Methadone Clinics Research Articles

Methadone clinic staff perceptions of trauma-informed and patient-centered care: the role of individual staff characteristics

BackgroundU.S. policy intervention to increase methadone treatment accommodations during COVID did not result in national adoption of the new patient-centered treatment practices. Staff-level interventions may facilitate adoption of these treatment practices, but this will depend upon knowledge about staff level characteristics and beliefs. Currently, the role of clinic staff characteristics, beliefs about patient-centeredness, and perceptions about the need for treatment practice change is unknown. This study explored the relationship between opioid treatment program staff characteristics, work roles and staff beliefs to identify opportunities for future staff-level treatment practice change interventions.MethodsStaff of three Arizona opioid treatment programs were surveyed (n = 40) from April 11–22, 2023 using a hybrid online survey method. The 161 survey items required less than 30 min to complete. Pearson point biserial correlation coefficients assessed the covariation between staff beliefs, staff characteristics and staff work roles. Perception of the clinic as person-centered was a potential proxy indicator for staff awareness of discontinuity between the clinic’s person-centeredness and person-centered approaches to methadone treatment.ResultsAmong staff, 47.5% reported lived substance use disorder experience and 27.5% reported lived opioid use disorder experience. Most staff (70%) held at least 1 prior clinic role at the current clinic and 5% had had more than 4 prior roles. Rotation was observed with roles that did not require licensure or degrees. Staff with lived experience with substance use disorder or opioid use disorder treatment reported having more prior roles at the clinic than those without such experience. Abstinence-oriented views were significantly associated with reporting vicarious (work related) trauma symptoms. Those who rated the clinic as significantly more person-centered were staff with lived substance use disorder experience who also held abstinence-oriented views, staff with trauma exposure, and staff with lived opioid use disorder treatment experience who held harm reduction beliefs. In contrast, staff without substance use disorder experience who held harm reduction beliefs perceived the clinic as less person-centered.ConclusionsStaff beliefs, personal and work characteristics are likely factors in the recognition of need for clinic practice change. How these characteristics function in a clinic culture may also be influenced by clinic staffing patterns. A patient-to-provider pipeline with role cycling was observed and this staffing pattern may also influence shared beliefs of trauma-informed care or clinic person-centeredness. Vicarious trauma may also be an important factor. Larger studies should examine these relationships further to understand mechanisms associated with recognition of need for clinic practice change in order to inform staff-level interventions to increase opioid treatment program patient-centeredness.

Experience and challenges delivering hepatitis C virus treatment for people who inject drugs in Kenya.

Despite having a higher risk of hepatitis C virus (HCV) infections, people who inject drugs (PWID) in sub-Saharan Africa (SSA) have limited access to HCV treatment. There is scarce literature on treatment delivery modalities that overcome logistical and financial barriers. We utilized different service delivery modalities to provide direct-acting antivirals (DAAs) to PWIDs infected with HCV through methadone clinics and needle and syringe program (NSP) sites in Kenya. In collaboration with Kenya's National AIDS and STI Control Programme (NASCOP), we enrolled individuals with active HCV infection confirmed by HCV RNA detection from methadone and NSP sites in Nairobi, Mombasa, and Kilifi counties. Liver function and hepatitis B virus (HBV) status were assessed at baseline. Those eligible for treatment were offered ledipasvir-sofosbuvir treatment provided by NASCOP through directly observed therapy (DOT). Participants completed a follow-up visit 12 weeks after completing treatment to measure sustained viral response (SVR-12). Challenges faced while delivering HCV treatment at participating sites included the limited availability and reliability of laboratory assays, and financial constraints faced by PWIDs to attend daily DOT. Based on our experience, strategies to deliver HCV treatment for PWID in Kenya should consider improving the availability of laboratory tests and prioritizing treatment through methadone centers to achieve good outcomes.

Satisfaction Amongst Drug-dependent Population with Methadone Maintenance Treatment Services, A Comparison between Public and Private Clinics: Implications for Private Sector Engagement in the Delivery of Methadone Maintenance Programs Across Vietnam.

In Vietnam, the public sector has largely been responsible for delivering methadone maintenance treatment (MMT) services. However, with foreign aid anticipated to decline in the coming years, the involvement of the private sector in delivering MMT services is critical to ensure the continued sustainability of MMT programs across Vietnam. This study aims to evaluate patient satisfaction and identify correlated factors among Vietnamese drug users undergoing MMT in both public and private methadone clinics. A cross-sectional study was conducted in one private and two public methadone facilities in Nam Dinh, a province in the North of Vietnam. A convenience sampling technique was applied to recruit 395 participants. Data was collected through 20-minute face-to-face interviews using a structured questionnaire. Multivariate Tobit regression was utilized to measure associated factors with patient satisfaction. Results showed that patients were highly satisfied with MMT services in both public and private; however, they expected a higher degree of comprehensive care services. Compared with public facilities, the satisfaction level of patients in private facilities was significantly lower in the following aspects: health administration and professional capacity of health workers. However, there were insignificant differences in regard to infrastructure, equipment, and availability of medical services resources, supporting a promising role of the private sector in supporting the expansion of the MMT programs in Vietnam. Integrating MMT with other physical and mental healthcare services, along with strategies for improving administrative procedures and health workers' capacity in private clinics, are critical implications of this study.

“Smoking weed it gets you over the hump”: Cannabis co-use as a facilitator of decreased opioid use among people who inject drugs in Los Angeles, California

IntroductionOpioid overdose mortality rates have surged dramatically in the last decade due largely to fentanyl in the illicit US drug supply. As of June 2024, 38 states, three territories, namely US Virgin Islands, Guam and the Northern Mariana Islands, and the District of Columbia, allow the medical use of cannabis products. However, there remains limited qualitative community-based evidence on the role of cannabis co-use among opioid using and injecting populations. In this study, we present data from people who inject drugs (PWID)’s co-use of cannabis-opioid. MethodsWe conducted 30 one-on-one semi-structured interviews with PWID from July 2021 to April 2022 at two community sites in Los Angeles, CA, near a syringe service program and a methadone clinic. Interviews were recorded and transcribed. We used constructivist grounded theory methods for identifying and comparing the emerging themes that appeared across transcripts to construct a conceptual explanation of how PWID co-used cannabis and opioids. Participant inclusion criteria included injection drug use, opioid and cannabis use, English fluency, and age 18+ years. ResultsPWID described that cannabis co-use assisted in developing patterns of reduced opioid use in a number of ways: 1) maintain opioid cessation and/or adhere to opioid use disorder treatment by managing cessation-specific symptoms, 2) manage symptoms of opioid withdrawal episodically and, 3) decrease opioid use due to low barrier accessibility of cannabis. DiscussionParticipants reported myriad benefits of opioid and cannabis co-use for reducing patterns of opioid use. These findings have two major harm reduction implications for PWID: 1) the distribution of cannabis via low threshold peer programming and interventions can facilitate changes in opioid use patterns and 2) access to cannabis co-use, potentially alongside existing Medication for Opioid Use Disorder, in treatment settings may improve efficacy of uptake and treatment outcomes and goals for individual PWID.

Đánh giá tình trạng sức khoẻ tâm thần của người đang điều trị Methadone có HIV tham gia chương trình tư vấn can thiệp “băng ghế tình bạn” tại một số cơ sở điều trị Methadone ở Hà Nội, giai đoạn 2022-2023

Introduction: Mental health intervention counseling helps improve common mental disorders in people with HIV and/or substance abuse. However, there are very few mental health intervention programs for this population in Vietnam. This study was conducted to assess mental health in people who are on methadone maintenance treatment and live with HIV participating in the “Friendship Bench” intervention counseling program in some Methadone clinics in Hanoi in the period 2022-2023. Research subjects and methods: This is a randomized controlled trial. 75 people on methadone maintenance treatment and with HIV were individually randomized 1:1:1 to one of three arms: intervention by health providers, or intervention by lay counselors, or standard of care. Results: The intervention was effective immediately after 6 weeks of intervention in both intervention groups. The problems of depression, anxiety, and stress of subjects in all three study groups did not change much at 3 and 6 months after intervention. Conclusion: Mental health of all study subjects was improved after participating in the “Friendship Bench” program. Keywords: Common mental disorders, Methadone, HIV, intervention counseling.

Methadone Take-Home Policies and Associated Mortality: Permitting versus Non-Permitting States.

To mitigate COVID-19 exposure risks in methadone clinics, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a temporary modification of regulations in March 2020 to permit, with state concurrence, extended take-home methadone doses. The modification allowed for up to 28 days of take-home methadone for stable patients and 14 days for those less stable. Using both interrupted time series and difference-in-differences methods, this study examined the association between the policy change and fatal methadone overdoses, comparing states that permitted the expansion of take-home doses with states that did not. The findings suggest the pandemic emergency take-home policy did not increase methadone-involved mortality.

Simulated impact of mobile opioid treatment program units on increasing access to methadone for opioid use disorder.

To model the potential impact of mobile methadone unit implementation in Louisiana on net medication for opioid use disorder (MOUD) treatment rates. We use secondary Louisiana Medicaid claims data between 2020 and 2021. We simulate the impact of mobile methadone units in Louisiana using two approaches: (1) a "Poisson regression approach," which predicts the number of opioid use disorder (OUD) patients that might use methadone at mobile locations based on the underlying association between methadone use and proximity to a brick-and-mortar methadone clinic; (2) a "policy approach," which leverages local treatment uptake rates following the expansion of methadone coverage to Louisiana Medicaid beneficiaries in 2020 to estimate methadone use following mobile unit implementation. Models were run in cases where mobile methadone operators could choose their operation locations freely and in a separate instance where they were restricted to serving rural locations. Our analytic sample includes 43,341 Louisiana Medicaid beneficiaries with one or more primary or secondary diagnoses for opioid dependence. We predict that 10 new mobile methadone units in Louisiana would increase the net MOUD treatment rate in the state by 0.54-2.39 percentage points. If these mobile units delivered Methadone exclusively to rural areas, they could increase rural MOUD treatment by 8.54-13.67 percentage points. Further, roughly 20% of all beneficiaries residing in rural areas being treated with methadone would be an average of 24 miles closer to a methadone treatment provider following mobile unit implementation. Mobile methadone units represent a promising innovation in the delivery of methadone that is likely to increase methadone use, especially in underserved rural locations. However, we find significant variation in their impact conditional on where they choose to operate, and so careful location planning will be required to maximize their benefit.

Predictors of Suicidal Ideation and Continued Substance Use Problems Among Patients Receiving Methadone Maintenance Treatment Who Have Co-Occurring Cocaine Use Disorder

Background Persons with polysubstance use problems are at high suicide risk, which may complicate substance use treatment. The purpose of this study was to a) examine cross-sectional and longitudinal risk factors for suicidality among persons in methadone maintenance treatment who present with co-occurring cocaine use disorder and b) evaluate whether suicidality impacts substance use outcomes independently and differentially depending on treatment type (i.e. standard methadone care [SC] vs. contingency management plus standard care [CM + SC]). Methods Data come from five randomized controlled trials of CM conducted within methadone clinics (N = 562). Participants were categorized (mutually exclusive) as no history of suicidality (56.4%, n=317), past suicidal ideation (SI; 11%, n=62), recent SI (3.6%, n=20), or lifetime suicide attempt (29%, n=163). Results Suicidality groups differed by sex and baseline employment, income, trauma history, and psychosocial functioning. Suicide attempt history was positively associated with years of polysubstance use, prior drug treatments, and unintentional overdose history. Baseline psychological problem severity and emotional abuse history were associated with SI likelihood 12 weeks later. Past SI was associated with longer durations of abstinence than no suicidality. Unexpectedly, those with recent SI reported lower drug use severity at 12 week if they received SC compared to CM + SC. Effects were small to medium. Conclusions Despite greater polysubstance use history, patients with suicide attempts did not show worse substance use outcomes than persons without suicidality. Patients with past SI fared better than those without suicidality on abstinence over 12 wk. Methadone clinics could be key points of entrance and continued services for suicide prevention.

Using Medicaid funds to transport patients to OTPs

Yes, Medicaid funds pay for transportation to and from opioid treatment programs (OTPs), otherwise known as methadone clinics, at least in California via Medi‐Cal. Here are the details, obtained exclusively from California's Department of Health Care Services (DHCS) for ADAW. If the patient is covered by Medicaid, Medicaid will pay for transport.

Study will use OTP to look at methadone reform

A new study funded by the National Institute on Drug Abuse (NIDA) and headed by researchers interested in changing the way methadone for opioid use disorder is utilized will use Community Medical Services treatment staff and patients as research subjects. Community Medical Services operates more than 60 opioid treatment programs in 11 states, and is the first OTP, or methadone clinic, to be open around the clock in some areas, with head Nicholas Stavros incorporating novel ways to reach out to patients. The MPACT (Methadone Patient Access to Collaborative Treatment) study will develop and test a medical intervention using a $1 million NIDA grant. Researchers at the University of Arizona Health Sciences, under the direction of Beth Meyerson, Ph.D., will test a “patient‐empowered, trauma‐informed” treatment using methadone in Arizona. Meyerson is a professor, and director of the Harm Reduction Research Lab in the University of Arizona College of Medicine at Tucson. The study will take two years. “Improving methadone treatment is critical because one person dies from an opioid overdose every five minutes in this country,” said Meyerson, who is also director of policy for the University of Arizona Health Sciences Comprehensive Pain and Addiction Center. “Access to methadone has been found to reduce opioid overdoses by 80%, but it is currently being delivered in ways that can create suboptimal patient outcomes, where only 30% of patients complete treatment and over 30% experience significant treatment interruptions.” The protocol will be used to focus on how to make treatment more acceptable to patients and includes a staff‐focused intervention to reduce trauma related to actually working in the OTP. “Vicarious trauma has been found to impact both patient care and staff recognition of the need to adopt treatment and practice innovations,” Meyerson said, adding, “This study is the crucial first step in assessing MPACT's feasibility, acceptability and preliminary effects on patient and staff outcomes. Once our established milestones are reached from the pilot program, the second phase of funding will enable us to expand the study of MPACT among 30 clinics with 600 patients and 450 staff members across the U.S.” Kristen Rundell, M.D., professor and chair of the Department of Family and Community Medicine at the University of Arizona, where Meyerson's harm reduction lab is based, said the study “is a prime example of our department's emphasis of social justice through medicine.”

Methadone prescribing by addiction specialists likely to leave communities without available methadone treatment.

Methadone treatment for opioid use disorder is not available in most suburban and rural US communities. We examined 2 options to expand methadone availability: (1) addiction specialty physician or (2) all clinician prescribing. Using 2022 Health Resources and Services Administration data, we used mental health professional shortage areas to indicate the potential of addiction specialty physician prescribing and the location of federally qualified health centers (ie, federally certified primary care clinics) to indicate the potential of all clinician prescribing. We examined how many census tracts without an available opioid treatment program (ie, methadone clinic) are (1) located within a mental health professional shortage area and (2) are also without an available federally qualified health center. Methadone was available in 49% of tracts under current regulations, 63% of tracts in the case of specialist physician prescribing, and 86% of tracts in the case of all clinician prescribing. Specialist physician prescribing would expand availability to an additional 12% of urban, 18% of suburban, and 16% of rural tracts, while clinician prescribing would expand to an additional 30% of urban, 53% of suburban, and 58% of rural tracts relative to current availability. Results support enabling broader methadone prescribing privileges to ensure equitable treatment access, particularly for rural communities.

Prevalence and correlates of violence among sexual and injecting partners of people who inject drugs living with HIV in Kenya: a cross-sectional study

BackgroundIn Kenya, violence is common among people who inject drugs (PWID) living with HIV and their sexual and injecting partners and may lead to decreased uptake of HIV services, increased HIV risk behaviors, and increased HIV transmission. Violence is defined as any physical harm, threatened harm, or forced sexual acts inflicted on a person in the past year. Understanding the nature of violence and its correlates among PWID and their partners will inform population-specific public health interventions and policy recommendations.MethodsThis is a cross-sectional study nested in a prospective cohort study conducted in eight public health centers, methadone clinics, and needle syringe programs in Nairobi, Kilifi, and Mombasa counties in Kenya. 3,302 sexual and/or injecting partners of PWID living with HIV were recruited through assisted partner services and participated in the study. Prevalence and correlates of violence were identified using the Wald test and negative binomial regression.ResultsOut of 3302 study participants, 1439 (44%) had experienced violence within the past year. Physical violence was the most common form of violence experienced (35%), followed by being threatened (23%) or subjected to sexual violence (7%). In an adjusted analysis, female participants reported higher experiences of sexual violence (prevalence ratio [PR] = 2.46; 95% confidence interval [CI] 1.62, 3.74; p < 0.001) compared to male participants. In adjusted analysis, coastal residents had a higher experience of overall violence (PR = 1.48; 95% CI 1.27, 1.72; p < 0.001) than those living in Nairobi. This regional effect was relatively stronger among the female respondents (pinteraction = 0.025). Participants’ sex modified the association between region and experiencing violence after adjusting potential confounding factors.ConclusionsThe study reveals the prevalence of violence among PWID and identifies high-risk sub-groups, including women, specifically for sexual violence, and coastal residents. Tailored interventions addressing their unique needs are essential. A holistic approach that combines violence prevention and response, comprehensive harm reduction, healthcare access, and community support is crucial to address the complex issue of drug use and HIV burden among PWID in Kenya for improved health outcomes.

Remote tracking system eases methadone take‐home process

For anyone concerned about diversion of methadone take‐homes, there's a solution in technology. It's a remote tracking system called Sonara. Michael Giles, M.D., who was a resident in psychiatry working in an opioid treatment program (OTP, commonly known as a methadone clinic), founded Sonara Health after his experience there: he learned that many patients couldn't stay in treatment because they couldn't make it to the clinic for the required number of times to maximize methadone take‐homes. He founded Sonara before the COVID‐19 pandemic, which resulted in the federal government's liberalization of take‐home rules (see https://onlinelibrary.wiley.com/doi/10.1002/adaw.32664). But still, many patients do not get as many take‐homes as they would like, and this is partly due to the worries by OTPs about patient and public safety, and the concerns by drug enforcement and government officials about diversion (related to public safety).

Challenges to Providing Integrated HIV Prevention in Substance Use Treatment Settings: Frontline Staff Perspectives on HIV and Sex-Related, Education, Communication and Stigma

Introduction Substance use treatment settings can play a critical role in ending the HIV epidemic. Community-based methadone clinics are potentially useful sites to offer biomedical HIV prevention, but little is known about how clinicians and other clinic staff communicate with patients about sexual behavior and HIV-related topics. Methods Thirty semi-structured interviews were conducted at two methadone clinics in Northern New Jersey. Participants included medical providers (physicians, RNs, DNPs), methadone counselors, intake coordinators, lab technicians, and other auxiliary staff members. Results: Three major themes were identified: (1) HIV education is primarily provided by external organizations, (2) there is limited staff-patient communication around HIV and sexual behaviors, and (3) HIV stigma is prevalent among staff and patients. Conclusion To implement PrEP in methadone treatment settings, clinic staff must be able to engage in non-judgmental communication about HIV and sex with patients. Additionally, federal and state funding for HIV prevention in substance use treatment settings must be prioritized to enable clinics to access the necessary training and resources.

Using ADAPT-ITT framework to tailor evidence-based interventions for addressing methamphetamine use among methadone patients in Vietnam.

Methamphetamine use threatens positive treatment outcomes in substance use and HIV, for people with opioid use disorders (POUD) in many countries. This paper describes the adaptation of four evidence-based interventions (EBI) (motivational interviewing, contingency management, Matrix group model and SMS text messaging) for treating methamphetamine use among POUD receiving methadone maintenance therapy in Vietnam. Following the ADAPT-ITT (Assessment-Decision-Administration-Production-Topical experts-Training-Testing) framework, we conducted 16 focus group discussions with POUD (n = 25) and providers (n = 22) at four methadone clinics in two largest cities (Hanoi in the North, Ho Chi Minh City in the South) to assess patterns of methamphetamine use and to get feedback on proposed EBIs. The proposed EBIs were properly adapted and used to train providers in two of the four methadone clinics. The revised EBIs were tested over 12 weeks among 42 POUD on methadone who use methamphetamine. Post-intervention feedback served to fine-tune the revised EBIs. Insights about patterns of methamphetamine use suggested that EBIs should focus on different triggers to methamphetamine use among POUD receiving methadone treatment in the two cities. All EBIs should emphasise family-related topics to build a strong motivation for treatment. Participants suggested when, where and how each EBI should be delivered. Most participants were satisfied with the adapted EBIs. Limited human resources at methadone clinics might hinder implementation of the adapted EBIs. We successfully completed the adaptation of EBIs for POUD who use methamphetamine on methadone in Vietnam. The pilot testing of the adapted EBIs demonstrated feasibility and acceptability. NCT04706624. Registered 13 January 2021. https://clinicaltrials.gov/ct2/show/NCT04706624.

Racial and Ethnic Inequities in Buprenorphine and Methadone Utilization Among Reproductive-Age Women with Opioid Use Disorder: an Analysis of Multi-state Medicaid Claims in the USA.

Associations between race/ethnicity and medications to treat OUD (MOUD), buprenorphine and methadone, in reproductive-age women have not been thoroughly studied in multi-state samples. To evaluate racial/ethnic variation in buprenorphine and methadone receipt and retention in a multi-state U.S. sample of Medicaid-enrolled, reproductive-age women with opioid use disorder (OUD) at the beginning of OUD treatment. Retrospective cohort study. Reproductive-age (18-45years) women with OUD, in the Merative™ MarketScan® Multi-State Medicaid Database (2011-2016). Differences by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, "other" race/ethnicity) in the likelihood of receiving buprenorphine and methadone during the start of OUD treatment (yes/no) were estimated using multivariable logistic regression. Differences in time to medication discontinuation (days) by race/ethnicity were evaluated using multivariable Cox regression. Of 66,550 reproductive-age Medicaid enrollees with OUD (84.1% non-Hispanic White, 5.9% non-Hispanic Black, 1.0% Hispanic, 5.3% "other"), 15,313 (23.0%) received buprenorphine and 6290 (9.5%) methadone. Non-Hispanic Black enrollees were less likely to receive buprenorphine (adjusted odds ratio, aOR = 0.76 [0.68-0.84]) and more likely to be referred to methadone clinics (aOR = 1.78 [1.60-2.00]) compared to non-Hispanic White participants. Across both buprenorphine and methadone in unadjusted analyses, the median discontinuation time for non-Hispanic Black enrollees was 123days compared to 132days and 141days for non-Hispanic White and Hispanic enrollees respectively (χ2 = 10.6; P = .01). In adjusted analyses, non-Hispanic Black enrollees experienced greater discontinuation for buprenorphine and methadone (adjusted hazard ratio, aHR = 1.16 [1.08-1.24] and aHR = 1.16 [1.07-1.30] respectively) compared to non-Hispanic White peers. We did not observe differences in buprenorphine or methadone receipt or retention for Hispanic enrollees compared to the non-Hispanic White enrollees. Our data illustrate inequities between non-Hispanic Black and non-Hispanic White Medicaid enrollees with regard to buprenorphine and methadone utilization in the USA, consistent with literature on the racialized origins of methadone and buprenorphine treatment.

Changes to methadone maintenance therapy in the United States, Canada, and Australia during the COVID-19 pandemic: A narrative review

IntroductionIn response to the COVID-19 pandemic, countries across the world made adaptations to policies regulating the provision of methadone maintenance therapy (MMT) to facilitate social distancing for health care providers and people in treatment. Many countries issued guidance about increasing take-home methadone doses after the onset of the pandemic. MethodsIn this review, we compare the regulation of MMT prior to the pandemic in the United States, Canada, and Australia, analyze changes to treatment policy in the context of COVID-19, and review emerging data on treatment outcomes. ResultsThe United States only permits the prescription and disbursement of methadone for MMT treatment at federally designated opioid treatment programs (OTPs). Conversely, Australia and Canada operate on a community pharmacy-based distribution model, where patients can access methadone doses either in participating pharmacies or in some methadone clinics. ConclusionGiven reports of similar treatment outcomes and increased patient satisfaction since the pandemic-related policy changes, some changes including increased receipt of take-home doses should be considered for incorporation into post-pandemic treatment policies and regulations.

Encouraging Improvements to Opioid and Substance Use Disorder Care Quality in Nursing Homes

Encouraging Improvements to Opioid and Substance Use Disorder Care Quality in Nursing Homes

A new collaborative care approach toward hepatitis C elimination in marginalized populations

BackgroundTreating marginalized populations with HCV infection for elimination is faced with the challenge for the integration of HCV screening service offered for patients often moving across multiple settings. We envisaged a novel collaborative care approach to identify to what extent HCV patients overlapped between and within these multiple institutions and reported the findings of treatment coverage of these marginalized populations after HCV care cascades. MethodsWe enrolled 7765 patients residing in the Changhua County, Taiwan offered with HCV screening from correctional institutions, HIV clinics, methadone clinics, and the existing HIV surveillance program (four subgroups including police-arrested people, probationers, non-injection drug user, and high-risk behavior people) between 2019 and 2020. The collaborative care and information were integrated through a teamwork of gastroenterologists, psychologists, infectious disease specialists, and nursing coordinators under the auspices of local health authority. ResultsThe overall participation rate in HCV screening was 92.65% (7194/7765). The prevalence rate was the highest in methadone clinics (90.17%) followed by correctional institutions (37.67%), HIV clinics (34.60%), and the surveillance program (18.14%). We found 25.41% (77/303) of methadone clinic patients, 17.65% (129/731) of HIV clinic patients, and various proportions for 44.09% (41/93) of deferred prosecuted or probationers under surveillance program were also recruited into other settings. Individuals' patient flow within setting was more frequent than that between setting. After calibrating the overlap of patient flow, a total of 1700 anti-HCV positives out of 4074 after screening were traced with available follow-up information to complete 92.52% treatment coverage of 1177 RNA-positives (77.23%) diagnosed from 1524 undergoing RNA testing with similar findings across multiple settings. ConclusionA new collaborative integrated care was adopted for elucidating patient flow between and within multiple settings in order to calibrate the accurate demand for HCV care cascades and enhance HCV treatment coverage in marginalized populations.

"Swallow Them All, and It's Just Like Smack": Comorbidity, Polypharmacy, and Imagining Moral Agency alongside Methadone and Antipsychotics

This research article investigates moral agency in the spaces between the methadone clinic and the inpatient psychiatric ward by exploring the ways dually-diagnosed service users move though ever-more labyrinthine networks of care. I ask: how are patients’ own engagements with the ethical stakes of such care both made possible and delimited by virtue of their proximity to substances that are understood to affect their subjectivities, wills, and capacities for self-governance? Drawing on fieldwork in the community mental health network of Dublin, Ireland, and following my interlocutors’ own reflections, I analyse the moral dimensions of polypharmaceutical treatment for substance use disorder in the context of psychiatric dual diagnosis. I illustrate how various apparatuses of coercion and care apprehend and govern patients who are thought to be both addicted and mad, simultaneously enthralled by one form of the pharmakon and dangerously unreasonable when other medications are absent or neglected. In the space of such medicated subjectivities, a curious but ultimately revelatory claim to authority about the intended and unintended effects of polypharmaceutical treatment takes shape.