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A Qualitative Study on Reasons for Relatively Low Methadone Dosing among Persons who Inject Drugs in Three Provinces in China Presenter: Lifeng Han, U.S. CDC-GAP China

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  1. A Qualitative Study on Reasons for Relatively Low Methadone Dosing among Persons who Inject Drugs in Three Provinces in China • Presenter:LifengHan, U.S. CDC-GAP China • Co-authors: Zhijun Li, Wei Luo, Marc Bulterys, Fang Yang, RongjianLi, LimeiShen, Serena Fuller, ZunyouWu

  2. Background (1) No. of Clinics • Drug use is an important risk factor and driver of the HIV/AIDS epidemic in China. • 1.03 million registered DUs in 2003 • In 2003, 44% of HIV+ infected via IDU • Methadone maintenance treatment (MMT) began as a small pilot project with 8 clinics in 2004. • Since then, the national MMT program has been rapidly scaled up. No. of Cumulative Clients

  3. Background (2) • However, methadone maintenance dose for many clients is lower than the recommended dose(60 -100mg) by Chinese National Guidelines on MMT Clinical Management. • Lower methadone dosing may result in higher drop-out and continued risk behavior. On average, 7.8% of MMT clients are infected with HIV and 60% are infected with HCV.

  4. Background (3) • In 2009, PEPFAR supported China CDC and GAP China to conduct a public health evaluation (PHE) “A Methadone Maintenance Treatment Outcome Study in Three Provinces in China.” • The study is led by Drs. Zunyou Wu, Marc Bulterysand Zhijun Li. • The purpose is to evaluate the impact of an intensive health care provider training program combined with expanded services on treatment retention, methadone dosing, and heroin use

  5. Background (4) • The qualitative study presented here was conducted during July and August 2011 to determine reasons for current dosing practices and for drug users to stay in and drop out of MMT. • Results informed questionnaire and training material development for the cluster-randomized trial which started in March 2012.

  6. Methods GZ 4 MMT clinics GX 3 MMT clinics GD 3 MMT clinics • All interviews were conducted using an open-ended question guide and lasted between 30 to 60 minutes. • All interviews were tape recorded and transcribed with respondents’ permission. • Transcripts were analyzed using a coding scheme and thematic sorting. 13 former clients 18current clients 6 family members 18 MMT providers • Clients & Family • Expectations • Perception & experience • Reasons for drop-out • Providers • Training & work experience • Patterns of dose determination & adjustment • Obstacles to increasing dosage

  7. Results (1) • Expectations and perception of MMT • Most clients did not view drug users as patients with a chronic disease in need of long-term treatment. • They viewed MMT as a new type of detoxification and expected MMT to end their drug use in a short time. • Many clients thought that methadone was more addictive and toxic than heroin, methadone withdrawal was more severe and long-lasting.

  8. Results (2) • Clients’ experience with MMT • Little communication between providers and clients about MMT dosing and psychosocial support. • Most clients thought an adequate dose was one that prevented withdrawal. • In many cases, dose adjustment was based on client request. • Peer influence also played an important role in clients’ perception of MMT and their own adherence. • Most clients requested to decrease dose after 2 to 3 months of treatment.

  9. Results (3) • Reasons for dropping out of MMT • Expectations and perception contributed to clients’ preference for lower and tapering methadone dosing • Insufficient counseling and psychosocial support • Structural factors such as inadequate local police support, clinic open hours, clinic physical location, and number of clinic staff

  10. Results (4) • Training and experience of providers • Many doctors did not have previous work experience in psychiatry or with drug users. • Some doctors did not receive adequate training in MMT. • Patterns of dose determination and adjustment • Maintenance dose of 40-50 mg reached within 5-7 days. • Most doctors adjusted dose based on client request or on symptoms only. Craving, illicit drug use, and its euphoric effects were not taken into account. • Some doctors believed in tapering dose after several months with negative urine tests. • Some doctors thought they were too busy to educate clients.

  11. Results (5) • Obstacles to increasing dosage • Lack of experience and insufficient training led to client-dominated, lower methadone dosing and the common misperception “the lower dose, the safer and better for patients.”

  12. Conclusions • Factors contributing to lower methadone dosing and retention in MMT include: • Clients’ expectation and perception of MMT • MMT providers’ limited experience and training in MMT • Recommendations • To improve capacity building for providers • To strengthen education and counseling of clients and their family members

  13. Acknowledgements • Co-authors • Zhijun Li, Wei Luo, Marc Bulterys, Fang Yang, Rongjian Li, LimeiShenSerena Fuller, ZunyouWu • GAP China staff • Chin-YihOu, Mingshan Qi, Lijun Wang • NCAIDS staff • Jiangping Sun, Keming Rou • Three provincial CDC staff • Peng Lin, Zhang Li, Yongming Yao, Lei Fan, Yaohui Liu, Zhenzhu Tang, Wei Liu • Local CDC staff and participants

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