoms were able to differentiate patients who were satisfied with treatment (holders, n=25), partially satisfied with treatment (partial holders, n=35), and not satisfied with treatment(nonholders, n=30). Results suggested that these patient satisfaction groups cluster differently depending on physical opioid withdrawal, mood, psychological distress, and personality. Nonholders experienced more physical withdrawal symptoms, craving for opioids, and negative drug effects. Holders had less psychological distress and experienced less negative mood states than the other groups. Partial holders had less agreeable personalities compared to patients in the other groups. In Study 3, opioid and nicotine withdrawal symptoms and effects were measured in 40 methadone-maintained patients who were current smokers during trough and peak methadone effects, both pre and post-nicotine administration. Cigarette smoking enhanced opioid withdrawal suppression during the peak methadone condition, methadone attenuated nicotine withdrawal, and methadone and nicotine shared many of the same main effects, suggesting that smoking and methadone effects may be inseparable dimensions. In summary, the results of these studies suggest that in addition to physical symptoms, mood related factors are important to opioid withdrawal perception and that the mood factors and drug interactions can impact on a patient’s perception of satisfaction with methadone treatment.

Hepatitis C (HCV) is an infectious disease of the liver which affects more than 250,000 Canadians; the majority of those living with the disease have experience with injection drug use. Treatment for HCV involves a strict protocol, has only a 50% success rate and has harsh side effects. Interest in HCV treatment among people who use drugs is high, but actual uptake of treatment remains low. The objective of this research was to explore the barriers to accessing HCV treatment for individuals who were accessing methadone. A mixed methods approach was used; a cross sectional survey and an in-depth interview were administered to clients of a methadone maintenance program. The two sets of data identified three main barriers to HCV treatment; stigma, the toxicity of treatment, and day-to-day struggles. Future research should be conducted to further explore how stigma guides decisions around HCV treatment, particularly in a methadone treatment setting.

Over the past ten years, there has been a consistent increase in opioid use, which has resulted in an increase in enrolment in methadone maintenance therapy [MMT]. With retention in MMT being a key factor, in order to understand the process of retention, it is important to gain an understanding of individual perceptions and experiences. No research in Ottawa, Ontario has addressed the perspective of MMT from people enrolled in MMT; therefore, nursing based research was undertaken. The objective was to understand the process and experiences associated with MMT from the perspective of persons who are enrolled in treatment. Twelve participants were engaged in semi-structured interviews. These participants described that, although MMT can positively affect the people who use such a treatment option, it continues to have a negative impact that repeatedly affects MMT initiation and delivery. The theoretical framework of Hardt and Negri’s “Triple Imperative of Empire” was used to analyze the research participants’ interviews within the current MMT program, to help develop a more inclusive healthcare service that addressed the current barriers hindering access and retention in treatment. The integration of this framework can help engage persons in treatment, tailor treatment to patient specific needs, and as a result increase access and retention in MMT programs.

We examined internal consistency and test-retest reliability of a measure of dispositional optimism, the Life Orientation Test-Revised, in 121 opiate-dependent patients seeking methadone treatment. Internal consistency was adequate at baseline (α=.69) and follow-up (α=.72). Low socioeconomic status and being on disability were significantly associated with reduced internal consistency; ethnic and educational differences approached significance. Test-retest reliability was good (ICC=.72), varying across gender, race, ethnicity, education, employment and income (ICC Range=.24-.85). Criterion validity was strong; the LOT-R was significantly negatively correlated with hopelessness (r=-.65, p<.001) and depression (r=-.60, p<.001). Findings support the use of this measure of optimism and pessimism to assess positive cognitive and emotional attributes and improve treatment strategies for opiate-dependent individuals. Future research should address the measurement and significance of optimism in minority, low socioeconomic status and poorly-educated individuals.

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)