Randy Seewald

A Randomized Trial of a Hepatitis Care Coordination Model in Methadone Maintenance Treatment

OBJECTIVES We evaluated the efficacy of a hepatitis care coordination intervention to improve linkage to hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination and clinical evaluation of hepatitis C virus (HCV) infection among methadone maintenance patients. METHODS We conducted a randomized controlled trial of 489 participants from methadone maintenance treatment programs in San Francisco, California, and New York City from February 2008 through June 2011. We randomized participants to a control arm (n = 245) and an intervention arm (n = 244), which included on-site screening, motivational-enhanced education and counseling, on-site vaccination, and case management services. RESULTS Compared with the control group, intervention group participants were significantly more likely (odds ratio [OR] = 41.8; 95% confidence interval [CI] = 19.4, 90.0) to receive their first vaccine dose within 30 days and to receive an HCV evaluation within 6 months (OR = 4.10; 95% CI = 2.35, 7.17). A combined intervention adherence outcome that measured adherence to HAV-HBV vaccination, HCV evaluation, or both strongly favored the intervention group (OR = 8.70; 95% CI = 5.56, 13.61). CONCLUSIONS Hepatitis care coordination was efficacious in increasing adherence to HAV-HBV vaccination and HCV clinical evaluation among methadone patients.

An integrated relapse prevention and relationship safety intervention for women on methadone: testing short-term effects on intimate partner violence and substance use.

This study tests the feasibility, safety, and short-term preliminary effects of a relapse prevention and relationship safety (RPRS) intervention in reducing drug use and the experience of intimate partner violence (IPV) among women on methadone. For this randomized controlled trial, 34 women who met IPV and drug use criteria were randomly assigned to either the RPRS condition (n = 16) or a one-session informational control (IC) condition (n = 18). RPRS participants were more likely than IC participants to report a decrease in minor physical or sexual IPV (OR = 7.1, p = .05), minor psychological IPV (OR = 5.3, p = .03) and severe psychological IPV (OR = 6.07, p = .03) at the 3month follow-up. Data suggest that RPRS participants were also more likely than IC participants to report a decrease in any drug use at 3 months (OR = 3.3, p = .08). This study provides preliminary evidence that the RPRS intervention is effective in reducing IPV and drug use among women on methadone.

Perceptions of drug users regarding hepatitis C screening and care: a qualitative study.

BackgroundIllicit drug users have a high prevalence of HCV and represent the majority of newly infected persons in the U.S. Despite the availability of effective HCV treatment, few drug users have been evaluated or treated for HCV. Racial and ethnic minorities have a higher incidence and prevalence of HCV and higher HCV-related mortality. Factors contributing to poor engagement in care are incompletely understood.MethodsFourteen mixed-gender focus groups of either African American or Latino/a drug users (N = 95) discussed barriers to HCV testing and treatment. Themes were identified through content analysis of focus group discussions.ResultsMany drug users were tested for HCV in settings where they were receiving care. Outside of these settings, most were unaware of voluntary test sites. After testing HCV positive, drug users reported not receiving clear messages regarding the meaning of a positive HCV test, the impact of HCV infection, or appropriate next steps including HCV clinical evaluations. Many drug users perceived treatment as unimportant because they lacked symptoms, healthcare providers minimized the severity of the diagnosis, or providers did not recommend treatment. Mistrust of the motivations of healthcare providers was cited as a barrier to pursuing treatment. Social networks or social interactions were a source of HCV-related information and were influential in shaping drug users perceptions of treatment and its utility.ConclusionDrug users perceived a paucity of settings for self-initiated HCV testing and poor provider-patient communication at test sites and during medical encounters. Notably, drug users reported having an unclear understanding about the meaning of a positive HCV test, the health implications of HCV infection, the importance of clinical evaluations and monitoring, and of treatment options for HCV. Efforts to improve the delivery of clinical messages about HCV infection for drug users at test settings and clinical encounters are needed.

Epidemiology of Pain among Outpatients in Methadone Maintenance Treatment Programs

BACKGROUND This analysis explored the prevalence and correlates of pain in patients enrolled in methadone maintenance treatment (MMT). METHODS Patients in two MMT programs starting a hepatitis care coordination randomized controlled trial completed the Brief Pain Inventory Short-Form and other questionnaires. Associations between clinically significant pain (average daily pain≥5 or mean pain interference≥5 during the past week) and sociodemographic data, medical status, depressive symptoms, and health-related quality of life, and current substance use were evaluated in multivariate analyses. RESULTS The 489 patients included 31.8% women; 30.3% Hispanics, 29.4% non-Hispanic Blacks, and 36.0% non-Hispanic Whites; 60.1% had hepatitis C, 10.6% had HIV, and 46.8% had moderate or severe depressive symptomatology. Mean methadone dose was 95.7mg (SD 48.9) and urine drug screening (UDS) was positive for opiates, cocaine, and amphetamines in 32.9%, 40.1%, and 2.9%, respectively. Overall, 237 (48.5%) reported clinically significant pain. Pain treatments included prescribed opioids (38.8%) and non-opioids (48.9%), and self-management approaches (60.8%), including prayer (33.8%), vitamins (29.5%), and distraction (12.7%). Pain was associated with higher methadone dose, more medical comorbidities, prescribed opioid therapy, and more severe depressive symptomatology; it was not associated with UDS or self-reported substance use. CONCLUSIONS Clinically significant pain was reported by almost half of the patients in MMT programs and was associated with medical and psychological comorbidity. Pain was often treated with opioids and was not associated with measures of drug use. Studies are needed to further clarify these associations and determine their importance for pain treatment strategies.

Assessment of methadone clinic staff attitudes toward hepatitis C evaluation and treatment.

We used a 25-item, self-administered questionnaire to assess staffs perceived barriers and willingness to engage in onsite treatment of hepatitis C virus (HCV) at the Beth Israel Medical Center methadone maintenance treatment program (MMTP) at its Harlem sites. Of 80 participants, 50% were counselors and 24% were directly involved in referral or HCV testing. Although 92% of the MMTP staff indicated that they discuss HCV evaluation and treatment with patients at least annually, 70% believed that less than 25% of patients accept referral for HCV treatment and attend their initial appointment. Most staff (66%) supported onsite HCV evaluation and treatment, although support was higher among those with a bachelors degree or higher (p = 0.046). Lack of infrastructure was perceived as the greatest obstacle to onsite treatment. Educational interventions and skill building for staff to confidently engage and support MMTP patients in HCV treatment may be necessary prerequisites for onsite HCV management in MMTPs.

Effectiveness and feasibility study of routine HIV rapid testing in an urban methadone maintenance treatment program

Abstract Background: Universal Human Immunodeficiency Virus (HIV) testing and treatment are strategies to decrease AIDS-related morbidity and mortality and to reduce HIV transmission. Objective: This study examined the feasibility and effectiveness of routine HIV rapid testing implemented in the largest New York City (NYC) Methadone Maintenance Treatment Program (MMTP). Methods: A routine HIV rapid testing program performed by medical providers without pretest counseling or the provision of incentives was compared to HIV rapid testing done by referral to HIV counselors with pretest counseling and incentives over the prior 12 months. Results: Routine HIV rapid testing proved feasible and effective when performed by the medical staff in the setting of a large urban MMTP. The program increased HIV testing in all genders, race/ethnicities, and ages. HIV-positive individuals were diagnosed and successfully linked to care. The elimination of HIV prevention counseling may have facilitated expanded testing. Conclusion: This study confirms that routine HIV rapid testing without HIV-prevention counseling or the provision of incentives for patients is feasible on a large scale in a busy, urban methadone clinic.

MMTP Patients with Chronic Pain Switching to Pain Management Clinics. A Problem or an Acceptable Practice

Among the many patients served by methadone maintenance treatment programs (MMTPs) is a small population with severe, refractory pain that may be effectively managed using long-term opioid therapy. Pain specialists have begun to treat these patients, and in some cases, methadone has been selected as the opioid analgesic administered for pain management. The use of methadone for pain in patients treated by MMTPs may lead to complex management issues. We present four patients who illustrate different outcomes associated with one challenging scenario, specifically the expressed desire on the part of the patient to withdraw from the MMTP because the opioid has become available for pain. Research is needed to evaluate the phenomenology of pain and addiction in this population and the outcomes associated with varied therapeutic strategies.

Education and counseling in the methadone treatment setting improves knowledge of viral hepatitis

The aim of this study was to evaluate the effectiveness of an educational method of providing viral hepatitis education for methadone maintenance patients. Four hundred forty participants were randomly assigned to either a control or a motivationally-enhanced viral hepatitis education and counseling intervention. Viral hepatitis A (HAV), B (HBV), and C (HCV) knowledge tests were administered at baseline, following each of two education sessions (post-education), and at a 3-month follow-up assessment. Results indicated a significant increase in knowledge of HAV, HBV, and HCV over time. No differences were found in knowledge between the intervention groups in knowledge acquisition regarding any of the hepatitis viruses suggesting that a motivational interviewing style may not augment hepatitis knowledge beyond standard counseling. A two-session viral hepatitis education intervention effectively promotes hepatitis knowledge and can be integrated in methadone treatment settings.

Traditional Male Ideology and Service System Involvement Among Drug-Involved Men Who Perpetrate Intimate Partner Violence: A Longitudinal Study:

The purpose of this study is to examine the extent to which drug-involved men who perpetrate male-to-female intimate partner violence (IPV) are engaged with various formal service systems as well as whether adherence to traditional male ideologies—thought to drive perpetration of male-to-female IPV—affects help-seeking behavior. This study also seeks to redress a gap in the research literature stemming from the general reliance on batterers intervention programs to acquire samples of IPV perpetrators. A sample of 126 men receiving methadone maintenance treatment who reported perpetrating IPV against a female partner participated in this longitudinal study. A large majority (88%) of participants reported use of additional services beyond methadone treatment (e.g., medical, employment/ vocational, etc.). Using generalized linear modeling, we found that greater endorsement of traditional male ideologies significantly predicted lower subsequent service utilization overall, except for legal services, for which there was a significant positive association. These findings suggest targeted assessment and engagement strategies may be required to involve a greater number of drug-involved men who perpetrate IPV with a wider spectrum of health and social services.

Use of Methadone in Opioid Maintenance Treatment

Many studies have repeatedly shown that the daily administration of methadone decreases morbidity and mortality in patients with an addiction to opioids and related substances. First established in the 1960s, methadone programs soon become an essential component for the treatment of this patient population. In addition to the dispensing of methadone, the program provides medical and counseling services that are active components of the treatment plan. The legal aspects that regulate the MMT programs and the unique pharmacokinetics and pharmacodynamics of methadone require special attention.