Patient perceptions of and experiences with stigma using telehealth for opioid use disorder treatment: a qualitative analysis.

BACKGROUND: Patients with opioid use disorder (OUD) experience various forms of stigma at the individual, public, and structural levels that can affect how they access and engage with healthcare, particularly with medications for OUD treatment. Telehealth is a relatively new form of care delivery for OUD treatment. As reducing stigma surrounding OUD treatment is critical to address ongoing gaps in care, the aim of this study was to explore how telehealth impacts patient experiences of stigma. METHODS: In this qualitative study, we interviewed patients with OUD at a single urban academic medical center consisting of multiple primary care and addiction clinics in Oregon, USA. Participants were eligible if they had (1) at least one virtual visit for OUD between March 2020 and December 2021, and (2) a prescription for buprenorphine not exclusively used for chronic pain. We conducted phone interviews between October and December 2022, then recorded, transcribed, dual-coded, and analyzed using reflexive thematic analysis. RESULTS: The mean age of participants (n = 30) was 40.5 years (range 20-63); 14 were women, 15 were men, and two were transgender, non-binary, or gender-diverse. Participants were 77% white, and 33% had experienced homelessness in the prior six months. We identified four themes regarding how telehealth for OUD treatment shaped patient perceptions of and experiences with stigma at the individual (1), public (2-3), and structural levels (4): (1) Telehealth offers wanted space and improved control over treatment setting; (2) Public stigma and privacy concerns can impact both telehealth and in-person encounters, depending on clinical and personal circumstances; (3) The social distance of telehealth could mitigate or exacerbate perceptions of clinician stigma, depending on both patient and clinician expectations; (4) The increased flexibility of telehealth translated to perceptions of increased clinician trust and respect. CONCLUSIONS: The forms of stigma experienced by individuals with OUD are complex and multifaceted, as are the ways in which those experiences interact with telehealth-based care. The mixed results of this study support policies allowing for a more individualized, patient-centered approach to care delivery that allows patients a choice over how they receive OUD treatment services.

Risk and Protective Factors Affecting Drug Craving among Patients with Substance Use Disorders Undergoing Opioid Agonists Maintenance Therapy.

Background: In this study, the purpose was to investigate the risk and protective factors affecting craving among patients with substance use disorders (SUDs) on buprenorphine, methadone, or opium maintenance treatment in Isfahan, Iran. Methods: In the current cross-section path analysis model, the statistical population was all SUD patients in Isfahan who were under treatment with Methadone or Buprenorphine in 2018. The study sample included 482 people who were on maintenance treatment in Isfahan who were selected by random sampling in two stages. The Franken, Hendriks, and Brink Opiate Craving Questionnaire (OCQ), Substance Related Beliefs Questionnaire (SRBQ), Cognitive Emotion Regulation Questionnaire (CERQ), Patient Health Questionnaire, Sixbey Family Resilience Assessment Scale (FRAS) and the Self-Resiliency Scale (SRS) were used to collect data. A path analysis method and PLS software were used to analyze the data. Results: The results showed that the direct impacts of self-resilience (ß=-0.147, p = 0.009) and uncompromising strategies (ß = 0.249, p = 0.0001) on depression are significant. Also, the direct effects of belief in drugs (ß = 0.518, p = 0.0001) and depression (ß = 0.219, p = 0.0001) on craving are significant. Conclusion: Substance-related beliefs play an essential role in craving both directly and indirectly. The results of the present study can be used to carry out educational and therapeutic interventions for drug SUD patients.

Psychosocial Factors and the Care Cascade for Hepatitis C Treatment Colocated at a Syringe Service Program.

BACKGROUND: Direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) is highly effective. However, people who inject drugs face significant barriers to DAA access. METHODS: We describe a program that colocates HCV management within a syringe service program in New York City. We performed a retrospective chart review of all patients with confirmed HCV viremia. RESULTS: From 2015 to 2018, 102 patients with viremia completed intake. Fifty-eight patients started DAAs. Nine patients discontinued treatment or were lost to follow-up before completion; 1 is continuing DAA treatment. Of 48 patients who completed therapy, sustained virologic response (SVR) was achieved in 43 (89.6%). Age and established mental health treatment at intake were associated with SVR. Regular cocaine use was negatively associated with SVR in univariate analysis, but this association was not significant after adjustment for age. Of 30 patients completing DAA therapy with active illicit opioid use at intake, 14 (46.4%) engaged in opioid use disorder (OUD) treatment during therapy, and 9 remained in OUD treatment after completion of DAA treatment. CONCLUSIONS: Loss to follow-up is a challenge for people who inject drugs, but among those who completed treatment, SVR was achieved at a high rate. Mental health treatment may facilitate HCV cure. Conversely, HCV therapy may facilitate engagement in OUD treatment and other services.

Impact of Medications for Opioid Use Disorder on Discharge Against Medical Advice Among People Who Inject Drugs Hospitalized for Infective Endocarditis.

BACKGROUND AND OBJECTIVES: The impact of medications for opioid use disorder (MOUD) on against medical advice (AMA) discharges among people who inject drugs (PWID) hospitalized for endocarditis is unknown. METHODS: A retrospective review of all PWID hospitalized for endocarditis at our institution between 2016 and 2018 (n = 84). RESULTS: PWID engaged with MOUD at admission, compared with those who were not, were less likely to be discharged AMA but this did not reach statistical significance in adjusted analysis (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.033-1.41; P = .11). Among out-of-treatment individuals, newly initiating MOUD did not lead to significantly fewer AMA discharges (OR, 0.98; 95% CI, 0.26-3.7; P = .98). CONCLUSION AND SCIENTIFIC SIGNIFICANCE: PWID hospitalized for endocarditis are at high risk for discharge AMA but more research is needed to understand the impact of MOUD. (Am J Addict 2020;29:155-159).

HIV care continuum characteristics among people with opioid use disorder and HIV in Vietnam: baseline results from the BRAVO study.

BACKGROUND: Little is known about patient characteristics that contribute to initiating antiretroviral therapy (ART) and achieving viral suppression among HIV people with opioid use disorder in Vietnam. The primary objective of this analysis was to evaluate associations between participant characteristics and the critical steps in the HIV care continuum of ART initiation and HIV viral suppression among people with opioid use disorder and HIV in Vietnam. METHODS: We assessed baseline participant characteristics, ART status, and HIV viral suppression (HIV RNA PCR < 200 copies/mL) enrolled in a clinical trial of HIV clinic-based buprenorphine versus referral for methadone among people with opioid use disorder in Vietnam. We developed logistic regression models to identify characteristics associated with ART status and HIV viral suppression. RESULTS: Among 283 study participants, 191 (67.5%) were prescribed ART at baseline, and 168 of those on ART (90%) were virally suppressed. Years since HIV diagnosis (aOR = 1.12, 95% CI 1.06, 1.19) and being married (aOR = 2.83, 95% CI 1.51, 5.34) were associated with an increased likelihood of current prescription for ART at baseline. Greater depression symptoms were negatively associated with receipt of ART (aOR = 0.97, 95% CI = (0.94, 0.9963)). In the HIV suppression model, once adjusting for all included covariates, only receipt of ART was associated with viral suppression (aOR = 25.9, 95% CI = (12.5, 53.8). In bivariate analyses, methamphetamine was negatively correlated with ART prescription (p = 0.07) and viral suppression (p = 0.08). CONCLUSION: While fewer than 90% of participants had received ART, 90% of those on ART had achieved HIV viral suppression at baseline, suggesting that interventions to improve uptake of ART in Vietnam are essential for achieving UNAIDS 90-90-90 goals in people who use heroin in Vietnam. Social determinants of health associated with ART and HIV viral suppression suggest that social support may be a key to facilitating both of these steps in the HIV care continuum.

Rapid qualitative evidence syntheses (rQES) in health technology assessment: experiences, challenges, and lessons.

Healthcare decision makers are increasingly demanding that health technology assessment (HTA) is patient focused, and considers data about patients' perspectives on and experiences with health technologies in their everyday lives. Related data are typically generated through qualitative research, and in HTA the typical approach is to synthesize primary qualitative research through the conduct of qualitative evidence synthesis (QES). Abbreviated HTA timelines often do not allow for the full 6-12 months it may take to complete a QES, which has prompted the Canadian Agency for Drugs and Technologies in Health (CADTH) to explore the concept of "rapid qualitative evidence synthesis" (rQES). In this paper, we describe our experiences conducting three rQES at CADTH, and reflect on challenges faced, successes, and lessons learned. Given limited methodological guidance to guide this work, our aim is to provide insight for researchers who may contemplate rQES. We suggest several lessons, including strategies to iteratively develop research questions and search for eligible studies, use search of filters and limits, and use of a single reviewer experienced in qualitative research throughout the review process. We acknowledge that there is room for debate, though believe rQES is a laudable goal and that it is possible to produce a quality, relevant, and useful product, even under restricted timelines. That said, it is vital to recognize what is lost in the name of rapidity. We intend our paper to advance the necessary debate about when rQES may be appropriate, and not, and enable productive discussions around methodological development.

Chronic Disease Medication Adherence After Initiation of Buprenorphine for Opioid Use Disorder.

BACKGROUND: Although buprenorphine is an evidence-based treatment for opioid use disorder (OUD), it is unknown whether buprenorphine use may affect patients' adherence to treatments for chronic, unrelated conditions. OBJECTIVES: To quantify the effect of buprenorphine treatment on patient adherence to 5 therapeutic classes: (1) antilipids; (2) antipsychotics; (3) antiepileptics; (4) antidiabetics; and (5) antidepressants. RESEARCH DESIGN: This was a retrospective cohort study. SUBJECTS: We started with 12,719 commercially ensured individuals with a diagnosis of OUD and the buprenorphine initiation between January 2011 and June 2015 using Truven Health's MarketScan data. Individuals using any of the 5 therapeutic classes of interest were included. MEASURES: Within the 180-day period post buprenorphine initiation, we derived 2 daily indicators: having buprenorphine and having chronic medication on hand for each therapeutic class of interest. We applied logistic regression to assess the association between these 2 daily indicators, adjusting for demographics, morbidity, and baseline adherence. RESULTS: Across the 5 therapeutic classes, the probability with a given treatment on hand was always higher on days when buprenorphine was on hand. After adjustment for demographics, morbidity, and baseline adherence, buprenorphine was associated with a greater odds of adherence to antilipids [odds ratio (OR), 1.27; 95% confidence interval (CI), 1.04-1.54], antiepileptics (OR, 1.22; CI, 1.10-1.36) and antidepressants (OR, 1.42; CI, 1.32-1.60). CONCLUSIONS: Using buprenorphine to treat OUD may increase adherence to treatments for chronic unrelated conditions, a finding of particular importance given high rates of mental illness and other comorbidities among many individuals with OUD.

Deploying science to change hearts and minds: Responding to the opioid crisis.

The U.S. opioid epidemic, now in its third decade, continues to claim tens of thousands of lives each year. Despite strong scientific evidence to support the deployment of effective interventions from prevention to treatment, implementation and access to quality care continue to lag, in part, due to continued opioid prescribing, siloing of treatment services for those with opioid use disorder (OUD), public support for non-evidence-based practices, stigma, and discrimination. Primary prevention efforts should focus on avoiding exposure to opioids for chronic non-cancer pain, as there is little evidence of efficacy but substantial evidence of harms. FDA-approved medications for OUD (MOUD) have incontrovertible evidence supporting their efficacy, and their use saves lives. However, fewer than 10% of those in need are able to receive MOUD. The barriers include an inadequate workforce, inadequate reimbursement, challenges navigating the treatment system, and profiteering bad actors (e.g., treatment brokers, programs delivering non-evidenced-based care). Perhaps the greatest challenge (and deterrent from receiving MOUD) is stigma and lack of public knowledge about their efficacy. Detoxification is probably the most common form of "treatment" for OUD, but the evidence shows that detoxification actually increases the risk for overdose. Expansion of MOUD delivery in the criminal justice system, health care systems and communities is essential to stemming the tide of this epidemic. This article is a call to action for the scientific community to ensure that scientific evidence is guiding patient care, funding for treatment, and policy decisions that address the opioid epidemic.

Post-release treatment uptake among participants of the Rhode Island Department of Corrections comprehensive medication assisted treatment program.

The Rhode Island Department of Corrections (RIDOC) recently implemented the first state-wide, comprehensive medications for addiction treatment (MAT) program in the US. The objective of this study was to elucidate perceived barriers for individuals who participated in RIDOC's MAT program while incarcerated. Of the 588 individuals eligible for this study, 227 phone surveys were completed with 214 individuals. Data relevant to demographic characteristics, probation/parole status, retention in MAT treatment, MAT type received during incarceration, MAT treatment history, location where they received community treatment, perceived barriers to treatment, and future goals for MAT were collected. Simple percentages, frequencies, means, and standard deviations were calculated with SPSS. Most participants (82.4%) reported continuing MAT post-release and a majority (74.3%) received treatment at an opioid treatment program. Those who did not connect with treatment post-release reported transportation issues (23.1%) and not wanting to continue MAT (20.5%) as major reasons for not continuing treatment. The most commonly reported goal for treatment was to continue MAT long-term (43.5%). Results indicate that most participants linked to MAT treatment post-release. Participants reported reasons for why they did not continue MAT and had mixed intentions about continuing MAT in the future. Results provide identification of novel factors, such as side effects, time between release and treatment linkage, and family and friends' opinions that influence MAT continuation post-incarceration. Results highlight areas of exploration to influence treatment retention, including the role of probation/parole officers and the potential for peer support specialists to assist in reducing stigma and increasing interest in MAT.

Brief Report: Low-Barrier Buprenorphine Initiation Predicts Treatment Retention Among Latinx and Non-Latinx Primary Care Patients.

BACKGROUND AND OBJECTIVES: Patients are at risk of dropout while waiting for buprenorphine treatment. Study goals are to compare 3-month retention in two different methods to buprenorphine initiation among persons with opioid use disorder. METHODS: We compared 3-month treatment retention rates of low-barrier buprenorphine initiation (i.e., rapid induction) (n =58) or a traditional method of buprenorphine initiation ( n = 45) for persons with opioid use disorder seen at an urban community health center. RESULTS: Logistic regression revealed that low-barrier initiation had 11.11 greater odds of retention compared with traditional methods (p <0.001). Latinx patients benefited more than non-Latinx patients (OR = 14.79, p =.039). DISCUSSION AND CONCLUSIONS: All patients were more likely to be retained using low-barrier initiation. A significantly larger effect on retention among Latinx patients was observed. SCIENTIFIC SIGNIFICANCE: Rapid buprenorphine initiation increases treatment retention which improves treatment outcomes for persons with opioid use disorder. Study findings support a less restrictive services model that is even more effective for Latinx patients. (Am J Addict 2019;28:409-412).

Worries About Discontinuing Buprenorphine Treatment: Scale Development and Clinical Correlates.

BACKGROUND AND OBJECTIVES: Despite the benefits of maintenance buprenorphine treatment for opioid use disorder (OUD), many individuals report an interest in discontinuing the medication, while also expressing worries about tapering. The purpose of this study was to develop a measure of worries about buprenorphine discontinuation ("Off Bupe") and determine the demographic and clinical characteristics associated with these worries. METHODS: Between May 2017 and May 2018, we surveyed adults in an outpatient primary care buprenorphine program (n = 138). Reliability and validity of the Off Bupe measure were examined. RESULTS: Participants averaged 39 years of age, 54% were male, average duration of buprenorphine was 189 weeks and 85.5% reported eventually wanting to discontinue buprenorphine, although fewer than 10% were actively tapering. We derived two scales, withdrawal symptom worry (10 items, ɑ = 0.94) and relapse worry (7 items, ɑ = 0.88). Worry about symptoms was positively associated with current buprenorphine dose (P = 0.016), physical discomfort avoidance (P < 0.001), and inversely associated with self-efficacy to quit buprenorphine (P < 0.001) and distress tolerance (P < 0.001). Worry about opioid relapse was associated positively with age (P = 0.019), current buprenorphine dose (P = 0.004), physical discomfort avoidance (P < 0.001), and impulsivity (P = 0.002), and inversely associated with self-efficacy to quit buprenorphine (P < 0.001). DISCUSSION AND CONCLUSIONS: Psychometric evaluation of the "Off Bupe" scale demonstrated its content and construct validity and internal reliability. SCIENTIFIC SIGNIFICANCE: The scale might help individuals with OUD and their providers identify concerns about discontinuing buprenorphine. (Am J Addict 2019;28:270-276).

Treatment for Individuals With Severe Mental Illness Who Use Illicit Drugs While Maintained on Methadone: Mindfulness and Modification Therapy.

Substantial research has noted the serious consequences of 1) co-occurring severe mental illness (SMI) and substance use disorders, and 2) use of illicit drugs while maintained on methadone for opioid dependence. However, treatment needs of individuals who meet both of the above criteria remain largely unmet. This pilot study investigated the feasibility and acceptability of a 12-week, transdiagnostic group therapy (mindfulness and modification therapy [MMT]) tailored for opioid-dependent individuals (N = 6) with SMI and illicit drug use. Retention was 83%. At posttreatment and 2-month follow-up, participants rated the treatment as highly helpful (9 of 10; 8.67 of 10, respectively), reported routinely practicing the guided-mindfulness exercises, and reported high confidence that they would continue to practice. Assessments revealed clinically meaningful decreases in reported days of illicit drug use at posttreatment and follow-up, with large effect sizes. Preliminary evidence suggests that MMT may be a feasible and acceptable therapy that may improve treatment engagement in this underserved population.

Attention-Deficit Hyperactivity Disorder Symptom Status in a Mixed Gender Population of Opioid-Maintained Prison Inmates.

OBJECTIVE: Attention-deficit hyperactivity disorder (ADHD) often coincides with substance abuse and delinquency. A sample of opioid-maintained inmates was assessed for symptoms of ADHD, substance abuse history, types of offense, psychiatric comorbidities, and psychopharmacological treatment using a standardized battery of instruments. METHOD: Adult inmates (n = 133, mean age 35.7 years, 21.8% female) in opioid-maintenance therapy (OMT) were administered the Adult ADHD self-report scale, Wender Utah Rating Scale, Mini International Neuropsychiatric Interview, -European Addiction Severity Index. RESULTS: Fifty percent screened positive for childhood and 17% for adult ADHD, four (3.1%) received ADHD medication. Inmates with ADHD symptom status were significantly younger at first substance abuse, reported more drug overdoses, longer duration of cocaine and prescribed medication abuse and more in- and outpatient treatments (all p < 0.05). For all inmates in OMT a high rate of psychiatric comorbidities was observed (78.9%). CONCLUSION: There is a need for assessment of ADHD and other psychiatric comorbidities in OMT prisoners. Evidence-based treatment should be routinely provided.

Loneliness and Illicit Opioid Use Among Methadone Maintenance Treatment Patients.

Background: Loneliness has been linked to greater substance use, especially among women. Yet little is known about how loneliness is associated with treatment outcomes for patients with opioid use disorder (OUD). Objectives: We evaluated how patient reports of using illicit opioids (i.e. heroin or non-prescription pain medications) are linked to perceptions of loneliness in a sample of adults receiving methadone maintenance treatment (MMT), and whether this link varies by gender. Methods: Participants for this cross-sectional observational study included 371 MMT patients aged 18 and older drawn from four opioid treatment programs in Southern New England and the Pacific Northwest. Patients completed a self-administered survey assessing sociodemographic and health information, loneliness, illicit opioid use, and MMT characteristics. Logistic regressions were estimated to examine the link between patient odds of illicit opioid use in the past month and perceived loneliness. Results: Patient gender moderated the association between illicit opioid use and loneliness such that severe loneliness was associated with higher odds of using illicit opioids among women (OR = 3.00, 95% CI [1.19, 7.57], p=.020) but lower odds of using illicit opioids among men (OR = 0.35, 95% CI [0.14, 0.87], p=.024), accounting for age, marital status, work status, depressive symptoms, and MMT characteristics (treatment episode, treatment duration, and methadone dose). Conclusions/importance: This study underscores the importance of considering loneliness in the management of OUD. Routine clinical care and treatment may benefit from strategies to build and sustain social connections that support long-term recovery among MMT patients.

Underutilization of medications to treat opioid use disorder: What role does stigma play?

There is consensus in the scientific literature that the opioid agonist medications methadone and buprenorphine are the most effective treatments for opioid use disorder. Despite increasing opioid overdose deaths in the United States, these medications remain substantially underutilized. For no other medical conditions for which an effective treatment exists is that treatment used so infrequently. In this commentary, we discuss the potential role of stigma in the underutilization of these opioid agonist medications for addiction treatment. We outline stigma toward medications for addiction treatment and suggest that structural and policy barriers to methadone and buprenorphine may contribute to this stigma. We offer pragmatic public health solutions to reduce stigma and expand access to these effective treatments.

Managing the stigma of opioid use.

Substance use stigma makes it difficult to reframe the opioid crisis as a public health issue and has been a barrier to accessing life-saving treatments. Interventions using people that convey recovery stories are promising practices. Groups that may benefit from targeted stigma reduction interventions include opioid users (to combat shame and blame), at-risk youth, first responders, dispensary personal, media, and healthcare professionals. The evidence supporting antistigma interventions is thin, with little Canadian research. Research is needed to establish the effectiveness of substance-related stigma reduction strategies. Health leaders should examine their own responsibilities to lead the public health debate, reduce opioid-related stigma, and actively engage members of the community of those with lived experience to become partners in these activities.

Perceived barriers to methadone maintenance treatment among Iranian opioid users.

BACKGROUND: Opioid use is a severe problem in Iran. Despite methadone maintenance treatment (MMT) programs being one of the most important treatment strategies for reducing individual and public harms associated with opioid use, a large proportion of Iranian patients refuse to participate in such treatment programs. METHODS: The present study aims to explore the beliefs and attitudes toward MMT programs of opioid-dependent patients who were participating or had participated in methadone therapy. In-depth interviews were conducted with 23 opioid users between 27 and 58 years of age from Kurdistan provinces. RESULTS: Overall, six themes were discovered to be key barriers relating to methadone treatment, including financial barriers related to methadone treatment, lack of awareness about methadone treatment, negative attitudes regarding using methadone, worries about methadone's side effects, social stigma ascribed to methadone therapy, and systemic barriers to methadone treatment. CONCLUSION: Our study revealed that the cost of treatment is a major obstacle to attending and continuing at MMT programs and that addicts and their families are not always accurately informed about the duration of MMT programs and the side effects of methadone treatment.

Pilot Study of a Tailored Smoking Cessation Intervention for Individuals in Treatment for Opioid Dependence.

Introduction: Over 85% of opioid-dependent individuals in methadone treatment smoke cigarettes; however, smoking cessation interventions are minimally effective in this population. To better help opioid-dependent individuals quit smoking, we developed and pilot-tested an intervention, based in the Information-Motivation-Behavioral Skills (IMB) model of behavior change, which could be tailored to address individual barriers to smoking cessation in this population. Methods: We randomized participants (n = 83) in methadone treatment to the eight-session, IMB model-based, intervention plus nicotine replacement therapy (intervention, n = 41) or a facilitated referral to the state Quitline (control, n = 42). All participants completed assessments at baseline, 3 months, and 6 months. Results: Intervention participants completed a median of five sessions (interquartile range [IQR] 3-8) and had significantly higher intervention satisfaction than control participants. Intervention participants reported smoking significantly fewer cigarettes per day at 3 months (median [IQR] = 6 [4-15]) and 6 months (median [IQR] = 8 [4-14]) as compared control participants at 3 months (median [IQR] = 10 [5-20]) and 6 months (median [IQR] = 10 [6-20]). Fifty-six percent of the intervention group and 41% of the control group a made a quit attempt during the study (p = .16). At 3 months, 7% (n = 3) of intervention participants and none of the control participants were abstinent from smoking (p = .23). At 6 months, 2% of participants in both groups were abstinent. Twenty-four percent and 10% of the intervention and control group participants, respectively, reported 20 or more smoke-free days (p = .43). Conclusions: An IMB model-based smoking cessation intervention for opioid-dependent smokers is feasible and acceptable in methadone treatment and may help methadone maintained smokers cut down on their smoking. Implications: This is the first study of a tailored, IMB Model-based, smoking cessation intervention for opioid dependent smokers. Results showed that opioid dependent smokers are willing and able to participate in an IMB model-based smoking cessation intervention, and this intervention may help this population cut down on their smoking. Also, the Quitline seems less feasible and acceptable for this population than a face-to-face intervention. Further research is needed to determine how to integrate smoking cessation treatment into methadone programs and how to improve interventions so that treatment gains can lead to long-term abstinence in this population.

A pilot feasibility randomised controlled trial of an adjunct brief social network intervention in opiate substitution treatment services.

BACKGROUND: Approximately 3% of people receiving opioid substitution therapy (OST) in the UK manage to achieve abstinence from prescribed and illicit drugs within three years of commencing treatment. Involvement of families and wider social networks in supporting psychological treatment may be an effective strategy in facilitating recovery, and this pilot study aimed to evaluate the impact of a social network-focused intervention for patients receiving OST. METHODS: A two-site, open feasibility trial randomised patients receiving OST for at least 12 months but still reporting illicit opiate use in the past 28 days to one of three treatments: 1) treatment as usual (TAU), 2) Brief Social Behaviour and Network Therapy (B-SBNT) + TAU, or 3) Personal Goal Setting (PGS) + TAU. The two active interventions consisted of 4 sessions. There were 3 aims: 1) test the feasibility of recruiting OST patients to a trial of B-SBNT, and following them up over 12 months; 2) test the feasibility of training clinicians to deliver B-SBNT; 3) test whether B-SBNT reduces heroin use 3 and 12 months after treatment, and to explore potential mediating factors. The primary outcome for aim 3 was number of days of heroin use in the past month, and a range of secondary outcome measures were specified in advance (level of drug dependence, mental health, social satisfaction, therapist rapport, treatment satisfaction, social network size and support). RESULTS: A total of 83 participants were randomised, and 70 (84%) were followed-up at 12 months. Fidelity analysis of showed that B-SBNT sessions were clearly distinguishable from PGS and TAU sessions, suggesting it was possible to train clinical staff to an adequate level of competence. No significant differences were found between the 3 intervention arms in the primary or secondary outcome measures. Attendance at psychosocial treatment intervention sessions was low across all three arms (44% overall). CONCLUSIONS: Patients receiving OST can be recruited into a trial of a social network-based intervention, but poor attendance at treatment sessions makes it uncertain whether an adequate dose of treatment was delivered. In order to achieve the benefits of psychosocial interventions, further work is needed to overcome poor engagement. TRIAL REGISTRATION: ISRCTN Trial Registration Number: ISRCTN22608399 . Date of registration: 27/04/2012. Date of first randomisation: 14/08/2012.

"I Was Not Sick and I Didn't Need to Recover": Methadone Maintenance Treatment (MMT) as a Refuge from Criminalization.

BACKGROUND: Methadone Maintenance Treatment (MMT) in the United States (U.S.) has been undergoing a shift towards conceptualizing the program as recovery-based treatment. Although recovery is seen by some as a means to restore MMT to its rightful position as a medically-based treatment for addiction, it may not represent the experiences, or meet the needs of people who use drugs (PWUD), many of whom who use the program as a pragmatic means of reducing harms associated with criminalization. OBJECTIVES: To examine alternative constructions of MMT in order to produce a richer, more contextualized picture of the program and the reasons PWUD employ its services. METHODS: This paper uses semi-structured interviews with 23 people on MMT (either currently or within the previous two years). RESULTS: Most participants linked their use of MMT to the structural-legal context of prohibition/criminalization rather than through the narrative of the recovery model. Responses suggested the recovery model functions in part to obscure the role of criminalization in the harms PWUD experience in favor of a model based on individual pathology. Conclusions/Importance: In contrast to the recovery model, MMT cannot be understood outside of the structural context of criminalization and the War on Drugs which shape illegal drug use as a difficult and dangerous activity, and consequently position MMT as a way to moderate or escape from those harms.