METHODS: A convenience sample of 96 HIV-positive and 104 HIV-negative incarcerated men who met pre-incarceration criteria for opioid dependence was interviewed using a structured questionnaire to examine participant characteristics and attitudes toward MMT. Factors associated with interest in prison-based MMT initiation were identified using logistic regression analysis.
RESULTS: Among all participants, 85 (42.5%) were interested in receiving MMT within prison. Independent correlates of interest in prison-based MMT were being previously married (AOR=4.15, 95% CI: 1.15, 15.02), previously incarcerated (AOR=5.68, 95% CI: 1.54, 21.02), depression (AOR=3.66, 95% CI: 1.68, 7.98), daily heroin use in the 30days prior to incarceration (AOR=5.53, 95% CI: 1.65, 18.58), and more favorable attitudes toward MMT (AOR=19.82, 95% CI: 6.07, 64.74).
CONCLUSIONS: Overall, interest in receiving prison-based MMT was low, and was associated with adverse social, mental health, and drug use consequences. Incarceration provides a unique opportunity to initiate MMT for those who need it, however, optimal scale-up efforts must be systemic and address modifiable factors like improving attitudes toward and motivation for MMT. Informed or shared decision-making tools may be useful in improving expectations and acceptability of MMT.
METHODS: The cold pressor pain responses of 148 opioid dependent patients receiving MMT were evaluated using the cold pressor test (CPT). DNA was extracted from whole blood and subjected to polymerase chain reaction (PCR)-genotyping.
RESULTS: Of the 148 subjects, 77 (52.0%) were carriers of CYP2B6*6 allele. CYP2B6*6 allele carriers had shorter cold pain threshold and pain tolerance times than non-carriers of CYP2B6*6 allele (21.05s vs 33.69s, p=0.036 and 27.15s vs 44.51s, p=0.020, respectively). Pain intensity scores of the CYP2B6*6 allele carriers was 67.55, whereas that of the CYP2B6*6 allele non-carriers was 64.86 (p=0.352).
CONCLUSION: Our study indicates that the CYP2B6*6 allele is associated with a lower pain threshold and lower pain tolerance among males with opioid dependence on MMT. The CYP2B6*6 allele may provide a mechanistic explanation for clinical observations of heightened pain sensitivity among opioid dependent patients receiving MMT.
METHODS: The three hundred participants comprised 152 opioid naive subjects and 148 opioid dependent patients. Opioid naive subjects had not taken any opioids including morphine and methadone to their best knowledge and were presumed so after two consecutive negative urine screenings for drugs. All opioid dependent patients were stabilized in treatment, defined as having been enrolled in the program for more than one month with no change of methadone dosage over the past one month. Excluded from the study were individuals with chronic or ongoing acute pain and individuals with a history of analgesics ingestion within 3 d before the cold pressor test (CPT). Pain tolerance to CPT was evaluated at 0 h, and at 2, 4, 8, 12, and 24 h post-methadone dose.
RESULTS: Patients exhibited a significantly shorter mean pain tolerance time of 34.17 s (95% CI 24.86, 43.49) versus 61.36 (52.23, 70.48) [p < 0.001] compared with opioid naive subjects. Time-dependent mean pain tolerance was also significantly different when naive subjects were compared to patients (p = 0.016).
CONCLUSIONS: This study revealed hyperalgesia amongst patients on MMT, as manifested by their quicker hand withdrawal. The complaints of pain in this population should not be underestimated and the pain should be evaluated seriously and managed aggressively.
METHODS: Two hundred thirty-eight men participated in this cross-sectional study. Four questionnaires were used, the Mini International Neuropsychiatric Interview, Opiate Treatment Index, Malay version of the International Index of Erectile Function 15 (Mal-IIEF-15), and World Health Organization Quality of Life-BREF Scale. Multivariate analysis of covariance was used to examine the relationship between MMT and BMT and the Mal-IIEF 15 scores while controlling for all the possible confounders.
RESULTS: The study population consisted of 171 patients (71.8%) on MMT and 67 (28.2%) on BMT. Patients in the MMT group who had a sexual partner scored significantly lower in the sexual desire domain (p < 0.012) and overall satisfaction (p = 0.043) domain compared with their counterparts in the BMT group. Similarly, patients in the MMT group without a sexual partner scored significantly lower in the orgasmic function domain (p = 0.008) compared with those in the BMT group without a partner. Intercourse satisfaction (p = 0.026) and overall satisfaction (p = 0.039) were significantly associated with the social relationships domain after adjusting for significantly correlated sociodemographic variables.
CONCLUSIONS: Sexual functioning is critical for improving the quality of life in patients in an opioid rehabilitation program. Our study showed that buprenorphine causes less sexual dysfunction than methadone. Thus, clinicians may consider the former when treating heroin dependents who have concerns about sexual function.
METHODS: We did a parallel, two-arm, prospective observational study of opioid-dependent individuals aged 18 years and older who were treated in Malaysia in the Klang Valley in two settings: CDDCs and VTCs. We used sequential sampling to recruit individuals. Assessed individuals in CDDCs were required to participate in services such as counselling sessions and manual labour. Assessed individuals in VTCs could voluntarily access many of the components available in CDDCs, in addition to methadone therapy. We undertook urinary drug tests and behavioural interviews to assess individuals at baseline and at 1, 3, 6, 9, and 12 months post-release. The primary outcome was time to opioid relapse post-release in the community confirmed by urinary drug testing in individuals who had undergone baseline interviewing and at least one urine drug test (our analytic sample). Relapse rates between the groups were compared using time-to-event methods. This study is registered at ClinicalTrials.gov (NCT02698098).
FINDINGS: Between July 17, 2012, and August 21, 2014, we screened 168 CDDC attendees and 113 VTC inpatients; of these, 89 from CDDCs and 95 from VTCs were included in our analytic sample. The baseline characteristics of the two groups were similar. In unadjusted analyses, CDDC participants had significantly more rapid relapse to opioid use post-release compared with VTC participants (median time to relapse 31 days [IQR 26-32] vs 352 days [256-unestimable], log rank test, p<0·0001). VTC participants had an 84% (95% CI 75-90) decreased risk of opioid relapse after adjustment for control variables and inverse propensity of treatment weights. Time-varying effect modelling revealed the largest hazard ratio reduction, at 91% (95% CI 83-96), occurs during the first 50 days in the community.
INTERPRETATION: Opioid-dependent individuals in CDDCs are significantly more likely to relapse to opioid use after release, and sooner, than those treated with evidence-based treatments such as methadone, suggesting that CDDCs have no role in the treatment of opioid-use disorders.
FUNDING: The World Bank Group, Doris Duke Charitable Foundation, National Institute on Drug Abuse, Australian National Health & Medical Research Council, National Institute of Mental Health, and the University of Malaya-Malaysian Ministry of Higher Education High Impact Research Grant.
METHODS: We conducted an analysis of policy documents and over 60 h of participant observation in February 2016, which included focus groups with a convenience sample of 20 therapeutic community staff members, 110 prisoners across three male and one female prisons, and qualitative interviews with two former Clean Zone participants. Field notes containing verbatim quotes from participants were analyzed through iterative reading and discussion to understand how participants generally perceive the program, barriers to entry and retention, and implications for future treatment within prisons.
RESULTS: Our analyses discerned three themes: pride in the mission of the Clean Zone, idealism regarding addiction treatment outcomes against all odds, and the demonization of methadone.
CONCLUSION: Despite low enrollment and lack of an evidence base, the therapeutic community is buttressed by the strong support of the prison administration and its clients as an "ordered" alternative to what is seen as chaotic life outside of the Clean Zone. The lack of services for Clean Zone patients after release likely contributes to high rates of relapse to drug use. The Clean Zone would benefit from integration of stabilized methadone patients combined with a post-release program.
METHODS: We recruited 176 clients from methadone maintenance treatment (MMT: N=110) and needle/syringe programs (NSP: N=66) between November 2015 and August 2016. After baseline knowledge assessments, clients participated in a standardized, 45-min HCV education program and completed post-intervention knowledge assessments to measure change in knowledge and treatment interest.
RESULTS: Participants were mostly male (96.3%), Malay (94.9%), and in their early 40s (mean=42.6years). Following the intervention, overall knowledge scores and treatment interest in MMT clients increased by 68% and 16%, respectively (p<0.001). In contrast, NSP clients showed no significant improvement in overall knowledge or treatment interest, and perceived greater treatment barriers. Multivariate linear regression to assess correlates of HCV knowledge post-intervention revealed that optimal dosage of MMT and having had an HIV test in the past year significantly increased HCV knowledge. Having received a hepatitis B vaccine, however, was not associated with increased HCV knowledge after participating in an education session.
CONCLUSION: Generally, HCV knowledge and screening is low among clients engaged in MMT and NSP services in Malaysia. Integrating a brief, but comprehensive HCV education session within harm reduction services may be a low-cost and effective strategy in improving overall HCV knowledge and risk behaviors in resource-limited settings. In order to be an effective public health approach, however, education interventions must be paired with strategies that improve social, economic and political outcomes for PWID. Doing so may reduce HCV disparities by increasing screening and treatment interest.
METHODS: Nominal Group Technique (NGT), a key ingredient of the NIATx toolkit, was directed by three trained coaches within a learning collaborative of 18 OAT clinicians and administrators to identify barriers to increase OAT capacity at the regional "oblast" level, develop solutions, and prioritize local change projects. NGT findings were supplemented from detailed notes collected during the NGT discussion.
RESULTS: The top three identified barriers included: (1) Strict regulations and inflexible policies dictating distribution and dispensing of OAT; (2) No systematic approach to assessing OAT needs on regional or local level; and (3) Limited funding and financing mechanisms combined with a lack of local/regional control over funding for OAT treatment services.
CONCLUSIONS: NGT provides a rapid strategy for individuals at multiple levels to work collaboratively to identify and address structural barriers to OAT scale-up. This technique creates a transparent process to address and prioritize complex issues. Targeting these priorities allowed leaders at the regional and national level to advocate collectively for approaches to minimize obstacles and create policies to improve OAT services.
DESIGN, METHODS AND RESULTS: A case series of seven patients from Malaysian private and public hospital settings who had an adverse reaction with methadone is discussed.
DISCUSSION AND CONCLUSION: Despite methadone being an effective therapy for opioid dependence, there is a need for other alternative effective therapies, such as naltrexone, buprenorphine and the co-formulation of buprenorphine-naloxone, to be made available to physicians in both public and private sectors. There is need for individual treatment consideration to avoid adverse effects, drug-drug interactions, overdosing and in the presence of co-morbidities. An emphasis on safe storage of takeaway methadone is also needed. [George P, Vicknasingam B, Thurairajasingam S, Ramasamy P, Mohd Yusof H, Yasin MABM, Shah ZUBS. Methadone complications amongst opioid-dependent patients in Malaysia: A case series. Drug Alcohol Rev 2018;37:147-151].