Opiate Substitution Research Articles

The politics of place(ment): Problematising the provision of hepatitis C treatment within opiate substitution clinics

The hepatitis C virus (HCV) epidemic is a significant public health challenge in Australia. Current initiatives to expand access to HCV treatment focus on opiate substitution therapy (OST) settings where the prevalence of hepatitis C among clients is high. In Australia, the provision of OST for many clients is via large clinics, with an estimated median of 150 clients per service. Conceptually informed by the work of Michel Foucault, our analysis of the proposed integrated treatment model focuses on the critical but overlooked question of organisational culture and power operating within OST. We argue that the specific context of OST not merely reflects but actively participates in the political economy of social exclusion via which the socio-spatial segregation and stigmatisation of the service user as ‘drug user’ is enacted. This paper analyses data collected from two samples during 2008/9: OST clients living in New South Wales, Australia and a range of OST health professionals working in Australian settings. In total, 27 interviews were conducted with current OST clients; 19 by phone and 8 face-to-face. One focus group and 16 telephone interviews were conducted with OST health professionals. Our analysis of key themes emerging from the interview data suggests that the successful introduction of HCV treatment within the OST clinic is not a given. We are concerned that particular areas of tension, if not explicit contradiction, have been overlooked in current research and debates informing the proposed combination treatment model. We question the appropriateness of co-locating a notoriously arduous, exacting treatment (HCV) within the highly surveillant and regulatory environment of OST. While applauding the intention to improve access to HCV care and treatment for people who inject drugs we caution against a treatment model that risks further entrenching (socio-spatial) stigmatisation amongst those already experiencing significant marginalisation.

Individual-level syringe coverage among Needle and Syringe Program attendees in Australia

BackgroundHarm associated with injecting drug use is a significant public health issue and a major cause of morbidity and mortality, with global estimates of 3 million injectors infected with HIV and 8 million living with chronic hepatitis C virus (HCV) infection. Estimates of program coverage are widely used in the context of HIV prevention and are critical in determining the effectiveness of interventions such as Needle and Syringe Programs (NSPs). MethodsData from a national cross-sectional study of NSP attendees in Australia were used to estimate individual-level syringe coverage as a proportion of monthly injections covered by a new syringe. Univariate and multivariate logistic regressions modelled associations between demographics, injecting risk, anti-HIV and HCV prevalence and syringe coverage. The median number of syringes retained per NSP attendee per annum was also estimated. ResultsTwenty percent of participants had insufficient new syringes for all injections. Syringe reuse (including reuse of one's own syringe) was independently associated with syringe coverage of <100%. Conversely, procurement of syringes from an NSP was independently associated with syringe coverage ≥100%, with a greater protective effect occurring when NSP utilisation was combined with current engagement in opiate substitution therapy. The median number of syringes retained per participant per annum was 720, equivalent to 2 per day. ConclusionsWhile Australian NSP attendees report high syringe coverage by international standards, prevention efforts could be scaled up. Syringe reuse was associated with syringe coverage of <100%, suggesting the utility of reuse as a proxy for individual-level syringe coverage.

Outcome of heroin-dependent adolescents presenting for opiate substitution treatment

Because the outcome of methadone and buprenorphine substitution treatment in adolescents is unclear, we completed a retrospective cohort study of 100 consecutive heroin-dependent adolescents who sought these treatments over an 8-year recruitment period. The participants' average age was 16.6 years, and 54 were female. Half of the patient group remained in treatment for over 1 year. Among those still in treatment at 12 months, 39% demonstrated abstinence from heroin. The final route of departure from the treatment program was via planned detox for 22%, dropout for 32%, and imprisonment for 8%. The remaining 39% were transferred elsewhere for ongoing opiate substitution treatment after a median period of 23 months of treatment. Males were more likely to exit via imprisonment ( p < .05), but other outcomes were not predicted by gender. There were no deaths during treatment among these 100 patients who had a cumulative period of 129 person years at risk. Our findings suggest that this treatment delivers reductions in heroin use and that one fifth of patients will exit treatment following detox completion within a 1- to 2-year time frame.

The impact of needle and syringe provision and opiate substitution therapy on the incidence of hepatitis C virus in injecting drug users: pooling of UK evidence

To investigate whether opiate substitution therapy (OST) and needle and syringe programmes (NSP) can reduce hepatitis C virus (HCV) transmission among injecting drug users (IDUs). Meta-analysis and pooled analysis, with logistic regression allowing adjustment for gender, injecting duration, crack injecting and homelessness. Six UK sites (Birmingham, Bristol, Glasgow, Leeds, London and Wales), community recruitment. A total of 2986 IDUs surveyed during 2001-09. Questionnaire responses were used to define intervention categories for OST (on OST or not) and high NSP coverage (≥100% versus <100% needles per injection). The primary outcome was new HCV infection, measured as antibody seroconversion at follow-up or HCV antibody-negative/RNA-positive result in cross-sectional surveys. Preliminary meta-analysis showed little evidence of heterogeneity between the studies on the effects of OST (I2=48%, P=0.09) and NSP (I2=0%, P=0.75), allowing data pooling. The analysis of both interventions included 919 subjects with 40 new HCV infections. Both receiving OST and high NSP coverage were associated with a reduction in new HCV infection [adjusted odds ratios (AORs)=0.41, 95% confidence interval (CI): 0.21-0.82 and 0.48, 95% CI: 0.25-0.93, respectively]. Full harm reduction (on OST plus high NSP coverage) reduced the odds of new HCV infection by nearly 80% (AOR=0.21, 95% CI: 0.08-0.52). Full harm reduction was associated with a reduction in self-reported needle sharing by 48% (AOR 0.52, 95% CI: 0.32-0.83) and mean injecting frequency by 20.8 injections per month (95% CI: -27.3 to -14.4). There is good evidence that uptake of opiate substitution therapy and high coverage of needle and syringe programmes can substantially reduce the risk of hepatitis C virus transmission among injecting drug users. Research is now required on whether the scaling-up of intervention exposure can reduce and limit hepatitis C virus prevalence in this population.

Briefing Paper- Heroin Assisted Treatment: The State of Play

The United Nations Office on Drugs and Crime (UNODC) estimates that there are presently between 15.5 and 21.1 million opiate users in the world, the majority of whom are heroin users.1 There has been a growing awareness of the importance of treatment for this population in recent decades, with Opiate Substitution Therapy (OST) prominent amongst the range of treatment modalities. While methadone remains the most widely used substitute, clinicians and researchers recognize that there is a significant number of users for whom methadone has proved ineffective. This recognition has driven an expansion in the range of substitution modalities, and, in some parts of the world, clinicians have employed heroin (or, more precisely, diacetylmorphine or diamorphine, its licit, unadulterated pharmaceutical form) in the treatment of opiate addiction.This briefing paper explores the question of Heroin Assisted Treatment (HAT), examines the growing body of evidence emerging from its clinical use in addiction therapies, and makes recommendations for policy makers.

Substance-misusing women: Stigma in the maternity setting

This article examines the reproduction of stigma in maternity services by exploring the workplace discourse of antenatal staff in three hospital trusts. Interviews with antenatal staff, field notes and observation of antenatal practice carried out as part of a larger study into the experiences of substance‐misusing women of antenatal services in three hospital trusts are referred to. It is argued that since stigma and judgmental attitudes have been found to be a barrier for substance‐misusing women’s access to antenatal care, discourse concerning drug‐using pregnant women and how it is deployed by staff must be taken seriously. The article concludes that these findings emphasize the continued need—set out in recent guidelines from the National Institute for Health and Clinical Excellence (NICE) (2010) —for regular training for antenatal staff about substance misuse, opiate substitution therapy and the social and emotional experiences of a substance‐misusing lifestyle. There is also a need for funding of specialist substance‐misuse midwifery posts and centres of expertise in order for guidance and policy to be properly implemented.

Intravenous drug use: not a barrier to achieving a sustained virological response in HCV infection

Hepatitis C virus (HCV) is commonly transmitted by intravenous drug use (IDU) but drug users are under represented in many treatment cohorts, this is because of the assumption of lowered treatment success. We assessed HCV treatment outcomes in active intravenous drug users and patients on opiate substitution therapy. The Tayside HCV treatment database was retrospectively analysed for consecutively treated patients based on risk factor for acquisition of HCV. Primary end point was sustained virological response (SVR). Two hundred and ninety-one consecutively treated patients were assessed. The overall SVR rate was 55.3%. The SVR rates by risk factor were; Non-IDU 61.4%, Ex-IDU 54.8% and Active IDU 47.1% (P = n/s). In the groups G1 patients SVR was; Non-IDU 52.7%, Ex-IDU 30.7% and active IDU 35.4% (P = n/s). In the non-G1 patients: non-IDU 65.1%, Ex-IDU 76.7% and active IDU 53.5%. Ex-IDU had a significantly better SVR than active IDU, other differences were not significant. Our results demonstrate that SVR rates in the active drug users and those on opiate substitution therapy can be achieved which are comparable with non-IDU infected individuals. Intravenous drug use in those engaged with treatment services should not be seen as a barrier to treatment of HCV.

Methadone and buprenorphine as opiate substitution therapy

AbstractThe author describes how to prescribe methadone and buprenorphine safely and effectively as part of a maintenance programme in opiate substitution therapy. Copyright © 2011 Wiley Interface Ltd

Pharmacological Treatments of Opiate Dependence

Opiate substitution therapies have largely contributed to improving outcomes in opiate dependent patients. Their impact has significantly diminished HIV transmission rates, decreased incidence of overdose and reduced delinquency due to heroin trafficking. Since then, some advances have been made in the formulations and dosing regimen of these treatments. They have also largely facilitated opiate withdrawal. However, concerning the maintenance of opiate abstinence, very few new treatments have been proposed. Despite considerable advances in our knowledge of the neurobiological mechanisms of opiate dependence, few clinical trials have been proposed to test new molecules both in accompanying opiate substitution and in maintaining abstinence from illicit opiate use. The objective of this article is to examine the evidence concerning the treatment of opiate dependent patients, especially new treatments and to examine the eventual gaps between currently knowledge, available treatment and demands.

Crime-minimizing drug policy

Objective To identify changes in drug abuse control measures that would reduce non-drug crime. Method Policy analysis. Results Expanding current anti-drug efforts in the conventional triad of enforcement, prevention, and treatment (including drug courts) holds out little hope of reducing non-drug crime. Routine drug law enforcement risks increasing crime by raising drug prices and creating incentives for violence among dealers. Low-arrest crackdowns to break up flagrant markets promise better results. Even good prevention programs have modest effect sizes, and most prevention programs are not based on proven models. The overlap between the population of heavy illicit drug users and the population of frequent non-drug offenders presents a problem and a policy opportunity that current programs largely fail to grasp. Drug treatment, except for opiate substitution, has difficulty recruiting and retaining clients, and weak sanctions systems render treatment mandates largely nominal. Abstinence-mandate programs such as HOPE and Sobriety 24/7 have shown superior results in reducing re-offending and incarceration. Raising alcohol taxes reduces heavy alcohol use and crime due to intoxication without generating any offsetting criminogenic effects. Conclusion Current drug policies are not optimally designed for the control of non-drug crime. Improvements are within relatively easy reach.

Patients receiving opiate substitution have elevated mortality risks at the start and end of treatment

Patients receiving opiate substitution have elevated mortality risks at the start and end of treatment

Does geographic access to primary healthcare influence the detection of hepatitis C?

Recent work in France has suggested that poor geographic access to primary healthcare may have a negative influence upon detection rates of the hepatitis C virus. Topography and poor infrastructure can exacerbate geographic remoteness, while the stigma surrounding hepatitis C and intravenous drug use may also discourage healthcare-seeking behaviour in rural communities with limited choice of general practitioner. No similar study has been conducted in the UK, where detection rates of hepatitis C are also low. Moreover, the previous French findings did not adjust for the uneven spatial distribution of HCV prevalence and associated risk factors, which raises the possibility that the reported travel-time associations were a reflection of greater hepatitis C prevalence in urban areas (where the travel-times to primary healthcare are short) and not an effect of geographic access to primary healthcare. Using geographic information systems, Poisson regression and a dataset from Tayside (Scotland), we explored whether lower rates of hepatitis C detection were associated with higher travel-times to primary healthcare. We tested whether any travel-time effects remained once the models were adjusted for deprivation, by controlling for the spatial variation of some of the known risk factors of hepatitis C infection. Separate models were calculated according to patient history of opiate substitution therapy to take account of people likely to have been infected through intravenous drug use. Rates of detected hepatitis C were highest among males aged between 25 and 39 years. A statistically significant travel-time-decay effect was observed, though with notable attenuation for all patients after adjusting for deprivation. Further modelling identified a travel-time effect only for those who had received opiate substitution therapy. The absence of a similar effect in the non-opiate substitution therapy group indicates that selection effects, not causation, are the most likely explanation for the initial travel-time-decay effects. Thus, future studies of hepatitis C detection and geographic access to primary healthcare will need to consider ways of controlling for the uneven spatial distribution of HCV prevalence and associated risk factors beyond ecological measures of socioeconomic deprivation.

Factors associated with hepatitis C knowledge among a sample of treatment naive people who inject drugs

BackgroundAssessment and uptake of treatment for hepatitis C among people who inject drugs (PWID) is low and strategies to enhance hepatitis C care in this group are needed. Knowledge of hepatitis C and its treatment is one precursor to decisions about treatment. MethodsWe conducted a cross-section study designed to evaluate treatment considerations in participants with self-reported hepatitis C infection in New South Wales, Australia. Participants were recruited from needle and syringe programs, opiate substitution clinics, pharmacies that dispensed opiate substitution treatment and from the mailing list of a community-based hepatitis C organisation and completed a self-administered survey. Knowledge of hepatitis C was assessed by a 48-item scale addressing the natural history and treatment of hepatitis C. Factors associated with knowledge were assessed by ordinal regression. ResultsAmong the 997 participants recruited, 407 self-reported acquiring hepatitis C through injecting drug use and had never received hepatitis C treatment. Knowledge about hepatitis C was overall poor and the effects of the long term consequences of hepatitis C were over-estimated. Higher knowledge scores were associated with recruitment site, higher education levels and recent contact with a general practitioner. One-third of participants indicated that they did not intend to have treatment and one-fifth did not answer this question. ConclusionKnowledge is a precursor to informed decisions about hepatitis C treatment. These results indicate that efforts to support those less engaged with hepatitis C care (and specifically those on opiate substitution treatment) and those with lower literacy are required.

High death rate at beginning and end of opiate substitution

High death rate at beginning and end of opiate substitution

Risk of death highest at start of opiate substitution

Risk of death highest at start of opiate substitution

Human Rights and HIV Prevention, Treatment, and Care for People Who Inject Drugs: Key Principles and Research Needs

Efforts to provide HIV prevention, treatment, and care to injecting drug users (IDU) are shaped by tensions between approaches that regard IDU as criminals and those regarding drug-dependent individuals as patients deserving treatment and human rights. Advocates for IDU health and human rights find common cause in urging greater attention to legal frameworks, the effects of police abuses, and the need for protections for particularly vulnerable populations including women and those in state custody. Arbitrary detention of drug users, and conditions of pretrial detention, offer examples of how HIV prevention and treatment are adversely impacted by human rights abuse. National commitments to universal access to prevention and treatment for injecting drug users, and the recognition that users of illicit substances do not forfeit their entitlement to health services or human dignity, offer a clear point of convergence for advocates for health and rights, and suggest directions for reform to increase availability of sterile injection equipment, opiate substitution treatment, and antiretroviral therapy. For IDU, protection of rights has particular urgency if universal access to HIV prevention and treatment is to become an achievable reality.

Treatment experience and needs of older drug users in Bristol, UK

Recent publications raise concerns about meeting the treatment needs of an ageing drug-using population. At Bristol Drugs Project (BDP) we noted the absence of older users attending services beyond health centre-based opiate substitution therapy (OST). Twenty drug-users aged 55 or over were interviewed about their experience of treatment, barriers to further treatment, and what might encourage participation in our community drugs project. Thematic analysis revealed barriers as reluctance to be associated with younger drug users and a sense of shame at ‘still using at this age’. Assumptions that health professionals would interpret asking for medical help with other age-related symptoms as ‘merely seeking more medication’ prevented some from getting adequate pain relief and there was a tension between fear of detox and fear of drug dependency in old age. Most reported positive relationships with general practitioners (GPs) and BDP Shared Care workers in respect of their drug use, but others had felt stigmatized and inadequately treated within Tier 4 (mainly hospital) services which they attributed to their drug-user status. A focus group developed ideas for an age-specific support group to be piloted. Advocacy work and training for health professionals should be ongoing to improve treatment for older drug users.

Uptake and delivery of hepatitis C treatment in opiate substitution treatment: perceptions of clients and health professionals

Uptake of treatment for hepatitis C virus (HCV) infection is very low particularly among people who have injected drugs. Opiate substitution treatment (OST) programs, with a high prevalence of people living with HCV, have been a site of growing interest in the delivery of hepatitis C treatment. There has been no exploration of OST clients' and health professionals' perceptions of the barriers and facilitators to uptake and delivery of HCV treatment in OST clinics from personal and organizational perspectives. This qualitative study involved interviews with 27 OST clients in New South Wales and a focus group and interviews with 22 Australian OST health professionals. Clients and health professionals viewed hepatitis C treatment in OST as a 'one-stop-shop' model which could increase access to and uptake of treatment and build on existing relationships of trust between OST client and health professional. Elements of the organizational culture were also noted as barriers to HCV treatment delivery including concerns about confidentiality, lack of discussion of HCV treatment and that HCV treatment was not perceived by clinicians as a legitimate activity of OST clinics. OST client participants also reported a number of personal barriers to engaging with HCV treatment including family responsibilities (and concerns about treatment side effects), unstable housing, comorbidities and perceptions of the unsatisfactory level of treatment efficacy. These findings emphasize the need for future research and delivery of services which addresses the complexity of care and treatment for people in marginalized social circumstances.

A systematic review of interventions to increase the uptake of opiate substitution therapy in injecting drug users

Opiate substitution therapy (OST) has multiple benefits and is a key component of overdose and blood-borne virus prevention in injecting drug users (IDUs). Interventions that can increase the uptake of OST and/or re-engage people in treatment could become an important component of harm reduction. A systematic literature review was conducted for studies of interventions designed to increase the uptake of OST. Searches were conducted using Medline, Embase, PsycInfo and CINHAL. We concentrated on an adult population in a community setting and English language studies. Eighty nine studies were identified after filtering search results, of which, 14 met the inclusion criteria. Studies were broadly categorized into motivational interventions (MI), case management (CM) or mixed approaches. Meta-analysis was performed on six studies investigating MI and two studies investigating CM interventions. Individuals exposed to MI were 1.46 times more likely to enter treatment at follow-up (95% CI: 1.14-1.86, P = 0.003) and individuals exposed to CM were 2.95 times more likely to be entering treatment at follow-up (95% CI: 2.08-4.17, P < 0.001). There appears to be a promising effect for the use of both CM and MI approaches to increase the uptake of IDUs into treatment. Further investigation of these interventions is warranted.

Transforming Mental Healthcare in the Veterans Health Administration: A Model for Measuring Performance to Improve Access, Quality, and Outcomes

In this paper we present the conceptual framework and research design of a national evaluation of the quality of mental healthcare provided to veterans by the Veterans Health Administration, and present results on the reported availability of evidence-based practices. We used the Donabedian paradigm to design a longitudinal evaluation of the quality of mental healthcare. To evaluate the structure of care we used a combination of survey and administrative data and designed a web-based facility survey to examine the availability and characteristics of 12 evidence-based practices and other mental health services. We identified 138 unique facilities that provided mental healthcare to 783,280 veterans. With the exception of opiate substitution therapies, every evidence-based practice was reported in at least one location in each service network. We use maps to estimate the maximum number of veterans that might benefit from expanding the availability of an evidence-based practice. We demonstrate the feasibility of overcoming several major challenges typically associated with measuring the quality of healthcare systems. This framework for evaluation of mental healthcare delivery provides a model upon which other stakeholders can continue to build and expand.