PEPFAR

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 Co-authors: Zhijun Li, Wei Luo, Marc Bulterys, Fang Yang,

Rongjian Li, Limei Shen, Serena Fuller, Zunyou Wu

AIDS 2012 - Turning the Tide Together

Background (1)

• 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 Clinics

No. of Cumulative Clients

2004 2005 2006 2007 2008 2009 2010 2011 20120

100200300400500600700800

858

320

503600

680 701 738 748

2004 2005 2006 2007 2008 2009 2010 2011 20120

50000

100000

150000

200000

250000

300000

350000

400000

1209 811637345

97554

178684

241975

295182

344254361894

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.

Year The number of clients accumulatively

The number of clients still in treatment

The average methadone dose (mg)

2004 1209 2005 8116 2006 37345 26166 2007 97554 57947 482008 178684 93773 522009 241975 112831 542010 295182 122032 572011 332996 132979 59

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 Bulterys and 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

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.

Methods• 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.

GZ4 MMT clinics

GX3 MMT clinics

GD3 MMT clinics

13 former clients18 current 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

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.

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.

Results (3)

• Reasons for dropping out of MMTExpectations 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

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.

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.”

Conclusions

• Factors contributing to lower methadone dosing and retention in MMT include:Clients’ expectation and perception of MMTMMT providers’ limited experience and training in

MMT• Recommendations

To improve capacity building for providersTo strengthen education and counseling of clients

and their family members

Acknowledgements• Co-authors

Zhijun Li, Wei Luo, Marc Bulterys, Fang Yang, Rongjian Li, Limei Shen Serena Fuller, Zunyou Wu

• GAP China staff Chin-Yih Ou, 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