Methadone Maintenance Treatment Experience in ...

Journal of Psychoactive Drugs, 45 (4), 313–321, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 0279-1072 print / 2159-9777 online DOI: 10.1080/02791072.2013.825032

Methadone Maintenance Treatment Experience in Macao – Prospective Follow-up for Initial 4.5 Years Miriam Adelson, M.D.a,b,c ; Hon Wai Wilson, B.A.d ; Vong Yim Mui Celeste, B.A.e ; Shirley Linzy, R.N., M.S.b ; Mary Jeanne Kreek, M.D.c & Einat Peles, Ph.D.a

Abstract — The initiation of the first methadone maintenance treatment program (MMT) in Macao was founded in collaboration between MMT clinics in the USA and Israel. All patients admitted into treatment between October 2005 and October 2008 were prospectively followed through March 2010. Of the 163 patients, 81% were male, the mean age on admission was 39.5 (sd = 10.2). Seventy-three percent (n = 119) were hepatitis C sera positive, and 4.9% (n = 8) were HIV sera positive. One-year treatment retention rate was 59.5%, with 52.6% of the 95 patients who stayed in treatment having an opiate-negative urine test at the 10-month evaluation. Four and a half years of follow-up showed mean long-term retention (Kaplan Meier analyses) of 2.2 years. Higher methadone dose (≥80mg/day) and hepatitis C sera positive status were predictors for longer treatment retention. This study describes an effective model of MMT that supports the expansion of addiction treatment in other countries. Keywords — high methadone dose, Macao, methadone maintenance treatment, predictors, retention

INTRODUCTION

Peninsula, the islands of Taipa, Coloane, and the reclaimed area, Cotai. This small SAR is growing in size, with more buildings on reclaimed land and in the number and diversity of its attractions. Macao’s unique society consists of communities from the East and West complementing each other. The total population is estimated to be 544,200. About 94% are ethnic Chinese from different provinces, mainly Guangdong and Fujian. The remaining 6% include Portuguese as well as other nationalities and ethnicities. Macao has had a long history of drug abuse problems. Back in the 1840s, at the time of the Opium Wars, opiate

Macao became a Special Administrative Region (SAR) of the People’s Republic of China, becoming independent from Portugal, on December 20, 1999. Macao, like Hong Kong, benefits from the principle of “one country, two systems.” It is located on the southeast coast of China on the western bank of the Pearl River Delta. Bordering the Guangdong Province, it is 60 km from Hong Kong and 145 km from the city of Guangzhou. Macao has an area of 29.2 sq. km, comprised of the Macao

d Division for Treatment and Rehabilitation of Drug Dependence, Social Welfare Bureau, Government of Macao Special Administrative Region, People’s Republic of China. e Department for Prevention and Treatment of Drug Dependence, Social Welfare Bureau, Government of Macao Special Administrative Region, People’s Republic of China, Please address correspondence to Einat Peles, 1 Henrietta Szold St., Tel Aviv 64924, Israel; phone: +972-3-6973226; +fax: 972-3-6973822; email: [email protected]

We would like to acknowledge Anat Sason for data collection help and Christian Lavoie, Brenda Ray, and Rosanna Volchok for their significant contribution during the editing process. a Dr. Miriam & Sheldon G. Adelson Clinic for Drug Abuse, Treatment & Research, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. b Dr. Miriam & Sheldon G. Adelson Clinic for Drug Abuse, Treatment & Research, Las Vegas, NV. c Laboratory of the Biology of Addictive Diseases, The Rockefeller University, New York, NY.

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addiction was commonplace (Lu et al. 2008). A Voluntary Treatment Service was provided in 1992 and again in 1999, when Macao became an SAR. At that time, the Voluntary Treatment Service merged with the Social Welfare Bureau (SWB) of the Macao SAR Government. In 2003, there were about 4,100 opiate users, which was about 0.87% of the total population (480,000) (Office on Drugs and Crime 2008). In 2008, the Annual Drug Control Report stated that, in a sample of 388 patients, 82% were heroin abusers and 70% were injecting drug users (IDUs) (Annual Drug Control Report 2008, 133). More than 90% of the IDUs were hepatitis-C-infected (Annual Drug Control Report 2008, 138). In 2004, there was an outbreak of HIV infection among IDUs. According to the Macao Annual Drug Report, prevalence jumped from 0.5% in 2003 to 5% in 2004 (Annual Drug Control Report 2008, 138). In the same report, a total of 30 cases were HIV-positive, 18 (60%) of which were IDUs (HIV/AIDS Situation in Macao 2006). In 2004, 350 patients received counseling for drug abuse in Macao. Of this sample, 205 were tested for HIV and 5% were positive (Annual Drug Control Report 2008, 138). In 2008, three years after the initial launch of the Methadone Maintenance Treatment (MMT) program, 388 patients were treated with some modality for heroin addiction, of which 153 were tested for HIV and 1.5% tested positive (Annual Drug Control Report 2008, 138). The Government of Macao SAR’s Social Welfare Bureau began pharmacotherapy for opiate addiction with the establishment of a buprenorphine maintenance program in the first quarter of 2005. The Methadone Maintenance Program was initiated in the fourth quarter of 2005. A limited number of patients were admitted to MMT during the first two years while the program was first being evaluated. Using the Adelson clinics in the U.S. and Israel as models (Adelson et al. 2000), Adelson Clinic staff gave training, education, and guidance to the new MMT clinical staff in Macao in 2005. Full MMT service was enacted in 2008. Opening hours were extended from two hours per day to 12 hours per day. As of March 22, 2010, a total of 239 patients had joined the program. The current paper reports on a prospective evaluation of Macao’s first MMT program. We provide analyses of retention rates after one year and up to 4.5 years of treatment and evaluate the predictors of long-term retention.

March 20, 2010. All patients met DSM-IV-TR criteria of dependence on heroin, with urine for toxicology positive for opiates at the time of admission. MMT is a voluntary program and, upon admission, patients sign a contract to agree to the terms of the MMT program. The contract states that the clinic offers MMT service and will not start any dose reduction/dose elimination of methadone within the first six months after admission. Patients who leave have the right to rejoin the MMT program at any time, at which point they must sign a new contract. The contract is a declaration of consent for receiving treatment, and it also includes a sentence saying “information will be used for statistic and research purposes.” This study was approved by the Tel Aviv Sourasky Medical Center (TASMC) Helsinki committee in Israel. The clinic is open seven days a week from 8 a.m. to 8 p.m. The individual methadone dose is taken daily, and all doses must be taken at the clinic. Patients attend regular appointments with therapists (social workers and physicians) twice a week to once a month, according to the patient’s clinical status. The clinic has weekly case review meetings, in which all current patient activity is discussed, including attendance, weekly urine toxicology results, and psychological/social progress. Social services include drug treatment counseling and family counseling, drug treatment assessment, medical referrals, motivational interviewing, emotional counseling, treatment reports for court cases, attendance summary reports for cases that are financially subsidized, group therapy, and other activities. Patients are asked to consent to periodic blood tests for infectious diseases (i.e., HCV antibodies, HIV antibodies, and HBV antigen and antibodies), liver-kidney function tests, and X-ray screenings for tuberculosis. Medical evaluations are arranged after the first 30 days, and after the fourth, tenth, and then every six months thereafter. Urine toxicology tests are performed under observation and a high-risk behavior questionnaire is administered during each evaluation session. The blood and urine samples are collected in the clinic and analyzed in the hospital laboratory. The clinic nurses inform patients of upcoming urine tests a week before the test day. If a patient refuses to comply with urine testing, they are referred to the social worker for an evaluation. If a patient misses the test, a new test day is scheduled during the following week. Patients are asked to sign a form acknowledging the change in test day. If a patient neglects to keep their test date a third time, a warning note informs him or her that, if no test is performed, the clinical staff will proceed with an administrative dose tapering procedure. During the time of this study, only a few patients refused to do the test. All treatment services for drug dependency, including MMT, are free of charge in accordance with the Law of Macao SAR. By the end of the first year, there were 23 patients in treatment, increasing to 163 by the end of the third year, and to 239 patients as of March 2010.

METHODS Clinical Setting One hundred and sixty-three patients were admitted to the Macao MMT between October 27, 2005 (opening of the clinic) and October 26, 2008 (closing date of this study). We followed these patients up to 4.5 years until Journal of Psychoactive Drugs

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Adelson Clinic Support In 1993, when our MMT was first introduced in Israel, it was accompanied by close support from the experienced MMT programs related to the Rockefeller University in New York and had great success from the beginning (Adelson et al. 2000), and for the next 10 years (Peles et al. 2006) and 15 years (Peles et al. 2010). Bringing this clinical model to another part of the world, the Adelson senior staff and leadership from Las Vegas, Nevada, and Tel Aviv, Israel, educated the Macao clinic’s staff about addiction biology, as well as offering guidance and training in MMT. The guidelines and procedures of the Adelson clinics were given to the Macao staff. The Adelson Medical clinic in Las Vegas sent their director, a registered nurse, to observe the new staff in Macao and to advise them in all practical matters of clinic policy and procedure. The director explained to the Macao clinic’s medical staff how to determine the dose to be administered to each patient, how to perform each step in dispensing of the methadone doses, and taught them to listen to the patients about any withdrawal symptoms while simultaneously checking urine toxicology results. She taught the clinical staff how to keep careful methadone medication records and how to calibrate the medication-dispensing equipment. The director stayed on with the clinical staff in Macao during the first week that they were giving methadone doses to patients. She visited the clinic three times offering advice and support. In addition to assisting the clinic’s nurses and physicians, the director of the Adelson Clinic provided guidance to the entire staff and mentored the new clinic’s director. Moreover, a researcher from the Adelson clinic in Tel Aviv gave a tutorial on collecting and tracking data so that it would be possible to analyze treatment outcomes.

For this study, we analyzed data from the results of urine screenings in the tenth month, as well as all other available urine test results at that month. For patients without data from the tenth month, we used the urine test results from the nearest available month. All urine samples were analyzed for opiates using established methods from the U.S. (CliawaivedTM .com (San Diego, California) and Viva-E® EMIT® of Siemens methods). One test was specific for analyzing for methadone (≥0.3 µg/ml), while two others were specific for analyzing for opiates, one of them with high sensitivity for morphine. In specific patients, other drugs of abuse, including benzodiazepines, amphetamines, methamphetamines, MDMA (“ecstasy”), cannabinoids, cocaine, buprenorphine, and ketamine, were screened for as well. The initial methadone dose is up to 40 mg/day for patients who have a clinical record of heroin abuse history or up to 30 mg/day for patients who have never been registered to any other addiction treatment program and were not previously known to the facility. Dosages are increased gradually at a rate not to exceed 10 mg per day, but no more than 30 mg per week. The optimum dose is adjusted according to the patient’s response. If a patient is absent from the clinic for more than three consecutive days, methadone dosage is tapered temporarily by 5 mg per each missing day; however, the tapered dose is never lowered below 40 mg/day. A patient with more than 28 continuous days of absence will be discharged from the facility. Re-joining the program is defined as “re-admission.” After six months, patients are allowed to start tapering the methadone dose slowly down to a 0 dose. Dosages are initially decreased at a rate of 5 mg per two weeks (or 10 mg/week maximum if the dose is higher than 80 mg/day). During the “tapering period,” the patient is allowed to rejoin the maintenance program, having never left it; however, this is defined by the clinic as a “re-admission” and, therefore, the patient must sign a new six-month contract.

Urine Analysis and Methadone Administration in the Macao Clinic Urine sampling and screening is required of each patient in every medical evaluation session. Random urine tests are arranged by social workers, depending on different circumstances. There are at least two additional situations in which urine toxicology would be carried out: (1) by special order from social workers after weekly case review meetings; and (2) by order from a court of law for patients who are under probation, and are thus legally obligated to provide urine samples. For patients under probation, there is a special urine test program: at least six tests within the first month, on days that are decided upon by the social worker and the patient. If a patient’s urine toxicologies are negative for other pertinent illicit use of substances in the first month’s tests, the social worker will then reduce the number of screenings to two to four times a month. If the patient’s urine is negative for all screenings within the first six months, then the social worker may reduce the screenings to once a month. Journal of Psychoactive Drugs

Definitions for the Analyses All 163 patients who were admitted to MMT at the Macao clinic from October 2005 through October 2008 were studied and followed until March 22, 2010. Duration of treatment is defined as starting at the time of the patient’s initial admission and ending when the patient either left treatment or until March 22, 2010. For analysis of treatment outcome, we defined “re-admission” as a patient leaving treatment for three consecutive months or more. Three months is consistent with the criteria that we used in Tel Aviv and in Las Vegas analyses (Peles et al. 2006; 2008; 2010). We analyzed only the first admission for each patient. One-year retention is defined as the patient staying for a period of at least one year. Cessation of opiate use was evaluated by the results of the urine tests at the tenth month of treatment. This 315


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evaluation time was chosen because it was closest to the one-year retention point. At the tenth month, all available urine samples were analyzed. If the urine screens were negative for illicit use of opiates, this was defined as no opiates. The most recent dose, or the maximum methadone dose, was used in this analysis for each patient. Methadone dose was defined as “high” (≥80mg/day) if either the most recent dose or the maximum dose was ≥80mg/day. This was done to eliminate misclassification of patients whose most recent dose was low as a result of dose tapering before leaving MMT. Similarly, the other groups of methadone doses, 40-80 mg/d and