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It has since expanded into a nationwide program encompassing more than clinics covering 27 provinces and serving some heroin users by the end of In spite of these difficulties, ongoing evaluation has suggested reductions in heroin use, risky injection practices and, importantly, criminal behaviours among clients, which has thus provided the impetus for further expansion. Clinic services have been extended to offer clients a range of ancillary services, including HIV, syphilis and hepatitis C testing, information, education and communication, psychosocial support services and referrals for treatment of HIV, tuberculosis and sexually transmitted diseases. Cooperation between health and public security officials has improved through regular meetings and dialogue. However, institutional capacity building is still needed to deliver sustainable and standardized services that will ultimately improve retention rates. This article documents the steps China made in overcoming the many barriers to success of its methadone program. These lessons might be useful for other countries in the region that are scaling-up their methadone programs. Under the leadership of Chairman Mao, China experienced a relatively drug-free period between the s and the s. In the early s, government officials began the lengthy process of understanding how best to constrain the dual epidemic of HIV and drug use. A major component of this program has been the methadone maintenance treatment MMT program, which was initiated in The program was rapidly expanded from the initial pilot of just 8 clinics serving drug users in to clinics serving drug users daily in When first introduced, harm reduction was controversial because it conflicted with laws and regulations on narcotics control. Thus, despite a large body of evidence supporting the effectiveness of MMT, 15—17 it was initially difficult to convince government officials, especially those in law enforcement, to try this strategy. As early as the mids, Chinese officials began to organize study tours to learn from the experiences of other nations, such as Australia, the USA, the UK and The Netherlands. These tours influenced the attitudes of key officials towards harm reduction, making them more amenable to the idea of tailoring such strategies to the Chinese context. Further reinforcement came in the form of frequent workshops, conferences and seminars among key sectors as well as with international agencies, such as the WHO, United Nations UN and World Bank, and academic institutions, both local and international. These meetings opened dialogue on the issues and built a foundation for future collaboration between sectors, which ultimately led to a consensus to trial MMT in China. In the meantime, the underlying policy environment was changing. Prior to , efforts focused on policy advocacy and development. Thus, higher targets for educational interventions were set and harm reduction as a control strategy was formally introduced. The Plan called for a pilot of pharmacotherapy to treat drug users in therapeutic institutions, with the guidelines to be developed and approved by the Ministries of Health and Public Security. The National Working Group was given overall responsibility for managing the program, supervising the operation and overseeing its expansion. At the provincial and county level, working groups have also been established to take on these duties locally. The NCAIDS serves as the secretariat for the National Working Group, which is tasked with executing the national plan, coordinating the implementation, providing technical support to the clinics and conducting routine monitoring and evaluation. The National Working Group members meet regularly to identify potential gaps, resolve emerging issues and refine the management of the program. The first task was to develop guidelines for the MMT pilot. The national guidelines were drafted by the Secretariat, reviewed by National Working Group members, and further consultation was sought from stakeholders. This protocol laid the foundation for administrative and technical support at all levels of government, from national to local. The Temporary Scheme prioritized MMT implementation in those areas most severely affected more than drug users and outlined eligibility criteria for participation. The eligibility criteria to participate in MMT were: i opiate users who had failed more than one attempt to quit; ii at least two terms in a detoxification centre or once in a re-education-through-labour detoxification facility; iii at least 20 years of age; iv a local resident and settled in the local area where the clinic was located; and v capable of complete civil liability. Drug users testing HIV-positive needed only to fulfil requirements iv and v to qualify. Clients were permitted to miss a maximum of 15 days in 90 days, or risked expulsion. They could also be expelled for not cooperating with clinic doctors or failing to obey program regulations, which included maintaining abstinence from opiate use while in treatment. The temporary scheme also outlined the safety and security protocol to guide methadone production, transport and distribution under the supervision of the State Food and Drug Administration. Methadone powder was purchased centrally and distributed to participating provinces, which have each assigned one pharmaceutical body to produce methadone liquid according to the Chinese Pharmacopoeia. Patients had to appear in person to collect their daily dose. A total of clients were enrolled during the first calendar year of the pilot. To estimate the effectiveness of these first eight clinics, the national secretariat established a monitoring and evaluation system. This system has since become the basis for an internet-based database that all clinics use to enter and update information on their clients and services. At entry, 6 and 12 months, , and clients, respectively, were surveyed to assess changes in drug using behaviours, drug-related criminal activity, employment, family relationship and HIV status. The proportion of clients reporting employment permanent or temporary increased from By the third survey, Only eight HIV sero-conversions were found among sero-negative clients during the month follow-up. Despite these limitations, as early as 6 months into the pilot, noticeable improvements among clients provided sufficient impetus to scale-up the program. A major challenge during the pilot was retention. The National Working Group tried to address this problem by inviting various international experts to visit the clinics and conduct an external review. They observed that lower dosages of methadone and the absence of adequate counselling and psychosocial support for the clients were likely contributing to the high drop-out rate. The Secretariat encouraged further research on how to best improve the MMT program. In , the first national meeting on piloting MMT was convened among government officials from the three key ministries, including the vice-Minister for Health, Dr Longde Wang, and Yuanzhen Li, Deputy Director-General of the National Narcotics Bureau, as well as experts from related areas. The meeting served to share the experiences, and more importantly the problems, identified from the first phase, and to promote rapid scale-up throughout the country under the increasingly supportive environment. Human resources were and still are one of the major impediments to the expansion of the MMT program. A national training centre was established in the Yunnan Institute of Drug Abuse to provide clinical and administrative training for key staff working in MMT clinics. Two specific training programs are provided to trainees. The first is a day intensive training course covering addiction theory, clinical practice and administrative skills for delivery of MMT services. The second is hands-on training provided on-site by clinical addiction experts who assist local staff for the first 7 days after a clinic has opened, to guide them in the practice of addiction treatment and data management. Roughly, staff have received this training. With growing political and technical support, the MMT program began to steadily expand. By the end of , there were 58 MMT clinics opened in 11 provinces serving drug users. Thus, the pilot period ended and the MMT program moved to national scale. In , several important policy changes occurred. Several crucial improvements were made to benefit and cover more target groups. Notably, the enrolment and exclusion criteria were relaxed. For example: i clients are no longer required to have a history of detoxification or several failed attempts to quit using drugs to enter the program; ii clients are no longer required to be registered as local residents and a transfer system has been set up to meet the needs of those who are relocating either permanently or temporarily; iii the number of allowable missing treatment days has been reduced to 7 consecutive days a rare event ; and iv relapse is no longer a strong reason for expulsion, though it could be considered grounds for expulsion since the informed consent still requires clients to promise not to use illegal drugs while in treatment. Furthermore, a detailed clinical guideline for methadone treatment was added to the protocol to support clinical practice and comprehensive interventions are highlighted in the new protocol that suggests clinics offer ancillary services. These include counselling, psychosocial support, testing for HIV, syphilis, hepatitis C and tuberculosis, referrals for antiretroviral treatment, peer education, health education, group activities, social support and skills training for employment. The treatment fee for MMT services was not specified, as in some areas where heroin is easily obtained at low cost, the fee is reduced or even waived. With support from the above-mentioned legislation, a decision was made by senior government officials to accelerate the expansion. A target was set to open clinics by the end of Recognizing the cost-effectiveness of MMT relative to compulsory detoxification, the Public Security Ministry challenged the Secretariat to meet this target by the end of September Under significant pressure, the team had clinics operational by this time, with a total of clinics opened by the end of that year, serving 37 drug users. Multiplied by the number of users, the initiative would avoid millions of dollars trade in heroin, not to mention the millions more saved in the community by reducing drug-related crimes. See supplementary data in IJE online for details. The expansion did not stop there. In , central government funding was also allocated to the program, enabling those places with less than registered drug users to establish MMT clinics. Another target of MMT clinics was set and MMT clinics were cumulatively accomplished by the end of , in 23 provinces serving 97 clients. By the end of , there were clinics with some clients ever-enrolled, roughly half of whom remain in treatment. Areas of greatest need now have MMT clinics and the expansion has thus slowed down. MMT clinics have now been opened in 27 provinces. They may be affiliated with a local Centre for Disease Control, hospital, psychosocial health centre, community-based health centre, voluntary detoxification centre or a hospital in the Public Security system. Flexibility has been enhanced by the introduction of mobile services; the first was in Yunnan and later in another nine provinces, with a total of 26 MMT vans. This service enables drug users in remote, rural areas to access to methadone. Flexibility has also been enhanced by longer and later operating hours at some clinics. The law has integrated MMT into the existing anti-drug strategies requiring drug users to undergo community-based, rather than forced, interned detoxification up to 2 years , and to be provided with vocational training and employment assistance. This law is an important sanction for the MMT program and will ensure its sustainability. Regular monitoring and evaluation missions have been led by senior officials from the three relevant government sectors to improve multi-sector corporation at local levels and investigate reasons for high drop-out in certain clinics. During these missions, officials convene on-site multi-sectoral meetings at different levels, exchange opinions with local authorities, and hear the concerns of clinical staff, addiction experts and, most importantly, MMT clients. In —9, there were three joint monitoring and evaluation missions, one each to Yunnan, Guangdong and Hainan, which were used to make recommendations for improving the program. Every 2 years, a review meeting is organized by the National Working Group, which includes participants from the three relevant government sectors at national, provincial and county levels as well as representatives from the clinics. During these meetings, participants exchange and summarize their experiences and a field trip is organized to visit clinics that are performing well so that staff from other clinics can observe and learn how to improve their services. A national MMT program database was developed in to monitor the pilot and was later upgraded to a web-based management database in The database enables regular reporting on the implementation of the program. Such information can be used to identify gaps in the delivery of services in a timely manner. Each of the clinics uploads its daily services records to the database in real time. Behavioural risk information is collected at entry, 6 months, 12 months and then at month intervals thereafter. These data are also uploaded to the database, allowing the Secretariat to measure the relative change in clients staying in the program in order to evaluate the effectives of MMT for reducing HIV risks. However, some clinic staff fail to collect and upload patient information, which hinders evaluation efforts. The Secretariat is attempting to raise awareness among clinics as to the importance of data collection for monitoring and evaluation. In and , respectively, an estimated and new HIV infections excluding secondary transmission were prevented, consumption of heroin was reduced by These achievements can be attributed to at least three factors: strong political commitment—the MMT program is supported legislatively and financially by the central government multi-sector cooperation; the incorporation of MMT clinics into existing medical infrastructure, which has facilitated delivery of services; and the leadership role of the National Working Group and hard work of local implementers. However, despite the progress made, there remain a wide range of challenges and gaps that need to be addressed to achieve the overall goal of universal access. A major concern is that the current coverage of MMT may still be too low to have sufficient impact on the epidemic. A problem closely related to coverage is retention, which is less than optimal. The major reason for the high dropout is thought to be dose. Alternatively, given that most staff believe that the ultimate goal of MMT is complete detoxification, lower doses may seem preferable. Clinic practitioners have been encouraged to increase the methadone doses but many fail to do so. Clients are also reluctant to take higher doses as they expect that the goal of MMT should be abstinence, rather than maintenance. This suggests that the goals of MMT are not clearly explained to clients when they commence treatment. Staff have also expressed their desire for further training on how to manage patient regimens. Another major factor contributing to poor retention and coverage is accessibility. In some areas, it is simply not cost-effective to provide methadone. Mobile clinics have helped to address this issue somewhat, but for higher coverage the program will also need to consider more flexible dosing strategies, such as take-home doses. Accessibility is also hindered by cost. For some clients, the fee may be waived or reduced to help them adhere to treatment. A system to provide travel subsidies or other reimbursements to poor clients should be considered. A further problem contributing to drop out is interruption of treatment due to incarceration or mobility. The program has attempted to address the mobility problem by allowing transfers between clinics. Interruptions to treatment due to incarceration are more difficult to resolve as they require coordination with law enforcements agencies in local. Many clients may find themselves being arrested and incarcerated due to relapse and will then be unable to continue treatment. This puts drug users at severe risk of infection with HIV, hepatitis C or other infections. MMT clinics can and should be employed as a comprehensive service platform for the control of both HIV and drug use. Evidence exists from both China 31 , 32 and abroad 33 that relapse decreases when additional services are offered by the clinics. Ancillary services recommended by the Secretariat include counselling, psychosocial support, education, referrals for related health issues and incentives. Incentives such as reduced or waived fees are being introduced by some clinics for clients who successfully abstain from using other opiates while in MMT, attend group activities or refer other drug users to the program. These clinics have observed positive changes in client retention. Some other clinics, however, still focus solely on administering methadone and lack capacity to deliver ancillary services, leaving the service target unmet. MMT clinics should also increase the range of services available and improve coordination with related services. Many drug users are at high risk of infection by HIV, hepatitis C, sexually transmitted infections and other blood-borne diseases. Clients also present with tuberculosis, sexually transmitted infections and other infections. Currently, clients needing treatment can only be referred for such services at most of the clinics. In addition, many clients continue to use drugs while in MMT and need access to needles, but these are also unavailable at MMT clinics. MMT clinics should offer a one-stop-shop for comprehensive services, e. This would save clients time and could improve adherence, retention and satisfaction with the service. It would benefit staff who would like to increase their range of skills see next section. The different services should also work together to improve referrals between services to increase the numbers of clients in MMT. For example, designated tuberculosis clinics should refer drug users to MMT. Although staff do receive training, their knowledge and skills in addiction treatment and clinic management may be inadequate. Negative attitudes of staff towards patients can also affect retention. MMT clinic staff do not enjoy status and may receive a lower salary than their counterparts in other specialties. Quality assurance monitoring by the MMT Secretariat is needed to ensure the training provided is of high quality and is adhered to, and to ensure that staff maintain professional, non-discriminatory attitudes towards clients. Cooperation between the Ministries of Health and Public Security functions well at the central and provincial levels, but less so at lower levels. Public security and public health staff have different understandings of the nature of addiction, the importance of MMT and particularly the meaning of relapse as defined by a urine test. The fear of being registered as a drug user deters potential clients from exposing themselves and accessing the service; registered drug users are sometimes harassed by police. Training for public security officers to help them understand the principles and operation of MMT is being conducted but needs to reach more officers to improve their support for the program. China has made impressive progress in moving its MMT program from a pilot project to a national scale. Experiences and lessons learned from this period will be applied to continued improvement of the program. Many important challenges remain before the program will achieve its desired success. Key goals to improve the program include: i increasing the coverage of MMT and the number of its beneficiaries; ii improving accessibility of services; iii improving the quality of services offered, increasing the range of services offered at clinics and introducing referral systems between related services; iv providing on-going staff training to improve the quality of their service, increase their understanding of drug addiction and enhance their professionalism; and v enhancing multi-sector cooperation, especially at local levels to ensure that clients enjoy uninterrupted treatment. Supplementary data are available at IJE online for calculating benefits from bringing forward the opening date of about more MMT clinics in The authors thank the staff and clients of the methadone clinics around China for helping make the program a success. Conflict of interest: Drs Y. They direct the overall development of national MMT program. Drs W. They are responsible for daily operation of management of national MMT program. Methadone treatment services have been extended to offer clients a range of ancillary services, including HIV, syphilis and hepatitis C testing, information, education and communication, psychosocial support services and referrals for treatment of HIV, tuberculosis and sexually transmitted diseases;. Institutional capacity building at methadone clinics is still needed to deliver sustainable and standardized services that will ultimately improve methadone treatment program. Google Scholar. Google Preview. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Advertisement intended for healthcare professionals. Sign in through your institution. Advanced Search. Search Menu. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents Abstract. The Pilot Phase. Legislative Support for a Rapid Expansion. Monitoring and Evaluation. Challenges and Response. Supplementary Data. Journal Article. Scaling up the national methadone maintenance treatment program in China: achievements and challenges. Wenyuan Yin , Wenyuan Yin. Oxford Academic. Yang Hao. Xinhua Sun. Xiuli Gong. Fang Li. Jianhua Li. Keming Rou. Sheena G Sullivan. Changhe Wang. Xiaobin Cao. Wei Luo , Wei Luo. E-mail: wuzy Select Format Select format. Permissions Icon Permissions. Methadone maintenance treatment , scaling-up , national program , challenges , China. Figure 1. HIV sentinel surveillance data for drug users, — Open in new tab Download slide. Figure 2. No pain no gain, establishing the Kunming, China, drug rehabilitation center. Google Scholar Crossref. Search ADS. Methadone maintenance treatment modalities in relation to incidence of HIV: results of the Amsterdam cohort study. Effectiveness of first eight methadone maintenance treatment clinics in China. Advocacy and coverage of needle exchange programs: results of a comparative study of harm reduction programs in Brazil, Bangladesh, Belarus, Ukraine, Russian Federation, and China. Correlates of methadone client retention: a prospective cohort study in Guizhou province, China. Google Scholar PubMed. Challenges in providing services in methadone maintenance therapy clinics in China: service providers' perceptions. Treatment and care for injecting drug users with HIV infection: a review of barriers and ways forward. Analysis of human immunodeficiency virus type 1 nef gene sequences among inmates from prisons in China. MPH Thesis. Structural-level factors affecting implementation of the methadone maintenance therapy program in China. Issue Section:. Download all slides. Views 3, More metrics information. Total Views 3, Email alerts Article activity alert. Advance article alerts. New issue alert. In progress issue alert. Receive exclusive offers and updates from Oxford Academic. Citing articles via Web of Science Device-measured stationary behaviour and cardiovascular and orthostatic circulatory disease incidence. Ambient temperature exposure and rapid infant weight gain. Staggered interventions with no control groups. Probabilistic bias analysis for exposure misclassification of household income by neighbourhood in a cohort of individuals with colorectal cancer. More from Oxford Academic. Medicine and Health. Public Health and Epidemiology. Looking for your next opportunity? Advanced Gastroenterologist. Assistant Professor. View all jobs. Authoring Open access Purchasing Institutional account management Rights and permissions. Get help with access Accessibility Contact us Advertising Media enquiries.

Treatment of opioid dependence: a call for papers

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Official websites use. Share sensitive information only on official, secure websites. An estimated 11 million people are dependent on heroin or other opioid drugs, a condition associated with a high morbidity and fold mortality from causes including overdose and infections such as human immunodeficiency virus HIV , tuberculosis TB and hepatitis. Where it has been measured, the social cost of illicit drug use has been found to rival that of tobacco and alcohol, due to a combination of health care costs, lost productivity and crime. Recent World Health Organization guidelines have endorsed methadone maintenance treatment as the mainstay of opioid dependence treatment. Since the first studies of methadone treatment were published in the s, methadone has been used extensively for the treatment of opioid dependence and has saved millions of lives worldwide. Despite the high need for treatment, global coverage of methadone and other services for people with opioid dependence is poor, with most treatment limited to high-income countries. The purpose of this theme issue of the Bulletin is to highlight the paths to success that some countries have achieved, so that others may consider similar solutions. This purpose will be achieved via the following three allied objectives. The first objective is to describe the global situation with regard to opioid dependence and its relationship to HIV and TB, highlighting the current data on the global response to these problems and examining what has enabled some countries to scale up rapidly to address the joint problems of opioid dependence, HIV and, in many cases, TB. It is expected that a series of papers from different countries and geographical regions, examining the process of scaling-up, its challenges and responses to those challenges, will be included. These articles will describe policies and strategies used for scaling-up national methadone maintenance treatment programmes, methods of evaluating treatment success, and means of addressing common co-morbidities such as HIV, TB and hepatitis. The second objective is to facilitate communication and collaboration within the scientific, medical and public health communities across political borders so that low- and middle-income countries in all regions, can learn from their neighbours the best practices in providing safe and effective treatment of opioid dependence and related conditions. As the Bulletin is free to developing countries, it is an ideal platform in which to share the experiences of other low- and middle-income countries. The third objective is to disseminate key findings to high-level decision-makers in an attempt to promote a stronger commitment to a therapeutic approach to opioid-dependence treatment and its wider application in contributing to the reduction of new HIV infections, particularly among injecting drug users. These countries have expanding, concentrated epidemics, notably among people who inject drugs and their sexual partners. The deadline for submissions to this theme issue is 31 May As a library, NLM provides access to scientific literature. Find articles by Zunyou Wu. Find articles by Nicolas Clark. All rights reserved. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

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