Opioid Substitution Treatment Patients Research Articles

The impact of methadone or buprenorphine treatment and ongoing injection on highly active antiretroviral therapy (HAART) adherence: evidence from the MANIF2000 cohort study

To date, no data exist assessing the impact of either methadone or buprenorphine on adherence to highly active antiretroviral therapy (HAART) in the long term. This study was conducted in order to evaluate whether receiving take-home methadone and buprenorphine may ensure better adherence to HAART in individuals infected with human immunodeficiency virus (HIV) through injection drug use (IDU). Longitudinal data on adherence, opioid substitution treatment (OST) and patient behaviours starting from their first HAART prescription were collected for 276 individuals HIV-infected through drug use (n=1558 visits). Out-patient hospital services delivering HIV care in Marseilles, Avignon, Nice and Ile de France. At any given visit, patients were classified both according to the type of OST received and ongoing injection. Patients who reported no injection and no OST over the whole study period were considered as 'abstinent' and used as a reference category. A logit model based on generalized estimation equations (GEE) was used to identify predictors of non-adherence. After adjustment for alcohol consumption, depression and self-reported side effects, patients ceasing injection during OST and abstinent patients exhibited comparable adherence. Patients reporting injection, on OST or not, had a twofold and threefold risk, respectively, of non-adherence compared with abstinent patients (P<0.01 linear trend). Duration on OST without injecting was associated significantly with virological success. Both access to and effectiveness of OST contribute to sustaining adherence to HAART in HIV-infected IDUs. These results advocate strongly the need of wider use of OST in countries scaling-up HAART where HIV is driven by IDUs.

Methadone vs. buprenorphine/naloxone during early opioid substitution treatment: a naturalistic comparison of cognitive performance relative to healthy controls

BackgroundBoth methadone- and buprenorphine-treated opioid-dependent patients frequently show cognitive deficits in attention, working memory, and verbal memory. However, no study has compared these patient groups with each other during early opioid substitution treatment (OST). Therefore, we investigated attention, working memory, and verbal memory of opioid-dependent patients within six weeks after the introduction of OST in a naturalistic setting and compared to those of healthy controls.MethodsThe sample included 16 methadone-, 17 buprenorphine/naloxone-treated patients, and 17 healthy controls matched for sex and age. In both groups buprenorphine was the main opioid of abuse during the recent month. Benzodiazepine codependence, recent use, and comedication were also common in both patient groups. Analysis of variance was used to study the overall group effect in each cognitive test. Pair-wise group comparisons were made, when appropriateResultsMethadone-treated patients, as a group, had significantly slower simple reaction time (RT) compared to buprenorphine/naloxone-treated patients. In Go/NoGo RT methadone patients were significantly slower than controls. Both patient groups were significantly debilitated compared to controls in working memory and verbal list learning. Only methadone patients were inferior to controls in story recall. In simple RT and delayed story recall buprenorphine/naloxone patients with current benzodiazepine medication (n = 13) were superior to methadone patients with current benzodiazepine medication (n = 13). When methadone patients were divided into two groups according to their mean dose, the patient group with a low dose (mean 40 mg, n = 8) showed significantly faster simple RT than the high dose group (mean 67 mg, n = 8).ConclusionDeficits in attention may only be present in methadone-treated early phase OST patients and may be dose-dependent. Working memory deficit is common in both patient groups. Verbal memory deficit may be more pronounced in methadone-treated patients than in buprenorphine/naloxone-treated patients. In sum, to preserve cognitive function in early OST, the use of buprenorphine/naloxone may be more preferable to methadone use of, at least if buprenorphine has been recently abused and when benzodiazepine comedication is used. Longitudinal studies are needed to investigate if the better performance of buprenorphine/naloxone-treated patients is a relatively permanent effect or reflects "only" transient opioid switching effect.

Evaluation of a minimal services treatment track for noncompliant patients in opioid substitution treatment.

Opioid substitution treatment (OST) is the most widely used treatment for opiate dependence.1,2 The preponderance of evidence suggests that retention in OST is associated with decreased opiate use and criminality.3–5 However, continued illicit drug use among patients in OST is common.6–8 Program responses to ongoing use vary widely,9 though discharge is a frequent response. Some patients nevertheless are unable or unwilling to cease illicit use despite the threat of treatment termination. Unfortunately, outcomes for out-of-treatment opiate addicts are very poor.3 Recently published OST guidelines recommend that programs find alternatives to treatment termination for ongoing drug use.10 For treatment programs, such a no-discharge policy poses certain dilemmas. If a program retains patients despite ongoing drug use, harm may be reduced for that subset of patients. However, the potential benefits of retention of drug-using patients in treatment could be offset if illicit use were to increase among other patients in the program who might have otherwise been motivated to cease or reduce their use by the threat of discharge. The value of a putative harmreduction strategy is determined not only by its effectiveness in reducing harm among members of the target group (i.e., microharm) but also by the extent to which it does not inadvertently increase harm among members of other groups or the larger population (macroharm).11 In April 1998, the OST program at the Veterans Affairs Puget Sound Health Care System (VAPSHCS) in Seattle, Washington, instituted a minimal services (MS) treatment track as an alternative to discharge for patients who continued to use illicit drugs. MS was designed to retain these patients in treatment. MS also was designed to introduce additional contingencies that 1) encouraged abstinence and 2) simultaneously minimized demands on clinic and staff resources and opened additional treatment slots to reduce the waiting list for new patients. The components of the MS program are listed in Table 1 ▶. After the MS program was in place for 1 year, the new policy’s impact on both MS patients and the clinic population at large was assessed by means of a program evaluation. TABLE 1— Components of the Minimal Services Treatment Track