1.We compared opioid use treatment across nine international jurisdictions.2.Treatment settings, physicians’ roles, medications used and patient costs differed.3.Most jurisdictions offered treatment ...through primary care settings.4.Health system and regulatory change is needed to improve opioid use treatment.
Opioid use disorder (OUD) and opioid-related harms are current health priorities in many high-income countries such as Canada. Opioid agonist therapy (OAT) is an effective evidence-based treatment for OUD, but access is often limited.
To describe and compare OUD treatment policies across nine international jurisdictions, and to understand how they are situated within their primary care and health systems.
Using policy documents, we collected data on health systems, drug use epidemiology, drug policies, and OUD treatment from Australia, Canada, France, Germany, Ireland, Portugal, Sweden, Switzerland, and Taiwan. We used the health system dynamics framework and adapted definitions of low- and high-threshold treatment to describe and compare OUD treatment policies, and to understand how they may be shaped by their health systems context.
Broad similarities across jurisdictions included the OAT pharmacological agents used and the need for supervised dosing; however, preferred OAT, treatment settings, primary care and specialist physicians’ roles, and funding varied. Most jurisdictions had elements of lower-threshold treatment access, such as the availability of treatment through primary care and multiple OAT options, but the higher-threshold criteria of supervised dosing.
From the Canadian perspective, there are opportunities to improve accessibility of OUD care by drawing on how different jurisdictions incorporate multidisciplinary care, regulate OAT medications, remunerate healthcare professionals, and provide funding for services.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Aims
To investigate the impact of scaling‐up opiate substitution therapy (OST) and high coverage needle and syringe programmes (100%NSP—obtaining more sterile syringes than you inject) on HCV ...prevalence among injecting drug users (IDUs).
Design
Hepatitis C virus HCV transmission modelling using UK estimates for effect of OST and 100%NSP on individual risk of HCV infection.
Setting
Range of chronic HCV prevalent (20/40/60%) settings with no OST/100%NSP, and UK setting with 50% coverage of both OST and 100%NSP.
Participants
Injecting drug users.
Measurements
Decrease in HCV prevalence after 5–20 years due to scale‐up of OST and 100%NSP to 20/40/60% coverage in no OST/100%NSP settings, or from 50% to 60/70/80% coverage in the UK setting.
Findings
For 40% chronic HCV prevalence, scaling‐up OST and 100%NSP from 0% to 20% coverage reduces HCV prevalence by 13% after 10 years. This increases to a 24/33% relative reduction at 40/60% coverage. Marginally less impact occurs in higher prevalence settings over 10 years, but this becomes more pronounced over time. In the United Kingdom, without current coverage levels of OST and 100%NSP the chronic HCV prevalence could be 65% instead of 40%. However, increasing OST and 100%NSP coverage further is unlikely to reduce chronic prevalence to less than 30% over 10 years unless coverage becomes ≥80%.
Conclusions
Scaling‐up opiate substitution therapy and high coverage needle and syringe programmes can reduce hepatitis C prevalence among injecting drug users, but reductions can be modest and require long‐term sustained intervention coverage. In high coverage settings, other interventions are needed to further decrease hepatitis C prevalence. In low coverage settings, sustained scale‐up of both interventions is needed.
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BFBNIB, DOBA, FSPLJ, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Background: Methadone treatment is one of the opioid substitution therapies (OSTs) used to manage opioid use disorder (OUD). Clients on methadone treatment experience a high attrition rate from OST ...programs due to diverse barriers such as access to methadone treatment, treatment modality, transportation, and stigma.
Methods: The aim of this project is to explore the experiences and perspectives of clients on methadone treatment who had previously dropped out of an OST program. We used an explorative qualitative design to interview 22 participants currently receiving methadone treatment at a clinic in a small city in western Canada.
Results: Four phases designated as critical moments in their lives were identified from their narratives: 1) pre-addiction phase; 2) early substance use; 3) first methadone treatment; and 4) methadone treatment failure and reenrollment.
Conclusion: Understanding clients' experiences on OST treatment and presenting them temporally on a prevention-rehabilitation continuum expands possibilities for community-based interventions focussing on the individual, their family, and the community on substance use prevention, harm reduction activities, and supported treatment and recovery.
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IJS, NUK, OILJ, UL, UM, UPUK, VSZLJ
BACKGROUND:Current service delivery systems do not reach all people in need of antiretroviral therapy (ART). In order to inform the operational and service delivery section of the WHO 2013 ...consolidated antiretroviral guidelines, our objective was to summarize systematic reviews on integrating ART delivery into maternal, newborn, and child health (MNCH) care settings in countries with generalized epidemics, tuberculosis (TB) treatment settings in which the burden of HIV and TB is high, and settings providing opiate substitution therapy (OST); and decentralizing ART into primary health facilities and communities.
DESIGN:A summary of systematic reviews.
METHODS:The reviewers searched PubMed, Embase, PsycINFO, Web of Science, CENTRAL, and the WHO Index Medicus databases. Randomized controlled trials and observational cohort studies were included if they compared ART coverage, retention in HIV care, and/or mortality in MNCH, TB, or OST facilities providing ART with MNCH, TB, or OST facilities providing ART services separately; or primary health facilities or communities providing ART with hospitals providing ART.
RESULTS:The reviewers identified 28 studies on integration and decentralization. Antiretroviral therapy integration into MNCH facilities improved ART coverage (relative risk RR 1.37, 95% confidence interval CI 1.05–1.79) and led to comparable retention in care. ART integration into TB treatment settings improved ART coverage (RR 1.83, 95% CI 1.48–2.23) and led to a nonsignificant reduction in mortality (RR 0.55, 95% CI 0.29–1.05). The limited data on ART integration into OST services indicated comparable rates of ART coverage, retention, and mortality. Partial decentralization into primary health facilities improved retention (RR 1.05, 95% CI 1.01–1.09) and reduced mortality (RR 0.34, 95% CI 0.13–0.87). Full decentralization improved retention (RR 1.12, 95% CI 1.08–1.17) and led to comparable mortality. Community-based ART led to comparable rates of retention and mortality.
CONCLUSION:Integrating ART into MNCH, TB, and OST services was often associated with improvements in ART coverage, and decentralization of ART into primary health facilities and communities was often associated with improved retention. Neither integration nor decentralization was associated with adverse outcomes. These data contributed to recommendations in the WHO 2013 consolidated antiretroviral guidelines to integrate ART delivery into MNCH, TB, and OST services and to decentralize ART.
Introduction
A cohort of clients was recognised attending an addiction medicine clinic with similar presentations of opioid dependence from use of a rarely known Ayurvedic medication in a specific ...ethnic community. This retrospective case series was completed to promote wider recognition and further understanding of dependence on Kamini Vidrawan Ras (Kamini).
Methods
A retrospective file audit of the electronic medical record for clients of an addiction medicine outpatient clinic with a history of dependent use of Kamini identified 12 clients meeting inclusion criteria.
Results
All 12 clients were male, aged 27–41 years, all but one of north Indian origin, predominantly employed and predominantly (but not exclusively) without significant other substance use history. All 12 clients were treated with opioid substitution therapy.
Discussion and Conclusions
This case series highlights an opioid dependence syndrome resulting from use of an Ayurvedic medicine by men from a specific area of India, highlighting a potential adverse effect of traditional medicines in ongoing use by migrant and ethnic populations that have emigrated to Australia.
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BFBNIB, DOBA, FSPLJ, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Abstract
Background
Opioid dependence carries the highest disease burden of all illicit drugs. Opioid agonist therapy (OAT) is an evidence-based medical intervention that reduces morbidity and ...mortality. There is limited knowledge on the health-related quality of life (HRQoL) of long-term patients in OAT. This study measures HRQoL and self-perceived health of long-term patients on OAT, compares the scores to a Norwegian reference population, and assesses changes in these scores at 1-year follow up.
Methods
We conducted a nested prospective cohort study among nine OAT outpatient clinics in Norway. 609 OAT patients were included, 245 (40%) followed-up one year later. Data on patient characteristics, HRQoL, and self-perceived health was collected. HRQoL was assessed with the EQ-5D-5L, which measures five dimensions (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) on a five-point Likert scale (from “no problems” to “extreme problems”). An UK value set was applied to calculate index values (from 0 to 1) for the EQ-5D-5L and compare them to a Norwegian reference population. Self-perceived health was measured with EQ-VAS (from 0 to 100).
Results
Mean (standard deviation (SD)) EQ-5D-5L index value at baseline was 0.699 (0.250) and EQ-VAS 57 (22) compared to 0.848 (0.200) and 80(19) for the Norwegian reference population. There were large variations in EQ-5D-5L index values, where 43% had > 0.8 and 5% had < 0.2 at baseline. The lowest EQ-5D-5L index values were observed for female patients, age groups older than 40 years and for methadone users. At follow-up, improvements in HRQoL were observed across almost all dimensions and found significant for mobility and pain/discomfort. Mean (SD) overall index value and EQ-VAS at follow up were 0.729 (0.237) and 59 (22) respectively.
Conclusion
The average HRQoL and self-perceived health of OAT patients is significantly lower than that of the general population, and lower than what has been found among other severe somatic and psychiatric conditions. Around 34% had very good HRQoL, higher than average Norwegian values, and around 5% had extremely poor HRQoL.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Objective
Emergency department (ED)–initiated buprenorphine may prevent overdose. Microdosing is a novel approach that does not require withdrawal, which can be a barrier to standard inductions. We ...aimed to evaluate the feasibility of an ED‐initiated buprenorphine/naloxone program providing standard‐dosing and microdosing take‐home packages and of randomizing patients to either intervention.
Methods
We broadly screened patients ≥18 years old for opioid use disorder at a large, urban ED. In a first phase, we provided consecutive patients with 3‐day standard‐dosing packages, and then we provided a subsequent group with 6‐day microdosing packages. In a second phase, we randomized patients to standard dosing or microdosing. We attempted 7‐day telephone follow‐ups and 30‐day in‐person community follow‐ups. The primary feasibility outcome was number of patients enrolled and accepting randomization. Secondary outcomes were numbers screened, follow‐up rates, and 30‐day opioid agonist therapy retention.
Results
We screened 3954 ED patients and identified 94 with opioid use disorders. Of the patients, 26 (27.7%) declined participation: 10 identified a negative prior experience with buprenorphine/naloxone as the reason, 5 specifically cited precipitated withdrawal, and none cited randomization. We enrolled 68 patients. A total of 14 left the ED against medical advice, 8 were excluded post‐enrollment, 21 received standard dosing, and 25 received microdosing. The 7‐day and 30‐day follow‐up rates were 9/46 (19.6%) and 15/46 (32.6%), respectively. At least 5/21 (23.8%) provided standard dosing and 8/25 (32.0%) provided microdosing remained on opioid agonist therapy at 30 days.
Conclusions
ED‐initiated take‐home standard‐dosing and microdosing buprenorphine/naloxone programs are feasible, and a randomized controlled trial would be acceptable to our target population.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
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