Commentary on Farnum et al.: Agonist maintenance in Ukraine-ambivalence, success and moving forward.

Abstract

Agonist maintenance arrived late in Ukraine and shared many of the issues that occurred when methadone was introduced in the United States. It has been well-accepted by patients and could have a meaningful impact on the spread of HIV if the number of patients receiving it is substantially increased. The paper by Farnum et al. on methadone and buprenorphine maintenance in Ukraine is an important contribution to a growing literature on the use of these therapies in former Soviet states [1]. The usual approach in Ukraine has followed the Russian model, where using a medication with opioid agonist effects is against the law. Treatment is provided in specialized addiction (‘narcology’) hospitals that are part of the National Health system, although some patients are treated by private practitioners in a fee-for-service arrangement. Upon treatment admission, patients are detoxified with non-opioid medications, receive 2–4 weeks of cognitive behavioral or relapse prevention therapy, relaxation exercises, social work services and employment counseling, and are referred to local health centers for continuing care after discharge. Treatment is voluntary, and patients can leave at any time and be re-admitted if needed, usually after relapsing. The basic idea is to help patients to stop using drugs. The model was developed for alcohol dependence but high relapse rates, unsterile injecting practices and the rapid spread of HIV showed its limitations in Ukraine when used for opioid addiction [2]. Health authorities and clinicians were aware of the findings from methadone and buprenorphine studies [3-5] and of later studies showing that agonist maintenance reduced HIV risk and infection [6]. Regulations were changed to allow agonist therapy and, like the United States, when methadone treatment began in the late 1960s, it was a major policy change and accompanied by strict new regulations that were later modified to make treatment more accessible. Also like the United States, some providers viewed agonist maintenance as ineffective (‘substituting beer for whiskey or vodka’), and residential programs did not offer or even continue it for patients who were receiving it, although that practice has been changing due to the opioid epidemic. The finding that higher methadone doses are associated with better retention is identical to US studies, as is the gap between treatment need and participation, although that gap is greater in Ukraine than in the United States. The average 75% retention on methadone in Ukraine at 12 months is higher than the approximate 50% retention at 6–12 months in a meta-analysis of methadone treatment in the United States, Australia and China [7], and is also consistent with the findings of a National Institute of Drug abuse (NIDA)-funded study in Kiev, where 47 of 50 patients chose to continue methadone after their 20-week follow-up [8]. The 89% buprenorphine retention in Ukraine at 12 months is much greater than the 43% retention at 24 weeks in a recent US study [9]. Collectively, these findings show that attitudinal barriers and processes associated with the introduction of agonist maintenance in Ukraine bear similarities to the processes associated with the introduction of methadone maintenance in the United States. Importantly, agonist maintenance is being well accepted by patients, and has the potential to reduce the spread of HIV if treatment can be expanded to include a larger proportion of opioid addicted individuals. Not to be overlooked while focusing on dosing outcomes is the role of psychosocial treatments. Papers by Bejerot [10], and Dole [11], from a 1980 NIDA Research Monograph, point to craving as the root of the chronic, relapsing nature of opioid addiction and explain the apparent paradox of patients completing treatment, then returning to prior behaviors and relapsing. Bejerot describes an addiction as beginning with occasional use that at some point, in some individuals, becomes a craving that results in compulsive use with remissions and relapses even after periods of extended remission [12, 13]. He associates the change from occasional to compulsive with a range of factors, but a problem that is stubbornly persistent once established. Many psychosocial interventions have been developed to address craving and the associated behaviors [14-18], but opioid-addicted patients usually drop out unless in a controlled environment or the psychosocial treatment is combined with an effective relapse prevention medication. An additional advantage of medication is that it works quickly to reduce drug use, overdose deaths and HIV risk behavior. How long medication needed is unknown, but probably varies widely among patients. Developing medications, vaccines or other interventions that safely erase the craving would be a wonderful achievement. None.