The GFTAM-funded pilot MAT project in Kazakhstan clearly demonstrates the feasibility and efficacy of prescription of methadone to treat opioid dependence in the local context. Between 46% and 61% of MAT patients at each pilot site were retained in the program at 12 months, which is similar to retention rates observed in other countries [24
]. Of those retained in the program for 12 months or longer, between 41% and 92% of patients at each MAT site remained free from opioids. Patients reported that following the enrollment in MAT there was a decrease in their heroin use, risky drug injection behavior, spending on non-prescribed psychoactive substances, and criminal behavior, as well as an improvement in their health status.
It is crucial to adopt evidence-based policies for the success of any health intervention, including MAT (6). The existing policies allow introducing MAT as a standard of care for treatment of opioid dependence in Kazakhstan. Furthermore methadone-based MAT may be provided in Kazakhstan at a relatively low cost: in 2011, the daily dose of methadone per patient was procured at US $1.00. This cost could be even lower if methadone was produced locally without dependence on external suppliers.
Results of the assessment show several best practices that should be considered when scaling up MAT in Kazakhstan. In Pavlodar, MAT and other narcological services were effectively integrated with harm reduction programs, so that injection equipment and condoms could be accessed through a trust point located in the same building. The MAT site also supports the work of a patient self-help group, placing the nongovernmental organization's office adjacent to the MAT dispensing room. In addition, Pavlodar Narcology Center has arranged for an HIV specialist from the Oblast AIDS Center to work part time at the MAT site, to provide integrated HIV care for MAT patients which is in line with the best international practices and associated with decreased substance use, HIV, and health care utilization outcomes [26
The assessment also revealed some limitations that challenge effective implementation of MAT in Kazakhstan. Firstly, despite the legislature that enables provision of MAT and the highest political support, MAT program has been limited to only three cities of the country with a low number of patients enrolled. Biased attitudes towards MAT among the general public, medical professionals, and PWID, based upon incorrect information about the clinical and pharmacological features of opiate substitution therapy, have led active opposition to MAT. Some authors explain this opposition by the fact that Kazakhstan, as a former Soviet Union country, maintains close relationships with the Russian Federation and its older medical professionals are still much influenced by the Russian medical practice and theory [28
]. Russia proactively promotes its well-known and internationally criticized antiopioid treatment policies [29
] employing various resources, including internet, mass media, professional medical journals, books, and conferences and these information channels still play a major role in the professional development of medical doctors in Central Asia. Secondly, training and technical assistance for MAT staff are currently provided as a part of the international development aid without the involvement of local medical education institutions and thus are not sustainable. An effective methadone procurement system is also lacking, and as a result there are often supply interruptions and the cost of the medication is unreasonably high.
The MAT monitoring and evaluation system is limited in that it is primarily focused on patient coverage and program expenditure indicators, with little attention paid to patient level outcomes or patient satisfaction. Clinicians providing MAT commonly rely on patients' feedback regarding the adequacy of their methadone dose as the sole measure of service quality. However our study found that while most patients gave high scores to the adequacy of their methadone dose to avoid experiencing withdrawal symptoms and craving drugs, they had a relatively modest perception of the quality of MAT services. This is an important observation as patients' satisfaction with services has been identified as a strong predictor of retention in treatment and better treatment outcomes [4
Other limitations of the pilot MAT program include facility infrastructure and availability of services. There is a need for more patient-friendly locations for MAT sites, as well as adequate space for patient counseling. The opening hours of MAT sites are not always responsive to patients' needs, as patients are obliged to visit the narcological clinic on a daily basis while meeting their social responsibilities including employment and family-related functions. The unregistered status of methadone in Kazakhstan does not allow for take-home doses, and as a result MAT is often interrupted when patients must undergo inpatient treatment in other medical facilities or move away from their home cities. Such restrictive dispensing policy is maintained despite a growing body of evidence that take-home doses of methadone improve treatment outcomes and reduce health care costs [3
]. In addition MAT is not available in the penitentiary system, which not only results in treatment interruption for incarcerated patients but also seriously limits the health care system's ability to control HIV and other blood-borne diseases among opioid dependent prison population. International evidence suggests that MAT in prison settings can be as equally beneficial as in community settings, helping opioid dependent inmates access health care services, increase adherence to ART when indicated, and reduce criminality and HIV risk behaviors [35
In order to prevent further expansion of the HIV epidemic, the government of Kazakhstan should support staged expansion of MAT starting with localities with a high prevalence of intravenous opioid use and HIV among PWID, followed by other places in the country where there is a need for such therapy. Such expansion should be implemented in accordance with the target coverage and quality indicators recommended by the WHO, UNAIDS, and UNODC [37
]. Further expansion can be attained through training and authorization of narcologists at outpatient departments of dispensaries to prescribe MAT to opioid dependent patients in their catchment areas. Doing so would contribute to scaling up MAT availability and would also reduce the workload of narcologists currently working in the pilot MAT project, who currently are the only providers authorized to prescribe methadone.
The assessment results demonstrated insufficiency in MAT related specialist training that limits further expansion of this treatment method. To strengthen staff capacity building, updated information on MAT should be integrated into graduate and postgraduate medical curricula and qualified local professionals, including addiction psychiatry specialists, should be trained and engaged to work as technical advisors to support MAT sites in the provision of quality services consistent with national and international guidelines.
Considering the wealth of knowledge gained during the MAT pilot phase, the existing clinical guidelines and standards on MAT should be revised based on lessons learned and WHO recommendations. This includes allowing the provision of MAT outside of narcological facilities, such as in correctional settings and nonnarcological hospitals; revision of admission and discharge criteria to ensure that the maximum number of PWID in need of MAT benefit from and are retained in treatment; and expanding the hours of operation at MAT sites.
Given previous disruptions in methadone procurement and supply, the Kazakhstan's Ministry of Health should establish a centralized state-controlled mechanism of procurement and distribution of medications for MAT. Procurement should be properly planned considering all of the factors affecting time of actual product delivery, including tendering, licensing requirements, import procedures, and customs clearance. Regular monitoring of procurement performance should be established in order to address emerging challenges in a timely manner [38
Improvements in monitoring and evaluation procedures should aim to ensure collection and analysis of data related not only to program implementation but also to its impact on patient behavior and health. It is also important to ensure standardization and simplification of data collection and reporting forms from various sites. Introduction of reliable health management information systems can increase data quality as well as clinical and programmatic decision making.
It is essential to develop comprehensive advocacy and communication strategies for MAT in order to deliver easy to comprehend evidence-based information for medical professionals and the general public, thus reducing the negative impact of false information. Nongovernment and community-based organizations should be engaged in such activities as intensively as possible, particularly to promote MAT among PWID and their families. Such organizations can include self-organized groups of MAT patients as in Pavlodar or parents of MAT patients such as in Ukraine [39
Finally, we recommend that the Ministry of Health continues to make evidence-based decisions regarding the development of HIV and drug dependence treatment services and strengthens its emphasis on state-of-the-art research data, such as Cochrane reviews, that repeatedly confirm the safety and effectiveness of MAT compared to other methods of treatment for opiate addiction [40
]. It is our pleasure to note that based on the findings and recommendations of our assessment report the Ministry of Health of the Republic of Kazakhstan has decided to expand MAT to two additional sites in the country [43