Opioid Substitution Therapy Program Research Articles

Retention of service users on opioid substitution therapy in the City of Tshwane, South Africa.

Opioid substitution therapy (OST) is evidence-based treatment for opioid use disorders and, when taken as maintenance therapy, has proven health and social benefits. The benefits of OST are achieved through the retention of service users in the treatment programme. To identify factors that affected retention of service users who had OST interrupted in less than 6 months of being in an OST programme. This qualitative study was conducted with 19 service users from eight Community-Oriented Substance Use Programme (COSUP) sites in the City of Tshwane, Gauteng, South Africa. Participants were COSUP service users who had interrupted OST in less than 6 months since initiation and were purposefully selected from all COSUP sites. Demographic information was obtained and four focus group discussions covered challenges of OST retention. Discussions were recorded, transcribed and qualitatively analysed using Attride-Stirling's thematic networks framework. The 19 participants were all male, mostly black African, with a mean age of 26 years. Facilitators of retention in OST were individual readiness to change OST accessibility, positive family and peer support, treatment monitoring, understanding and managing expectations of service users, contribution in society and meaningful opportunities for engagement. Barriers were the cost of OST, bureaucracy within the programme, inability to communicate challenges timeously and effectively to treatment providers, boredom, cravings and poverty. Opioid substitution therapy programmes can ensure a holistic approach to prevent and treat harms related to illicit opioid use if they remain person-centred and are well-funded.Contribution: Understanding the barriers to, and facilitators of retention on OST can contribute to improved community-based service delivery.

ЭПИДЕМИОЛОГИЧЕСКАЯ ХАРАКТЕРИСТИКА ВИЧ-ИНФИЦИРОВАННЫХ НАРКОПОТРЕБИТЕЛЕЙ НА ЭТАПЕ ВСТУПЛЕНИЯ В ПРОГРАММУ ОПИОИДНОЙ ЗАМЕСТИТЕЛЬНОЙ ТЕРАПИИ В Г. МИНСКЕ

Objectives. To identify the medico-social and epidemiological peculiarities of HIV-infected people injecting drugs (PWID) at the stage of joining the opioid substitution therapy (OST) program, who adopted it in 2019 in the city of Minsk. Material and methods. The data of the primary accounting documentation of the Health Care Institution «City Clinical Narcological Dispensary» and the Health Care Institution «City Clinical Infectious Diseases Hospital» of PWID HIV-infected patients were analyzed on joining the opioid substitution therapy program who adopted it in 2019 in the city of Minsk (n=91). Results. It has been found that the largest proportion of the OST program participants constituted males (73.63%) aged 36 years and older (73.62%); 64.84% of them were convicted more than 3 times, 83.52% were not officially married, 64.84% were officially unemployed. The median experience of using opioid drugs made up 21 (19-24) years. Almost ½ (46.15%) of HIV-infected drug users were members of OST program for 3 (1-5) years in 2019. Most of the OST program participants (83.52%) had up to 3 periods without drug use, while in 54.95% of them these breaks were due to serving a sentence, and in 21.98% because of undergoing rehabilitation. Lifestyle changes and socialization in society were authentically the most significant reasons and motives for the participation of PWID HIV-infected persons in the OST program in Minsk (p<0.05). The analysis of the comorbidity rate showed that all the participants in the studied group were infected with viral hepatitis C, 6.59% - with hepatitis B against the background of hepatitis C virus (HCV), and 1.01% - with hepatitis D. Conclusions. The revealed medical, social and epidemiological features of HIV-infected PWID persons at the stage of joining the opioid substitution therapy program will make it possible to increase the efficiency of providing medical care to opioid drug users with HIV infection and parenteral viral hepatites and extend the coverage of the studied contingent by this program.

Risk of hepatitis C virus infection in injecting and noninjecting drug users receiving opioid substitution therapy.

Hepatitis C virus (HCV) is the most common viral infection among illicit drug users in the world. Although intervention of needle and syringe program and opioid substitution therapy had engaged to prevent HCV infection, the prevalence of HCV infection does not seem to decline. The aim of this study was to estimate the risk of HCV infection in injecting drug users (IDUs) and noninjecting drug users (NIDUs) receiving opioid substitution therapy. We recruited 1179 heroin-dependent patients (age: 20-66 years) under opioid substitution therapy from 2012 to 2015 in a Psychiatric Center, Southern Taiwan. The data of HCV, hepatitis B virus and HIV infection and liver biochemical examination were obtained. We used multivariate logistic regression analysis to predict the risk of HCV infection. There were 93.1% of IDUs and 68.1% of NIDUs positive for HCV infection. In IDUs, HIV infection, age of heroin initiation, duration and dose of heroin use, frequency of detoxification, and number of criminal conviction were significantly associated with HCV infection. In NIDUs, snort/sniff heroin exhibited a significantly increased risk of HCV infection. Intravenous injecting (odds ratio [OR] = 23.10, 95% CI = 8.04-66.40, p < 0.001), intravenous injecting combined snort/sniff (OR = 12.95, 95% CI = 3.90-42.97, p < 0.001), and snort/sniff (OR = 4.14, 95% CI = 1.30-13.18, p = 0.016) were significantly associated with increased risk of HCV infection compared with smoking. The trend was significant (p for trend <0.001). In Taiwan, IDUs had harmful characteristics compared with NIDUs and both had extremely high prevalence of HCV infection. We provided evidence that snort/sniff is a possible way of leak in HCV infection despite needle-syringes supplement program been provided. Opioid substitution therapy program should include HCV assessment and treatment in the new direct-acting antiviral therapy era.

Directly observed hepatitis C treatment with opioid substitution therapy in community pharmacies: A qualitative study.

The hepatitis C virus (HCV) will only be eliminated through successful engagement with people who inject drugs (PWID), however some of this population experience socioeconomic and individual issues that can lead to poor HCV treatment adherence. A key sub-group of (PWID) are those who receive opioid substitution therapy (OST). In Australia, OST is most often delivered under direct supervision by a community pharmacist every day or multiple times a week. This regular interaction could be an ideal opportunity to enhance direct-acting antiviral (DAA) treatment adherence under directly observed therapy (DOT) by the pharmacist. The aim of this study was to explore the perspectives of OST patients with a lived experience of HCV to understand whether or not dispensing DAAs in the same way as, or simultaneously with OST would benefit HCV treatment. Data collection occurred from June to August 2017. Semi-structured interviews were conducted with a sample of PWID living with HCV and on OST programs (n = 12) in Melbourne, Australia. Interviews were voice recorded and transcribed in verbatim. Interpretive phenomenology guided analysis of the data. Themes reported by participants that provide insight into the suitability of DOT of DAAs include: Adherence and non-adherence to DAA treatment; Mixed views towards DOT of DAAs; Experiences and perceptions of OST providers; and Perceived stigma in the pharmacy. Community pharmacies offering OST may be an effective place for DOT of HCV treatment, but is likely only to benefit people who face significant challenges to adherence. We suggest that a positive pharmacist-patient relationship, high OST adherence, and commitment to reducing stigma in the pharmacy would be necessary for the intervention to be effective. Further research is needed to evaluate the expanded-role of community pharmacies in improving DAA adherence and eliminating HCV.

Integrated, Co-located, Telemedicine-based Treatment Approaches for Hepatitis C Virus Management in Opioid Use Disorder Patients on Methadone.

Despite high hepatitis C virus (HCV) prevalence, opioid use disorder (OUD) patients on methadone rarely engage in HCV treatment. We investigated the effectiveness of HCV management via telemedicine in an opioid substitution therapy (OST) program. OUD patients on methadone underwent biweekly telemedicine sessions between a hepatologist and physician assistant during the entire HCV treatment course. All pretreatment labs (HCV RNA, genotype, and noninvasive fibrosis assessments) were obtained onsite and direct-acting antivirals were coadministered with methadone using modified directly observed therapy. We used multiple correspondence analysis, least absolute shrinkage and selection operator, and logistic regression to identify variables associated with pursuit of HCV care. Sixty-two HCV RNA-positive patients (24% human immunodeficiency virus [HIV] infected, 61% male, 61% African American, 25.8% Hispanic) were evaluated. All patients were stabilized on methadone and all except 4 were HCV genotype 1 infected. Advanced fibrosis/cirrhosis was present in 34.5% of patients. Of the 45 treated patients, 42 (93.3%) achieved viral eradication. Of 17 evaluated patients who were not treated, 5 were discontinued from the drug treatment program or did not follow up after the evaluation, 2 had HIV adherence issues, and 10 had insurance authorization issues. Marriage and a mental health diagnosis other than depression were the strongest positive predictors of treatment pursuit, whereas being divorced, separated, or widowed was the strongest negative predictor. HCV management via telemedicine integrated into an OST program is a feasible model with excellent virologic effectiveness. Psychosocial and demographic variables can assist in identification of subgroups with a propensity or aversion to pursue HCV treatment.

THE MODEL OF PSYCHOPATHOGENESIS OF NONPSYCHOTIC MENTAL DISORDERS IN PERSONS UNDERGOING THE PROGRAMS OF SYNTHETIC OPIOIDS SUBSTITUTION THERAPY

In order to identify the structural and dynamic characteristics of comorbid non-psychotic psychopathological symptoms in patients on the synthetic opioid substitution therapy program, 100 patients of the narcological dispensary were examined with the help of the Simptom Check List – 90 – Revised. The study used the inclusion and exclusion criteria that are identical to the criteria for participation in the substitution therapy program. The results were distributed to 3 levels, which correspond to the degree of clinical significance of the symptoms: - minimal (discomfort for this reason occurs rarely or does not occur at all, it has a low intensity) - the range of results obtained is from 0 to 0.50; - subclinical (the presence of not frequent, moderately intense discomfort for this reason) - the range of values is from 0.51 to 1.50; - clinical (frequent or persistent high intensity discomfort for this reason) - range of values greater than 1.51. The study found that non-psychotic mental disorders among this group of patients have three stages of development. All groups of symptoms are considered in the context of the three main classes of disorders (patho-affective — anxiety and depression symptoms; pseudo-neurotic — obsessive-compulsive phenomena; psycho-vegetative symptoms and self-perception disorders; and psychoorganic — associative disorders, paranoia and hostility) and two groups of intermediate symptoms (phobic — intermediate between pathogenic and pseudoneurotic and psychotic - intermediate between psychoorganic and pseudoneurotic). Also, according to the results of the assessment of the correlation dynamics of symptom groups, a model of psycho-pathogenesis of non-psychotic mental disorders in people who are on the program of drug addiction substitution therapy was constructed

A Clinical Study of Opioid Substitution Therapy in a Tertiary Care Center of Eastern India.

Background:Opioid substitution therapy (OST) is an evidence-based intervention for opiate-dependent persons that replaces illicit drug use with medically prescribed, orally administered opiates such as buprenorphine and methadone. OST reduces HIV risk behaviors and harms associated with injecting opioid. Most of the evidence for OST effectiveness has been generated in middle- and high-income countries where programs are mostly located in dedicated health-care settings; evidence regarding the outcomes of OST programs in low-income countries where OST is often provided in grassroots settings such as drop-in centers is limited.Aims and Objectives:To study the sociodemographic variables, HIV ELISA status, HIV risk behavior, comorbid substance use pattern, and required dose of buprenorphine used for treatment of injection drug users (IDUs) attending oral substitution therapy (OST) center at a tertiary health care center.Methodology:A total of IDUs aged 18–60 years who attended the OST center during 1-year period at a government medical college are included in the study.Results:Majority of the IDUs are male with mean age of 32.8 years. The mean dose of buprenorphine used for the substitution was 4.6 mg/day at the start of therapy. Most of the IDUs are of lower educational status and educated up to primary or middle school. 32.50% of the participants who are unemployed are totally dependent on the family. Most common substance abuse among IDU users were tobacco (74.17%), followed by heroine (57.5%). High-risk behavior found among OST clients was unprotected sexual intercourse (19.17%), sharing needle (11.67%), and sexual intercourse with multiple partners (6.67%). HIV ELISA testing showed positive among 2 (1.67%).Conclusion:These findings have relevance to other parts of India and Asia, where injecting drug use is common and is a first step toward filling the gap in knowledge regarding the effectiveness of community-based OST programs delivered in resource-constrained settings.

Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review.

SummaryBackgroundPeople who inject drugs (PWID) are a key population affected by the global HIV and hepatitis C virus (HCV) epidemics. HIV and HCV prevention interventions for PWID include needle and syringe programmes (NSP), opioid substitution therapy (OST), HIV counselling and testing, HIV antiretroviral therapy (ART), and condom distribution programmes. We aimed to produce country-level, regional, and global estimates of coverage of NSP, OST, HIV testing, ART, and condom programmes for PWID.MethodsWe completed searches of peer-reviewed (MEDLINE, Embase, and PsycINFO), internet, and grey literature databases, and disseminated data requests via social media and targeted emails to international experts. Programme and survey data on each of the named interventions were collected. Programme data were used to derive country-level estimates of the coverage of interventions in accordance with indicators defined by WHO, UNAIDS, and the UN Office on Drugs and Crime. Regional and global estimates of NSP, OST, and HIV testing coverage were also calculated. The protocol was registered on PROSPERO, number CRD42017056558.FindingsIn 2017, of 179 countries with evidence of injecting drug use, some level of NSP services were available in 93 countries, and there were 86 countries with evidence of OST implementation. Data to estimate NSP coverage were available for 57 countries, and for 60 countries to estimate OST coverage. Coverage varied widely between countries, but was most often low according to WHO indicators (<100 needle-syringes distributed per PWID per year; <20 OST recipients per PWID per year). Data on HIV testing were sparser than for NSP and OST, and very few data were available to estimate ART access among PWID living with HIV. Globally, we estimate that there are 33 (uncertainty interval [UI] 21–50) needle-syringes distributed via NSP per PWID annually, and 16 (10–24) OST recipients per 100 PWID. Less than 1% of PWID live in countries with high coverage of both NSP and OST (>200 needle-syringes distributed per PWID and >40 OST recipients per 100 PWID).InterpretationCoverage of HIV and HCV prevention interventions for PWID remains poor and is likely to be insufficient to effectively prevent HIV and HCV transmission. Scaling up of interventions for PWID remains a crucial priority for halting the HIV and HCV epidemics.FundingOpen Society Foundations, The Global Fund, WHO, UNAIDS, United Nations Office on Drugs and Crime, Australian National Drug and Alcohol Research Centre, University of New South Wales Sydney.

Use of opioid substitution therapies in the treatment of opioid use disorder: results of a UK cost-effectiveness modelling study

Aims: This study investigated the cost-effectiveness of buprenorphine maintenance treatment (BMT) and methadone maintenance treatment (MMT) vs no opioid substitution therapy (OST) for the treatment of opioid use disorder, from the UK National Health Service (NHS)/personal social services (PSS) and societal perspectives over 1 year.Methods: Cost-effectiveness of OST vs no OST was evaluated by first replicating and then expanding an existing UK health technology assessment model. The expanded model included the impact of OST on infection rates of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection.Results: Versus no OST, incremental cost-effectiveness ratios (ICERs) for BMT and MMT were £13,923 and £14,206 per quality-adjusted life year (QALY), respectively, from a NHS/PSS perspective. When total costs (NHS/PSS and societal) are considered, there are substantial savings associated with adopting OST; these savings are in excess of £14,032 for BMT vs no OST and £17,174 for MMT vs no OST over 1 year. This is primarily driven by a reduction in victim costs. OST treatment also impacted other aspects of criminality and healthcare resource use.Limitations: The model’s 1-year timeframe means long-term costs and benefits, and the influence of changes over time are not captured.Conclusions: OST can be considered cost-effective vs no OST from the UK NHS/PSS perspective, with a cost per QALY well below the UK’s willingness-to-pay threshold. There were only small differences between BMT and MMT. The availability of two or more cost-effective options is beneficial to retaining patients in OST programs. From a societal perspective, OST is estimated to save over £14,032 and £17,174 per year for BMT and MMT vs no OST, respectively, due to savings in victim costs. Further work is required to fully quantify the clinical and health economic impacts of different OST formulations and their societal impact over the long-term.

Prevention of HIV/AIDS with opioid substitution therapy: An exploratory study among injecting drug users in a tertiary health-care center of Kolkata

Background: Globally maintenance of HIV epidemic has been attributed to unsafe injection practice among the injecting drug users (IDUs). Despite significant achievements in containment of HIV in India among different high-risk groups, IDUs demonstrate high prevalence of HIV. Opioid substitution therapy (OST) is a medical intervention program for opioid dependent IDUs. OST entails replacement of an illicit and euphoric injectable opioid with a medically prescribed and longer acting but less euphoric oral opioid, such as buprenorphine and methadone, creating a steady state without distress of withdrawal and craving. Objectives: Our study was aimed at exploring the sociodemographic profile, choice of injectable psychoactive substances used, and injecting as well as sex-related high-risk behavior and treatment adherence of IDUs attending the OST center. Materials and Methods: An observational, cross-sectional study was conducted on 90 IDUs using a structured schedule along with reviewing of hospital records. SPSS version 16 was employed for analysis of data. Results: The study revealed that nearly 98% of IDUs were males. The majority belonged to lower socioeconomic class and had lower educational level. Nearly, 34% of IDUs had history of sharing needle and 33% had sex-related high-risk behavior at least once in their lifetime. Proportion of HIV infection among IDUs was 15%. Buprenorphine was the most common substance of abuse. At the end of 6 months, the retention rate on OST program was 68%. Conclusion: The OST center was effectively catering to its IDU clients while achieving good compliance and success of its whole endeavor.

Retention in Georgia opioid substitution therapy program and associated factors.

BackgroundSubstance abuse has been considered as a growing challenge in Georgia that is closely linked with human immune deficiency virus (HIV) and hepatitis C transmission due to unsafe injection and other uncontrolled behaviors. Methadone maintenance therapy is one of the major treatment options for opioid-dependent individuals. It has proven efficacy in decreasing illegal opioid consumption and criminal behavior as well as reducing the level of HIV infection, mortality, HCV infection, and increasing social functioning.MethodsThe data was initially extracted from the electronic database, as of October 30, 2015, for the patients undergoing methadone maintenance therapy in 2014 and 2015. We used two types of statistical analysis: binary regression and time-to-event analysis (Kaplan-Meier). For binary regression analysis, patients who initiated the treatment 12, 9, 6, and 3 months prior to October 30, 2015, respectively, were eligible for >12-, >9-, >6-, and >3-month retention analysis. We identified two types of the retention periods: (I) “the program specific retention period” (the time spent (uninterruptedly) in the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria (GFATM) opioid substitution treatment (OST) program after the clients’ last entry) and (II) “being on OST retention period” (the time spent (uninterruptedly) on OST since the clients’ last entry).For time-to-event analysis, the two different endpoints were investigated: (i) dropouts and (ii) being detained.ResultsThe analysis showed that at each time point, “being on OST retention” rates are slightly higher than “program specific retention” rates. The percentages of patients retained in OST treatment after 3, 6, 9, and 12 months from the initiation of the treatment, respectively, were 89, 86, 85, and 83% and the percentages of patients retained in the GFATM program at the same time points were 88, 83, 82, and 80%. Patients older than 40 years are twice as likely to stay in the program compared to younger individuals. Gender is only associated with >9 and >12 months retention with approximately three times the odds for men compared to women. The strength of the association between hepatitis C status and “program specific” retention increases with time spent in the program as p values decrease from 0.07 for >3- and >6-month retention to 0.01 for >9- and >12-month retention. The younger age group was more likely to get dropouts and be detained. HIV status and social status did not show statistically significant association with retention.ConclusionsThese findings identify the need for more support for younger patients as they are more vulnerable to dropouts and detention compared to the older age group, especially during the early stage of treatment.

Effects of combination approach on harm reduction programs: the Taiwan experience.

BackgroundIn 2003, a major epidemic of human immunodeficiency virus emerged among injection drug users in Taiwan. In response to the twin epidemics of HIV and intravenous drug addiction, the government implemented comprehensive harm reduction programs beginning in 2005. Collected data from relevant agencies were used to explore the impact of the harm reduction programs on HIV and illicit drug use.MethodsThis study divided 2002–2015 into three intervention phases and used the surveillance data and statistics on the HIV epidemic, drug abuse, and the intervention from relevant agencies to explore the correlations between different variables in different intervention periods and the combination effects of interventions on the HIV epidemic.ResultsIn the pre-intervention phase, the growth of the HIV epidemic followed the rapidly increasing number of heroin users, reaching a peak in 2005. After the initiation of harm reduction programs, the HIV epidemic ceased growing, even rapidly declining with the expansion of needle and syringe exchange programs and opioid substitution therapy; however, the number of heroin users remained high. When the implementation of the needle and syringe exchange programs and the opioid substitution therapy program reached the plateau level in the consolidation phase, the number of heroin users also decreased rapidly. The combination effects of the harm reduction programs in this period also pushed levels of HIV infection below those before this outbreak.ConclusionsThe HIV epidemic among injection drug users incorporates the dual problems of drug addiction and needle-sharing behaviors, so the use of a single intervention will not resolve all of the problems. Facing a severe HIV epidemic among injection drug users, quickly scaling up and promoting comprehensive harm reduction programs is a good strategy that can be used to simultaneously reverse the HIV epidemic and to resolve the illicit drug use problems.More research is needed to find out the reasons behind why there were cases that declined opioid substitution therapy, so that efforts can be undertaken to avoid the epidemic rebounding.

Lessons Learned: A Qualitative Study of Integrated Care for HIV-Infected Injecting Drug Users in Lviv, Ukraine

Of an estimated 170,000 individuals in Ukraine living with HIV, approximately 60% are injecting drug users (IDUs). Despite demonstrated need for increased access to both antiretroviral therapy (ART) and opioid substitution therapy (OST) in Ukraine, integrated, comprehensive care for HIV-infected IDUs remains limited. For this study, semi-structured interviews with 15 healthcare staff were conducted at the Lviv Regional AIDS Center. These interviews explored the perspectives of the AIDS Center’s integrated ART and OST program staff on patient care-seeking behavior as well as potential barriers to treatment for HIV-infected IDUs. Findings from this single-site, qualitative study highlight themes such as adherence, the value of support services, and the continued discrimination of IDUs by local community members. This study offers useful insights from healthcare providers on the efficacy of co-located care for HIV-infected IDUs in Lviv, as well as valuable suggestions for improving services for this patient population.

Sex-specific disease outcomes of HIV-positive and HIV-negative drug users admitted to an opioid substitution therapy program in Spain: a cohort study

BackgroundOpioid substitution therapy has improved the survival of heroin users with and without HIV infection. We aimed to analyze sex differences in mortality rates and predictors of death among those admitted to a methadone treatment program (MTP).MethodsLongitudinal study of patients enrolled in a MTP from 1992 to 2010. Socio-demographic and drug use characteristics, and markers of viral infections were assessed at entry. Vital status was ascertained by clinical charts and the mortality register. Four calendar periods were defined according to the introduction of preventive and treatment interventions in Spain. Predictors of death were analyzed by Cox regression models.Results1,678 patients (82.8% men) were included; age at first heroin use was 18.6 years (IQR: 16–23 years), and age at first entry into a MTP was 30.7 years (IQR: 26–36 years). A total of 441 (26.3%) deaths occurred during 15,124 person-years (p-y) of follow-up (median: 9.2 years, IQR: 4–13 years). HIV infection was the main predictor of death in men (HR = 3.5, 95% CI: 2.1-5.7) and women (HR = 3.2, 95% CI: 1.2-8.7 ) and main cause of death was HIV/AIDS. Overall mortality rate was 2.9 per 100 p-y (95% CI: 2.7-3.2 per 100 p-y) and death rates decreased over time: 7.4 per 100 p-y (95% CI: 6.3-8.8 per 100 p-y) for the 1992–1996 period to 1.9 per 100 p-y (95% CI: 1.6-2.4 per 100 p-y) for the 2007–2010 period. In women, a slightly increase in mortality was observed in recent periods specifically among HIV-positive women (3.7 per 100 p-y in period 2002–2006 and 4.5 per 100 p-y in 2007–2010).ConclusionsSignificant reductions in mortality of patients in MTP are observed after nineteen years of observation. However, HIV infection shows a great impact on survival, particularly among HIV-infected women.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2334-14-504) contains supplementary material, which is available to authorized users.

A latent class analysis of self-reported clinical indicators of psychosocial stability and adherence among opioid substitution therapy patients: Do stable patients receive more unsupervised doses?

AimsTo develop a stability typology among opioid substitution therapy patients using a range of adherence indicators derived from clinical guidelines, and determine whether stable patients receive more unsupervised doses. MethodsAn interviewer-administered cross-sectional survey was used in opioid substitution therapy programmes in three Australian jurisdictions, totalling 768 patients in their current treatment episode for ≥4 weeks. A structured questionnaire collated data from patients about their demographics, treatment characteristics, past 6-month drug use and medication adherence, psychosocial stability, comorbidity, child welfare concerns and levels of supervised dosing. Latent class analysis (LCA) was used to derive a stability typology. Linear regression models examined predictors of unsupervised dosing in the past month. ResultsLCA identified two classes: (i) a higher-adherence group (67%) who had low-moderate probabilities of endorsing the opioid substitution therapy stability indicators and (ii) a lower-adherence group (33%) who had moderate-high probabilities of endorsing the stability indicators. There was no association between adherence profile and the number of unsupervised doses. Significant predictors of receiving larger numbers of unsupervised doses included being older, living in New South Wales or South Australia (vs. Victoria), receiving methadone (vs. mono-buprenorphine), being prescribed in private clinic or general practice (vs. public clinic), reporting a longer current treatment episode, not receiving a urine drug screen in the past month, being currently employed and not having a prison history. ConclusionsThis study suggested that system-level factors and observable indicators of social functioning were more strongly associated with the receipt of less supervised treatment. Future research should examine this issue using prospectively collected data.

The HIV Epidemic in Eastern Europe and Central Asia

Eastern Europe and Central Asia represent one of the few regions globally where there is a continued increase in the incidence of HIV infection. For example, in Eastern Europe the rate of diagnosed cases of HIV infection per 100 000 population has increased from 11.7 in 2004 to 22.5 in 2011. Initially propelled by injection drug use, heterosexual transmission has now become a major driver of new infections in the region. Nonetheless substance use remains an important factor, with its control limited by challenges in scaling up harm reduction efforts. While most countries have implemented opioid substitution therapy programs, their scale remains very limited. Similarly, coverage of needles syringe programs across the region is variable. Complicating the control of HIV has been the emergence of non-injection drugs and inadequate access to antiretroviral therapy. In addition, structural barriers and stigma toward HIV infected people may contribute to the high proportion of late presentations for HIV care. Finally in the wake of the HIV epidemic, high rates of hepatitis C infection and tuberculosis have been noted.

Advocating for opioid substitution therapy in Central Asia: Much still to be done

Opioid substitution therapy (OST) was first introduced in the formerly-Soviet Central Asian Republics as an HIV prevention intervention for people who inject drugs (PWID) in 2002. Presently, pilot programs function in Kazakhstan and Tajikistan, and Kyrgyzstan has scaled-up from the pilot phase to the operation of over 20 OST sites nation-wide. All three countries have taken steps towards lower-threshold programs, allowing clients to enroll regardless of HIV status, and, in some cases, without documentation of failure to complete other drug treatment programs. However, OST programs remain exclusively funded by international donors, and political and societal opposition to these programs threaten their stability. In order to counter negative campaigns and political attacks on OST, organized advocacy efforts are needed. This commentary explores efforts undertaken by international donor partners supporting advocacy efforts to scale-up OST and assure a sustainable future for programming. It examines both proactive and reactive efforts, and the variety of target audiences that need to be reached to conduct effective advocacy. Ultimately we find that, while a range of tools are available for OST advocacy in the hostile environments of the former Soviet Union, the strengthening of advocacy groups is needed to assure an optimized platform exists for using the evidence and developing relevant materials in the appropriate languages (including, but not limited to, Russian) for both proactive and reactive efforts; and that more robust monitoring is desirable to bring sharper focus to replicable methods.

An alternative way of managing acute pain in patients who are in buprenorphine opioid substitution therapy programs

Editor, We read with great interest the review article by Stromer et al.1 on the perioperative management of pain in patients who abuse opioids. It adds much to the knowledge base on which we rely to manage such a complex patient group. However, in our experience, there is an alternative and perhaps simpler and more effective way of managing patients who are in buprenorphine opioid substitution therapy (BOST) programs. This is of growing relevance as in many countries the number of such patients is increasing due to the perceived greater safety profile of buprenorphine compared with methadone. We acknowledge that the management of acute perioperative pain in a patient prescribed BOST is controversial.2 We agree that concerns about buprenorphine's long half-life, partial μ-agonist and κ-antagonist effects,1 in addition to its high opioid receptor affinity and slow dissociation from the μ-opioid receptor,3 have led many experts to recommend that it be ceased preoperatively and replaced with methadone or a pure μ-opioid agonist to ensure adequate intraoperative and postoperative pain relief.1,4,5 However, we believe that such concerns are unfounded. Contrary to the management plan suggested by Stromer et al., some authors have recommended that the buprenorphine, even in the high doses of 4 to 32 mg often used in BOST, be continued throughout the perioperative period.2 We, therefore, recently undertook a retrospective cohort study comparing pain relief and patient-controlled analgesia (PCA) opioid requirements in the first 24 h after surgery in 51 patients in methadone opioid substitution therapy (MOST; 29 patients) and BOST (22 patients) programs.3 The patients were further subgrouped into those whose methadone or buprenorphine was given or withheld on the first postoperative day. We found no statistically significant differences in the pain scores (rest and movement) or PCA morphine equivalents used between the MOST and BOST patients, suggesting that even for planned major surgery, adequate intraoperative and postoperative analgesia can be equally achieved for patients taking methadone and buprenorphine. Thus, changing preoperatively from buprenorphine to methadone seems to offer no advantage. Of special interest was that BOST patients who were not given their buprenorphine the day after surgery had statistically significantly higher PCA morphine equivalent requirements in the first 24 h after surgery (though similar pain scores) compared with those who were given their usual dose. As a result, concerns about the ability of high doses of buprenorphine to limit the access of full μ-opioid agonists to opioid receptors and reduce their analgesic efficacy would seem to be unwarranted.3 We also found that the BOST and MOST patients had a higher incidence of increased sedation (a better clinical indicator of early respiratory depression than a decrease in respiratory rate)6 than our opioid-naive patients. Although the reason for this is unclear, it is a finding also noted by Rapp et al.7 in opioid-tolerant patients in general. Thus, when opioid doses are rapidly and significantly escalated to deal with new acute pain in the opioid-tolerant patient2 as recommended by Stromer et al.,1 monitoring for respiratory depression, including using sedation scores, must still be mandated, as these patients may, perhaps counterintuitively, be at greater risk of respiratory depression than the opioid-naive patient. We routinely continue buprenorphine (or any other opioid the patient may be taking in the long-term) throughout the perioperative period, irrespective of its dose or the perceived size of the surgical insult. We manage additional acute pain with a full-agonist PCA opioid in higher-than-usual doses, adjuvant nonopioid analgesic agents including ketamine, and regional analgesia, whenever possible. Acknowledgements relating to this article Assistance with the letter: none. Financial support and sponsorship: none. Conflicts of interest: none. Presentation: none.

At the crossroads: HIV prevention and treatment for people who inject drugs in Ukraine

At the crossroads: <scp>HIV</scp> prevention and treatment for people who inject drugs in <scp>U</scp>kraine

Knowledge and barriers associated with assessment and treatment for hepatitis C virus infection among people who inject drugs

Uptake of treatment for hepatitis C virus (HCV) infection among people who inject drugs is low. Further understanding is required of the relationship between HCV knowledge and treatment willingness, assessment and treatment in this population. A cross-sectional self-administered survey was conducted with clients of four opioid substitution therapy (OST) clinics and the Medically Supervised Injecting Centre in Sydney, Australia. Of 132 participants, 85 (64%) self-reported having HCV infection. HCV knowledge was mixed (mean 6.5, range 0-12) and was relatively lower on items measuring knowledge of factors impacting HCV-related disease progression. The likelihood of being in a higher knowledge category was associated with being female [adjusted odds ratio (AOR) = 3.78, 95% confidence interval (CI) (1.79, 7.98)], higher formal education [AOR = 3.28, 95% CI (1.57, 6.88)], being on a current OST program [AOR = 2.61, 95% CI (1.10, 6.19)] and being older [AOR = 1.04, 95% CI (1.01, 1.09)]. Participants receiving OST were more likely to report higher willingness to have HCV treatment [OR = 4.45, 95% CI (2.23, 8.17)]. Having been assessed for HCV treatment was associated with younger age [AOR = 0.93; CI 95% (0.88, 1.00)] and higher formal education [AOR = 7.81; 95% CI (1.62, 37.71)]. Overall, knowledge scores were mid-range. Knowledge of modifiable factors influencing HCV-related liver disease progression was particularly low indicating the need for ongoing education. Education should also be targeted at older people and those not on OST, and be inclusive of those with lower literacy levels.