Implementation opportunities for scaling up methadone maintenance treatment in Kyrgyzstan: Methadone dosage and retention on treatment over two years

Exploration of the multi-level barriers to scaling up methadone for HIV prevention among people who inject drugs in Kazakhstan

INTRODUCTION

Kazakhstan's HIV epidemic is concentrated among key populations like people who inject drugs (PWID), with a prevalence of at least 7.6 %. Opioid agonist therapies like methadone are the most effective treatment for opioid use disorder and HIV prevention in PWID. Despite methadone being free in Kazakhstan since 2008, coverage has remained at <0.5 % of those in need. This study explored barriers and solutions for methadone scaleup.

METHODS

Using the Exploration-Preparation-Implementation-Sustainment framework, the research team explored barriers to methadone scaleup at the client, clinic, community, and policy levels. The study used nominal group technique (NGT) to assess PWID clients on methadone (N = 30, mean age 45.9, 73 % male) and not on methadone (N = 31, mean age 45.8, 74 % male), along with narcologists (N = 13, mean age 42.3, 46 % male) and community health workers (CHWs, N = 6, mean age 45.7, 17 % male) in four cities in Kazakhstan. In-depth interviews were conducted with methadone clinic directors (N = 4) and policymakers (N = 4). NGT, a mixed-methods focus group, produced rank-ordered lists that researchers analyzed across groups. Researchers conducted interviews in Russian, coded them thematically, and aligned barriers within the socioecological model to prioritize implementation opportunities.

RESULTS

For clients, the top barriers to methadone scaleup were concerns about methadone safety (i.e., the belief that methadone was more harmful than heroin) (24 %), restrictive eligibility and program entry/retention requirements (18 %), and limited accessibility (18 %), although these barriers differed by those on and not on methadone. Narcologists and CHWs identified lack of accurate information about methadone as the largest barrier (35 %), with restrictive eligibility (21 %) and accessibility (11 %) also important. CHWs also noted a lack of alternative medications to methadone. For solutions, clients prioritized more flexible dosing of medications while clinicians prioritized easing treatment entry and engagement requirements.

CONCLUSIONS

Clients and clinicians viewed the program differently, underscoring the need to better understand the customer so that clinicians can improve implementation. Process improvements can address most barriers by easing demands on patients during entry and retention and by educating clients and community stakeholders about methadone. System changes are also necessary to reform governmental registration and methadone administration policies and to expand clinical sites nationwide.

Exploring barriers and potential solutions before implementing a scale-up strategy to expand methadone coverage among people who inject drugs in Tajikistan

INTRODUCTION

The Eastern European and Central Asian region has the most rapidly growing HIV epidemic worldwide, concentrated among people who inject drugs (PWID). Scaling up opioid agonist therapies (OAT) is a highly effective primary and secondary HIV prevention strategy, yet coverage remains low (2.7 %) among the 18,000 PWID injecting opioids in Tajikistan.

METHODS

As part of a pre-implementation activity before using the blended NIATx implementation strategy, we focused on the first NIATx principle, to understand and involve the customer by exploring the barriers and facilitators to OAT scale-up (i.e. greater methadone program entry and retention resulting in more people on methadone). From October to December 2023, recipients (i.e., PWID) were assessed across all 14 OAT sites in 12 cities in 28 focus groups, stratified by those on (N = 120) and not on (N = 108) methadone. Nominal group technique (NGT) was selected as a rapid, inclusive and mixed methods strategy to identify and prioritize the most important barriers and facilitators. Barriers and solutions were categorized to guide implementation targeting individual (i.e., patients/providers), organizational (i.e., clinic) and policy (e.g., laws/regulations) factors.

RESULTS

The three highest-ranking barriers nationally to scaling up methadone were similar for both groups: 1) organizational factors like logistical inconvenience and demands on patients (transport, schedule, daily dosing); 2) policy factors like requirements to be listed in the national OAT registry which can restrict access to a driver's license and employment; and 3) individual and societal factors like widespread disinformation about methadone. The three highest-ranking solutions included: 1) changing policies to allow take-home dosing (both groups); 2) expanding the number of sites where methadone could be dispensed (e.g., primary healthcare clinics and pharmacies); and 3) widely disseminating reliable information about methadone to PWID and other stakeholders like governmental organizations and police. For those not on methadone, site expansion was the second highest solution, while for those not on methadone, disseminating accurate information was second highest.

CONCLUSION

This pre-implementation study provides important insights into implementation strategies that might be considered to scale-up methadone that targets recipients (patients, providers, and family), organizations and policies.

Retention and dropout from sublingual and extended-release buprenorphine treatment: A comparative analysis of data from a nationally representative sample of commercially-insured people with opioid use disorder in the United States

BACKGROUND AND AIMS

Maintenance on medications for opioid use disorder, particularly buprenorphine, is critical for reducing overdose risk and improving health outcomes in the United States. This study evaluates retention and dropout probabilities between sublingual buprenorphine (SL-BUP) and extended-release buprenorphine (XR-BUP) among commercially-insured individuals with opioid use disorder (OUD).

DESIGN AND SETTING

A retrospective cohort study using Meretive™ Markeskan® claims data from 2019 to 2020. A multi-state Markov model assessed transitions between treatment states over 12 months.

PARTICIPANTS

The study included 58,933 individuals aged 18-64 years with OUD, initiating SL-BUP (n = 57,520) or XR-BUP (n = 1,413). XR-BUP patients were divided into XR-BUP only (n = 684; 49 %) and XR-BUP with supplemental SL-BUP (XR-BUP+sSL; n = 729; 51 %).

MEASUREMENTS

Primary outcomes included probabilities of remaining in treatment or transitioning between states at 1, 3, 6, and 12 months. The impact of dosage and days of supply on retention was also examined.

RESULTS

The probability of permanent treatment dropout at 6 months was similar for SL-BUP (38.59 %, 95 % CI: 37.9 %-39.4 %) and XR-BUP (41.3 % 95 %CI: 36.8 %-46.1 %), yet the probability of remaining in treatment was significantly higher for SL-BUP than XR-BUP (49.5 %; 95 %CI: 48.8 %-50.1 % vs. 13.5 % 95 % CI: 10.5 %-16.5 %). The high proportion of individuals initially prescribed XR-BUP later transitioned to SL-BUP. Higher doses and longer days supplied of SL-BUP reduced dropout rates. Among patients receiving ≥16 mg/day and ≥28 days, dropout probabilities were 5.7 % (95 % CI: 5.4 %-6.0 %) at 1 month, 15.4 % (95 % CI: 14.8 %-16.2 %) at 3 months, 28.0 % (95 % CI: 26.9 %-29.2 %) at 6 months, and 47.8 % (95 %CI: 45.2 %-49.5 %) at 12 months. In contrast, patients prescribed <16 mg/day and <28 days had a 46.3 % (95 %CI: 45.0 %-47.6 %) dropout rate by 6 months.

CONCLUSION

SL-BUP demonstrates higher retention rates and lower dropout compared to XR-BUP in real-world settings. Optimizing SL-BUP dosing and providing extended supplies can improve retention and reduce treatment discontinuation.

Prescribing methadone in prison predicts linkage to HIV care after release from prison: A randomized and patient preference trial

PURPOSE

The transition from prison is hazardous, especially for people with HIV and opioid use disorder. To determine the impact of methadone on linkage to HIV care in people with HIV and opioid use disorder, we prospectively compared those allocated to pre-release methadone or not.

METHODS

A prospective, open-label trial of 310 people with HIV and opioid use disorder at Malaysia's largest prison were allocated to pre-release methadone up to 24 weeks before release or not by randomization (n = 64) or preference (n = 246); 296 were included in the final analytical sample. Directed acyclic graphing was used to theorize the relationship between pre-release methadone and post-release linkage to HIV care and identify confounding variables. An inverse probability weighted Cox proportional hazards model estimated the impact of pre-release methadone on linkage to HIV care through 360 days after release.

RESULTS

Overall, 218 (73.6 %) of 296 study participants initiated methadone before release. Receiving pre-release methadone significantly predicted linkage to HIV care at all time points through 360 days (aHR = 1.87; 95 % CI 1.15-2.85) after release. The corresponding numbers needed to treat with pre-release methadone for one increased linkage to HIV care at 30 and 360 days were 14 (95 % CI 9.2-62.4) and 5 (95 % CI 3.4-22.0), respectively.

CONCLUSIONS

While treatment with methadone should be available to everyone with opioid use disorder, it should especially be included as part of an HIV treatment-as-prevention strategy for people in prisons, especially by the time of release. It can optimize HIV treatment outcomes by jumpstarting the HIV treatment cascade.

Trajectory and progress of opioid agonist therapy programs in the Kyrgyz Republic

The incidence and mortality of human immunodeficiency viruses (HIVs) are rising in Eastern Europe and Central Asia (EECA), particularly among people who inject drugs. Opioid agonist therapies (OATs), such as methadone or buprenorphine, are the most effective treatments for opioid use disorder and serve as a key HIV-prevention strategy in EECA. OAT uptake across the region, however, has been limited. The Kyrgyz Republic was the first Central Asian country to initiate OAT and remains a pioneer in the region. To understand the progression of OAT scale-up, all legislations related to drug policies or methadone in the Kyrgyz Republic were analyzed from the country's founding to March 2023 and compared with policies in neighboring countries, particularly Kazakhstan and Tajikistan. Concurrently, local news coverage and policy reports were also assessed. OAT has been available in the Kyrgyz Republic since 2001, initially as a pilot project funded by international donors, and then with gradually increasing state support. Since its inception, the methadone program has evolved and influenced neighboring countries in Central Asia, despite numerous political challenges. The Kyrgyz Republic has expanded access to methadone, revised clinical protocols, and increased the number of distribution sites in communities and the carceral system to ensure broader access, aiming for program sustainability. While methadone policies and implementation in the Kyrgyz Republic have advanced earlier and more expansively than in neighboring countries, some challenges persist. Based on the findings, the suggestions provided may support the sustainable scale-up of methadone programs, enabling continued growth and improvement.

The impact of emergency guidance to the COVID-19 pandemic on treatment entry, retention and mortality among patients on methadone in Ukraine

BACKGROUND AND AIMS

Ukraine's Ministry of Health released urgent COVID-19 guidelines, allowing for early implementation of take-home dosing (THD) for opioid agonist therapies (OAT) such as methadone. Enrollment in OAT and retention in the program are the most effective HIV prevention strategies for people who inject drugs (PWID). This study aimed to evaluate the impact of Ukraine's COVID-19 emergency guidance on OAT treatment enrollment, retention on treatment and mortality.

DESIGN AND SETTING

Using Ukraine's national OAT registry for 252 governmental clinics across 25 regions, we conducted a 12-month comparative prospective cohort survival analysis. This study compared newly enrolled methadone patients within the initial 6 months following the COVID-19 guidance (COVID) with patients from the preceding year (pre-COVID) in a country with high adult HIV prevalence (1.2%) that is concentrated in PWID.

PARTICIPANTS

In the nation-wide sample of newly enrolled PWID in Ukraine, comprising 2798 individuals, 1423 were in the COVID cohort and 1375 were in the pre-COVID cohort. The majority were male (86.7%), with an average age of 39.3 years.

MEASUREMENTS

Primary outcomes were average monthly enrollment per cohort, treatment retention and mortality, with internal time-dependent predictors, including THD and optimal (> 85 mg) methadone dosing.

RESULTS

Relative to the pre-COVID period, the monthly average patient enrollment was statistically significantly higher during the COVID period (283.7 versus 236.0; P < 0.0001), where patients were more likely to transition to THD and achieve optimal dosing earlier. Significant differences were observed in the proportions of person-months on THD (41 versus 13%, P < 0.0001) and optimal dosing (38 versus 31%, P < 0.0001) between the COVID and pre-COVID cohorts. Predictors of treatment retention, expressed as adjusted hazard ratios (aHR), included early THD [aHR = 1.90, 95% confidence interval (CI) = 1.47-2.45], early optimal dosing (aHR = 1.71, 95% CI = 1.37-2.13) and prior methadone treatment (aHR = 1.39, 95% CI = 1.15-1.68). These factors persisted, respectively, in the pre-COVID (aHR = 2.28, 95% CI = 1.41-3.70; aHR = 1.84, 95% CI = 1.32-2.56; and aHR = 1.36, 95% CI = 1.06-1.74) and COVID (aHR = 1.91, 95% CI = 1.40-2.59; aHR = 1.61, 95% CI = 1.20-2.16; and aHR = 1.49, 95% CI = 1.08-1.94) cohorts. Survival did not differ significantly between the two prospective cohorts.

CONCLUSION

Ukraine's prompt adoption of early take-home dosing for opioid agonist therapies, such as methadone, following the emergency COVID-19 guidance appears to have increased enrollment into methadone and improved treatment retention for people who inject drugs without adverse effects on patient survival.

Early disruptions to syringe services programs during the Russian invasion of Ukraine

Introduction

The widespread HIV epidemic in Ukraine is concentrated among people who inject drugs (PWID), making access to sterile injection paraphernalia (SIP) like sterile needles and syringes a critical method of HIV/AIDS prevention; however, the Russian invasion has threatened to disrupt the operations of syringe services programs (SSPs), creating a risk of HIV outbreaks among PWID.

Methods

We conducted 10 semi-structured interviews with outreach workers from SSPs. Interviews were purposively sampled to cover three prototypic regions of Ukraine: temporarily Russian-controlled, frontline, and destination. Qualitative results from interviews were then compared against a standardized, nationwide harm reduction database.

Results

We found that the Russian invasion triggered both supply and demand challenges for SSPs. Demand increased for all regions due to client transitions from pharmacies that closed to SSPs, increases in illicit drug use, greater client openness to NGO support, and displacement of clients to destination regions. Supply decreased for all areas (except for remote destination regions) due to battle-related barriers like curfews, roadblocks, and Internet disruptions; diminished deliveries of SIP and funding; and staff displacement. Time series plots of the number of unique clients accessing harm reduction services showed that an initial decrease in service provision occurred at the start of the war but that most regions recovered within several months except for Russian-controlled regions, which continued to provide services to fewer clients relative to previous years.

Conclusion

To ensure continued scale-up of SIP and other HIV prevention services, the SyrEx database should be leveraged to serve as a streamlined harm reduction locator that can inform workers and clients of open site locations and other pertinent information.

Interest without uptake: A mixed-methods analysis of methadone utilization in Kyrgyz prisons

HIV incidence continues to increase in Eastern Europe and Central Asia (EECA), in large part due to non-sterile injection drug use, especially within prisons. Therefore, medication-assisted therapy with opioid agonists is an evidence-based HIV-prevention strategy. The Kyrgyz Republic offers methadone within its prison system, but uptake remains low. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a framework for identifying people who would potentially benefit from methadone, intervening to identify OUD as a problem and methadone as a potential solution, and providing referral to methadone treatment. Using an SBIRT framework, we screened for OUD in Kyrgyz prisons among people who were within six months of returning to the community (n = 1118). We enrolled 125 people with OUD in this study, 102 of whom were not already engaged in methadone treatment. We conducted a pre-release survey followed by a brief intervention (BI) to address barriers to methadone engagement. Follow-up surveys immediately after the intervention and at 1 month, 3 months, and 6 months after prison release assessed methadone attitudes and uptake. In-depth qualitative interviews with 12 participants explored factors influencing methadone utilization during and after incarceration. Nearly all participants indicated favorable attitudes toward methadone both before and after intervention in surveys; however, interest in initiating methadone treatment remained very low both before and after the BI. Qualitative findings identified five factors that negatively influence methadone uptake, despite expressed positive attitudes toward methadone: (1) interpersonal relationships, (2) interactions with the criminal justice system, (3) logistical concerns, (4) criminal subculture, and (5) health-related concerns.