clinic in Israel: disease incidence
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1 15 years of Methadone Maintenance Treatment clinic in Israel: Drug abuse abstinence and minimal infectious disease incidence Dr. Miriam & Sheldon G. Adelson Clinic for Drug Abuse Treatment & Research Tel-Aviv Sourasky Medical Center & Tel-Aviv University Sackler Faculty of Medicine Einat Peles Ph.D., Shaul Schreiber M.D., Miriam Adelson M.D.
2 Methadone Maintenance Treatment The best treatment for opiates addiction is Methadone Maintenance Treatment (MMT) accompanied with psychosocial therapy. Developed in 1964 (Dole, Nyswander, Kreek) Federal regulation and stigmatization of heroin addiction prevented implementation ti of treatment 1997, NIH published a report unequivocally supporting MMT
3 NIH Consensus Statement 1997 Opiate dependence is a brain-related medical disorder that can be effectively treated with significant benefits for the patient and society, and society must make a commitment to offer effective treatment for opiate dependence to all who need it. Effective medical treatment of opiate addiction. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction.
4 Impact of Short-Acting Heroin versus Long-Acting Methadone Administrated on a Chronic Basis in Humans 1964 Study unctiona al State F "High" "Straight" "Sick" Heroin AM PM AM PM AM Days Function nal State "High" "Straight" "Sick" Methadone AM PM AM H PM AM Days Dole, Nyswander and Kreek, 1966
5 Hypothalamus Pituitary Adrenal Axis MMT normalizes the HPA (hypothalamic-pituitary-adrenal) axis
6 MMT Main Goal: Stop Opiates Secondary Goals: Cocaine, Benzodiazepines, Amphetamines, THC, Alcohol Infectious disease Health status Crime, Antisocial behavior (Family, Society) Work Patient retention in treatment
7 Methadone Maintenance Treatment (MMT) Ambulatory system Methadone maintenance (drinking daily) Privilege take home doses Urine monitoring for drug abuse (random, observed) Psychosocial sessions (personal & groups) Periodical Medical test
8 Aims To evaluate MMT success (opiate abstinence and one year retention ) To characterize predictors for cumulative retention.
9 Population Study Former opiate addicts (DSM-IV-TR) Adults (18+ years) Arriving voluntarily All 618 patients admitted between June 25 th 1993 and June 24 th 2007 and followed up until June 24 th 2008.
10 Results
11 Characteristics of Study Group (N=618) Variables Female (%) N(%) 618(100) 164(26.5) Age opiate onset (y) 22.6±7.1 (12-55) Admission Age (y) 37.5±8.9 (18-75) Opiate abuse before MMT (y) 15±8.7 (1-55) Hepatitis C antibody (%)* 334(54.0) HIV antibody (%)** Hepatitis B antigen (%)*** 46(7.4) 31(5.0) *5%, **12.9%, ***6.8% patients unknown
12 One year retention rate: 75.4% (466 of 618) One eyear retention t rate by year of admission % Year of 1st admission
13 Among patients who stayed year Opiates abstinence after one year: 66.5% (310 of 466) % Opiates abstinence (%) after one year by year of admission Year of admission
14 Drug Abuse on Admission (N=618)* % n= n=113 n=72 n=48 Cocaine Benzodiazepine THC Amphetamines *4 were unknown
15 Net reduction in Drug abuse after 1 year (n=466) Stopped % (month13) Started % (month 13) % / / /195 41/378 54/409 31/57 27/ /433 Cocaine Benzodiazepines THC Amphetamines 57.4% 10.3% 41.2% 75.3% Net Reduce
16 Fifteen years cumulative retention by gender Female, 26.5 Male, 73.5 Overall: mean =6.5years (95% Confidence Interval 6-7years) Einat Peles, Ph.D., Adelson Clinic
17 Fifteen years cumulative retention by age of admission group * % y 30-39y 40+y * Log Rank Chi square=5.6, p=0.06
18 Fifteen years cumulative retention by way of admission * Others, 31.8 Medical Center, Self, 56.3 * Log Rank Chi square=18.4, p<0.0005
19 Fifteen years cumulative retention by BDZ in urine on admission * BDZ, no, 42.5 * Log Rank Chi square=4.2, p=0.04
20 Fifteen years cumulative retention by Cocaine on admission Cocaine, 18.4 no, 81.6 Cocaine after 1y n=451 n=91 * *Log Rank Chi square=8.6, p=0.003
21 Fifteen years cumulative retention by opiate abstinence * Opiate, 39.3 n=214 n=330 no, 60.7 * Log Rank Chi square=35.2, p<0.0005
22 Fifteen years cumulative retention by methadone dose * n=389 n=130 <100mg, mg+, 75 * Log Rank Chi square=15.1, p<0.0005
23 Cox model -multivariate analyses predictors retention in MMT (15y f u) Variable OR %95 CI P Methadone 100mg < No Opiate abuse after 1y < Way of admission Self vs. MC Self vs. others No BDZ
24 Fifteen years cumulative retention by hepatitis C antibody UKN, 5 n=334 HCV+, 54 n=253 HCV-, 40.9 Log Rank chi square=1.1, p=0.3
25 Incidence of sero-conversion (June February 2009) 2.2 per 100 person years 25 of the 197 patients* who were negative to HCV antibody became positive, with py follow up *(78% of 253 patients had one test)
26 Comparison between yes and no hepatitis C seroconversion Variable Admission age (y) Opiate usage history (y) Yes n= ± ±6.4 No n=172 39± ±8.7 P Female (%) Readmission (%) Drug injector (%) Amphetamines urine (%) BDZ urine (%)
27 Hepatitis C sero-conversion predictors Cox model included: gender, amphetamines, aged group, readmission, opiate abuse history Variable OR %95 CI Drug injector BDZ abuse P Drug injection BDZ abuse p=0.001 p=0.003
28 Fifteen years cumulative retention by HIV antibody UKN, 12.5 HIV+, 7.5 n=46 n=492 HIV+, 80
29 Incidence of HIV sero-conversion (June February 2009) per 100 person years 1 of the 358 patients who were negative to HIV antibody and followed up for HIV, became positive, with py follow up
30 Summary High retention rate (75.4%),high opiate abstinence rate (66.5%), and net reduction in all drug abuse after one year Predictors for cumulative retention ti of f15 years : no BDZ abuse on admission, high methadone dose 100mg/d, no opiate after one year, and self admission to MMT Retention was not related to hepatitis C, HIV status. Nor to cocaine on admission Sero-conversion to HIV was minimal (1 patient) Sero conversion to hepatitis C was 2.2/100py (25patients) - predictors were ever drug injectors and BDZ abuse on admission
31 Conclusions Outcomes justify the expansion of the MMT clinic network in Israel in order to make treatment available to all those who need it. A protocol favoring higher methadone dosage as appropriate is recommended. Special intervention to stop BDZ abuse is recommended to increase retention and reduce hepatitis C sero-conversion
32
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