Study Aims. Evaluate the quality and effectiveness of the medication-assisted therapy (MAT) pilot in Kazakhstan and review implementation context and related challenges. Methods. We performed a desk review of MAT policy and program documents and reviewed medical records at three MAT sites in Kazakhstan. MAT patients were interviewed to assess their perceptions of the program and its impact on their health, criminal, drug use, and HIV risk related behaviors as well as expenditures on nonprescribed psychoactive drugs. Persons injecting drugs who are not in treatment, MAT program staff, and other stakeholders were interviewed to obtain their perspectives on MAT. Results. Legislation supports introducing MAT as a standard of care for treatment of opioid dependence; however, its progress has been hampered by active opposition. Inadequate access and coverage, insufficient supply management, scarce infrastructure of narcological facilities, limited opportunities for staff development, and restrictive methadone dispensing policies compromise the quality of the intervention and limit its potential benefits. There were significant reductions in criminal, drug use, and HIV risk related behaviors in patients receiving MAT. Conclusions. The MAT pilot in Kazakhstan demonstrated its feasibility and effectiveness in the local context and is recommended for scaleup throughout the country. 1. Introduction Kazakhstan faces a concentrated HIV epidemic, with drug use being the most important risk factor for HIV transmission [1, 2]. The country is located on a major drug trafficking route from Afghanistan, resulting in the availability of inexpensive heroin and a high prevalence of drug use in the country, an environment that is increasingly conducive to the spread of HIV and other blood-borne infections. According to the national HIV integrated biobehavioral surveillance data from 2010, the estimated number of people who injected drugs (PWID) during the last 12 months was 119,140, which is 3.5-times higher than the number of PWID officially registered with the drug addiction treatment service. Medication-assisted therapy (MAT), more widely known in the region as opioid substitution therapy (OST), is a rigorously evaluated and evidence-based medical intervention to treat opioid dependence that consists of prescription of methadone or buprenorphine as a replacement for illicit street opioid narcotics such as heroin. Research conducted to date has generated a great amount of evidence demonstrating that MAT in combination with psychosocial support produces the best outcomes in
References
[1]
Republican AIDS Center, Report on Activities of the AIDS Service in 2011, Almaty, Kazakhstan, 2012.
[2]
WHO, UNAIDS, and UNICEF, Global HIV/AIDS Response—Epidemic Update and Health Sector Progress Towards Universal Access—Progress Report, Geneva, Switzerland, 2011.
[3]
WHO, Guidelines For the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence, Geneva, Switzerland, 2009.
[4]
J. Marsden, D. Stewart, M. Gossop et al., “Assessing client satisfaction with treatment for substance use problems and the development of the treatment perceptions questionnaire (TPQ),” Addiction Research and Theory, vol. 8, no. 5, pp. 455–470, 2000.
[5]
S. Darke, W. Hall, A. Wodak, N. Heather, and J. Ward, “Development and validation of a multidimensional instrument for assessing outcome of treatment among opiate users: the Opiate Treatment Index,” British Journal of Addiction, vol. 87, no. 5, pp. 733–742, 1992.
[6]
M. L. Copersino, C. S. Meade, G. E. Bigelow, and R. K. Brooner, “Measurement of self-reported HIV risk behaviors in injection drug users: comparison of standard versus timeline follow-back administration procedures,” Journal of Substance Abuse Treatment, vol. 38, no. 1, pp. 60–65, 2010.
[7]
L. C. Sobell, M. B. Sobell, G. Buchan, P. A. Cleland, I. Fedoroff, and G. I. Leo, “The reliability of the Timeline Followback method applied to drug, cigarette, and cannabis use,” in Proceedings of the 30th Annual Meeting of the Association for Advancement of Behavior Therapy, New York, NY, USA, November, 1996.
[8]
L. T. Midanik, A. M. Hines, D. C. Barrett, J. P. Paul, G. M. Crosby, and R. D. Stall, “Self-reports of alcohol use, drug use and sexual behavior: expanding the timeline follow-back technique,” Journal of Studies on Alcohol, vol. 59, no. 6, pp. 681–689, 1998.
[9]
Z. S. Morris and M. Gannon, “Drug misuse treatment services in Scotland: predicting outcomes,” International Journal for Quality in Health Care, vol. 20, no. 4, pp. 271–276, 2008.
[10]
A. Sharman, Acquired immunodeficiency syndrome. Monograph, part 1. 3. Injecting drug use and HIV infection, July 2012, http://www.zdrav.kz/data/cms/file/part1_3.pdf.
[11]
“Harm Reduction Development 2005,” IHRD, 2012, http://www.hivpolicy.org/Library/HPP001740.pdf.
[12]
The State Program on the Development of Health Care of the Republic of Kazakhstan for 2011–2015 “Salamatty Kazakhstan”, Endorsed by President’s Decree No. 1113 (November 2010).
[13]
L. Kunekova, Physicians in Almaty Refuse to Implement Heroin-Substitution Program for Drug Addicts, KTK News Agency, Almaty, Kazakhstan, 2012, http://www.ktk.kz/ru/news/video/2011/02/03/11351/.
[14]
Ministry of Health, “On expansion of accessibility of opioid substitution therapy,” Order No. 333, (May 2010).
[15]
Republican Applied Research Center on Medical and Social Problems of Drug Abuse, Application of Opiate Agonists Maintenance Therapy in Narcological Practice of the Republic of Kazakhstan, Methodological recommendations, Pavlodar, Kazakhstan, 2010.
[16]
B. P. Smyth, J. Fagan, and K. Kernan, “Outcome of heroin-dependent adolescents presenting for opiate substitution treatment,” The Journal of Substance Abuse Treatment, vol. 42, no. 1, pp. 35–44, 2012.
[17]
Law on Narcotics, Psychotropic Substances, Precursors and Counteracting Measures to Prevent Illegal Circulation and Abuse of these Substances, Law No. 279-1 adopted 10. 10. 1998 (with amendments and additions as of 07. 17. 2009). Astana, Kazakhstan.
[18]
E. C. Strain, G. E. Bigelow, I. A. Liebson, and M. L. Stitzer, “Moderate- versus high-dose methadone in the treatment of opioid dependence: a randomized trial,” Journal of the American Medical Association, vol. 281, no. 11, pp. 1000–1005, 1999.
[19]
L. Ganina, Review of the HIV Epidemiologic Situation in the Republic of Kazakhstan, Republican AIDS Center, Almaty, Kazakhstan, 2010.
[20]
R. Noori, H. Narenjiha, H. Aghabakhshi, G. Habibi, and B. Khoshkrood Mansoori, “Methadone maintenance therapy outcomes in Iran,” Substance Use Misuse, vol. 47, no. 7, pp. 767–773, 2012.
[21]
I. I. Michels, H. St？ver, and R. Gerlach, “Substitution treatment for opioid addicts in Germany,” Harm Reduction Journal, vol. 4, article 5, 2007.
[22]
N. M. Noordin, M. I. Merican, H. A. Rahman, S. S. Lee, and R. Ramly, “Substitution treatment in Malaysia,” The Lancet, vol. 372, no. 9644, pp. 1149–1150, 2008.
[23]
S. B. Sells and D. D. Simpson, Eds., The Effectiveness of Drug Abuse Treatment, Ballinger, Cambridge, Mass, USA, 1976.
[24]
R. L. Hubbard, M. E. Marsden, J. V. Rachal, H. J. Harwood, E. R. Cavanaugh, and H. M. Ginzburg, Drug Abuse Treatment: A National Study of Effectiveness, University of North Carolina Press, Chapel Hill, NC, USA, 1989.
[25]
J. C. Ball and A. Ross, The Effectiveness of Methadone Maintenance Treatment: Patients, Programs, Services, and Outcomes, Springer, New York, NY, USA, 1991.
[26]
L. E. Sullivan, D. Barry, B. A. Moore et al., “A trial of integrated buprenorphine/naloxone and HIV clinical care,” Clinical Infectious Diseases, vol. 43, supplement 4, pp. S184–S190, 2006.
[27]
B. Spire, G. M. Lucas, and M. P. Carrieri, “Adherence to HIV treatment among IDUs and the role of opioid substitution treatment (OST),” International Journal of Drug Policy, vol. 18, no. 4, pp. 262–270, 2007.
[28]
A. Latypov, D. Otiashvilli, O. Aizberg, and A. Boltaev, Opioid Substitution Therapy in Central Asia: Towards Diverse and Effective Treatment, Eurasian Harm Reduction Network, Vilnius, Lithuania, 2010.
[29]
T. Burki, “Russia's drug policy fuels infectious disease epidemics,” The Lancet Infectious Diseases, vol. 12, no. 4, pp. 275–276, 2012.
[30]
R. Elovich and E. Drucker, “On drug treatment and social control: Russian narcology's great leap backwards,” Harm Reduction Journal, vol. 5, article 23, 2008.
[31]
L. M. Sanders, C. Trinh, B. R. Sherman, and S. M. Banks, “Assessment of client satisfaction in a peer counseling substance abuse treatment program for pregnant and postpartum women,” Evaluation and Program Planning, vol. 21, no. 3, pp. 287–296, 1998.
[32]
Z. S. Morris and N. McKeganey, “Client perceptions of drug treatment services in Scotland,” Drugs, vol. 14, no. 1, pp. 49–60, 2007.
[33]
E. Peles, S. Schreiber, A. Sason, and M. Adelson, “Earning, “take-home” privileges and long-term outcome in a methadone maintenance treatment program,” Journal of Addiction Medicine, vol. 5, no. 2, pp. 92–98, 2011.
[34]
H. M. Rhoades, D. Creson, R. Elk, J. Schmitz, and J. Grabowski, “Retention, HIV risk, and illicit drug use during treatment: methadone dose and visit frequency,” American Journal of Public Health, vol. 88, no. 1, pp. 34–39, 1998.
[35]
H. Dagmar, A. Paula, F. Michael, S. Heino, M. Lars, and M. Soraya, “The effectiveness of opioid maintenance treatment in prison settings: a systematic review,” Addiction, vol. 107, no. 3, pp. 501–517, 2012.
[36]
UNODC, Drug Dependence Treatment: Interventions for Drug Users in Prison, Vienna, Austria, 2012, http://www.unodc.org/docs/treatment/111_PRISON.pdf.
[37]
WHO, UNODC, and UNAIDS, Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users, 2009.
[38]
WHO, Operational Principles for Good Pharmaceutical Procurement, Geneva, Switzerland, 1999.
[39]
UNDP, Opioid Substitution Therapy from the Viewpoint of Specialists and Former Injecting Drug Users, Kiev, Russia, 2007.
[40]
R. P. Mattick, C. Breen, J. Kimber, and M. Davoli, “Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence,” Cochrane Database of Systematic Reviews, no. 3, p. CD002209, 2009.
[41]
S. Minozzi, L. Amato, S. Vecchi, and M. Davoli, “Maintenance agonist treatments for opiate dependent pregnant women,” Cochrane Database of Systematic Reviews, no. 2, p. CD006318, 2008.
[42]
M. Connock, A. Juarez-Garcia, S. Jowett et al., “Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation,” Health Technology Assessment, vol. 11, no. 9, pp. 1–171, 2007.
[43]
Ministry of Health, Minutes of the Meeting on Results of Evaluation of Opioid Substitution Therapy in Kazakhstan, Astana, Kazakhstan, 2012.
[44]
Ministry of Health, Roadmap for Execution of the Decision Made at the Meeting on Results of Evaluation of Opioid Substitution Therapy in Kazakhstan, Astana, Kazakhstan, 2012.
