Literature Review - Methadone Maintenance Treatment

7. Specific Considerations

Individuals entering methadone maintenance treatment have many, highly diverse needs related to their drug use and other life circumstances. A client/patient-centred approach to methadone maintenance treatment includes taking into account these multiple needs of various client/patient groups.

7.1 MMT and Multiple Substance Use Behaviours

Multiple substance use behaviours among people who are receiving methadone maintenance treatment is very common. Although methadone maintenance treatment is an effective form of treatment, it cannot be considered a "cure" for opioid dependence. Based on their review, they conclude that many people who receive treatment actually continue to use illicit drugs, although at a reduced rate (Hall et al., 1998b, 50). Commonly used substances include heroin, cocaine, benzodiazepines, alcohol, marijuana and tobacco (Stitzer and Chutuape, 1999, 86).

Most people who are dependent on opioids have a history of multiple substance use behaviours. In their review of other substance use behaviours in methadone treatment, Stitzer and Chutuape (1999, 87) cite a study by Brooner et al. which found that clients/patients may have up to four or five substance use or dependency problems, and this number is even higher among clients/patients with comorbid psychiatric disorders including antisocial personality disorder. They note that the prevalence of substance use among methadone clients/patients, as illustrated by the Brooner et al. study, was as follows: cocaine (lifetime) 77%, (current) 43%; alcohol dependence 25%; marijuana dependence 20%; and benzodiazepine dependence 20%. Stitzer and Chutuape also point out that other studies have found higher rates of marijuana use (they cite Nirenberg et al.), and high rates of tobacco use (92%).

Heroin use is continued by up to 60% of methadone clients/patients, but as Stitzer and Chutuape (1999, 88) point out, during treatment, the amount and frequency of heroin use is lower compared to pre-treatment levels. They note that heroin use during treatment is affected by: "maintenance dose of methadone", as well as by length of time in treatment (with a decrease in the rates over time), and the program's level of "tolerance" for this behaviour. In addition, links between the use of different substances have been identified, such as:

• those who used cocaine in the last three months of treatment were six times more likely to have used heroin during treatment, compared to those who had not used cocaine (Hartel et al., as cited in Stitzer & Chutuape, 1999, 88)
• cocaine and benzodiazepine use are associated with "higher rates of heroin use, greater risk-taking behaviours and poor treatment response" (Stitzer & Chutuape, 1999, 92)

While much of the research reports that substance use, included heroin use, tends to decrease during methadone maintenance treatment (Hartel et al., as cited in Stitzer & Chutuape, 1999, 88-89), continued opioid use is common. For example, Belding, McLellan, Zanis and Incmikosk (1998, 490-491) found that a substantial proportion (22%) of people receiving methadone at their centre continued to use illicit opioids after at least six months in treatment. Given that there are compelling reasons for trying to reduce illicit opioid use, effective methadone maintenance interventions may require either motivational interventions (Saunders, Wilkinson & Phillips, as cited in Belding et al. 1998, 491), or external contingencies (Brooner et al; McCarthy & Borders; Silverman et al., as cited in Belding et al., 1998).

The review by Stitzer and Chutuape (1999) provides a valuable overview of the medical, psychological, and behavioural risks for people who continue to use substances during methadone maintenance treatment. This information is summarized in Table 6.¹⁶

Table 6: (based on Stitzer & Chutuape, 1999, 89-92)

Substance	Risks
Heroin	Exposure to HIV infection, hepatitis B and C infections, abscesses, other infections from contaminated equipment. Increasing physical dependence and increasing levels of withdrawal discomfort (based on "speculation") Continued association with drug users and drug using lifestyle.
Cocaine	Exposure to HIV infection, hepatitis B and C infections, abscesses, other infections from contaminated equipment. Continued association with drug users and drug using lifestyle. Severe hypertension Aortic rupture Restricted blood flow to organs (heart attacks, kidney and intestine damage) Spontaneous abortions Placental disruption Death due to medical complications Death due to trauma and injury (homicide, suicide, accidents) Mental confusion, anxiety, panic attacks, agitated delirium, paranoid psychosis
Alcohol	Increased mortality Disruptive behaviours Blackouts Aggressive or violent behaviours Arrests Accidents Loss of employment Disruption of family life Deterioration of mental and physical health - liver disease leading to acute and chronic cognitive impairment, heart, kidney and blood disorders Death Premature treatment discharges associated with absenteeism and disruptive behaviour at clinics
Benzodiazepines	Sedation Memory impairment (increasing chance of risky behaviour) Overdose (in combination with another sedating drug) Suicide Physical dependence and withdrawal symptoms (rebound anxiety and agitation, insomnia, tension, sweating, tremulousness, ringing in the ears, increased sensitivity to noises and to light, and sensory and perceptual distortions, withdrawal delirium and seizures) Road accidents (especially in combination with alcohol)
Marijuana	Motor incoordination Memory impairment Anxiety and panic attacks Perceptual distortions Toxic psychosis Lung diseases - bronchitis, emphysema, lung cancer
Tobacco	Elevated risk of mortality and morbidity (as in general population) - heart attack, stroke, lung cancer, other chronic lung diseases and premature death

Given the risks involved in continued and multiple substance use, retaining people who continue to use substances while in methadone maintenance treatment is an important element of a harm reduction strategy. According to Magura, Rosemblum and Rodriguez (1998b, Abstract) "From a harm reduction perspective, high priority should be given to retaining cocaine-using patients in methadone maintenance, intensifying in-program services for those with anti-social personality disorder, bipolar disorder, or alcoholism, as well as increasing access to needle exchanges and condoms."

Stitzer and Chutuape (1999,100-114) also make extensive recommendations for the treatment and clinical management of substance use by type of drug. These recommendations, as well as information from Best, Glossop, Greenwood, Marsden, Lehman and Strung (1999, 31) and Budney, Bickel and Amass (1998, 493) are summarized in Table 7.¹⁷

Table 7: (based on Stitzer & Chutuape, 1999, 100-114; Best et al., 1999, 31; Budney et al., 1998, 493)

Substance	Treatment Options	Clinical Recommendations
Heroin	Increase methadone dose Behavioural or counselling interventions Interventions designed to reduce cocaine use may be beneficial	Maximize dose for those continuing to use heroin. Monitor through urinalysis. Supplement with behaviour interventions. Target heroin and cocaine use simultaneously where necessary.
Cocaine	Increased counselling and surveillance combined with motivational interventions. Aversive control strategies (divided opinion about this - strong public health reasons for retaining individuals in treatment) Behavioural interventions utilizing positive reinforcers for abstinence	Intensified counselling treatment and urine surveillance. Motivational interventions with positive or negative incentives. Given continued HIV risk with cocaine injecting, discharge may not be appropriate. Methadone treatment can decrease cocaine use and other risk behaviours even without abstinence.
Benzo-diazepines and Other Sedative-Hypnotics	Detoxification with careful supervision. Outpatient detoxification has a low success rate.	If a prescription is necessary for treatment of a specific condition, employ benzodiazepines with lower abuse liability or use nonbenzodiazepines. Monitor use through urine testing. Inpatient detoxification plus intensive aftercare plan. Reevaluate mental health status once benzodiazepine free. Intensive treatment services including contingent incentive programs.
Alcohol	Psychosocial treatment (individual or group) Behavioural incentive programs for abstinence Medications (Antabuse, disulfiram). Note: Naltrexone cannot be used with methadone clients/patients.	Monitored disulfiram treatment. npatient detox may be required. Routine breath alcohol monitoring with contingencies.
Marijuana	"...there does not, in fact, appear to be a clear relationship between the use of marijuana and the use of other drugs (heroin, cocaine, and benzodiazepines) during treatment, nor do any data support a relationship between marijuana use and poor treatment response in methadone programs. While clinics may not want to ignore marijuana use completely, these findings suggest that they should consider ranking its use relatively low in their priorities for clinical attention and resources." (Stitzer & Chutuape, 1999, 112)	"While cannabis use is highly prevalent among opiate misusers in treatment, its relationship to treatment outcome is complex and requires greater research scrutiny." (Best et al., 1999, Abstract)
Tobacco	Smoking cessation treatment	Smoking cessation programs: nicotine patch, nicotine gum face-to-face therapy social support from counsellor relapse prevention problem solving.

7.2 MMT and Women

Statistics from the United States indicate that, despite the fact that overall rates of heroin and injection drug use are lower among women than men, the actual number of women involved is still significant. Over 700,000 women have used heroin in their lifetime, more than 850,000 have injected drugs, and almost 150,000 used heroin in 1996 (SAMHSA, as cited in Jones, Velex, McCaul and Svikis, 1999, 251). Furthermore, many of these women are of child-bearing age. Other U.S. statistics also indicate that, although some women reduce their drug use during pregnancy, a significant number continue to use drugs throughout pregnancy (NIDA, as cited in Jones et al., 1999, 252). In Canada, heroin (and other drugs such as cocaine, crack, LSD, amphetamines) are used primarily by subgroups of women such as street-involved women. Some researchers have noted that since surveys of drug use do not tend to include women in these subgroups, the use of heroin may be under reported (Hewitt et al.; Office of Alcohol, Drugs and Dependency Issues; Canadian Centre on Substance Abuse & Addiction Research Foundation, as cited in Health Canada, 2001).

7.2.1 Treatment Issues

Many women who use substances experience a range of issues and encounter barriers which impact on and relate to treatment. Much of the research that has been done in this area is relevant for women who are dependent on opioids.

The risk factors and reasons for starting to use substances are different among women than men (Stein & Cyr, as cited in Jones et al., 1999, 252, 254). For example, according to the research reviewed by Jones et al. (1999, 254) women who use substances are more likely to have a family history of alcohol or drug dependence; tend to have high rates of childhood sexual abuse; and are very likely to have relationships with substance-using men and experience violence at the hands of their partners.

Compared to men who use substances, women who use substances tend to function more poorly in terms of physical health, psychological well-being, relationships, social functioning, and economic stability (see Table 8 based on Jones, et al., 1999, 251-255). Some of the physical health differences may be due to gender differences in how substances are metabolized.

Table 8: (based on Jones, et al., 1999, 251-255)

Substance	Risks
Physical health	medical problems tend to be more severe than men's gynecologic problems and STDs common increased risk for reproductive complaints increased vulnerability to HIV infection.18 same injection drug use-related risks as men for hepatitis and many other medical problems
Psychological and social health	increased risk of affective disorders, attempted suicide, psychopathology, low self-esteem, anxiety, depression low levels of coping skills high psychological distress difficulties in relationships and social functioning lack of confidence in their communication skills passivity in partner relationships increased likelihood of being separated or divorced feelings of loneliness smaller social support networks more unresolved sexual issues social isolation fewer friends fewer romantic relationships more difficulties socializing
Economic and legal status	poorer occupational functioning often economically dependent on men via prostitution or exchanging sex for drugs, food, shelter, etc. low levels of vocational training and job skills high rates of unemployment overestimate their job capabilities relative to their education, job training and work experience less likely to engage in socially deviant behaviour involving the legal system majority have at least one legal conviction.

7.2.2 Barriers to Treatment

According to the Institute of Medicine (IOM, as cited in Jones et al., 1999, 255), only a small proportion of the women who need substance use treatment actually receive it. Jones et al. (1999, 255) describe the numerous barriers which researchers have identified that may account for this, such as:

• lack of treatment slots
• lack of financial resources
• insufficient women-focussed outreach
• gender and cultural insensitivity in treatment programs
• fear of criminal prosecution, and legal consequences such as loss of child custody
• lack of child care
• lack of transportation
• lack of health insurance coverage
• no one to care for other dependent children or family members
• ineligibility for treatment medications if pregnant or not using reliable birth control
• social stigmatization of women drug users, including stigmatization by medical community
• lack of treatment that addresses women's issues, including lack of attention to psycho social issues; exclusive focus on relapse prevention and abstinence-oriented counselling.

Comprehensive, gender-specific models for drug treatment services for women must address multiple areas of need (see Table 9).

Table 9: (based on Finnegan; Finnegan; Jansson et al; McCaul & Svikis, sas cited in Jones et al., 256, Table 12.1),

Medical

• General health care
• Obstetric and gynecologic care
• HIV prevention
• Nutritional counselling
• Family planning

Relationships and Social Functioning

• Parenting skills
• Communication skills
• Conflict resolution
• Developing a support network

Special Considerations

• Child care during treatment
• Transportation
• Housing Literacy

Psychologic

• Depression and anxiety
• Sexual abuse
• Sexuality
• Issues of loss
• Self-esteem

Economic

• Interview and job-skills training
• Employment
• Maintaining a job
• Money management

Researchers reviewed by Jones et al. (1999, 256) have also identified other considerations in providing treatment for women, including the need for outreach efforts that involve community based workers and organizations, and provide transportation; women-only groups to address issues such as self-esteem, anxiety, depression, sexuality, communications skills and personal health; screening for family violence; HIV intervention; and vocational training and skills development (Jones, et al. 1999, 256).

Gilbert, El-Bassel, Rajah, Foleno, Fontdevila, Frye and Richmand (2000, 461) have called for a better understanding of how partner violence contributes to HIV and HCV risk and drug use in order to develop more effective interventions for the problems experienced by women who are dependent on opioids. Based on the results of their study, they recommend the following:

• "routine screening for partner violence during intake and annual physical exams"
• provision of "concrete services (e.g. housing, job training and placement, and securing benefits) and enhancing the social support networks to increase financial and emotional independence of abused women from their partners"
• "addressing underlying trauma and related stress that many abused, drug-involved women present"
• raising awareness of the multiple ways in which drug-related activities increase the risk of partner violence.

Gilbert el al. (2000, 462) suggest that methadone maintenance treatment may be an "ideal setting" for implementing HIV, HCV and drug relapse intervention programs which are targeted to the specific context of abused, drug-involved women.

7.3 MMT and Pregnant Women

Pregnant women who are dependent on opioids are at high risk for many different medical complications. A review by Jones, et al. (1999, 260) provides a valuable overview of these issues (See Table 10)

Table 10: Obstetric Problems Associated with Opioid Use (based on Jones et al., 1999, 260)

• Issues with Opioid Use:
• Spontaneous abortion
• Intrauterine death
• Abruptio placentae
• Amnionitis
• Chorioamnionitis
• Septic thrombophlebitis
• Placental insufficiency
• Premature rupture of membranes
• Gestational diabetes
• Postpartum haemorrhage
• Eclampsia
• Increased hospitalization
• Preeclampsia
• Stillbirth
• Intrauterine growth retardation
• Premature labour

The extent to which these problems result directly from drug use, or from the poor nutrition, high-risk lifestyle and lack of prenatal care experienced by pregnant women who are dependent on opioids is not clear. (Robins & Mills, as cited in Jones et al., 1999, 256-257) In addition, Jones et al. (1999, 257) point out that drug-related complications vary depending on: drug(s) used; stage of pregnancy when drugs were used; route of drug administration; withdrawal, or cycles of intoxification and withdrawal; lack of prenatal care; and failure to diagnose and treat drug-related problems.

Since the 1970s, methadone maintenance has been the "treatment of choice" for the opioid-dependent pregnant woman (Finnegan; Finnegan; Kaltenbach et al., as cited in Ward et al., 1998d, 397). Kandall, Doberczak, Jantunen and Stein (1999, 180) conclude that: "General agreement exists that pregnancy offers a unique opportunity to bring women into medical, obstetric, and drug treatment." Ward et al. (1998d, 413) summarize the benefits of providing methadone maintenance treatment which have been demonstrated in the research, including:

• providing a pharmaceutical grade opioid under medical supervision rather than using an illicit opioid of "unknown quality and uncertain supply"
• avoiding the "peaks and troughs" in blood levels when a shorter-acting opioid such as heroin is used
• avoiding exposure to contaminants including those that may be teratogenic; and
• creating an opportunity to provide adequate antenatal care.

Ward et al. (1998d, 413) also conclude, based on their review of the evidence, that compared to women not in treatment, providing methadone maintenance treatment results in increased likelihood of carrying pregnancy to term; fewer birth complications; and larger infants (for their gestational age).

Like other women who are dependent on opioids, pregnant opioid-dependent women may experience significant barriers to accessing treatment (see Section 7.2). In addition, Ward et al. (1998d, 413) note that the research indicates that women who are pregnant may also experience conditions that are not conducive to a successful pregnancy, such as inadequate nutrition and rest; inadequate antenatal care, including poor access to obstetrical care; and exposure of themselves and their fetuses to fluctuating blood levels of heroin, unknown drugs and contaminants and infections with HIV, HCV and other blood-borne pathogens associated with injection drug use.

Other barriers to care include fear of involvement with the criminal justice system; fear that their children will be removed from their care; lack of transportation; lack of child care for other children; lack of access to obstetrical care; social stigma/attitudes of medical personnel; and lack of women's treatment services (Janson et al., as cited in Jones et al, 1999, 259).

Ward et al.(1998d, 398) suggest that the key clinical issues in providing methadone maintenance treatment for pregnant women who are dependent on opioids include selecting an appropriate dose; providing appropriate antenatal care; making counselling available during treatment; and managing the abstinence syndrome in the neonate.

Based on their review of the literature, Jones et al., (1999, 259-260) note that providing comprehensive care can improve pregnancy outcomes. A comprehensive approach to treatment which addresses the unique needs of pregnant women who are opioid dependent includes:

• primary medical care to address the range of problems related to opioid dependence including tuberculosis
• treatment and management of infection (with HIV, HCV or other blood-borne pathogens) for mothers, and possibly for infants
• intensive perinatal management for high-risk pregnancy
• psycho social counselling (including nutrition, parenting and money management education; social services advocacy for assistance with unstable living conditions, unemployment, and literacy)
• prenatal/parenting education classes
• mental health assessment and therapy, and
• methadone maintenance.

Based on their review, Ward et al. (1998d, 414) also suggest the following:

• women-only group sessions which also function as antenatal and parenting classes, and which address other relevant issues for opioid-dependent women
• non-judgmental antenatal care including special clinic times, access to analgesia or anaesthesia during labour or birth
• proper assessment of the severity of the neonatal abstinence syndrome using specially designed instruments
• provision of morphine, phenobarbital or paregoric, as needed, and
• encouragement of breastfeeding by mothers receiving methadone maintenance treatment.

Careful monitoring and adjustment of methadone dose and regimen is required throughout the pregnancy, especially during the third trimester, when the metabolism of methadone increases (Kreek, Schecter and Gutjar; Kreek; Pond et al; Gazaway, Bigelow and Brooner, as cited in Jones et al., 1999, 262). If unexpected withdrawal symptoms develop during this period, increased or split doses may be required (Ward et al., 1998d, 414). Jones et al. (1999, 272) conclude that detoxification from methadone during pregnancy is not recommended, except under "the most dire circumstances." According to Ward et al.'s summary (1998d, 413): "Few...women...can achieve total abstinence without relapse or obstetrical complications intervening. Therefore, the treatment of choice for most opioid dependent women is methadone maintenance throughout their pregnancy." In their review, Kaltenbach, Berghella and Finnegan (1998, 147-148), point out that, although prenatal exposure to heroin or methadone often results in neonatal abstinence syndrome, this syndrome can be treated with pharmacotherapy without negative effects. They conclude that: "There is no compelling evidence to reduce maternal methadone dose to avoid neonatal abstinence."

Comprehensive methadone maintenance treatment is widely considered the standard of care for pregnant women who are dependent on opioids. The benefits - compared to heroin use - include better prenatal care; increased fetal growth; reduced fetal mortality; decreased risk of HIV infection; decreased cases of preeclampsia and neonatal withdrawal; increased likelihood that infant will be discharged to his or her parents; and increased retention in treatment (Kandall et al., Finnegan; Svikis et al., as cited in Jones et al., 1999, 258).

Jones et al. (1999, 272) conclude that: "Overall it appears that when the physical, psychologic, and economic issues of the pregnant opioid abuser are addressed concurrently with methadone treatment, the benefits far outweigh the risks for the mother, the fetus and the infant."

7.4 MMT and Comorbid Medical Conditions

According to Lowinson, et al.(1997, 409), people who are dependent on opioids often experience chronic illnesses including: chronic hypertension; diabetes; chronic liver disease and cirrhosis; asthma; tuberculosis; syphilis; endocarditis; and other infectious diseases. In his comprehensive chapter on the medical needs of people receiving methadone maintenance treatment, Fingerhood (1999, 118-136) describes a wide variety of comorbid medical conditions commonly experienced by people receiving methadone maintenance treatment (see Table 11).

Table 11: [Common Medical Disorders Among People Receiving Methadone Maintenance Treatment (based on Fingerhood, 1999, 118-136)]

Skin and soft tissue infections from non-sterile injection techniques: infections caused by staphylococcus aureus, clostridium, aspergillus, streptococci, Gram-negative rods; infections caused by soft tissue injections; thrombus; complications from injection drugs include cellulitis, abscess, septic thrombophlebitis, pyomyositis, and pseudoaneurysms; osteomyelitis or septic arthritis from bacteremia; lymphatic obstruction and edema from chronic skin popping; foreign body reactions from subcutaneously lodged or migrated needle fragments.

Cardiac complications: endocarditis; cardiac complications linked to cocaine use (mycocardial infarction, coronary artery spasm with angina, and cardiomyopathy).

Sexually transmitted diseases: chlamydia, gonorrhea, genital herpes, HIV, syphilis, human papilloma virus related to cervical cancer.

Hepatitis: alcohol-induced liver damage; viral hepatitis (B, C and D); cirrhosis.

Pulmonary Complications: pulmonary complications related to HIV including pneumocystis carinii pneumonia and others; pulmonary complications related to frequent bacterial pneumonias (often linked to smoking); aspiration pneumonia due to alcohol use or overdosing; secondary lung infections resulting from septic emboli from endocarditis or thrombophlebitis (septic emboli may cause an abscess, an empyema, or a pulmonary infarction); tuberculosis.

Non-infectious pulmonary disease: (pulmonary edema due to heroin overdose, chronic lung disease, pulmonary hypertension due to hypoxia); bronchospasm; atelectasis, alveolar haemorrhage, pulmonary infarction and bronchiolitis obliterans due to smoking freebase cocaine; pneumothorax.

Renal complications: kidney failure (heroin nephropathy); renal amyloidoisis; acute renal diseases (myoglobinuria and glomerulonephritis related to endocarditis or hepatitis B or C infection); membranous, membranoproliferative and minimal change renal diseases. Neurologic complications: delirium and hallucinations related to alcohol or contaminated heroin or cocaine, or benzodiazepine use; seizures related to overdoses, cocaine-induced vasospasm, abscess, HIV-related infection, embolic or thrombotic stroke, meningitis, subdural hematoma, and alcohol withdrawal; traumatic and atraumatic mononeuropathies; Bell's palsy; infectious neurologic complications (meningitis, brain abscess, subdural and epidural abscesses, mycotic aneurysms).

Immunologic abnormalities: hypergammaglobulinemia; thrombocytopenic purpura.

Physical trauma or non-specific issues such as fatigue, insomnia, difficulty concentrating, related to domestic violence experiences.

Septal perforation.

Potential side effects of methadone: sweating, constipation, menstrual abnormalities, lymphocytosis, increased prolactin levels.

Based on his review, Fingerhood (1999, 135) concludes that, despite the frequency of comorbid medical conditions among clients/patients in methadone maintenance treatment, these individuals often receive inadequate medical care. Methadone maintenance treatment represents a key opportunity to provide this much-needed care, and doing so could decrease morbidity, mortality and long-term health care costs. Lowinson et al. (1997, 410) notes that: "...providing primary care to substance abusers treated in methadone maintenance clinics could reduce demand placed on emergency rooms and the need for hospitalizations and thereby drastically cut the overall cost of their care."

According to Leshner (1999): "[drug] treatment programs should...provide repeated assessments for HIV and acquired immunodeficiency syndrome, hepatitis B and C, tuberculosis, and other infectious diseases, as well as noninfectious diseases like diabetes mellitus and hypertension, in addition to counseling and referral for relevant medical treatment."

Fingerhood (1999, 135-136) points out that some aspects of medical care for people receiving MMT are unique. For example, many clients's/patients' medical conditions are related to drug use, and the potential for medications to interact with methadone is an important consideration. At the same time, many other aspects of medical care will not be different, such as the need for responsive, knowledgeable staff, and the need for a setting that promotes caring and trust.

According to a report by Salsitz et al. (2000, 394), physicians working in a methadone medical maintenance (MMM) program in the U.S.¹⁹ were well-positioned to play an important role in providing a range of health interventions. They were able to either treat or refer clients/patients to specialists for a wide range of acute and chronic illnesses. These physicians also played, with the permission of their clients/patients, an important role as ombudsmen, i.e., "contacting and working with other specialists, informing them about methadone maintenance, its overall safety, the need for adequate pain management, and the applicability of continued MMM for the patients."

7.5 MMT and Prevention and Treatment of Hepatitis C

Among individuals who inject drugs, the rate of infection with the hepatitis C virus (HCV) is very high - international estimates range from 50% to 100% (Finch, as cited in Health Canada, 2000a, 1). The primary transmission route is exposure to blood and blood products. Individuals who share needles and other drug paraphernalia are at high risk of infection²⁰. In Canada, 70% of all prevalent HCV infections are related to injection drug use (Laboratory Centre for Disease Control (LCDC), as cited in Health Canada, 2000a,6). Almost all MMT clients/ patients have injected drugs (Novick, 2000, 437), and hepatitis C infection among clients/patients receiving MMT is now recognized as a major health problem (Novick, Hagan & Des Jarlais; Salsitz et al., as cited in Joseph et al., 2000, 359)

Researchers in the U.S. have found that hepatitis C is the most prevalent serious health problem among clients/patients receiving MMT: for example, 92% of clients/patients enrolled in a methadone medical maintenance (MMM) program in the U.S. tested positive for hepatitis C virus-RNA (HCV-RNA). In this study, complications related to hepatitis C were the second highest cause of death among these clients/patients, after smoking related diseases (Salsitz et al., 2000, 394). According to studies reviewed by Novick (2000, 438), the seroprevalence of hepatitis C virus in methadone clients/patients ranges from 67-84%. These high seroprevalence rates are related to: the high prevalence of HCV among injection drug users; the extreme infectiousness²¹ of HCV; the likelihood that clients/ patients may be infected with HCV when they enter MMT; the fact that individuals can become infected after only a few injections; gaps in MMT treatment histories or injection of drugs during MMT (Crofts et al., as cited in Novick, 2000, 438); inadequate methadone dose (Dole; Bell, Chan & Kuk; Strain et al., as cited in Novick, 2000, 238); and cocaine injecting (Thomas, et al.; Novick et al., as cited in Novick, 2000, 238).

7.5.1 MMT and Prevention of Hepatitis C

According to Novick (2000, 440) for those individuals who have injected drugs but have not yet acquired the hepatitis C virus, entry into methadone maintenance treatment - combined with no further drug or alcohol use -is likely to prevent infection with hepatitis C. However, MMT's overall effectiveness as a tool in primary prevention may be rather limited, given the high seroprevalence of hepatitis C virus among MMT clients/patients.

MMT is, however, an opportunity for secondary prevention. Engaging people who are hepatitis C positive in MMT creates an opportunity to provide them with education to prevent the further transmission of the hepatitis C virus²². HCV prevention is a specific and emerging field in Canada. There is increasing recognition that, as a result of a number of factors including differences in the dynamics of transmission, measures to prevent and control HCV transmission among people who are dependent on opioids may pose an even greater challenge than prevention and control of HIV transmission (Hagan & Des Jarlais, 2000, 426).

7.5.2 MMT and Treatment for Hepatitis C

MMT is a key opportunity for clients/patients who have untreated infection with hepatitis C to more easily access appropriate medical treatment (Joseph et al., 2000, 361).

High numbers of clients/patients receiving methadone maintenance treatment will be at various stages of hepatitis C infection (Novick, 2000, 441). Methadone is not necessarily contraindicated for people who are

HCV-positive (Canadian Association for Study of the Liver, 2000, 14B): an individual with stable chronic liver disease can safely continue to receive methadone maintenance treatment for many years (Novick, 2000, 440), although caution must be exercised in some specific circumstances²³. Generally speaking, MMT programs should be prepared to identify, evaluate, monitor and consider various treatment options for clients/ patients who are HCV-positive and who would benefit from treatment. For example, vaccination against hepatitis A may help prevent HCV-positive clients/patients acquiring an additional infection that could increase the risk of hepatic failure and death (Vento et al., as cited in Novick, 2000, 443).

Providers should also recognize that treatment of hepatitis C is evolving. There are many - often complex - issues in providing care, treatment and support for individuals who are hepatitis C positive. For example:

• overall, the effectiveness of current treatments is 40% (with a range of 30-65%, depending on the genotype (Canadian Association for the Study of the Liver, 2000,13B)
• there can be numerous side effects from treatment
• based on current recommendations, some clients/patients may experience conditions which make them less likely to be given treatment for HCV infection. For example, there may be clinical requirements to not provide treatment to anyone who is not abstinent from all substances (and particularly alcohol), or who has a major psychosis (Novick, 2000, 440-441; Sherman & McSherry, 1999, Q7).
• the management of co-infection with HCV and HIV is an emerging area (it is expected that forthcoming guidelines will provide further information in this area)
• access to drug coverage for hepatitis C therapies varies across Canada
• current combination treatment with interferon and ribavarin requires that clients/patients self-administer thrice-weekly injections, although new therapies may reduce this requirement to one injection per week.

Providers should be aware that there are promising new treatments which are expected to become available in the near future.

7.6 MMT and Prevention and Treatment of HIV

Methadone maintenance treatment programs offer a critical opportunity to provide disease prevention and education - including screening and counselling for transmissible diseases, and information on safe sex, the risks involved in needle sharing, and how to clean syringes(Canadian HIV-AIDS Legal Network, 1999, 58). Specific interventions could be targeted to prevention of STDs, while others could be targeted to prevention of HIV, HCV and other blood-borne pathogens. According to Leshner (1999), "Counseling on the risks of disease transmission can be effective in helping patients modify or change behaviors that place themselves or others at risk of infection." In addition, MMT is also an opportunity to provide appropriate medical care for people who are dependent on opioids and who have acquired HIV, HCV or other blood-borne pathogens (see also Section 7.5).

7.6.1 MMT and Prevention of HIV

Methadone maintenance treatment has become an important tool in reducing the transmission of HIV among injection drug users, primarily because it decreases injection drug use. According to Zweben and Pate (as cited in Canadian HIV-AIDS Legal Network, 1999, 58), methadone maintenance treatment has become a "critical resource in the struggle against injection drug use and AIDS." Effective linkages between needle exchange programs and methadone maintenance treatment programs can help maximize the benefits: "When injection drug users enter treatment programs on the recommendation of needle exchange program (NEP) staff, the number of individuals in a community who require medical care is reduced; this has an impact on drug-related morbidity" (Loue et al., as cited in Canadian HIV-AIDS Legal Network, 1999, 90).

Broers, Junet, Bourquin, Déglon, Perrin and Hirschel et al. (1998, 2059) found that prevention measures targeting drug users in Geneva -including increased access to methadone maintenance treatment - may be linked to changes in risk-taking behaviours among drug users, such as a shift away from injecting drugs to smoking or inhaling and the adoption of safer injecting behaviour. Based on a study of HIV infection in New York over a ten year period, Hartel and Schoenbaum (1998, 114) found "strong protective associations against HIV infection for high dose methadone treatment and early entry into and continuous stay in methadone treatment, independent of cocaine injecting, shooting gallery injecting, and sex with other IDUs."

7.6.2 MMT and HIV Treatment

Although methadone maintenance treatment has been shown to reduce the transmission of HIV - primarily by reducing drug injecting - people entering treatment may already be HIV-positive, or they may become HIV-positive during treatment if they or their partners continue to engage in high risk behaviours. Fingerhood (1999,118) points out that the "AIDS epidemic" means many people will need "lifetime medical care and associated support services." Fingerhood (1999, 124) also notes that there are specific issues in caring for people who are HIV-positive and receiving methadone maintenance treatment. Some of these considerations include:

• morbidity related to injection-drug use (endocarditis, abscesses and viral hepatitis)
• higher rates of bacterial pneumonia and tuberculosis
• need for compliance with drug regimen to avoid the development of viral resistance
• need for practitioners to be well-versed in providing HIV care and knowledgeable about up-to-date therapies.

Based on their detailed review of interactions between methadone and medications used to treat HIV infection, Gourevitch and Friedland (2000, 435) conclude that: "Clinicians must be informed of those interactions documented thus far, and remain alert to the possibility that other interactions, which are still undocumented may be present among their patients."

7.7 MMT and Mental Health Disorders

7.7.1 Prevalence

In their review of the assessment and treatment of comorbid psychiatric disorders among clients/patients receiving methadone maintenance treatment, King and Brooner (1999, 140-143) note that, although studies differ and can be difficult to compare, there is a great deal of evidence that indicates that people who are dependent on opioids experience high rates of mental health disorders compared to the general population. Their description of the prevalence of mental health disorders is summarized in Table 12. Please note: information about whether or not studies included both men and women was not provided.

Table 12: (based on King & Brooner, 1999, 144-146)

Prevalence of Mood Disorders

• major depression (lifetime): 15.8% - 53.9%
• major depression (current): 0% - 26.3% (lower rates may be due to length of stabilization in treatment, inclusion of people not receiving treatment, and absence of standard time frame for evaluation)
• bipolar disorder(lifetime and current): 1% (same as general population)
• dysthymic disorder: 3%-15%

Prevalence of Anxiety Disorders

• phobias (lifetime): 2.3%-9.6%
• phobias (current): as high as 9.2%
• generalized anxiety disorder (GAD) (lifetime): as high as 5.4%
• GAD (current): 1%
• panic disorder (lifetime): as high as 2%
• panic disorder (current): less than 1%
• obsessive-compulsive disorder(lifetime): less than 2% (relatively rare)
• obsessive-compulsive disorder (current): 1% or less (relatively rare)

Prevalence of Personality Disorders

• overall rate of personality disorders is high: 34.8% - 68%
• antisocial personality disorder (APD):14.5% to 54.7% (most common personality disorder)²⁴
• borderline personality disorder: 3.7%-12.1%
• avoidant disorder: 5%
• passive-aggressive disorder: 4%
• paranoid disorder: 3%

Prevalence of Other Mental health Disorders

• schizophrenia: 1-2% (relatively rare)
• eating disorders (lifetime): greater than 1% in women (current diagnosis is rare)
• posttraumatic stress disorder (lifetime): 8.3% for cocaine/opiate users (significant problem)
• attention-deficit hyperactivity disorder (ADHD): one-fifth have history of ADHD; 12% have current symptoms.

7.7.2 Gender Differences

In their review of psychiatric comorbidity among individuals who are dependent on opioids, Ward et al.(1998f, 432) cite evidence that suggests the differences in the prevalence of mental health disorders among men and women that are found in the general population are also found in the population of individuals who are dependent on opioids. For example, women who are opioid dependent experience more anxiety disorders and depressive disorders than men who are dependent on opioids. Men are more likely to be diagnosed with, for example, antisocial personality disorders. In terms of global measures of psychopathology²⁵, women who are dependent on opioids appear to have much higher levels.

7.7.3 Associated Risks

King and Brooner (1999, 162) cite research that has found individuals with comorbid mental health disorders have higher rates of drug use while in treatment; continued drug use after treatment; and other substance use behaviours. Other researchers have found a relationship between mental health disorders among people who are dependent on opioids and increased risk behaviours such as needle sharing and rates of HIV infection (Brooner et al.; Brooner et al.; Gillet al., as cited in Abbott et al., 1998, 35.)

Although identifying comorbid mental health disorders can be challenging, it can be very helpful in identifying clients/patients who are likely to require additional help - including treatment for their comorbid mental health disorders and other resources - to improve their methadone maintenance treatment outcomes (King & Brooner, 1999, 152).

7.7.4 Screening, Assessment and Diagnosis

King and Brooner (1999, 146) suggest that standardized instruments can be used to screen, assess or diagnose mental health disorders in people who are dependent on opioids. Self-completed questionnaires, such as the Beck Depression Inventory or the Symptom Checklist 90-R(SCL-90-R), can be used as screening tools. Interview instruments, such as the Addiction Severity Index (ASI), the Structured Clinical Interview for DSM-IV(SCID), or the Diagnostic Interview Schedule (DIS) can be used to assess and/or diagnose mental health disorders.

King and Brooner (1999, 148) also note that clinical evaluation without the use of these tools is still possible, but should be based on standardized diagnostic criteria such as those contained in the DSM-IV. Clinical evaluation should take into account the most common mental health problems found in this population, i.e., major depression, dysthymic disorder, APD and other personality disorders, anxiety disorders, ADHD, as well as other substance use disorders.

According to King and Brooner (1999, 150-151) a challenging aspect of diagnosing comorbid mental health disorders is making a distinction between symptoms that are substance-induced and those that are evidence of an independent mental health disorder. This requires information about increases or decreases in drug use and the impact on symptoms; the presence or absence of symptoms during periods of drug abstinence; and the presence of other medical disorders or medical treatments that may produce similar symptoms

They emphasize that: "It is vital to rule out medical or substance-induced mood changes and to treat any independent mental health disorder in order to improve a patient's ability to engage in drug abuse treatment via counselling, medication treatments, and medical management." In a study by Brooner et al. (as cited in King & Brooner, 1999, 154), 77% of those seeking treatment for opioid dependence who met the criteria for lifetime major depression had a substance induced rather than an independent disorder. The use of methadone, marijuana, caffeine, nicotine, alcohol, cocaine, benzodiazepines and other sedatives/hypnotics can present as depression or interfere with the management of depressive or manic symptoms.

7.7.5 Treatment

Delivering methadone maintenance treatment programs to people who are dependent on opioids and who also have mental health disorders is a challenging reality of service provision, given the prevalence of mental health disorders among people receiving methadone maintenance treatment (Ward et al., 1998f, 435). Methadone maintenance treatment programs which are part of a comprehensive service model can be an important link in the provision of mental health treatment services, by providing access to: a stable environment (daily attendance, clear rules, etc.); dispensing of medication for mental health disorders alongside doses of methadone; referrals to mental health or medical evaluations; adequate medical care; linkages with outside health care providers; psychotherapy or counselling; work-related activity; and mental health psycho social rehabilitation programs.

7.8 MMT in Correctional Settings

In Canada, the transmission of HIV, HCV and other blood-borne pathogens in correctional facilities is a pressing concern. Between 1994 and 1995, the number of cases of HIV/AIDS rose by 40% in a little more than one year. The rates of hepatitis C among incarcerated populations range from 28-40% (Canadian Centre on Substance Abuse & Canadian Public Health Association, 1997, 8). Estimates of HIV prevalence among incarcerated offenders range from 1-4 percent among men, and 1-10 percent among women. HIV infection among both incarcerated men and women is strongly associated with a history of injection drug use (Rothon et al.; Calzavara et al.; Hankins et al.; Hankins et al.; Dufour et al., as cited in Health Canada, 1999b, 3). Based on their research, Rothon, Mathias and Schechter (1994, 785) note that the higher rates of HIV infection among women offenders was due to a greater proportion of women reporting a history of injection drug use - an association that is "likely due to a much closer relation between drug use, prostitution and incarceration among women than among men."

Rothon, Strathdee, Cook and Cornelisse (1997, 16) found an HIV prevalence rate of 0.25% among young offenders in British Columbia. According to Rothon et al.: "Despite low HIV prevalence, our study revealed that patterns of risk behaviour such as IDU, sex for trade and sex with injection drug users are already established among incarcerated youth. It is of particular concern that IDU as equally prevalent among younger youth aged 12 to 15 compared to 16 to 19 year olds."

According to a 1997 national report on HIV, AIDS and injection drug use in Canada, many injection drug users spend time in correctional facilities as the result of either convictions for drug offences, or other convictions related to their drug use. According to this report published by the Canadian HIV/AIDS Legal Network & Canadian AIDS Society (1996, 71), there is "abundant evidence that injecting drug users are over-represented in the prison population."

In recent years, many national and international organizations have recommended providing methadone maintenance treatment programs in correctional facilities as a key strategy to reduce the transmission of HIV, HCV and other blood-borne pathogens. These recommendations are based on the evidence that MMT is effective in reducing mortality, heroin consumption, high-risk injecting behaviour (and needle-sharing), criminality, and in retaining people in treatment.

Australian researchers conducted an evaluation of Prison Methadone Maintenance Treatment (PMMT) in Australia in which they noted that, as in community settings, MMT has the same potential to reduce injection and needle sharing in prison settings. However, they also note the need to provide adequate doses of methadone - and to provide methadone for the duration of incarceration - in order to realize these benefits (Dolan et al., as cited in Canadian HIV/AIDS Legal Network & Canadian AIDS Society, 1996, 72). These researchers concluded that: "MMT has an important role to reduce the spread of HIV and hepatitis in prison."

In addition, according to Dolan, Hall and Wodak (1998, 380), "The concentration of IDUs among inmate populations suggest that provision of drug treatment within prison might be more cost-effective than in the community."

According to an information and resource package on methadone maintenance treatment produced by Correctional Service Canada (Correctional Service Canada, 1998) and based on experiences in correctional systems in other jurisdictions, providing methadone maintenance treatment contributes to:

• Reduced injecting and needle sharing in prison;
• Decreased drug-related prison violence;
• Decreased crime after release from prison;
• Reduced staff anxiety with regard to HIV transmission;
• Improved management of inmates.

The National Task Force on HIV, AIDS and Injection Drug Use (Canadian Centre on Substance Abuse & Canadian Public Health Association, 1997, 15) recommended the following actions:

• Allow offenders who have been in a methadone maintenance program prior to incarceration to continue to receive such treatment while incarcerated.
• Ensure methadone treatment is available to opioid-dependent offenders who were not receiving it prior to incarceration.
• Evaluate the need for methadone maintenance therapy prior to release into the community, and ensure priority transfer to community programming at release.

In its report, the Canadian HIV/AIDS Legal Network (1999, 90) recommended that correctional systems should ensure that offenders who were in a methadone maintenance program prior to incarceration are able to continue methadone maintenance treatment while incarcerated, and that those who are able to start such treatment while incarcerated can do so whenever they would have been eligible for it outside.

According to their summary, Dolan et al. (1998, 382, 390-391), suggest that there are a number of different points at which methadone should be provided to inmates including:

• Entry into the correctional facility. Since so many IDUs are incarcerated, opioid withdrawal is very common. Methadone can be used to treat opioid withdrawal.
• During incarceration. There are much higher rates of injection-related risk behaviours in prison, and methadone maintenance probably helps reduce the transmission of HIV (although documented evidence of HIV transmission is difficult to obtain). Other prevention strategies such as syringe exchange and bleach programs are either not commonly available in prison settings or are not particularly effective (Dolan et al., 1998, 383-384, 389). Programs are needed for IDUs who enter prison as well as those who begin injecting drugs while in prison.
• Pre-release. Providing methadone to IDUs nearing release can increase tolerance and reduce risk of overdose, reduce illegal activity after release, and reduce likelihood of reincarceration (Dolan et al., 1998, 382).

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