Methadone Replacement Therapy Program – Klinik Kesihatan Salak

experience

P. Fuziah MMed, I. Ruhaini MPH, M. Nurhana BPharm, A. Nur Ariza

BPharm,

Introduction

• Methadone Replacement Therapy (MRT) was started in Malaysia in 2005

• Started in KK Salak in May 2007

• The program was implemented according to guideline given by Ministry of Health

• Helps from AADK for counseling ( 2-4 counseling sessions per patient)

• No dedicated clinic

• Integrate into daily clinic in OPD

Introduction

• Duration of MRT program : 4 years 4 months• Difficulties in doing activities as most of the

patients said that they are busy working even during week end.

• No public transport ( nearest bus stop 500m)• Managed to do a few “ gotong royong”, meeting ,

“ ceramah agama”. ( Poor attendances 20-30 patients)

• Therefore, evaluation of the program need to be done.

Objective

• To identify the demographic data and characteristics of heroin addicts in MRT program

• To determine the retention rate

• To determine the impact of MRT to prevention of blood borne virus infection

• To assess the quality of life (WHOQOL-BREF) after starting on MRT program

Methodology• Universal sampling, retrospective study• Inclusion criteria

- All patients registered in MRT program KK Salak-For WHOQOL- BREF : Patients registered and now under follow up in KK Salak at least 6 months in the program

• Exclusion criteria ( For WHOQOL BREF)- Transfer in patients, Transfer out patients, Defaulters

• Baseline QOL obtained from baseline WHOQOL-BREF taken at initiation of treatment

• Current QOL obtained from 14th September 2011 to 21st Sept 2011

• Baseline and current QOL were compared

Analysis

SPSS 17i) Descriptive analysis of all the cases registered for MRTii) WHOQOL BREF

-Paired t-test-Data were discarded if > than 20% missing-4 domains(Physical, psychological, social

relationship and Environment)-Calculation of the scores was based on: the WHO manual and transformation of domain scores to WHOQOL 100 (WHOQOL-BREF transformation table).

iii) Retention rate = No of active pt

No of registered patient –T/O-D/T/S

MRT Registration

Year Registration Total(cumulative)

2007 17 17

2008 20 37

2009 34 72

2010 10 82

2011 2 84

Source of referral

Source of referral No Percentage (%)

AADK 7 8.3

Walk in 31 36.9

Friend 43 51.2

NGOs -

NSEP -

Others 3 3.6

Total 84 100

Baseline Demographic dataCharacteristic No % Other studies

Sex Male 82 97.6 Jessica DE Maeyer te al 2010 (78.9%), ŽilvinasPadaiga et al 2007 (77.5%), Joseph O. Merrill et al 2005 (70%), Nasir M et al 2010 (100%)Female 2 2.4

Age <20 - Mean age: 37.01 yrs old , SD 7.92 (23-56)- Jessica De Maeyer te al 2010 (36.6 yrs old)

-Joseph O. Merrill et al 2005 ( 45 yrs old)-Norsiah et al 2010 ( 39.4 yrs old)Nasir Mohammad et 1l 2010 (33 yrs old)

20-29 13 15.5

30-39 42 50.0

40-49 22 26.2

≥50 7 8.3

Race Malay 77 91.7 Norsiah et al 2010 (94.4%)

Chinese 4 4.8

Indian 3 3.5

Others - -

Demographic data (n= 84)No % Other studies

Maritalstatus

Single 35 41.7 MarriedJoseph O. Merrill et al 2005 (53%)Norsiah et al 2010 (46.2%)Adline et al 2009 ( 50.0%

Married 42 50.0

Divorced 7 8.3

Education(Secondary school 86.9%)

Primary 5 5.9 Secondary school-Norsiah et al 2010 (88.11%)-Adline et al 2009 ( 84.8%)

Secondary 22 26.2

PMR/LCE 21 25.0

SPM/MCE 30 35.7

STPM/Diploma 1 7.2

Occupation(Working 83.2%)

Unemployed 10 11.9 EmployedJoseph O. Merrill et al 2005 ( 83%)Norsiah et al 2010 ( 81.1%)Adline et al 2009 ( 82.6%)

Odd jobs 22 26.2

Part time job 21 25.0

Full time job 31 36.9

Result

Reason for addiction (n=84)* Reason may be > 1

No Peratus(%)

Influence by friend 48 58.5

Try 42 51.2

Stress 7 8.5

Family problem 6 7.3

Others - -

Result

Investigations No Percentage(%)

Other studies

LFT normal 43 53.1 Norsiah et al 2010 ( HCV 83.2%, Hep B 5.6%, HIV 18.9%),

Syed Wasif et al 2009 ( HCV 76.3%, Hep B 3.3%, HIV 2.3%, LFT abnormal 37.7%)

Malliori M et al 1998 ( HBV 60%)

Nasir Mohammad et al 2010 ( 36% HIV)

Neshin S. et al 1993 (HBV 80%)

LFT abnormal 38 46.3

HIV reactive 10 12.2

HIV NR 71 86.6

HbsAg Reactive 4 4.9

HbsAg NR 77 93.9

Anti HCV detected 66 81.5

Anti HCV not detected

15 18.5

Outcome

• Transferred out: 12 ( 14.3%)

• Defaulter: 20 patients (23.8%) Jessica De Maeyer 2011 (

25.8%), Padiaga Z 2007 ( 30.0%)

• Terminated from the program: 1 patient

• Died: 3 patients ( 2 had MVA, 1 pt HIV and died at home)

• 2 patients stopped Methadone:

- 1 pt released from “Penjara” and came for f/U , refused Methadone

-1 patient had MVA and bed ridden

Retention rate

72.2%Ramli et al 2009 ( 63%)

Cochrane database ( 11 relevant studies) 1998 (68%)

Nasir Mohammad et al 2010 (54.69%)

A.Norsiah et al 2010 ( >90%)

WHOQOL-BREF

• 46 patients eligible for WHOQOL-BREF analysis

• 3 patients were discarded ( 1 pt nobaseline WHOQOL-BREF, 2 pts, > 20%data missing

• Respondent rate: 93.5%

Length of treatment with Methadone

Duration N %

0-6 month 0 0%

7-12 months 4 9.3%

>1 year-2 years 10 23.3%

>2 years – 3 years 13 30.3%

> 3 years -4 years 13 30.3%

> 4 years – 5 years 3 7.0%

Total 43 100%

Result

• Onset of heroin addiction: Mean age 20.9 yrsold ( max 32 yrs old, min 15 yrs old) SD 3.9

Jessica De Maeyer te al 2010 (21.0 yrs old),

Joseph O. Merrill et al 2005 (20. 0 yrs old)

Nasir Mohammad et al 2010 ( 20.0 yrs old)

• Duration of addiction:

Mean 15.7 years ( max 35 yrs min 3 yrs) SD 8.73

- Jessica De Maeyer et al al 2010 ( 10.8 years)

- Nasir Mohammad et al 2010 ( 13 years)

Results

• Occupation: Full time (86%), part time (4.7%), unemployed(9.3%)

• Education : Secondary school (23.3%), PMR (41.9%), SPM (32.6%), HSC (2.3%)

• Religion : 95.3% Muslim

• Mean age : 37.1 (23-56 years old)

• Age : 20-30 (27.9%), 31-40 (39.5%), 41-50(25.6%) >50 (7.0%)

• Marital status: married (64.4%), single (27.9%), divorced(4.7%)

Current Methadone dose

• Current Methadone dose

-Max 135 mg (HIV on HAART)

-Min 20 mg

-Mean 54 mgWHO recommended 60-80 mg maintenance dose

Nasir Mohammad et al 2010 ( mean 57.6 mg)

Repeat HIV ELISA, HbsAg and anti HCV

Test Baseline Repeat Not done

HIV NR 40 40

R 3 -

HbsAg NR 41 38 3

R 2 -

AntiHCV NR 4 2 2

R 39 -

3 pts HbsAg and 2pts antiHCV not done –difficulty in taking bloodNorsiah et al 2010: No new blood borne virus infection

WHOQOL-BREFWHOQOL - BREF Mean SD t P value 95% Confidence

interval

Lower Upper

Domain 1(Physical)

Baseline 49.00

Follow up 62.77

Mean diff 13.77 14.35 6.29 <0.001 18.18 9.35

Domain 2(Psychological)

Baseline 48.95

Follow up 64.88

Mean diff 15.93 14.75 6.99 <0.001 20.53 11.33

Domain 3(Social)

Baseline 51.32

Follow up 69.32

Mean diff 18.00 24.53 4.81 <0.001 25.55 10.45

Domain 4(Environment)

Baseline 54.74

Follow up 66.81

Mean diff 12.07 11.32 6.91 < 0.001 15.59 8.54

Discussion

• Padiaga Z et al 2007 ( improve in physical, psychological and environment but not social domain)

• Norsiah et al 2010 (improve in all the domain)

• Lin Xiao et al 2010 ( Physical and mental health improve)

Conclusion

• Majority of the patients were Malay, male with mean age 37.1 years old.

• Methadone maintenance treatment had a positive and statistically significant effect on drug-dependent patients’ quality of life (physical, psychological, social and environmental).

• Methadone Replacement Therapy able to prevent from infection of blood born viruses

Limitation

• Small sample for the WHOQOL (n=43)

• 3 patients repeat HbsAg not done (difficult blood taking) and 2 patients antiHCV not done

• WHOQOL analysis done with variable duration of recruitment in MRT program

Recommendation

• MRT showed improvement in quality of life and more primary care clinic should start the program – more accessible

• Moderate retention rate with high defaulters-need further evaluation in term of transportation, family support and cooperation from employer

• To get more support and involvement from community eg Panel Penasihat Kesihatan, NGO and other related agencies

Referrences

1. Jessica De Maeyer et al 2011, Current quality of life and it’s determinants among dependentindividuals five years after atarting methadone treatmentQual Life Res (2011) 20:139–150

2. A.Norsiah et al, Can Primary Care Clinic run MMT service well? Malaysian Family Physician 2010; vol 5No1

3. WHOQOL- BREF: WHO 2004

4. WHO –BREF Introduction, Administration, Scoring and Generic version of the assessment

5. Adeline Gong W.H. et al, Quality of life assessment of opioid substance abusers on methadonemaintenance therapy ( MMT) in University Malaya Medical centre. ASEAN Journal of psychiatry vol. 10 (1) jan-June 2009

6. Žilvinas Padaiga, Emilis Subata1, Giedrius Vanagas, Outpatient methadone maintenance treatmentprogram.Quality of life and health of opioid-dependent persons in Lithuania, Medicina (Kaunas) 2007;43(3)

7. Lin Xiao et al , Quality of Life of Outpatients in Methadone Maintenance Treatment Clinics. AcquirImmune Defic Syndr, Vol 53, Supplement 1, Feb 1 2010. Neshin S. HIV and other infectious diseases. In:Parrino

8. MW. State methadone treatment guidelines.Rockville, Md.: U.S. Department of Health and HumanServices, Public Health Service, Substance and Mental Health Services Administration, Center forSubstance Abuse Treatment. Treatmentimprovement protocol (TIP) series, 1993; DHHS

publication no. (SMA) 93-1991:95-118.

Referrences

8. Malliori M, Sypsa V, Psichogiou M, Touloumi G,Skoutelis A, Tassopoulos N, et al. A surveyof bloodborne viruses and associated risk behaviours in Greek prisons. Addiction1998;93:243-51.

9. Marsch LA. The efficacy of methadone maintenance interventions in reducing illicitopiate use, HIV risk behavior and criminality: a meta-analysis. Addiction. 1998;93(4):515-32.

10. Ramli M, Nora MZ, Zafri AAB, et al. High risk behaviors and concomitant medicalillnesses among patients at methadone maintenance therapy clinic, Hospital TengkuAmpuan Afzan, Malaysia. Malaysian Family Physician. 2009;4(2&3):77-82.

11. Nasir Mohamad et al 2010 Better retention of Malaysian opiate dependents

treated with high dose methadone in methadone maintenance therapy. Nasir Mohamad etal. Harm Reduction Journal 2010, 7:30

12. Syed Wasif Gillani, Syed Azhar Syed Sulaiman, Chronic Infections and ManagementSetting in Drug Addicts of MMT Program in Pinang, MalaysiaInternational Journal ofCollaborative Research on Internal Medicine & Public Health, Vol. 1 No. 2 (April 2009)

pp. 48-54

13. Adeline Gong Wooi Huong et al , Quality of life assessment of opioid substance abuserson methadone maintenance therapy (MMT) in University Malaya Medical CentreASEANJournal of Psychiatry Vol.10(1): Jan - June 2009

Acknowledgement

• Thanks to all the staffs involved in Methadone Replacement Therapy Program

Thank You

Addiction

Perkara Butiran Bilangan Peratus(%)

Types of addiction Heroin 82 100

Morfin 6 7.3

Cannabis 37 45.1

ATS 17 20.7

Benzodiazepine 14 17.1

Cordein 6 7.3

Hidu gam 4 4.9