A qualitative study exploring the reason for low dosage of methadone prescribed in the MMT clinics in China

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Abstract

Objectives

Dosage of methadone maintenance therapy (MMT) is an important factor influencing retention in methadone treatment. MMT clients in China received lower dosages of methadone compared with those provided in other countries. The objective of this study is to elucidate the reason for the low methadone dosage prescribed in MMT clinics in China.

Methods

Twenty-eight service providers were recruited from the MMT clinics in Zhejiang and Jiangxi Provinces, China. Qualitative in-depth interviews were conducted to ascertain the procedure for prescribing methadone in the MMT clinics.

Results

The average dosage prescribed in the 28 clinics was 35 mg/person/day. Four major themes resulting in low dosage of methadone were identified: (1) the service providers fear the liability resulting from large doses of methadone in combination with other substances which might result in overdose fatalities, (2) lack of understanding of harm reduction which resulted in low acceptance of the long term maintenance treatment approach, (3) break-down in communication between clients and service providers about dosage adjustment, and (4) dosage reduction is perceived by most service providers as an effective way to treat the side-effects associated with MMT.

Conclusions

The findings of the study highlighted the necessity to formulate clear guidelines concerning individualized dosage management and to improve training among service providers’ in MMT clinics in China.

Introduction

Methadone is a long-acting, orally administered synthesized analgesic drug used to treat cancer pain (Joseph et al., 2000). Since Dole and Nyswander (1965) proposed methadone as substitution treatment for heroin addiction in 1965, methadone maintenance therapy (MMT) has become a first-line treatment for opioid addiction. Methadone can be taken once a day to reduce craving for heroin and to suppress opioid withdrawal, thereby freeing the patient from the daily cycle of seeking out, buying, and using heroin (Ward et al., 1999, Joseph et al., 2000). Substantial evidence has shown that MMT is effective in reducing the morbidity and criminality associated with heroin abuse (Gossp et al., 2005, Flynn et al., 2003, Loughlin et al., 2004). Studies worldwide have also confirmed that MMT plays a crucial role in prevention of the transmission of blood borne diseases (Metzger et al., 1993, Thiede et al., 2000).

Many studies have found that methadone dose is an important factor influencing retention in methadone treatment. Some systematic reviews have reported higher rates of dropout among those who received lower doses of methadone (Amato et al., 2005, Bao et al., 2009, Faggiano et al., 2003). Several randomized controlled trials have also supported the findings by showing that higher doses of methadone were associated with significantly longer retention (Ling et al., 1996, Preston et al., 2000, Strain et al., 1999). The U.S. National Institutes of Health (NIH) Consensus Conference guidelines for methadone substitution therapy thus recommend that a dose of 60 mg is the minimum effective maintenance dose for most patients (NIH Consensus Conference, 1998). In most of countries, methadone is prescribed in dosages of 60–80 mg/day (Kimber et al., 2005).

MMT was initiated in China in 2004 (Pang et al., 2007). With the success of the pilot clinics, the MMT program has been rapidly scaled up in China. As of December 2009, 680 MMT clinics had been established nationwide in 27 provinces cumulatively serving more than 240,000 clients. The clinics are under the leadership of a national working group, consisting of members of the Ministries of Health, Public Security, and the State Food and Drug Administration. The national Working Group has overall responsibility for administration, planning, supervision and evaluation. Corresponding working groups have been organized at the provincial and county levels to take on these duties locally. MMT clinics are non-profit medical facilities assigned by local public security and public health departments to be established and operated by local Centers for Disease Control and Prevention (CDC), hospitals, or voluntary detoxification centers in areas with a concentration of drug users (Yin et al., 2010). Typically, each MMT clinic is required to have 8–10 staff members. Doctors are primarily responsible for prescribing methadone, providing physical examination, and psychological counselling, and they are required to be certified physicians authorized to prescribe analgesic and psychotropic drugs. A nurse is responsible for dispensing methadone to the clients and observing them taking the methadone. Other clinic staff members are responsible for data entry, management, report and other logistical issue. One or two security personnel are required for each of the MMT clinic (Ministry of Health, Ministry of Public Security of China, and SFDA, 2006).

MMT clients in China receive lower dosages of methadone compared with patients treated in other countries (Sullivan and Wu, 2007). The average daily dosage of methadone given to Chinese clients in eight pilot MMT clinics was 44.9 ± 21.9 mg (Pang et al., 2007). A prospective cohort study among 1003 clients has reported that the average methadone dose for all participants was 38.0 mg/day, and 79.4% of participants received lower than 50 mg/day (Liu et al., 2009). Lower dosages compared with what has been suggested optimal in other counties may contribute to the high drop-out rate in China (Pang et al., 2007, Sullivan and Wu, 2007). This study used qualitative methods to elucidate the reason for the low methadone dosages prescribed by service providers working in MMT clinics in China. The findings from this study would shed lights on the formulation of strategies to improve MMT program in China.

Section snippets

Study sites

The study was conducted in Zhejiang and Jiangxi Provinces, China (Fig. 1). Zhejiang Province is located on China's south-eastern coast, and covers a total land area of 101,800 sq km. It had a population of 51.8 million at the end of 2009. Zhejiang is a relatively wealthy coastal province with advanced educational and health care systems. The gross domestic product (GDP) was 2.28 trillion yuan in 2009 (The People's Government of Zhejiang Province, 2010). Jiangxi Province is one of China's inland

Results

At entry into treatment, the doctors initially prescribed a medication dosage on the basis of client report of drug usage that minimizes sedation and other undesirable side-effects, usually not more than 50 mg. Then the doctors started assessing the safety and adequacy of each dose from the second day of treatment and adjusted the methadone dosage according to the client's self-reported withdrawal symptoms, side effects, concurrent drug use and urine morphine test result. The average dosage

Discussion

Because of the rapid implementation of the MMT program in China and the apparent lack of sufficient experiences, currently there is no systematic and clear guideline regarding MMT dosage adjustments in China. Researchers in other countries have recommended that methadone doses be individualized and flexible, as there is no single best dose for all patients (Leavitt et al., 2000, Trafton et al., 2006). Bao et al. (2009) suggested that retention will be greatest when the dosing strategy is

Role of funding source

This project is funded through the UCLA/Fogarty AIDS International Training & Research Program, D43 TW000013. The Fogarty AIDS International Training & Research Program had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Contributors

Dr. Chunqing Lin designed the study, collected the data and wrote the draft of the manuscript. Dr. Roger Detels supervised the implementation of the study. All authors contributed to and have approved the final manuscript.

Conflict of interests

All authors declare that they have no conflicts of interest.

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