Methadone maintenance in general practice: patients,workload, and outcomes.

OBJECTIVE--To assess recruitment to and work-load associated with methadone maintenance clinics in general practice; to investigate the characteristics of patients and outcomes associated with treatment. DESIGN--Study of case notes. SETTING--Methadone maintenance clinics run jointly by general practitioners and drug counsellors in two practices in Glasgow. PARTICIPANTS--46 injecting drug users receiving methadone maintenance during an 18 month period, 31 of whom were recruited to clinic based methadone maintenance treatment and 15 of whom were already receiving methadone maintenance treatment from the general practitioners. Mean (SD) age of patients entering treatment was 29.6 (5.5) years; 29 were male. They had been injecting opiates for a mean 9.9 (5.1) years, and most had a concurrent history of benzodiazepine misuse. Average reported daily intake of heroin was approximately 0.75 g. Participants in treatment had high levels of preexisting morbidity, and most stated that they committed crime daily. RESULTS--2232 patient weeks of treatment were studied. Mean duration of treatment during the study period was 50.7 (21.1) weeks and retention in treatment at 26 weeks was 83%. No evidence of illicit opiate use was obtained at an average of 78% of patients'' consultations where methadone had been prescribed in the previous week; for opiate injection the corresponding figure was 86%. CONCLUSIONS--Providing methadone maintenance in general practice is feasible. Although costs are considerable, the reduction in drug use, especially of intravenous opiates, is encouraging. Attending clinics also allows this population, in which morbidity is considerable, to receive other health care.     

Failure of acetylmethadol in treatment of narcotic addicts due to nonpharmacologic factors.

Acetylmethadol, a new narcotic substitute, has a longer duration of action than methadone. Seventeen subjects, former heroin users currently under methadone treatment, entered a study of the toxicity and efficacy of this drug. Only nine subjects completed the assessment phase of the study and began the acetylmethadol phase, and only one completed the 8-week study phase. Hence, no conclusions can be drawn about acetylmethadol''s efficacy. The high attrition rate was unrelated to pharmacologic factors; the subjects were concerned that if this drug was effective there would be no methadone to take home and hence no opportunity to trade, sell or "play with" (that is, combine with other drugs) the latter. This study emphasizes the difficulty in determining the efficacy of specific drug treatments for opiate-dependent patients.     

Patient Satisfaction with Methadone Maintenance Treatment in Vietnam: A Comparison of Different Integrative-Service Delivery Models

Background

Patient satisfaction is an important component of quality in healthcare delivery. To inform the expansion of Methadone Maintenance Treatment (MMT) services in Vietnam, we examined the satisfaction of patients with regards to different services delivery models and identified its associated factors.

Methods

We interviewed 1,016 MMT patients at 5 clinics in Hanoi and Nam Dinh province. The modified SATIS instrument, a 10-item scale, was used to measure three dimensions: “Services quality and convenience”, “Health workers’ capacity and responsiveness” and “Inter-professional care”.

Results

The average score was high across three SATIS dimensions. However, only one third of patients completely satisfied with general health services and treatment outcomes. Older age, higher education, having any problem in self-care and anxiety/depression were negatively associated with patient’s satisfaction. Meanwhile, patients receiving MMT at clinics, where more comprehensive HIV and general health care services were available, were more likely to report a complete satisfaction.

Conclusion

Patients were highly satisfied with MMT services in Vietnam. However, treatment for drug users should go beyond methadone maintenance to address complicated health demands of drug users. Integrating MMT with comprehensive HIV and general health services together with improving the capacity of health workers and efficiency of services organisation to provide interconnected health care for drug users are critical for improving the outcomes of the MMT program.     

Creating a new drug service in Edinburgh.

After one year Edinburgh''s Community Drug Problem Service has shown that if psychiatric services offer consultation and regular support for drug users many general practitioners will share the care of such patients and prescribe for them, under contract conditions, whether the key worker is a community psychiatric nurse or a drug worker from a voluntary agency. This seems to apply whether the prescribing is part of a "harm reduction" strategy over a long period or whether it is a short period of methadone substitution treatment. Given the 50% prevalence of HIV infection among drug users in the Edinburgh area and the fact that only half of them have been tested for seropositivity, the health and care of this demanding group of young people with a chaotic lifestyle are better shared among primary care, community based drug workers, and specialist community drugs team than treated exclusively by a centralised hospital drug dependency unit. As the progression to AIDS is predictable in a larger proportion of drug users who are positive for HIV, there is an even greater need for coordinated care between specialists and community agencies in the near future.     

The behavioral risk factors for contracting HIV infection in the intravenous administration of narcotics in abusers of psychoactive substances in the city of Rostov-on-Don

150 persons (drug users) who had applied to the department of psycho-social consultations and voluntary tests for the presence of HIV infection and STD of the Regional AIDS Control Center, as well as partners of HIV-infected addicts in the intravenous use of drugs, were examined. Out of 150 examined persons 63 were found to be positive for HIV infection. Among dangerous behavioral patterns, characteristic of drug addicts introducing drugs intravenously, the practice of repeated aspiration of the drug into syringes from the dose of the drug solution, common for the whole group of addicts, was noted as the most widespread habit.     

Unacceptable face of private practice: prescription of controlled drugs to addicts.

Self administered questionnaires completed by 69 out of 100 consecutive drug addicts attending two drug dependence clinics suggested that some private general practitioners were easily persuaded to prescribe controlled drugs. These drugs were usually methadone, dipipanone-cyclizine (Diconal), and methylphenidate (Ritalin). Numbers of new narcotic addicts notified to the Home Office confirmed the practice, which may lead to a severe spread of addiction, as occurred in the 1960s with heroin and cocaine. If the General Medical Council or a tribunal set up in accordance with the Misuse of Drugs Act 1971 cannot stop the practice, then the present licensing system should be extended to include all controlled drugs.     

Heroin users: notifications to the Home Office Addict's Index by general practitioners.

In a study of 113 heroin users who attended a Scottish general practice of 11 doctors information was gathered retrospectively regarding notification of these patients to the Home Office. The doctors were questioned about their practices for notification. Surprisingly few of the patients had been correctly notified and renotified where appropriate, and there was great variation in the doctors'' notification practices, particularly with respect to defining addiction. General practitioners are now the largest source of notifications of controlled drug users, and the statistics issued by the Home Office must be interpreted in the light of their notification practices.     

Toxicology and pathology of deaths related to methadone: retrospective review

Objectives To clarify the mechanisms and risk factors of methadone toxicity and to describe the findings of deaths related to methadone use Design Retrospective review of case notes in the records of the San Francisco Medical Examiner comparing the findings in cases where methadone was deemed the cause of death with findings in decedents where methadone was an incidental finding, and with 50 age-matched, disease and drug free, trauma victims. Results 38 cases out of the 3317 processed by our office during 1997-1998 were identified in which methadone had been detected. Cases were mostly male 28/38 (74%) and white, 28/38 (74%). In 17 of 38 cases death was deemed to have been caused by methadone toxicity. For the group the mean blood methadone concentration for all 38 patients, was 957 ng/ml SD =.681, SE =.14). The mean blood concentration of the main methadone metabolite (EDDP) was 253 ng/ml, SD = 529 ng/ml, SE =.089. The mean ratio of methadone in the blood to EDDP in the blood was 13.6:1 Values were not significantly different between cases in which methadone toxicity was the cause of death and in those in which it was an incidental finding. Cocaine, or the cocaine metabolite benzoylecgonine, was detected in the blood or urine of 16/38 cases (42%); morphine in one-third (13/38) and methamphetamine in only one. Pulmonary edema was evident in all cases, coronary artery disease in 9/38 (24%) and cirrhosis in 7/38 (18%) of the methadone users. Necrotizing fasciitis was the cause of death in 4 of the 38 methadone users (11%). Nationally, a sizeable percent of methadone deaths are from drugs diverted from treatment programs. Conclusions The presence of methadone is often an incidental finding during postmortem examination which is unrelated to the cause of death. Postmortem measurements of methadone or its metabolite, or both, cannot be used in isolation to identify which deaths are associated with methadone toxicity.The Office on National Drug Control Policy is commited to making methadone treatment programs more widely available; deaths related to heroin use fall when where methadone replacement programs are available.^{1, 2, 3} Unfortunately, methadone is toxic. A total of 552 methadone-related deaths were reported to the government in 1996, making methadone the seventh most frequent cause of drug-related death in the United States (nearly 4000 deaths related to heroin were reported during that same period).⁴Most deaths that are related to methadone occur during the first few weeks of maintenance treatment; they are often the result of the dosage having been increased so quickly that fatal respiratory depression occurs.^5,6 The relative risk of fatal respiratory depression occurring during the first 2 weeks of methadone maintenance treatment is nearly seven times higher than that in untreated heroin addicts and 97.8 times higher than for patients who have been on methadone maintenance for more than 2 weeks.^3,7New opiate users who are using illicitly obtained methadone are also at risk. The amount of methadone diverted from treatment programs, and by inference the number of deaths occurring as a result, is limited because the number of heroin users actually enrolled in methadone programs is comparatively small. There are an estimated 810,000 heroin addicts in the United States but only 115,000 participate in maintenance programs.⁴ If methadone becomes more widely available opportunities for diversion from treatment programs will increase and so will the number of deaths.¹ Some of these deaths might be prevented, especially if the underlying cause of death was better understood. Little is known about the pharmacokinetics of methadone in opiate users. The data that have been published are largely derived from studies of single doses given to healthy volunteers or intravenous doses given to patients with cancer. Whether such studies are relevant to the pharmacokinetics in chronic heroin users is not known. Furthermore, nearly all of these studies were undertaken before differences in the tissue distribution of methadone isomers were understood,⁸ before methadone metabolites could be routinely measured, before chiral (special chemical techniques used to separate dextro- from levo- isomers of the same molecule) separation of methadone isomers was possible ⁹ and before the problem of determining the redistribution of drugs after death was appreciated.¹⁰     

HIV and Hepatitis C Virus Testing Delays at Methadone Clinics in Guangdong Province,China

In China, injection drug use is a major transmission route for HIV and hepatitis C virus (HCV) infection. Timely HIV and HCV testing among drug users is vital to earlier diagnosis, linkage to care, and retention. This study aimed to examine HIV and hepatitis C virus (HCV) testing delays at methadone clinics in Guangdong Province, China, and identify individual-level and clinic-level factors associated with delayed testing. Data from 13,270 individuals at 45 methadone clinics in Guangdong were abstracted from a national web-based surveillance database. A two-level binomial logit model was used to examine the association between individual- and clinic-level factors and delayed HIV and HCV testing, defined as receiving a test seven or more days after initial entry into the methadone system. Among 10,046 patients tested for HIV, 1882 (18.7%) had delayed testing; among 10,404 patients tested for HCV, 1542 (14.8%) had delayed testing. Among delayed testers, the median time to HCV testing was significantly longer than the median time to HIV testing (73 vs. 54 days, p<0.05). In the multivariate analysis, the likelihood of delayed HIV testing was higher among individuals with high school or greater education (adjusted odds ratio [aOR] 1.32, 95% confidence interval [CI] 1.02–1.72) and individuals enrolled at clinics with more patients (aOR 1.41, 95% CI 1.05–1.91, for each increase in 100). The likelihood of delayed HCV testing was higher among women (aOR 1.51, 95% CI 1.11–2.06) and employed individuals (aOR 1.21, 95% CI 1.02–1.43). Delayed testing for HIV and HCV is common among patients at methadone clinics in Guangdong, with many patients experiencing delays of two or more months. Structural interventions are needed to expedite testing once individuals enter the methadone maintenance program.     

Methadone maintenance treatment and drugs

The mental and physical capabilities of drivers in traffic are often seriously challenged these days. Not only do they need to concentrate on driving, predict connections between various phenomena, take appropriate judgements in current situations and foresee the sequence of measures to be taken, but they are also expected to be emotionally stable, etc. The problem with drugs in traffic is often encountered when assessing the actual safe driving capability of a person in a given moment, for example after a car accident or a police check, or medical check-ups that are required for a driving license. The Road Traffic Safety Law considers methadone a drug. Drug addicts do not meet the health standards required of drivers. This research program deals with the attitude of drivers who are in methadone maintenance treatment programs with respect to the driving ability as well as the effects of methadone use in combination with other drugs on driving. It has been established that drivers undergoing the methadone maintenance program, regularly drive not only under the influence of methadone but also under the influence of marijuana (20%) and heroin (18%) and sometimes under the influence of marijuana (58.6%), heroin (55.7%), and alcohol (48.6%). Certain initiatives have been taken by some therapists to give, under certain circumstances, a clean bill of health to responsible methadone maintenance patients who have an adequate level of responsibility for themselves and their deeds, in order to help them obtain a driving license. Since it has been established that methadone maintenance patients use methadone quite commonly in combination with illegal drugs and/or alcohol, the classification of this type of addicts among possible driving candidates remains disputable. Long term interdisciplinary research is still required to determine the basic principles required to asses and possibly admit this type of drivers to participate in traffic, as well as to determine which professional therapists can participate and evaluate the driving capabilities of these patients.     

Enhanced sensitivity to methadone in adult rats perinatally exposed to methadone

Adult rats, maternally exposed to methadone during gestation and/or lactation, were evaluated for thermoregulatory and nociceptive responsiveness following a challenge with 5 mg/kg (i.p.) methadone. Prior to drug administration, female rats in the gestation and gestation-lactation groups and all male rats perinatally exposed to methadone were subnormal in body temperature. One hour after acute methadone injection, male control rats were hypothermic. All groups of methadone-treated offspring exhibited a marked lowering in body temperature with respect to their pre-injection levels, as well as in regard to values of methadone-administered control animals. Prior to drug administration, male rats of the gestation-lactation group and female rats of the gestation and lactation groups had elevated nociceptive thresholds. Except for male rats in the lactation group, animals treated with methadone perinatally had longer latencies in response to the hot-plate relative to their pre-injection values, as well as to levels of methadone-injected controls. Three days after acute methadone administration, some groups of rats subjected to this drug during gestation and/or lactation were found to be hypothermic and hypalgesic in respect to their pre-injection values, and also relative to control rats. These results suggest that exposure to methadone early in life can have a profound influence on drug response in adulthood.     

Chiral analysis of methadone and its major metabolites (EDDP and EMDP) by liquid chromatography-mass spectrometry

Racemic methadone (MET) is administered to heroin users undergoing methadone maintenance therapy (MMT) in Australia. The enantiomers of methadone possess different pharmacological effects, and the enantioselective metabolism of methadone to its two major metabolites, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP) and 2-ethyl-5-methyl-3,3-diphenyl-1-pyrroline (EMDP) has been demonstrated. Therefore, a stereoselective method capable of quantifying methadone, EDDP and EMDP in biological samples could be of benefit in the monitoring of MMT patients. In particular, the analysis of hair samples would provide a means by which long-term monitoring of MMT patients could be achieved. To date, no HPLC method has been published for the simultaneous separation of the six enantiomers. A liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the chiral analysis of methadone, EDDP and EMDP was developed using an alpha-glycoprotein (AGP) stationary phase. The method development involved the utilisation of factorial analysis experimental designs and the application of artificial neural networks (ANNs) to model the chromatographic response surfaces. The optimal conditions were determined to be 20mM acetic acid: isopropanol (93:7, pH 7.4), with a flow rate of 0.9mL/min. The method was validated and subsequently applied to the analysis of 20 hair samples collected from MMT patients.     

Drug Defaulting in a General Practice

Different groups of patients in a general practice have been under close observation by defined methods to assess the extent of their adherence to drug schedules. Patients taking antibiotics, admitted to a short drug trial and prescribed long-term treatments, proved in most cases to be compliant. Antenatal patients taking a once-daily dosage of prophylactic iron were more co-operative than those taking divided dosages. Socially isolated patients and those of low social class were particularly likely to neglect their drugs.It is suggested that the significance and extent of the problem have been largely ignored and that all drug trials undertaken on outpatients should incorporate methods of detecting defaulters.     

Drug users in contact with general practice.

A group of heroin users who are in contact with a general practice in north west Edinburgh are described. The study group was younger and included more women than previous studies. These people used a large variety of drugs and mainly purchased them locally. Frequent and often prolonged abstinent periods occurred with no prescribed opiate treatment. The group had experienced a high rate of drug related medical disorders. All these points raise the possibility that opiate users who are known to general practitioners may be a distinctly different population from those who attend drug dependency clinics. The frequency of remission and the prevalence of polydrug use have profound implications for planning and evaluating an effective medical response.     

Heroin users in general practice: ascertainment and features

A case-control study of heroin users in general practice showed a prevalence of roughly two per 1000 of the urban population or four per “average” general practice list of patients. A method of studying heroin users who attend general practice was used that has advantages over existing techniques. Thirty six heroin users had a statistically significantly higher yearly doctor-patient consultation rate than a group of matched controls. More heroin users also failed to attend appointments than controls. When consultations directly related to heroin and its effects were excluded, however, the consultation rates in the two groups were similar. The heroin users did not have an excess of psychiatric disorder or disturbed family background compared with controls but had a noticeable history of dishonest and violent behaviour towards medical staff.A high proportion of heroin users in the study were antibody positive for the human immunodeficiency virus. General practitioners should take advantage of their frequent contacts with heroin users and their families to give them support and counselling about the acquired immune deficiency syndrome.     

Mutational analysis of the CCR5 and CXCR4 genes (HIV-1 co-receptors) in resistance to HIV-1 infection and AIDS development among intravenous drug users

We analysed a group of Spanish intravenous drug users and controls to determine the role of mutations at the chemokine receptor-5/HIV-1 cofactor (CCR5), previously implicated in resistance to HIV-1 infection, and CXCR4 genes in susceptibility to HIV-1 infection. The complete coding sequence of both genes was amplified by the polymerase chain reaction from genomic DNA of 50 seropositive slow progressors and 10 long-term non-progressors, and analysed by the single-strand conformation polymorphism technique in a search for mutations. No mutation in CXCR4 was found, and Δccr5 was the only mutation identified at the CCR5 gene. We genotyped (Δccr5 allele) 150 HIV-1+ intravenous drug users and 250 healthy controls from the same population (Asturias, Northern Spain). Patients were divided into rapid progressors, presenting an event indicating progression to the acquired immunodeficiency syndrome (AIDS) in the 2 years after infection (100 patients), and slow progressors, remaining asymptomatic for 2–10 years (50 patients). The frequencies of the Δccr5 allele were 0.105 and 0.040 in controls and HIV-1+ patients, respectively. Eighteen per cent of the controls (45/250) and 8% (12/150) of the patients carried the Δccr-5 allele (P=0.013). The frequency of Δccr5 carriers among rapid and slow disease progressors was 3 and 15%, respectively. A highly significant difference was found between rapid progressors and controls (P=0.0014). No patient (0/150) was Δccr5 homozygous compared with 1% among controls. Thus, the Δccr5 allele (the only CCR5 mutation found in our HIV-1 patients) was rare among seropositive intravenous drug users, suggesting that the absence of this mutation confers an advantage to the virus when infecting cells in vivo. In addition, patients carrying the Δccr5 allele tend to show a slow progression towards HIV-1-related disease, remaining asymptomatic for longer periods of time. Received: 15 October 1997 / Accepted: 12 January 1998     

Drug and alcohol referrals: are elderly substance abuse diagnoses and referrals being missed?

OBJECTIVE--To examine the diagnosis of problem substance use in hospital inpatients aged 65 years and over and their referral to drug and alcohol services by medical staff. DESIGN--Questionnaire to registrars or house officers caring for patients 65 years of age and over with problem substance use. SETTING--3 hospitals in New South Wales, Australia. SUBJECTS--Medical staff caring for 263 inpatients. RESULTS--Medical staff did not recognise substance misuse in older hospital patients and did not seem to be aware of current recommendations of the National Health and Medical Research Council recommendations for safe use of alcohol and benzodiazepines. Three out of 88 problem users of benzodiazepines, 29 out of 76 smokers, and 33 out of 99 problem drinkers were identified by medical staff. Of those identified with problems, 2 benzodiazepine users, 6 smokers, and 19 drinkers were considered for referral to drug and alcohol services. CONCLUSIONS--Greater awareness of recommendations for dealing with problem use of benzodiazepines and alcohol needs to be promoted among medical staff, along with an increased emphasis in medical education on substance use as a potentially important problem for older people. Drug and alcohol services also need to promote a broader role, particularly in regard to early intervention in a hospital setting for older patients.     

Assessment of psychological care in general practice.

OBJECTIVE--To pilot a method of assessing psychological care by general practitioners. DESIGN--Prospective examination of psychological care given in general practice by using general health questionnaire with predetermined quantifiable and case specific indices of outcome established at the original consultation. SETTING--Rural general practice in Clwyd, North Wales. SUBJECTS--447 consecutive adult general practice attenders. MAIN OUTCOME MEASURES--Three month follow up consultation rates, one year retrospective consultation rates, continuity of care, changes in general health questionnaire scores at follow up, general satisfaction, and acceptability of outcome measures. RESULTS--The principal and trainee identified 72 patients with psychological problems, 46 of whom had new conditions. 133 patients scored over 6 on the 28 item general health questionnaire, 33 of whom were identified as new cases by the general practitioners. 62 patients were seen at follow up, including 23 patients identified by the questionnaire but not by the doctor. The doctors used diagnostic terms to describe the presenting condition in 38 cases. At three month follow up the general health questionnaire scores had fallen by more than 5 points in 22/39 patients identified and managed by doctors and 11/23 identified by the questionnaire. The agreed index of good outcome was almost or completely achieved by 20 of the 39 patients managed by doctors. CONCLUSION--Quantifiable methods of evaluating the quality of the structure, process, and outcome of psychological care can be achieved in general practice.