Service providers’ adherence to methadone maintenance treatment protocol in China

Abstract

Background

Methadone maintenance treatment (MMT) programs have expanded rapidly in China during the last decade. However, variance in service providers’ practice may have an impact on the quality of care received by the patients. This study examined Chinese service providers’ adherence to the MMT protocol and its associated factors.

Methods

The study used baseline data from a randomized intervention trial implemented in MMT clinics in five provinces of China. The data were collected from January 2012 to August 2013. A total of 418 service providers from 68 MMT clinics participated in the study. Demographic and job-related characteristics were collected. The providers’ adherence to the MMT protocol, MMT knowledge, negative attitudes towards people who use drugs (PWUD), and perceived institutional support were assessed.

Results

The average adherence score was 36.7 ± 4.3 (out of 9–45). Fewer providers adhered to the protocol items where communications with patients or families were required. After controlling for potential confounders, adherence to the MMT protocol was positively associated with perceived institutional support (standardized β = 0.130; p = 0.0052), and negatively associated with prejudicial attitudes towards PWUD (standardized β = −0.357; p < 0.0001). Reception of national-level MMT training was not associated with higher level of adherence to protocol.

Conclusion

The findings suggest the potential benefits of providing institutional support to MMT providers to enhance their level of adherence to the MMT protocol. Intervention effort is needed to reduce negative attitudes towards PWUD among MMT service providers to achieve greater consistency with best-practice recommendations.

Introduction

A large body of literature has shown the efficacy of methadone maintenance treatment (MMT) for treatment of drug addiction and subsequent reduction in HIV risk behaviors and infection (Avants, Margolin, Usubiaga, & Doebrick, 2004; Sullivan, Metzger, Fudala, & Fiellin, 2005). In acknowledgment of the evidence, the Chinese government called for the use of MMT programs to mitigate opiate use and HIV epidemic in the country in 2004 (Sullivan et al., 2015). An evaluation of the pilot programs has shown a reduction in heroin use and drug-related crime and an increase in employment and healthy family relationships among the patients (Pang et al., 2007). The success of the pilot programs has led to a rapid scale-up of the MMT system in China, expanding from the initial eight pilot clinics to 785 clinics in 28 provinces by the end of 2015 (National Center for AIDS/STD Control and Chinese Center for Disease Control and Prevention, 2016). Despite the progress that MMT programs have made in the country, MMT providers are facing challenges that reduce the efficacy of the programs, including lack of training, inadequate knowledge and skills in addiction treatment, misunderstanding about the goals of harm reduction, as well as confusion regarding management of comorbidities (Lin et al., 2010; Yin et al., 2010). Although the Chinese government has issued national guidelines and clinical protocols for management of MMT patients (China Ministry of Health and China Ministry of Public Security and China Food and Drug Administration, 2006), the adherence with the practice guideline is highly variable (Yin et al., 2010). For example, even though the national guideline recommended 60–80 mg daily dose for maintenance stage patients, MMT providers in China usually prescribed a lower than suggested dosage (Sullivan et al., 2015). Some physicians even adjust MMT dosage based on patients’ demand (Lin & Detels, 2011). The uncertainties in medical practice and the gap between the best-practice recommendations and clinical practice may contribute to high patient drop-out rate and suboptimal treatment outcomes (Cao et al., 2014; Shen et al., 2016).

Treatment protocols are considered as one of the most influential and effective tools to promote evidence-based medicine (Grol & Grimshaw, 2003; Saja, 2013). Effective implementation of treatment protocol was found to improve the quality of care by reducing practice variation, improve clinical outcomes, and reduce the frequency of monitoring and healthcare cost (Mazrou, 2013). A study was conducted in the U.S. Veterans Affairs (VA) health system to examine the impact of consistent adherence to guideline recommendations in drug treatments. It was reported that patients attending clinics where guidelines were more consistently adhered to had a greater reduction in heroin and cocaine use than those attending less guideline-adhered clinics (Trafton, Humphreys, Harris, & Oliva, 2007). Nonetheless, compliance with clinical practice guideline is challenging as it depends on a variety of factors (Quaglini, 2008). Previous studies conducted in the U.S., Canada, European, and African countries have revealed several reasons for physician’s non-adherence to clinical guidelines, including lack of awareness or familiarity with the recommendations, perceived usefulness of the guideline, disagreement with the guidelines, or perceived difficulties in applying the guideline in daily practice (Amoakoh-Coleman et al., 2016; Arts, Voncken, Medlock, Abu-Hanna, & van Weert, 2016; Cabana et al., 1999; de la Sierra, Zamorano, & Ruilope, 2009; Quaglini, 2008). It was also reported that physician’s compliance with clinical guidelines depended on their personal beliefs and attitudes, availability of support system, and training in clinical guidelines (Sharif, Samara, Titi, & Awartani, 2015).

Despite the efforts to scale up the MMT clinics in China, there is currently a paucity of information regarding how adherent are MMT providers to the guidelines in the country. Even though the factors involved in physician’s adherence to guideline have been extensively studied in Western countries for chronic conditions and in emergency care settings (Arts et al., 2016; Ebben et al., 2013), limited studies have been conducted in MMT settings in China. To fill the gap in the literature, the study was conducted to document Chinese MMT providers’ level of adherence to clinical guidelines and to assess various factors that are associated with the level of provider adherence. The findings of this study will help to develop strategies for effective guideline adherence and management for MMT programs in China.