1
|
Macdonald C, Macpherson G, Leppan O, Tran LT, Cunningham EB, Hajarizadeh B, Grebely J, Farrell M, Altice FL, Degenhardt L. Interventions to reduce harms related to drug use among people who experience incarceration: systematic review and meta-analysis. Lancet Public Health 2024; 9:e684-e699. [PMID: 39214637 DOI: 10.1016/s2468-2667(24)00160-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/26/2024] [Accepted: 07/04/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Mortality, suicide, self-harm, and substance use are elevated among people who are incarcerated. There is a wide range of heterogeneous interventions aimed at reducing these harms in this population. Previous reviews have focused on specific interventions or limited their findings to drug use and recidivism and have not explored interventions delivered after release from prison. Our aim is to examine the effect of interventions delivered to people who use drugs during incarceration or after release from incarceration, on a wide range of outcomes. METHODS In this systematic review and meta-analysis, we searched Embase, MEDLINE, and PsycINFO databases up until Sept 12, 2023 for studies published from Jan 1, 1980 onwards. All studies evaluating the effectiveness of any intervention on drug use, recidivism outcomes, sexual or injecting risk behaviours, or mortality among people who use psychoactive drugs and who were currently or recently incarcerated were included. Studies without a comparator or measuring only alcohol use were excluded. Data extracted from each study included demographic characteristics, interventions, and comparisons. Pooled odds ratios and risk ratios were calculated using random-effects meta-analyses. FINDINGS We identified 126 eligible studies (47 randomised controlled trials and 79 observational studies) encompassing 18 interventions; receiving opioid-agonist treatment (OAT) in prison reduced the risk of death in prison (one study; hazard ratio 0·25; 95% CI 0·13-0·48), whereas receiving OAT in the first 4 weeks following release reduced risk of death in the community (two studies; relative risk 0·24; 95% CI 0·15-0·37). Therapeutic community interventions reduced re-arrest at 6-12 months (six studies; odds ratio [OR] 0·72; 95% CI 0·55-0·95) and reincarceration at 24 months (two studies; OR 0·66; 95% CI 0·48-0·96). There was scarce evidence that OAT and syringe service provision are effective in reducing injecting risk behaviours and needle and syringe sharing. INTERPRETATION There are effective interventions to reduce mortality and recidivism for people who use drugs who have been incarcerated. Nonetheless, there are also substantial gaps in the research examining the effect of interventions on risk behaviours and mortality during incarceration and a need for randomised designs examining outcomes for people who use drugs after release. FUNDING Australian National Health and Medical Research Council.
Collapse
Affiliation(s)
- Christel Macdonald
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Georgina Macpherson
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Oscar Leppan
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Lucy Thi Tran
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Evan B Cunningham
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Behzad Hajarizadeh
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Jason Grebely
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | | | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.
| |
Collapse
|
2
|
Kronfli N, Lafferty L, Leone F, Stoové M, Hajarizadeh B, Lloyd AR, Altice FL. Using nominal group technique to identify perceived barriers and facilitators to improving uptake of the Prison Needle Exchange Program in Canadian federal prisons by correctional officers and healthcare workers. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 130:104540. [PMID: 39079352 DOI: 10.1016/j.drugpo.2024.104540] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/14/2024] [Accepted: 07/14/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Elimination of bloodborne viruses including HIV and hepatitis C virus from prisons requires high coverage of evidence-based interventions that prevent bloodborne virus transmission, including needle and syringe programs. Canada launched a Prison Needle Exchange Program (PNEP) in nine federal prisons in 2018; however, uptake among people who inject drugs in prison remains low. We aimed to explore barriers and facilitators to improving PNEP uptake identified by correctional officers and healthcare workers. METHODS Participants from nine federal prisons with PNEP completed focus groups using nominal group technique, a rapid mixed-method consensus strategy. Responses were generated, rank-ordered, and prioritized by each stakeholder group. We identified the highest-ranking responses (≥10 % of the overall votes) to questions about barriers and facilitators to PNEP uptake. RESULTS Between September 2023 and February 2024, 16 focus groups were conducted with 118 participants (n = 51 correctional officers; n = 67 healthcare workers). Among correctional officers, the top perceived barriers were bullying from peers (22 %), fear of being targeted by correctional officers (14 %), and fear of repercussions due to drug use (13 %). The top facilitators were safe injection sites (30 %), provision of wrap-around services (16 %), and education of correctional officers (10 %). Among healthcare workers, the top perceived barriers were lack of confidentiality (16 %), fear of being targeted by correctional officers (12 %), and a long and complex application process (11 %). The top facilitators were education of correctional officers (29 %), delivery of PNEP by an external provider (15 %), automatic approval for participation in the PNEP (13 %), and safe injection sites (12 %). CONCLUSION Multiple modifiable barriers and solutions to improving PNEP uptake in Canadian federal prisons were identified by correctional employees. Both participant groups identified the potential for safe injection sites and education to correctional officers as enabling PNEP uptake. These data will inform Canadian efforts to improve engagement and to expand PNEP coverage.
Collapse
Affiliation(s)
- Nadine Kronfli
- Department of Medicine, Division of Infectious Disease and Chronic Viral Illness Service, McGill University, Montreal, Quebec, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
| | - Lise Lafferty
- Centre for Social Research in Health, UNSW Sydney, Level 1, Goodsell Building, Sydney, NSW 2052, Australia; The Kirby Institute, UNSW Sydney, Level 6, Wallace Wurth, Sydney, NSW 2052, Australia
| | - Frederic Leone
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Mark Stoové
- Behaviours and Health Risks, Burnet Institute, 85 Commercial Road, Melbourne, VIC 3004, Australia; Department of Epidemiology and Preventive Medicine, Monash University, 553St Kilda Road, Melbourne, VIC 3004, Australia; Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia
| | - Behzad Hajarizadeh
- The Kirby Institute, UNSW Sydney, Level 6, Wallace Wurth, Sydney, NSW 2052, Australia
| | - Andrew R Lloyd
- The Kirby Institute, UNSW Sydney, Level 6, Wallace Wurth, Sydney, NSW 2052, Australia
| | - Frederick L Altice
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine. 135 College St., Suite 323, New Haven, CT 06510, USA; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT 06510, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
3
|
Ahmad A, Bromberg DJ, Shrestha R, Salleh NM, Bazazi AR, Kamarulzaman A, Shenoi S, Altice FL. Higher methadone dose at time of release from prison predicts linkage to maintenance treatment for people with HIV and opioid use disorder transitioning to the community in Malaysia. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 126:104369. [PMID: 38484531 PMCID: PMC11056294 DOI: 10.1016/j.drugpo.2024.104369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Incarcerated people with HIV and opioid-dependence often experience poor post-release outcomes in the absence of methadone maintenance treatment (MMT). In a prospective trial, we assessed the impact of methadone dose achieved within prison on linkage to MMT after release. METHODS From 2010 to 2014, men with HIV (N = 212) and opioid dependence before incarceration were enrolled in MMT within 6 months of release from Malaysia's largest prison and followed for 12-months post-release. As a prospective trial, allocation to MMT was at random and later by preference design (predictive nonetheless). MMT dosing was individually targeted to minimally achieve 80 mg/day. Time-to-event analyses were conducted to model linkage to MMT after release. FINDINGS Of the 212 participants allocated to MMT, 98 (46 %) were prescribed higher dosages (≥80 mg/day) before release. Linkage to MMT after release occurred in 77 (36 %) participants and significantly higher for those prescribed higher dosages (46% vs 28 %; p = 0.011). Factors associated with higher MMT dosages were being married, on antiretroviral therapy, longer incarceration periods, having higher levels of depression, and methadone preference compared to randomization. After controlling for other variables, being prescribed higher methadone dosage (aHR: 2.53, 95 %CI: 1.42-4.49) was the only independent predictor of linkage to methadone after release. INTERPRETATION Higher doses of methadone prescribed before release increased the likelihood of linkage to MMT after release. Methadone dosing should be introduced into international guidelines for treatment of opioid use disorder in prisons and further post-release benefits should be explored. FUNDING National Institute of Drug Abuse (NIDA).
Collapse
Affiliation(s)
- Ahsan Ahmad
- Yale University School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Daniel J Bromberg
- Yale University School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Yale University School of Public Health, Department of Social and Behavioral Sciences, New Haven, CT, USA
| | - Roman Shrestha
- University of Connecticut, Department of Allied Health Sciences, Storrs, CT, USA
| | - Na Mohd Salleh
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; University of Malaya, Faculty of Medicine, Department of Social and Preventive Medicine, Kuala Lumpur, Malaysia
| | - Alexander R Bazazi
- Yale University School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA
| | - Adeeba Kamarulzaman
- Yale University School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; University of Malaya, Faculty of Medicine, Department of Social and Preventive Medicine, Kuala Lumpur, Malaysia
| | - Sheela Shenoi
- Yale University School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Frederick L Altice
- Yale University School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Yale University School of Public Health, Department Epidemiology of Microbial Diseases, New Haven, CT, USA.
| |
Collapse
|
4
|
Ponticiello M, Azbel L, Tate MM, Bromberg DJ, Pykalo I, Kiriazova T, Saichuk N, Altice FL. Introducing methadone maintenance therapy into Ukrainian prisons: a qualitative study of criminal subculture, Russia's full-scale invasion, and contested methadone objects. Front Psychiatry 2023; 14:1227216. [PMID: 38098632 PMCID: PMC10720714 DOI: 10.3389/fpsyt.2023.1227216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/17/2023] [Indexed: 12/17/2023] Open
Abstract
Background After pilot testing, methadone was newly being introduced into Ukrainian prisons in 2021 as part of a national scale-up strategy to treat opioid use disorder and prevent transmission of HIV and HCV infections. Opioid agonist therapy (OAT) scale-up in Eastern Europe and Central Asia prisons has been hampered by varying levels of influence of criminal subculture, an extralegal informal governance by a social hierarchy that operates in parallel to formal prison authorities. This study examined the socio-environmental factors influencing the uptake of methadone treatment in Ukrainian prisons, including changes that evolved during Russia's full-scale invasion of Ukraine and the displacement of people deprived of liberty (PDL) from conflict to non-conflict regions. Methods In-depth qualitative interviews (N = 37) were conducted from January 2021 to October 2022 in the only two Ukrainian prisons where methadone was being introduced with PDL (N = 18). These two prisons continued to provide methadone after the full-scale invasion. Former PDL (N = 4) were also interviewed and prison staff (N = 15). Interviews were audio-recorded, transcribed, and translated into English. Four authors independently reviewed, coded, and applied a phenomenological framework for data analysis, delineating themes related to criminal subculture, drug use, methadone uptake, and evolving changes during the Russian invasion. Findings Criminal subculture perceptions varied, with some seeing it as strongly discouraging drug use among certain groups, while others described it as a residual and weak influence from a more distant past. The influence of the subculture on methadone treatment uptake, however, was less clear. PDL and prison staff struggled to identify and articulate differences between illicit street-bought methadone, used recreationally, and medically prescribed methadone. Thus, the meaning of "methadone" varies in interpretation as it is being introduced, making it potentially conflicting for patients to opt into this evidence-based treatment. As Russia invaded Ukraine in 2022, PDL from conflict zones were transferred to non-conflict regions where methadone was being introduced. The prison environment became more enabling for PDL to start methadone as they were segregated and not subject to the existing criminal subculture's rules and lacked the social ties necessary to procure drugs illegally. Conclusion It appears that the criminal subculture is variable and evolving in Ukrainian prisons and appears to be impacted differently by the invasion of Russia. As methadone scale-up in prisons expands, it will be important to distinguish the meaning of methadone perpetuated negatively by the prison subculture versus that in which it is intended as a medical treatment by the formal prison authorities. The current invasion of Ukraine by Russia provides a potential disruption to alter this course.
Collapse
Affiliation(s)
- Matthew Ponticiello
- Yale School of Medicine, Yale University, New Haven, CT, United States
- Department of Epidemiology of Microbial Diseases, Yale University, New Haven, CT, United States
| | - Lyu Azbel
- Department of Social and Behavioral Sciences, Yale University, New Haven, CT, United States
| | - Mary M. Tate
- Department of Epidemiology of Microbial Diseases, Yale University, New Haven, CT, United States
| | - Daniel J. Bromberg
- Department of Social and Behavioral Sciences, Yale University, New Haven, CT, United States
| | - Iryna Pykalo
- European Institute on Public Health Policy, Kyiv, Ukraine
| | | | | | - Frederick L. Altice
- Yale School of Medicine, Yale University, New Haven, CT, United States
- Department of Epidemiology of Microbial Diseases, Yale University, New Haven, CT, United States
| |
Collapse
|
5
|
Stopka TJ, Rottapel RE, Ferguson WJ, Pivovarova E, Toro-Mejias LD, Friedmann PD, Evans EA. Medication for opioid use disorder treatment continuity post-release from jail: A qualitative study with community-based treatment providers. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 110:103803. [PMID: 35965159 PMCID: PMC10117037 DOI: 10.1016/j.drugpo.2022.103803] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/09/2022] [Accepted: 07/11/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND People released from jail are at elevated opioid overdose risk. Medications for opioid use disorder (MOUD) are effective in reducing overdoses. MOUD treatment was recently mandated in seven Massachusetts jails, but little is known about barriers and facilitators to treatment continuity post-release. We aimed to assess MOUD provider perspectives on treatment continuity among people released from jail. METHODS We conducted qualitative interviews with 36 medical, supervisory, and administrative staff at MOUD programs that serve jail-referred patients. We used the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation science framework to guide development of instruments, codes, and analyses. We employed deductive and inductive coding, and a grounded theory analytical approach to identify salient themes. RESULTS Inner context findings highlighted necessary adjustments among jail staff to approve MOUD treatment, especially with agonist medications that were previously considered contraband. Participants perceived that some staff within jails favored abstinence-based recovery, viewing agonists as a crutch. Bridging results highlighted the importance of inter-agency communication and coordination to ensure information transfer for seamless treatment continuity in the community post-release. Pre-release planning, release on pre-scheduled dates, medication provision to cover gaps between jail release and intake at community MOUD sites, and exchange of treatment information across agencies were viewed as paramount to success. Unexpected early releases and releases from court were viewed as barriers to treatment coordination. Outer context domains were largely tied to social determinants of health. Substantial barriers to treatment continuity included shelter, food security, employment, transportation, and insurance reactivation. CONCLUSION Through qualitative interviews with community-based MOUD staff, we identified salient barriers and facilitators to treatment continuity post-release from jails. Findings point to needed investments in care coordination, staffing, and funding to strengthen jail-to-community-based MOUD treatment, removing barriers to continuity, and decreasing opioid overdose deaths during this high-risk transition.
Collapse
Affiliation(s)
- Thomas J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 200 Harrison Avenue, Boston, MA, 02111, United States.
| | - Rebecca E Rottapel
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 200 Harrison Avenue, Boston, MA, 02111, United States
| | - Warren J Ferguson
- Department of Family Medicine and Community Health, University of Massachusetts Chan Medical School, 55 Lake Avenue North, Worcester, MA, 01655, United States
| | - Ekaterina Pivovarova
- Department of Family Medicine and Community Health, University of Massachusetts Chan Medical School, 55 Lake Avenue North, Worcester, MA, 01655, United States
| | - Lizbeth Del Toro-Mejias
- University of Massachusetts Chan Medical School-Baystate, 55 N Lake Ave, Worcester, MA 01655, United States; Baystate Health, 759 Chestnut St, Springfield, MA, 01199, United States
| | - Peter D Friedmann
- University of Massachusetts Chan Medical School-Baystate, 55 N Lake Ave, Worcester, MA 01655, United States; Baystate Health, 759 Chestnut St, Springfield, MA, 01199, United States
| | - Elizabeth A Evans
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, 312 Arnold House, 715 North Pleasant Street, Amherst, MA, United States
| |
Collapse
|
6
|
Bazazi AR, Culbert GJ, Wegman MP, Heimer R, Kamarulzaman A, Altice FL. Impact of prerelease methadone on mortality among people with HIV and opioid use disorder after prison release: results from a randomized and participant choice open-label trial in Malaysia. BMC Infect Dis 2022; 22:837. [PMID: 36368939 PMCID: PMC9652918 DOI: 10.1186/s12879-022-07804-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Mortality is elevated after prison release and may be higher in people with HIV and opioid use disorder (OUD). Maintenance with opioid agonist therapy (OAT) like methadone or buprenorphine reduces mortality in people with OUD and may confer benefits to people with OUD and HIV leaving prison. Survival benefits of OAT, however, have not been evaluated prospectively in people with OUD and HIV leaving prison. METHODS This study prospectively evaluated mortality after prison release and whether methadone initiated before release increased survival after release in a sample of men with HIV and OUD (n = 291). We linked national death records to data from a controlled trial of prerelease methadone initiation conducted from 2010 to 2014 with men with HIV and OUD imprisoned in Malaysia. Vital statistics were collected through 2015. Allocation to prerelease methadone was by randomization (n = 64) and participant choice (n = 246). Cox proportional hazards models were used to estimate treatment effects of prerelease methadone on postrelease survival. RESULTS Overall, 62 deaths occurred over 872.5 person-years (PY) of postrelease follow-up, a crude mortality rate of 71.1 deaths per 1000 PY (95% confidence interval [CI] 54.5-89.4). Most deaths were of infectious etiology, mostly related to HIV. In a modified intention-to-treat analysis, the impact of prerelease methadone on postrelease mortality was consistent with a null effect in unadjusted (hazard ratio [HR] 1.3, 95% CI 0.6-3.1) and covariate-adjusted (HR 1.2, 95% CI 0.5-2.8) models. Predictors of mortality were educational level (HR 1.4, 95% CI 1.0-1.8), pre-incarceration alcohol use (HR 2.0, 95% CI 1.1-3.9), and lower CD4+ T-lymphocyte count (HR 0.8 per 100-cell/mL increase, 95% CI 0.7-1.0). CONCLUSIONS Postrelease mortality in this sample of men with HIV and OUD was extraordinarily high, and most deaths were likely of infectious etiology. No effect of prerelease methadone on postrelease mortality was observed, which may be due to study limitations or an epidemiological context in which inadequately treated HIV, and not inadequately treated OUD, is the main cause of death after prison release. TRIAL REGISTRATION NCT02396979. Retrospectively registered 24/03/2015.
Collapse
Affiliation(s)
- Alexander R. Bazazi
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510-228 USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT USA
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA USA
| | - Gabriel J. Culbert
- Population Health Nursing Science, University of Illinois at Chicago, Chicago, IL USA
| | - Martin P. Wegman
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510-228 USA
| | - Robert Heimer
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT USA
| | - Adeeba Kamarulzaman
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510-228 USA
- Faculty of Medicine, Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
| | - Frederick L. Altice
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510-228 USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT USA
- Faculty of Medicine, Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
7
|
Ivasiy R, Madden LM, Farnum SO, Shumskaya N, de Leon SJG, Bromberg DJ, Kurmanalieva A, Duishenaliev A, Tokubaev R, Altice FL. Implementation opportunities for scaling up methadone maintenance treatment in Kyrgyzstan: Methadone dosage and retention on treatment over two years. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 4:100075. [PMID: 36267100 PMCID: PMC9581459 DOI: 10.1016/j.dadr.2022.100075] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 12/01/2022]
Abstract
Background Methadone maintenance treatment (MMT) is the most effective and cost-effective strategy to control HIV in Central Asian countries, where the epidemic is concentrated among people who inject drugs (PWID) who use opioids. Methods Using data from a prospective observational database of all people initiated on MMT in Kyrgyzstan since 2008, we analyzed a more contemporary subset of data for all persons receiving MMT from January 2017 through June 2021 after the national treatment guidelines were changed. Retention on MMT was assessed at 1, 6, 12, and 24 months and predictive variables included were dosage levels, HIV status, and type of clinical setting using survival analysis. Predictors of treatment dropout were estimated using Cox multivariate regression models. Results Among the 940 MMT patients, the proportion receiving low (<40mg), medium (40-85mg), and high (>85mg) dosage levels was 37.9%, 42.2%, and 19.9%, respectively. Increasing MMT dosage level was significantly (p<0.0001) correlated with retention at 1 (90%, 98%, 100%), 6 (42%, 63%, 95%), 12 (33%, 55%, 89%), and 24 (16%, 45%, 80%) months, respectively, with no differences between community and correctional settings. Significant predictors of dropout at 12 months included low (aHR=8.0; 95%CL=5.8-11.0) and medium (aHR=3.5; 95%CL=2.5-4.9) methadone dosage level relative to high dose, receiving MMT in three administrative regions relative to the capital Bishkek, and lower in the tuberculosis-specialized clinic in Bishkek. Clients with HIV receive higher average MMT doses (79.5mg vs 63.1mg; p<0.0001), but MMT retention did not differ after controlling for dosage in this group. Conclusions The proportion of patients receiving optimal dosage was low (19.9%). An implementation strategy that focused on getting a larger proportion of MMT on the optimal dosage to promote retention could potentially improve the quality of existing treatment and promote further scale-up of MMT in Kyrgyzstan.
Collapse
Affiliation(s)
- Roman Ivasiy
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, 135 College Street, Suite 355, New Haven, CT 06511 USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA
- Center for Interdisciplinary Research on AIDS at Yale University, New Haven, USA
| | - Lynn M. Madden
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, 135 College Street, Suite 355, New Haven, CT 06511 USA
- APT Foundation, New Haven, USA
| | - Scott O. Farnum
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, 135 College Street, Suite 355, New Haven, CT 06511 USA
- APT Foundation, New Haven, USA
| | - Natalia Shumskaya
- Public Foundation “AIDS Foundation East-West in the Kyrgyz Republic”, Bishkek, Kyrgyzstan
| | - Samy J. Galvez de Leon
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, 135 College Street, Suite 355, New Haven, CT 06511 USA
| | - Daniel J. Bromberg
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA
- Center for Interdisciplinary Research on AIDS at Yale University, New Haven, USA
| | - Ainura Kurmanalieva
- Public Foundation “AIDS Foundation East-West in the Kyrgyz Republic”, Bishkek, Kyrgyzstan
| | | | | | - Frederick L. Altice
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, 135 College Street, Suite 355, New Haven, CT 06511 USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA
| |
Collapse
|
8
|
Dorgay CE, Bromberg DJ, Doltu S, Litz T, Galvez S, Polonsky M, Dvoryak S, Altice FL. A pilot implementation study to scale-up methadone in incarcerated persons with opioid use disorder and retain them on treatment after release in Moldova. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 104:103683. [PMID: 35417790 PMCID: PMC9827420 DOI: 10.1016/j.drugpo.2022.103683] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Eastern Europe and Central Asia have intertwined HIV and incarceration epidemics, concentrated in people who inject drugs. Moldova is one of the few countries in this region that offers methadone within prisons, but uptake and post-release retention remains suboptimal. Screening, brief intervention, and referral to treatment (SBIRT) procedures are a potential implementation strategy to address this problem. METHODS From June 1, 2017 to March 3, 2018, we conducted a 2-stage SBIRT strategy in nine prisons and four pre-trial detention facilities in Moldova among incarcerated persons with opioid use disorder (OUD; N = 121) and within 90 days of release. Survey results were analyzed to evaluate the effect of the SBIRT strategy on the uptake of and post-release retention on methadone maintenance treatment (MMT). RESULTS Among the 121 screened with OUD, 27 were on MMT at baseline within the prison and this number increased to 41 after the two-step SBIRT intervention, reflecting a 51.9% increase over baseline. Eleven (78.6%) of the 14 participants that newly started MMT did so only after completing both SBIRT sessions. The brief intervention did not significantly improve knowledge about methadone but did improve attitudes towards it. Among the 41 participants who received methadone during this trial, 40 (97.6%) were retained 6 months after release; the one participant not retained was on methadone at the time of the intervention and had planned to taper off. CONCLUSION The SBIRT strategy significantly improved participant attitudes, but treatment initiation mostly occurred after completing both sessions, including soon after release, but remained low overall. Work within the Moldovan prison subculture to dispel negative myths and misinformation is needed to further scale-up OAT in Moldova.
Collapse
Affiliation(s)
- Coriann E Dorgay
- Yale School of Public Health, Yale University, 60 College Street, New Haven, Connecticut, 06510, United States
| | - Daniel J Bromberg
- Yale School of Public Health, Yale University, 60 College Street, New Haven, Connecticut, 06510, United States; Yale Center for Interdisciplinary Research on AIDS, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States
| | - Svetlana Doltu
- Act For Involvement, 7A Varșovia street, Chișinău, 2060, Republic of Moldova
| | - Taylor Litz
- Yale School of Medicine, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States
| | - Samy Galvez
- Yale Center for Interdisciplinary Research on AIDS, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States; Yale School of Medicine, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States
| | - Maxim Polonsky
- Yale School of Medicine, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States
| | - Sergey Dvoryak
- Ukrainian Institute on Public Health Policy, 5 Biloruska Str. Office 20, 27, Kyiv, 04050 Ukraine
| | - Frederick L Altice
- Yale School of Public Health, Yale University, 60 College Street, New Haven, Connecticut, 06510, United States; Yale Center for Interdisciplinary Research on AIDS, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States; Yale School of Medicine, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States; University of Malaya, 50603 Kuala Lumpur, Malaysia.
| |
Collapse
|