Methadone Treatment Programme Review

Report on Review of Methadone Treatment Programme

(December 2000)

Executive Summary
Foreword

1. Hong Kong adopts a multi-modality approach in providing drug treatment and rehabilitation services to cater for different needs of drug dependent persons from various backgrounds. This includes a compulsory placement scheme operated by the Correctional Services Department, voluntary residential treatment programme run by non-government organisations including Christian therapeutic agencies, Substance Abuse Clinics operated by the Hospital Authority, counselling centres and mixed mode clinics operated by non-government agencies which offer a combination of services including case-finding, crisis intervention, drug treatment and counselling, etc.

2. Amongst the different treatment modalities, the methadone treatment programme (MTP) which came into operation in Hong Kong in 1972 is the only “substitution” therapy which caters for those who are not suitable for or receptive to residential or other forms of treatment. Operating on a voluntary, out-patient mode, the programme allows patients to stay with their families or work as usual and continue to perform other daily activities.

3. MTP in Hong Kong comprises two components. A heroin dependent person can enroll in the “maintenance” part of the programme and replace illicit heroin use by adequate methadone dosage prescribed by doctor. He can also enroll in the “detoxification” part of the programme where he will be assisted to achieve a drug-free state by taking decreased dosages of methadone over a period of time.

4. MTP in Hong Kong adopts an open-door policy and services are provided to patients irrespective of sex, age, ethnic origin, religion, or nationality. It does not have a waiting list of patients as new patients are seen by the attending medical officer as they turn up. The only criteria for admission into MTP are opiate drug dependent persons without life-threatening medical condition. For clients suffering from medical illnesses which are considered by the attending medical officer as unsuitable for methadone treatment, they will be referred to specialist clinics/hospitals for treatment and advised to return to the methadone clinics after their conditions have improved. Patients aged under 21 or those with less than two years’ addiction history are normally first encouraged to go for residential programme.

The Review

5. Since the commencement of MTP in Hong Kong in 1972, the Government has been monitoring the usefulness and effectiveness of the programme and reviews of the programme were done in the past. In May 1999, as a major step forward to further monitor the effectiveness of the programme, the Action Committee Against Narcotics (ACAN) Sub-committee on Treatment and Rehabilitation decided that a comprehensive review on MTP should be conducted. The Review aimed at vigorously evaluating MTP in today’s circumstances, taking into consideration the controversy surrounding this treatment mode, namely, “methadone is just another addictive drug that substitutes heroin”, and the emergence of new drugs which allegedly might serve as a substitute for methadone. A Working Group on Review of MTP was formed to conduct the Review.

Major findings

6. Recognizing that drug addiction is a chronic relapsing illness, the Working Group concluded that the current MTP fulfiled its declared objectives and was effective in helping drug dependent persons to sustain their employment and social life, as well as helping society to reduce instances of drug overdose, drug-related death and even spread of blood-borne diseases. The Review also confirmed that MTP should continue to comprise maintenance and detoxification elements so as to offer choice, though the mainstay of the programme should remain a substitution therapy with a “harm reduction” objective. The Review affirmed MTP’s open-door policy and recognized that it worked well for those who had a need for the service. The Working Group observed that amongst the various drug treatment and rehabilitation modalities in Hong Kong, MTP engaged the most number of drug dependent persons at a time. Its voluntary, out-patient nature and well-established territory-wide clinic network made the programme one of the most convenient and accessible drug treatment programmes in Hong Kong.

7. However, balancing the current operational mode of MTP and the room MTP presents itself for further enhancement, the Working Group recognized that MTP should move towards a more knowledge-based approach to service provision. The Working Group considered that the existing support services of MTP could be improved. In connection with this, a clear set of outcome indicators for different MTP components can be developed and training of staff could be enhanced. To address the constraints of out-patient detoxification which, in the main, are the lack of intensity and relatively weak supervision and peer support, naltrexone should be considered as a drug to assist relapse prevention and a research in this regard should be conducted accordingly. At the same time, public education on MTP should be enhanced in order to strengthen community’s acceptance of the programme and in this connection, acceptance of the patronage of the programme.

8. Taking advantage of the large catchment of drug dependent persons under MTP, enhancement of referral services and coordination between MTP clinics and other drug treatment and rehabilitation agencies should facilitate patient management. With this development, the focal point of MTP should still remain on service recipients. Strengthened support services under MTP should, as far as practicable, contribute to a more comprehensive approach of service provision with emphasis on continuity of care for service recipients. A summary of the recommendations is given below.

Summary recommendations

Broad direction

9. MTP should continue with the following objectives :

(a) to provide a readily accessible, legal, medically safe and effective alternative to continued illicit opiate drug use;

(b) to help patients lead a normal and economically productive life;

(c) to assist in the prevention of blood-borne diseases like hepatitis, tetanus and HIV infection by reducing intravenous drug use and needle-sharing through surveillance, health education and counselling;

(d) to encourage drug dependent persons to come forward for treatment by providing an extensive supportive network;

(e) to help reduce antisocial behaviour related to illicit opiate drug use and protect the community by reducing drug-related crimes; and

(f) to assist drug dependent persons to achieve a drug-free state by providing a detoxification programme, or where appropriate, referring them to appropriate in-patient detoxification and rehabilitation services.

10. MTP should continue to comprise maintenance and detoxification elements.

11. MTP should continue to offer easy entry for those who wish to enroll.

Patient assessment

12. MTP should move towards a more knowledge-based approach by strengthening patient assessment on and during treatment, in order to facilitate subsequent patient monitoring, review and assessment of patient’s requirements for support services, including psychosocial, education and employment.

(a) Patient assessment on admission

A more detailed and structured initial patient assessment should be conducted as soon as possible upon admission.

In such assessment, consideration should be given to adopting tools such as addiction severity index which is a structured interview to assess patient’s problem severity in several commonly affected areas of drug dependent persons’ lives. Such areas include medical condition, employment, drug use, alcohol use, illegal activity, family relationship and psychiatric condition.

Following the assessment, individual treatment plans for patients should be developed. Such plans may include, amongst others –

patient’s short term goals;

tasks the patient must perform to complete short-term goals;

patient’s requirements for education, vocational rehabilitation and employment;

medical, psychosocial and other support services in need;

frequency with which patients can be referred to/provided with the above services; and

length of time in/recommended for maintenance treatment prior to reassessment.

Patients should be involved in developing their personal treatment plans.

(b) Reassessment

A structured patient reassessment mechanism should be put in place with a strengthened/improved protocol to allow for more regular and vigorous reviews of patients’ treatment plans. Such reassessment should also be used as a tool to facilitate placement of patients to suitable treatment modality if necessary. This would also help sustain patient’s motivation to make progress in the programme he has enrolled.

Support services

13. The following support service should be strengthened/continued :

(a) Counselling services

Counselling service should continue to be delivered to patients of all ages and background while maintaining a distinctively intensive approach for the young (e.g. through greater involvement with families).

Counselling services for patients enrolled in maintenance and detoxification programmes should be maintained with emphasis on prevention of poly-drug abuse and ensuring adequate dose for the former, and support to complete programme and prevent relapse for the latter.

The application of a “group” approach for patients undergoing detoxification, in addition to helping them on an individual basis, should be tried out.

Counselling on HIV/AIDS prevention and risk taking behaviour should be continued and strengthened.

Consideration should be given to tailor-making counselling service for women using more group/mutual support with particular attention to gender-specific problems such as child-caring, woman health, etc.

In line with the direction to provide more gender-specific programmes in the Three-year Plan on the Drug Treatment and Rehabilitation Services in Hong Kong (2000 – 2002), consideration should be given to special programmes to encourage and assist female MTP patients on maintenance and detoxification under MTP.

Focus of counselling should be adjusted towards mental attitudes, basic values in life and self-realization.

Employment of peer counsellors in supporting patients should be increased.

(b) Referral services

Where appropriate, MTP should provide through referral, adequate and reasonably accessible community resources, vocational rehabilitation, education services and employment services for patients.

The Society for the Aid and Rehabilitation of Drug Abusers’ initiative to use three of its social service centres as a gathering place for peer and social support with emphasis on supported employment and job-seeking skills training should receive due consideration and support.

Where appropriate, patients with motivation to pursue a drug-free goal should be referred to join residential detoxification programme with aftercare, whether provided by Government or non-government organizations.

Selective referral to specialist services for patients with more complex needs and problems should be encouraged.

(c) Support groups

Support groups should be formed to assist patients and their families.

HIV/AIDS education, amongst others, should be built in activities of such support groups.

MTP as a tool for HIV/AIDS surveillance and prevention

14. MTP staff (including doctors, Auxiliary Medical Service staff and social workers) should be asked to encourage voluntary HIV testing among methadone patients.

15. Patients should be actively encouraged to undergo HIV testing at first admission/re-admission and reassessment visits.

16. Enhanced publicity and education to encourage voluntary HIV testing by patients of MTP should be considered.

Treatment setting

17. Improvement on physical setting of methadone clinics should be made in order to cater for improved care services. Where resources are available, facilities to be provided in clinics should include :

(a) dedicated room(s) for counselling services and support activities;

(b) information corner providing information about job placement programmes, job-skill training programmes and other treatment and rehabilitation programmes, etc; and

18. With improved physical setting, methadone clinics should be used as a focal point for the delivery of additional activities such as :

(a) job-skill talks/seminars with assistance from other agencies;

(b) special sessions for patients with clinical psychologists’ support;

(d) support group activities; and

(e) public health education programmes.

19. A staff in each MTP clinic should be appointed as a liaison or line worker to facilitate delivery of services to patients in clinic.

20. Such clinic should be used to achieve incremental progress towards improved services; there should be a system to monitor such progress. A scheme should be launched to improve clinic’s physical setting in order to cater for improved services.

Operation

21. The following aspects of the operation on MTP should be strengthened :

(a) opening hours of clinics should continue to be kept under periodic review.

(b) the existing manual data management system should be computerized, by phase and having regard to the availability of resources, in order to release capacity of staff for supporting improvement measures and initiatives under MTP.

(c) the use of existing patient cards should be replaced by personal ID cards and streamline procedures for patient transfer upon computerization of patient database.

(d) the existing treatment protocol should be kept under periodic review.

Output/performance indicators

22. Two distinct sets of clear, measurable outcome indicators should be developed for maintenance and detoxification programmes respectively under MTP. The following, however, may be common in both sets of indicators :

(a) illicit drug use could be reduced/eliminated;

(b) associated criminal activities could be reduced/eliminated;

(d) restoration of/improvement to quality of life, physical and mental health status.

Staff education and training

23. The following is proposed :

More sharing sessions should be held amongst staff, with staff views on ways to improve service delivery be solicited.

Dedicated forums for social workers should be conducted with assistance from SARDA and the Hong Kong Council of Social Service to orientate workers towards attitude change to methadone patients and the programme, and to align them with the objectives of the changes/initiatives introduced/being contemplated for MTP.

Staffing training and retraining under MTP should be continued and strengthened. Assessment skills, in particular, need to be taught and strengthened.

Tailor-made educational kit or other aids for use in staff induction and retraining courses should be developed.

The possibility of recruiting and training families and increased use of peer counsellors should be actively explored.

Public education and publicity

24. Due attention should be paid to the following areas :

(a) public education/publicity on MTP should be geared towards greater distinction between maintenance and detoxification programmes. The public health functions of MTP should also be given due emphasis in all publicity.

(b) such education and publicity should also aim at educating the target on methadone as a drug in itself, its use as well as effect.

(c) while the overall nomenclature of MTP should be kept, two distinct names for two programmes, i.e. “methadone maintenance programme” and “methadone detoxification programme” under MTP, should be considered for adoption in publicity/information materials relating to MTP.

(d) a new series of information materials (pamphlets, leaflets, poster, etc) should be produced to aid enhanced educational and publicity efforts.

(e) a professional media campaign with celebrity endorsement should be launched.

(f) target of education should include not just existing patients but also staff and the public at large. A structured publicity strategy targeting district organizations should also be drawn up.

Further research

The following is proposed :

(a) Alternative/supplementary drugs

More research should be conducted with involvement of the Substance Abuse Clinics of the Hospital Authority and interested drug treatment and rehabilitation agencies to fully assess the effectiveness of naltrexone in relapse prevention for detoxified methadone patients.

The research should aim to test, amongst other, the application of a set of screening criteria, including both absolute and relative criteria, for patients undergoing naltrexone treatment as well as the relevant treatment protocol. A monitoring group should be formed under ACAN or a relevant sub-committee to monitor the research.

The cost-effectiveness of buprenorphine and LAAM should be continuously monitored through local contacts and review of overseas literature with a view to expanding the range of treatment options for heroin dependent persons in the long term.

Any clinical trial with Chinese medicine to assist detoxification of MTP patients should be considered only after the Chinese Medicine Ordinance including its subsidiary legislation fully comes into operation.

Development and applicability of Chinese medicine in drug treatment should be continuously monitored through liaison with the State Drug Administration of the People’s Republic of China and other sources.

(b) MTP and Crime

In due course, more in-depth research on the effectiveness of MTP in helping to reduce crime should be conducted.

Implementation

26. The Working Group considered that while some of the above recommendations could be implemented with internal redeployment of resources and support from the Beat Drugs Fund, some would only be implemented with the support from Government’s recurrent Resource Allocation Exercise and capital bids.

27. ACAN and its sub-committees would follow up on the implementation of the recommendations, and form special monitoring groups to keep in view the progress of implementing such recommendations where appropriate. The Narcotics Division, Department of Health and relevant agencies would work out feasible action plans with appropriate timeframes to implement the recommendations.