Evaluating the effectiveness of opioid dependence treatment using mmt in hai phong and ho chi minh city

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1 INTRODUCTION Drug addiction has severely affected individuals, families, social security and become the major cause of the outspread of HIV/AIDS epidemics in many countries in the world. Over the years, the international community has made great efforts in the fight against drugs, HIV/AIDS and got remarkable results. However, addiction treatment and drug relapse prevention remains a major challenge towards many nations. The progress of science has discovered/found the mechanism of drug addiction which is a chronic brain disease, requiring longterm treatment. One of the treatment methods that has been applied in many countries is the treatment of opiate addiction with Methadone. Researches in the world has showed the effectiveness of alternative treatment with methadone in reducing the use of illegal drugs, prevention of HIV transmission and other bloodborne diseases and reduction of crime and family violence. In Vietnam, Methadone treatment program was first piloted at the Institute of Mental Health, Bach Mai Hospital from 1996 to 2002. On the basis of the piloting results, in 2008, the Vietnamese Government assigned the Ministry of Health to implement a project entitled “Pilot opiate addiction treatment using methadone in Hai Phong and Ho Chi Minh City”. With the goal to evaluate the effectiveness of MMT model in two pilot cities, and provide evidence to inform policy makers and provincial authorities to implement the program, this thesis entitled "Evaluating the effectiveness of opioid dependence treatment using MMT in Hai Phong and Ho Chi Minh city" has two following objectives: 1. To describe the current status of illicit drug use and its association with health, social function of drug addicts before entering the MMT program in Hai Phong and Ho Chi Minh City, in 2009. 2 2. To evaluate the effectiveness of MMT program in Hai Phong and Ho Chi Minh City, during 2009-2011. New findings of the thesis: - This thesis has attempted to fully describe the demographic and social characteristics of drug addicts before entering an MMT program in Hai Phong and Ho Chi Minh City in 2009. - This is the first research that evaluates the effectiveness of the MMT program in community. The results focused on the main outcomes of the model, including decreased illicit drug use; reduced risk behaviors, reduced risk of HIV and bloodborne diseases; improved physical health and mental health; increased employment status, income, and socioeconomic effects; reduced crime activities and family violence amongst drug users receiving MMT. Layout of thesis The thesis consists of 121 pages (excluding references, appendices), including 4 chapters: Introduction: Chapter 1: Literature review: Chapter 2: Methods: Chapter 3: Results: Chapter 4: Discussion: Conclusion: Recommendation: 2 pages 31 pages 19 pages 31 pages 35 pages 2 pages 1 page 3 Chaper 1 LITERATURE REVIEW 1.1. SOME CONCEPTS AND CLASSIFICATION OF DRUGS 1.1.1. Some concepts and definitions 1.1.1.1. Narcotic drugs Narcotic drugs are addictive substances, psychotropic substances, which were regulated in the the lists issued by the Government. 1.1.1.2. Substances Substances are stimulants or neural inhibitors which can easily cause addiction among abusers. 1.1.1.3. Psychotropic substances Psychotropic substances are stimulants, neural inhibitors or hallucinogenic substances, if repeated use can lead to addiction for users. 1.1.2. Classification of opiats Narcotic drugs are classified into 4 groups: Canabis, Cocaine, Opioid and Synthetic drugs 1.2. CURRENT SITUATION OF DRUG USE AND HIV/AIDS IN VIETNAM AND GLOBALLY 1.2.1.1. Drug addiction globally According to UNODC, in the world, cannabis has the highest proportion with 2.82% to 5.03% of the world population got addicted. The second one is synthetic substances; the third one is opioid, accounting for 0.88% to 1.23% of the world population at the aged of 15-64 (from 40.6 to 56.4 million); and the lowest proportion is for cocaine. 4 1.2.1.2. Situation of HIV/AIDS in the world According to UNAIDS, by the end of 2011, there was about 31.4 million to 35.9 million HIV cases globally and about 0.8% of adults aged 15-49 living with HIV. 1.2.2.1. Situation of opioid dependence in Vietnam Opioid dependence in Vietnam is still complicated and tends to increase. By June 2013, there were nearly about 180,000 IDUs. Heroine was the main drug which accounted for 75% drug using population; synthetic drugs: 10%; opium: 7%; cannabis: 1.7%; and other substances: 6.3%. 1.2.2.2. Situation of HIV epidemics in Vietnam By December 2013, Vietnam had 212,714 people living with HIV, of these, 62,437 patients had AIDS and the total number of deaths from HIV/AIDS cases was 63,716. About half the number of people living with HIV was IDUs. 1.3. DETOXIFICATION TREATMENT Detoxification treatment is a combination of medical and psychological therapy in order to achieve goals of: (1) To reduce or stop using drugs; (2) To prevent harm related to drug use; (3) To recover and improve quality of life of drug user. 1.3.2. Maintenance therapy relapse prevention support 1.3.2.3. Treatment with agonist: a) Methadone: Methadone is an opioid agonist. In substitution treatment, methadone captured μ receptor and block the effects of other opioids, only drink drug one time/day. With stable doses, patients can work and live normally. b) Levo-Alpha acetyl-Methadol: LAAM is used as the second-line regimen for opioid dependence treatment, in case patient failed with Methadone or Buprenorphine. 5 c) Buprenorphine: Buprenorphine used to treat opioid dependence. Buprenorphine is a partial agonist of μ receptor and have antagonist activity at kappa opioid receptors. d) Levo-Alpha acetyl-Methadol: LAAM is used as the second-line regimen for opioid dependence treatment, in case patient failed with Methadone or Buprenorphine. 1.4. METHADONE MAINTENANCE TREATMENT 1.4.1. Methadone is a drug addiction treatment Drug addiction is a chronic brain disease, easy to relapse. Therefore, long-term treatment, long-life treatment. Methadone is considered as a drug for the most common treatment of opioid addiction. 1.4.2. The process of substitution treatment with methadone at some country in the world. Substitution treatment with methadone was first implemented in Canada in 1959 and later expanded, so far 80 countries have applied . In the United States, by 2010, there were more than 267 thousand people were treated with methadone. In Australia, methadone therapy has been implemented since 1969. Especially from the early 1980s, with the outbreak of HIV, the number of patients participate in methadone treatment has increased rapidly. By now, Australia has 35,850 people were under treatment. In European countries such as Sweden, the UK and the Netherlands, methadone treatment has been implemented from 1960s. In Asia, methadone treatment is available in many countries. China implemented the treatment from 2004 and by the end of 2010, there were 140,000 people enrolled in treatment. Hong Kong has implemented it since 1974, with coverage of about 95% drug users. 1.4.3. Effectiveness of MMT MMT has been proved as the most effective therapy for addiction treatment. The results of many research have showed the advantages of MMT: reducing illicit drug use; reducing needle 6 sharing; reducing transmission rate of HIV and other blood-borne diseases; reducing criminal activity; economically efficient: reducing costs for addicts; creating jobs, increasing incomes, fostering community reintegration, improving social functions; improving the health status; reducing deaths from drug overdoses and suicide. 1.4.4. MMT in Vietnam There were only one research study on MMT in Vietnam, conducted in Institute of mental Health, Bach Mai Hospital, when the Ministry of Health start the project "Pilot treatment of opiate addiction with methadone in Ho Chi Minh City and Hai Phong city". Another research conducted in Ha Noi (on 68 IDUs) and Hai Phong (on 74 IDUs) from 1996 to 2002 Chapter 2 PARTICIPANTS AND METHODS 2.1. PARTICIPANTS, STUDY SITES AND STUDY PERIOD 2.1.1. Participants 2.1.1.1. Participants quantitative 965 drug addicts enrolled in the “Pilot treatment of opiate addiction with methadone”. 2.1.1.3. Participants quanlitative 64 people are invited to participate in the study, including: - 18 staffs working at 6 methadone treatment centres. - 16 representatives of the departments. - 30 family members of some patients on methadone treatment. 2.1.2. Materials - Self-reported questionnaires; medical records, blood test and urine test; reports from MMT facility. - Questionnaires, opinion polls patients. - Medical records of patients treated with methadone. 7 - Books, reports, organizational processes, deployment models. 2.1.3 Study sites The study was conducted in six methadone treatment facilities of two cities: Hai Phong (Le Chan, Ngo Quyen, Thuy Nguyen) and Ho Chi Minh City (District 4, District 6, Binh Thanh). 2.1.4. Study period The study period: from January 2009 to November 2011, indicated two periods: - The first one: Situation evaluation (from 01/2009 to 11/2011) - The second: Intervention study (from 11/2009 to 11/2011). 2.2. Methods 2.2.1. Design - Cross-sectional study, integrating quantitative and qualitative research; - Intervention study without control group. 2.2.2. Cross-sectional study 2.2.2.1. Sample size and sampling cross-sectional All patients enrolled in MMT pilot program in Hai Phong and Ho Chi Minh City were selected. We invited 970 patients to participate in the study, 5 patients refused to participate. In total, 965 patients agreed to participate in the study (Hai Phong City: 467 patients, Ho Chi Minh City: 498 patients). - Sample size and sampling of qualitative research: + Select 64 participants. + 02 times to take the vote of patients participating in methadone treatment model. Total votes are 600 votes / 1 x 2 times = 1200 votes. 2.2.3. Intervention study: 2.2.3.1. Sample size and sampling intervention study Intervention studies were conducted on patients who agreed to participate in the research. A total of 965 patients were involved in 8 the study at baseline. The drop-out rate at 12 months were 113, and at 24 months were 101 (214 patients were not follow-up in total), 751 patients remained in the study. 2.6. RESEARCH ETHICS Ethical approval was granted by the Hanoi School of Public Healths’ Ethics Board. Consent forms to participate in the study were collected from participants before they are screened and chosen. The study participants were enlisted for free testing. Study results will be used for counselling and supporting for themselves in the treatment process. 2.7. LIMITED RESEARCH - Intervention study without control group. - Short duration of model testing (2 years). - Representativeness of objects who are addicted to opiates participating in this study is not high. Due to the piloting phase, the Judge priortised long-term addicts using intravenous drugs, regularly relapse and actively work for HIV/AIDS prevention and control. - In the study of this thesis, evaluation components on organization, model implementation and economic efficiency have not been mentioned remarkably, therefore, it requires further studies. 9 CHAPTER 3 RESULTS 3.1. DESCRIBE DRUG USE PATTERNS AND FACTORS ASSOCIATED WITH HEALTH, SOCIAL STATUS OF DRUG DENPENDENCE. 3.1.1. Socioeconomic characteristic of participants - Most of participants (94.9%) were male. Only 5.1% were female (Ho Chi Minh City: 8.0% and Hai Phong: 1.9%). - Mean ages of participants were 31.5 ± 0.2. Of these, 30-39 age group were accounted for the highest (44.3%), followed by were 25-29 age group (32.0%), 20-24 age group (9.8%) and under 20 age group were the lowest (1.6%). - Patients who passed the secondary school and high school were at the same percentage (45.5% and 44.0%). The percentage of patients who passed primary education or below were only 10.5%. - Patients who have jobs and income were accounted for 64.0% and 87.9%. 3.1.2. PATTERNS OF DRUG USE BEFORE TREATMENT 3.1.2.1. Patterns of drug use in participants The duration of drug use from 5 – 10 years was accounted for the highest percentage (46.2%), followed by 1-5 years (36.4%), above 10 years (16.6%), and below 1 year was the lowest (0.8%). Table 3.6. Drugs commonly used Drugs commonly used Hai Phong Ho Chi General city Minh city (n=965) (n=498) (n=467) TS % TS % TS % Heroin 375 80,3 434 87,1 809 83,8 Opium 117 25,1 27 5,4 144 14,9 10 Synthetic Drugs 47 10,1 64 12,9 111 11.5 Marijuana 41 8,8 104 20,9 145 15,0 Pharmaceutical 44 drugs 9,4 148 29,7 192 19,9 Table 3.7. Route of drug use Hai Phong Ho Chi Minh Total Route of drug (n=467) City (n=498) (n=965) use TS % TS % TS % Oral 38 8,1 114 22,9 152 15,8 Inhale 39 8,4 13 2,6 52 5,4 Smoke 408 87,4 469 94,2 877 90,9 Subcutaneous 3 0,6 4 0,8 7 0,7 Injection 375 80,3 423 84,9 798 82,7 3.1.2.2. Relapse of participants after treatment Most of the participants (97.9%) have been involved in detoxification drug at least once but failed. Only 2.1% have never been involved in any drug rehabilitation. Craving was the most reason for relapse (69.8%), followed by the enticement of friends (55.3%), depression, disappointed (45.9%) and other reasons (5.0%). The percentage of patients who had been shocked by overdose was 16.8%. 3.1.3. Blood test results before MMT HIV prevalence in patients before methadone treatment was 28.4%, of these, patients in Ho Chi Minh city had a higher positive rate (30.1%), in Haiphong, the rate was 26.6%. 11 Table 3.14. Prevalance of hepatitis B virus (HBV) and hepatitis C (HCV) infection before MMT Ho Chi Hai Phong Total Minh Blood test (n=467) (n=965) (n=498) N % n % n % HBV positive 55 11,8 103 20,7 158 16,4 HCV positive 200 42,8 349 70,1 549 56,9 3.1.4. Perceived risk of HIV transmission 3.1.4.1. Needle sharing The rate of needle sharing was 4.1%. 3.1.5. Illegal activites before MMT There were 40.8% of the patients reported that they had illegal activities in the past. 3.1.6. Health problems of patients before MMT The results indicated that the proportion of patients with mental health problems was 73.5%. Health ordinary highest proportion (50.1%), satisfaction (29.6%), non satisfied (18.1%), very satisfied (1.9%) and very dissatisfied (0.3%) 3.1.7. Access and utilization of health care before MMT Voluntary counseling and testing was accounted for the highest percentage (64.5%), ARV services (12.8%), tuberculosis (4.0%), OI (3.1%) and psychiatry treatment (0.1%). 12 3.2 THE EFFECTIVENESS OF MMT PROGRAM IN HAI PHONG AND HO CHI MINH CITY, IN 2009. (2009 – 2011) 3.2.2. Patients’ satisfaction with MMT program Analysis of results from vote polls in 6 methadone treatment facility showed that 90% of patients were satisfied with the specific process of the model. 3.2.4. Reduced drug use, risk behaviors and HIV, hepatitis B virus (HBV), hepatitis C virus (HCV) transmission of MMT patients Figure 3.2. The prevalence of patients having positive with heroin urine test (n=751) The percentage of patients having positive with heroin urine test decreased from 100% (before treatment) to 17.2% (after 12 months) and 12.4% (after 24 months), efficiency index were 87.6% (χ2=123,29, p<0,001). 13 Figure 3.3. Percentage of patients injecting drug (n=751) The percentage of patients Injecting drug decreased from 83.2% (before treatment) to 8.2% (after 12 months) and 6.7% (after 24 months), efficiency index were 91,9% (χ2=1306,15, p<0,001). Figure 3.5. Percentage of patients consistent condmom use The percentage of consistent condom use increased from 86.2% (before treatment) to 100% (after 12 and 24 months), efficiency index were 16.0 % (p <0.05). - The percentage of HIV-infected before treatment and after treatment was not different (p> 0.05), the rate at baseline was 28.2%; 28.2% after 12 months and 28,4% after 24 months. After 02 years of treatment, we found only 1 new HIV positive case. - The percentage of patients infected with hepatitis B before treatment was 16.1%/751 patients; after 12 months and after 24 months this percentage also increased a little but itwas not statistically significance (p> 0.05). The study on 751 patients showed that after 12 months, having 3 new infections and after 24 months, having 9 new infections - The percentage of patients infected with hepatitis C (before treatment) was increased from 58.5% to 59% (after 12 months) and 61.4% (after 24 months). However, the difference between pre- 14 treatment and post-treatment was not statistically significant (p> 0.05). The study on 751 patients showed that after 12 months, having 4 new infected HCV and after 24 months, having 22 new infected with HCV. 3.2.5. Effectiveness on health and social functions of patients - The percentage of patients having illegal activities decreased from 39.1% (before treatment) to 2.7% (after 12 months) and 1.6% (after 24 months). The difference between pre-treatment and posttreatment was statistically significant (p <0.001); efficiency index were 93.1% and 95.9%. - The percentage of patients having domestic violence decreased from 86.8% (before treatment) to 4.8% (after 12 months) and 2.3% (after 24 months). The difference between pre-treatment and posttreatment was statistically significant (p <0.001); efficiency index were 94.6.2% and 98.1%. Figure 3.6. The percentage of patients having job (n = 751) The proportion of patients having job increased from 55.7% (before treatment) to 62% (after 12 months) and 75.9% (after 24 months), efficiency index were 11.3% and 36.3% (χ2=70,25, p <0,001). The percentage of patients suffering mental health problems decreased from 61.7% (before treatment) to 34.6% (after 12 months) and 38.7% (after 24 months), efficiency index were 43.9.% and 37.3% (χ2=128,68; p <0.001). About the depression 15 of IDUs being treated with methadone are average overall score of Kessler (depression scale level), the results reduce from an average level of risk to non risk after 12 months of treatment. The percentage of patients having better quality of life increased from 15% (before treatment) to 52.5% (after 12 months) and 55% (after 24 months), efficiency index were 250% and 267,3% (χ2=88,16; p<0,001). The percentage of patients being satisfied with their health increased from 80.9% (before treatment) to 94% (after 12 months) and 94.1% (after 24 months), efficiency index were 16.2% and 16.3% (χ2=88,16; p <0.005). The percentage of patients accessing to health services, such as harm reduction interventions, behavior change communication, … relatively high, incresed from 75.8% (before treatment) to 76.9% (after 12 months) and 81.2% (after 24 months). 3.2.6. Economic efficiency 3.2.4.1. Cost per day/patient At baseline, the average cost per day/patient was high (over 241,000 VND). The average cost rapidly decreased to 42,700 VND and 27,000 VND in the next 2 quarters; the average cost per day/patient was approximately 21,700 VND with 57% of the design capacity of model. 16 Figure 3.12. Distribution of total cost of 6 MMT facilities With the current organizational structure, the cost per day / person treatment for methadone treatment facility with the size of 150 patients would be 20,750 dong ($ 1.26) (exchange rate at the first quarter / 2009: 1 USD = 16,450 dong), the cost of treatment for one year will be $460. Similarly, with the current organizational structure, methadone treatment facility with a capacity of 250 patients, the cost per day / person only 15,500 dong. With plans for a streamlined, cost per day / person of model Methadone can reached only 12,500 dong ($ 0.76) in the methadone treatment scale treatment of 400 patients (cost of one patient for one year will be $277). 17 Chapter 4 DISCUSSION 4.1. DESCRIBE DRUG USE PATTERNS AND FACTORS ASSOCIATED WITH HEALTH AND SOCIAL STATUS OF DRUG DENPENDENCE BEFORE PARTICIPATING IN MMT PROGRAM IN HAI PHONG AND HO CHI MINH CITY (2009) 4.1.1. The general situation of two cities In terms of age: As reported by the Ministry of Public Security at 2012, drug addicts in the country tends to rejuvenate, aged under 30 years old accounted for 50.2% rate, but according to this results of this study, the majority of IDUs are 30 years old or above (56.5%). Results of research on educational attainment shows that drug addicts have varied levels, the proportion of patient completing secondary school level was the highest in sample (45.5%), followed by high school or higher (44.0%), the lowest percentage was primary school or below (10.5%). 4.1.2. Patterns of drug use before treatment About the period of using drug, the study showed that, the duration of drug use from 5 – 10 years accounted for the highest percentage (46.2%), followed by 1-5 years (36.4%), above 10 years (16.6%), and below 1 years was the lowest (0.8%). The findings of Truong Tan Minh et al (2008) indicated that the patients having duration of drug use less than 5 years accounted for the highest percentage (48.0%). The most popular drugs was heroin (83.8%), the percentage of opium users accounted for 14.9% 4.1.3. The current situation of patients’ relapse The findings of the study showed that majority of patients (97.9%) had been involved in detoxification program at least once but 18 failed. Most of patients had a very short duration (< 1 year) from involving detoxification program to relapse (51,4%). This result was consistent with the report of the Ministry of Labour, Invalids and Social Affairs and the Ministry of Public Security on the work of drug addiction detoxification. 4.1.4. Blood test results of patients before MMT The findings indicated that the prevalence of HIV in patients before treatment was 28.4%, The prevalence of HBV and HCV in patients before treatment was 16.4 % and 56.9 %, respectively. Among those, reports in Bac Kan, Hoa Binh and Tuyen Quang (2011) also showed a very high prevalence of HCV, and HBV infection rates was several times lower than HCV in IDUs. The proportion of patients with positive HCV was very high: 83.6 % at Hoa Binh, 82.4 % at Bac Kan and 56 % at Tuyen Quang. 4.1.6. Illegal activites of patients before treatment Drug use also causes loss of social order and safety, was the source of many types of criminal offenses. The proportion of patients who had illegal activites was 40.8%, the proportion of patients had previous criminal was 13.0%, the proportion of patients had previous conviction was 20, 6%, the proportion of patients had domestic violence was 90.4%. 4.1.7. Employment status of patients before treatment Patients who have jobs and income were accounted for 64.0% and 87.9%, respectively. The findings of Lai Kim Anh and coworker (2006-2007) in Can Tho showed that 71% IDUs were unemployment; this rate on study of Pham Thi Dao (2008-2009) in Da Nang was 48%. 19 4.2. THE EFFECTIVENESS OF MMT PROGRAM IN HAI PHONG AND HO CHI MINH CITY. (2009 – 2011) 4.2.1. Drop-out rate at 12 and 24 months after treatment At baseline, a total of 965 patients enrolled in the study; 852 patients after 12 months (the drop-out rate was 11.7%) and 751 patients after 24 months (the drop-out rate was 22.2%) 4.2.2. The effectiveness of MMT program 4.2.2.2. Reducing prevalence of drug use, risk behaviors and HIV, HBV, HCV infection among MMT patients The study results indicated that methadone can reduce the use of illegal drugs: the percentage of positive with heroin urine test were decreased from 100% (before treatment) to 17.2% (after 12 months) and 12.4% (after 24 months) (with p<0.001), the efficiency index were 84% and 87.6% (for after 12 months and 24 months, respectively). Results of the study was also consistent with findings of other studies that methadone treatment reduced the daily drug use: findings from the Institute of Mental Health, Bach Mai hospital, and findings from Simpson DD, Sells SB reported that the illicit drug use at 02 months before treatment was 100%, after 01 years of substitution therapy for opioid addiction with methadone, the ratio decreased to 36%, and after 03 years of treatment, this rate decreased to 22%. The results showed that the prevalence of patients injecting decreased from 83.2% (before treatment) to 8.2% (after 12 months) and 6.7% (after 24 months). The difference between before treatment after treatment with 12 months and 24 months was statistically significant with p <0.001, IE reached 91% after 12 months and 91.9% after 24 months. The effectiveness of methadone treatment in the prevention of HIV transmission: before treatment, the prevalence was 28.2%; 28.2%after 12 months and 28.4% after 24 months (p> 0.05), in 02 years of methadone treatment, among patients enrolled in MMT 20 program, only 01 new HIV case was found, compared with the rate of new infections in the community in similar period, therefore MMT showed to be very effective intervention to prevent HIV infection in Vietnam. Although the rate increased slightly after treatment, MMT prevented numerous blood transmitted diseases, such as Hepatitis B, Hepatitis C... The proportion of patients with hepatitis B has increased from 16.4% before participating MMT program to 17.3% after 24 months, but the difference was unstatistical significance with p>0.05. 4.2.2.3 Effectiveness of MMT on health and accessing health and social support services of patients Participating MMT program helped addicts improving their health, nutritional status, and improve relationships with family. 4.2.2.4. Reduce illegal activities of patients MMT was contributed to psychological adjustment of patients, helping patients having the opportunity to improve their life, reintegrate into the community and participate in the usual social activities, reducing stigma and discrimination in the workplace as recommended by UNAIDS. 4.2.2.5. Increasing the opportunities to be employment Participant of methadone treatment have more opportunities to find employment as well as employment again. Findings of the study also showed that the proportion of patients with post-treatment employment has increased. That is accord the study conducted by Simpson DD, Sells SB showed that the proportion of employed after treatment increased by 33% compared to a previous year before treament, and, this percentage increased to nearly 60% after 03 years. 4.2.2.6 Economic effiency of MMT program With the current organizational structure, the cost per day/person for treatment with methadone (with capacity of 250 patients) will be 15,500 VND, the cost of treatment for one year will be 227460USD/person. Total cost of operation for methadone treatment
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