The scale-up for MMT programs in China has been very fast, benefiting tens of thousands of drug users with outcomes such as decreased drug use, criminality, and increased quality of life and employment (Sullivan & Wu, 2007
, Pang et al, 2007
). The communities have also profited from the ancillary effects of the program, including the reduction in size of local drug markets and corresponding crime rates and improved public security (Pang et al, 2007
). However, given the relatively short history there are many barriers facing the current MMT programs.
Despite the rapid scale-up, the coverage rates across the population of registered opiate addicts are not dissimilar from that observed in U.S. (Kleber, 2008
). It is unknown whether the actual number of opiate addicts in the area surrounding these clinics approximates the known number of registered addicts, but it likely is higher, which further reduces the estimates of coverage for MMT in this report. Similar to the U.S., the programs in China also demonstrate problems in enrolling and retaining clients (Fiellin & O'Connor, 2002
; Merrill et al., 2005
). Between clinic differences were observed in numbers of clients, retention rates, and extent of coverage as a factor of CDC-affiliated clinics and non-CDC-affiliated clinics. An understanding of the factors that lead to these disparities reflects different funding resources for these two types of clinics. CDC-affiliated clinics receive funding from the HIV/AIDS prevention program of the central government, whereas hospitals rely on client charges. MMT clinics in hospitals may not receive sufficient funding and other institutional support to provide comprehensive services for clients. In addition, it appeared that the service providers in hospitals were not as experienced in providing psychological counseling, HIV/AIDS and health education, and other additional services to clients as staff in CDC-affiliated clinics.
These results indicate that in MMT clinics with comprehensive services, the numbers of clients and retention rates were higher, and the clients were less likely to use illicit drugs while taking methadone. This finding is also reported in other studies. For example, Stevens’ 2008
study suggested that psychological counseling and motivational enhancement therapy increases MMT effectiveness (Stevens, 2008
). In a review of 12 trials, Amato and colleagues (2004)
found that adding psychosocial treatment to standard pharmacological MMT contributed to higher effectiveness in terms of treatment retention. However, comprehensive services have been provided only sparingly in China (Wu, et al, 2007
). The frequency, format, and quality of these services are not consistent across clinics (Pang et al, 2007
). More needs to be done to improve client recruitment, retention, and compliance by involving and improving comprehensive services such as psychological counseling, skills training, health education, and group activities in MMT clinics.
Service providers play an important role in the success of MMT programs and client outcome. However, there were wide variations in levels of training and qualifications of service providers working in MMT clinics in China (Gill & Okie, 2007
; Humeniuk & Ali, 2005
). Although there are national trainings available, half of the MMT clinics in our study had only one or two service providers who had received it, and the others only learned indirectly from those who were trained. In some clinics, none of the providers had the chance to receive national level training. Ongoing in-service training has been absent. Furthermore, very limited training was given to the service providers on behavioral intervention, psychological counseling, and health education for clients (Pang, 2007
). Inadequate training may contribute to service providers’ failure to prescribe an adequate methadone dosage due to concerns over malpractice (China CDC, 2007
). Without the knowledge of cognitive-behavioral strategies, service providers were not able to address clients’ motivation to change, personalized risk management, and other problems related to continued drug use and MMT drop-out. Appropriate training on behavioral intervention, psychosocial counseling, and side-effects management is urgently needed by service providers working in the MMT clinics in China.
Clients pay 10 Yuan per day (1.47 USD) for their treatment in China (Ministry of Health, Ministry of Public Security of China, and State Food and Drug Administration, 2006
). Although this payment is relatively small, it may be a financial barrier to treatment, especially for those who are unemployed or do not receive adequate support from their families. Our study revealed that providing incentives for compliance and abstaining from concurrent drug use was positively correlated with more clients, better retention rates, greater coverage, and lower concurrent drug use. Other studies showed similar relationships. In a pilot study in Sichuan China, incentives were given to clients who participated in the program continuously, which resulted in significantly increased retention rates in the intervention group and significantly reduced self-reported drug use and risky sex behaviors, as compared to the control group (Gao, 2006
). The positive outcomes of incentives may possibly be due to reduced financial burden and improved self-esteem and satisfaction through being rewarded. Incentives need not always be monetary, however. A well-developed literature in Western cultures describes outcomes using take home medications as incentives for positive behaviors in MMT programs (Chutuape, Silverman & Stitzer, 1999
; White, Ryan & Ali, 1996
). However, this option is currently not allowed in China (Ministry of Health, Ministry of Public Security of China, and State Food and Drug Administration, 2006
There are other active structural changes that may be useful in increasing treatment enrollment and retention. The clinics that were opened more than eight hours per day or stayed open during the noon hour were more likely to have more clients and greater coverage. Sufficient operating hours of MMT clinics strongly facilitates recruitment by providing convenience for the clients, especially those who are working. MMT clinics that provide extended hours of operation and operation during off-hours enable employed clients to access treatment within their work and family schedules. It remains, however, that these are associational finding that are also correlated to clinic size. It is not known whether the clinics that have extended hours do so in order to be able to meet the needs of a larger client base or become larger by first facilitating access to MMT by increasing operating hours.
Many studies have demonstrated that higher methadone dosages have beneficial effects on methadone treatment in terms of retention and abstinence. A meta-analysis of randomized controlled trials found that a dose of 50 mg per day was associated with higher retention rates (Farre et al, 2002). A study by Strain and colleagues showed that high-dose methadone resulted in significantly longer retention and fewer positive urine drug-tested samples compared with moderately dosed clients (Strain et al, 1999
). Hartel and Liu also found those who received less than 70 mg/day had higher levels of heroin use than those on higher dosages (Hartel et al, 1995
; Liu et al, 2008
). Other studies have also found an association between methadone dose, retention, and positive urine drug-test results (Blaney & Craig, 1999
; Maddux et al, 1997
). By contrast, we found that higher methadone doses in the clinics in China were associated with positive urine drug testing. As these data are associational, it is not possible to assign causation, although physicians prescribe higher doses to non-compliant clients. Once drug use is eliminated at higher doses, however, providers initiate dose reductions to move the client toward drug-free status. The widely held belief of providers and of clients that drug-free status is the desired outcome for MMT (instead of a prolonged stable course of MMT) may lead clients who need higher doses to terminate treatment, leaving clients who are non-compliant at the higher doses within the clinics.
There are certain limitations with regard to reliability and validity of the study. First, this study used a cross-sectional design that suffers the limitation of temporal ambiguity, so we are not able to make causal inferences. Second, both Zhejiang and Jiangxi Provinces have only a modest drug-use problem and not many reported HIV cases. The MMT programs, clients, and service providers in these areas might be different from those in other parts of China. One should be cautious in generalizing the findings to other geographic locations and populations. Nevertheless, even with the limitations noted above, this study indicates that certain structural elements associate significantly with successful outcomes in methadone treatment. At this early stage of the implementation of MMT in China, improvements in enrollments and in retention may result from providing comprehensive and supportive services to clients, offering extended operating hours, instituting incentives for compliance, and encouraging sustained, high-dose methadone for clients with severe dependence in order to eliminate drug use.