Overview of Methadone Maintenance Therapy in Region and Vietnam

1
Overview of Methadone Maintenance Therapy in
Region and Vietnam
Nguyen To Nhu M.D., Ph.D.Senior Program Officer,
IDU intervention, FHI Vietnam
2
Presentation contents

• Overview of Methadone Maintenance Therapy
• MMT benefits and cost effectiveness
• MMT implementation in Region
• MMT implementation in Vietnam

3
Presentation contents

• Overview of Methadone Maintenance Therapy
• MMT benefits and cost effectiveness
• MMT implementation in Region
• MMT implementation in Vietnam

4
Substitution maintenance treatment with methadone

• Provision of a long acting opioid (e.g. methadone
  or buprenorphine) which enables patient to cease
  or reduce their heroin use and related behaviours
• Long term treatment approach provides an
  opportunity for patients to distance themselves
  from drug-using lifestyle friends
• Combines medication with psychosocial services

5
Where does methadone come from?

• Developed during World War II
• Because of shortage of morphine in Germany
• synthesized in 1937
• IG Farben (Hoechst-Am-Main)
• Experiments to develop synthetic opioids
• Long acting pain killer for use in the
  battlefield
• Registered in 1941
• Introduced to the US by Eli Lilly in 1947
• Used as analgesic and cough suppressant

6
Maintenance therapy

• Dole and Nyswander published first paper on
  research in New York in 1965
• Initially 22 patients were treated
• Maintenance therapy
• Supervised, controlled supply of narcotics in a
  medical sense
• 2 useful effects
• relief of narcotic hunger
• induction of sufficient tolerance to block the
  euphoric effect of heroin
• In 1972 they published results of 25,000 patients
  on treatment!

7
Eligibility for Methadone Maintenance Therapy

• Opioid dependent
• Informed consent
• Inclusion criteria (suggested)
• Injecting opioids
• More than six months dependent use
• At least one withdrawal attempt
• Able to travel to dispensing site
• Exclusion criteria
• Not wanting maintenance treatment

8
Eligibility for Methadone Maintenance Therapy in
Vietnam

• Inclusion criteria
• Opioids dependents
• 18 years old or older. Those who are between 16
  to 18 needs legal guardians
• Voluntary with signed informed consent
• No contra-indication with Methadone
• Reference letter from commune peoples committee
• Priority criteria
• Injecting drug users
• Dependent at least 3 years
• Many withdrawal attempts but not successful
• Participate into the HIV/AIDS program (ei. PEs,
  member of PLWA)

9
Methadone pharmacology

• Well absorbed orally. Time course of effects
• Onset 3060 minutes
• Peak 24 hours after dose
• Therapeutic effects for 1530 hours (dose
  related)
• Half-life 2024 hours
• Steady state equilibrium only after 5 half-lives
  5 days
• Metabolized by hepatic cytochrome P450
• Impacted by drug interactions, individual
  variation, disease states
• Particular interactions with ART and TB drugs

10
Initiating methadone

• Start with low methadone doses
• According to neuroadaptation
• (Low 1520 mg/medium 2025 mg/high 2530 mg)
• Review the patient frequently
• Titrate the dose carefully to 60120 mg
• Start low, go slow, aim high.

11
MMT side-effects

• Side-effects common during treatment initiation,
  and then tolerance develops for many.
• Some early side-effects can be difficult to
  differentiate from withdrawal symptoms
• Nausea, joint aches, sweating, poor sleep
• Some side-effects are chronic problems
• Constipation, sweating, sleep disturbances
• Endocrine changes (reduced libido, menstruation)
• Dental problems

12
Ceasing Methadone Maintenancetherapy

• When to withdraw?
• There is a high relapse rate to dependent heroin
  use for clients who prematurely stop methadone
• Client behavioral factors
• Heroin abstinence
• Social stability/supports/relationships
• Treatment-related factors
• Stable doses
• Not missing doses and good clinic relationships
• Cannot involuntarily keep client in methadone
  treatment

13
Treatment length

• Long enough -? depend on individual
• At least 1 year to be an effective treatment

14
Relapse to IV drug use after MMT105 male
patients who left treatment
Percent IV Users
Months Since Stopping Treatment
Adapted from Ball Ross - The Effectiveness of
Methadone Maintenance Treatment, 1991
Opioid Agonist Treatment of Addiction - Payte -
1998
15
Extra requirements IDUs on ART

• Opportunity for synergies of care
• Higher doses of methadone will be required
• With NVP, EFV, rifampicin, some anticonvulsants
• Oral substitution therapy for IDUs on ART
• Improved compliance and convenience
• Research on ARV interactions and illicit drugs
• National ART Guidelines include OST
• Training for health-care providers on ART and OST
• Comprehensive care programs for IDUs include OST
• Treatment literacy about OST tailored for IDUs

16
Presentation contents

• Overview of Methadone Maintenance Therapy
• MMT benefits and cost effectiveness
• MMT implementation in Region
• MMT implementation in Vietnam

17
Methadone Maintenance Therapy

• Potential benefits
• Remarkable effectiveness
• Stabilizing effect of daily dosing
• Reduced crime and drug use
• Effective in chronic pain
• Safe in pregnancy
• Inexpensive doses (lt US 0.6cents /mg)
• Low diversion potential with observed dosing

18
Methadone cost-effectiveness

• NTORS study UK (National Treatment Outcome
  Study)
• For every dollar invested in treatment, there is
  a return of 3 dollars because of lesser costs of
  the justice department International consensus
  that MMT saves the community between 7 and 10
  times the program cost incurred on
• Legal
• Law enforcement/incarceration
• Health
• Social
• Insurance
• Customs
• Deaths

19
Crime among 491 patients before and during MMT at
6 programs
Crime Days Per Year
Adapted from Ball Ross - The Effectiveness of
Methadone Maintenance Treatment, 1991
Opioid Agonist Treatment of Addiction - Payte -
1998
20
Patient Status Before and After Methadone
Maintenance Treatment(Composite Average of Three
Treatment Programs for 2 Years)(Adapted from
McGlothlin and Anglin, 1981)
21
Mortality Rates in Treatment and 12 Months after
DischargeZanis and Woody, 1998
22
MMT in China saves resources

• Cost of having 200 heroin users participating MMT
  is US51,219.
• Taking lowest cost of US2,671 per user per year,
  if we let 200 users join MMT, savings from not
  using heroin will be US534,200. After Reduction
  of the cost of MMT, we will save some US483
  thousand
• Taking medium cost of US6,009 per user per year,
  if we let 200 users join MMT, savings from not
  using heroin will be US1,201,800. After
  reduction of the cost of MMT, we will save some
  US1.15 million

23
Presentation contents

• Overview of Methadone Maintenance Therapy
• MMT benefits and cost effectiveness
• MMT implementation in Region
• MMT implementation in Vietnam

24
Since then Methadone has become available in
Australia, Austria, Azerbaijan, Bahrain, Belarus,
Belgium, Canada, China, Croatia, Czech Republic,
Denmark, Estonia, Finland, France, Georgia,
Germany, Greece, Guatemala, Honduras, Hong Kong,
Iceland, Indonesia, Iran, Ireland, Israel, Italy,
Jordan, Kyrgyzstan, Latvia, Lithuania,
Luxembourg, Malaysia, Malta, Mauritius, Mexico,
Moldova, Monaco, Morocco, Myanmar, Nepal,
Netherlands, Norway, Oman, Panama, Paraguay,
Portugal, Singapore, Slovakia, Slovenia, Spain,
Sri Lanka, Sweden, Switzerland, Taiwan, Thailand,
Ukraine, United Kingdom, USA, Vietnam, and more
..
gt 585,000 patients in EU alone in 2005
25
Some photos from MMT in China, Hong Kong,
Indonesia, Myammar
26
Presentation contents

• Overview of Methadone Maintenance Therapy
• MMT benefits and cost effectiveness
• MMT implementation in Region
• MMT implementation in Vietnam

27
Pilot MMT sites
28
Goal and Objectives of MMT Program

• Goal
• Reduce the transmission of HIV and other
  infections among opiate drug users and from them
  to the community
• Improve the health status and quality of life and
  support opiate users to well integrate into the
  community
• Specific Objectives
• Implement a pilot MMT program in Hai Phong and
  HCMC
• Provide MMT services for 1,500 opiate users
• Reduce the risk for HIV transmission among MMT
  clients
• Decrease the frequency of use and then stay off
  opiate drugs among MMT clients

29
Some photos on MMT in Vietnam

• Resources
• Methadone international experience presentation
  by David Jacka/WHO
• MMT the basics presentation by Kevin Mulvey/FHI
• Implementing the Matrix model in MMT clinic by
  Dan George/Matrix Institute of Intensive Drug
  Addiction Treatment
• Photos of MMT implementation in Hai Phong