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Background: This study aimed to investigate patient perspectives regarding coming off maintenance opioid substitution treatment (OST). The study explored previous experiences, current interest and concerns about stopping treatment, and perceptions of how and when coming off treatment should be supported., Methods: A cross-sectional survey was used. Participants were 145 patients receiving OST at public opioid treatment clinics in Sydney, Australia., Results: Sixty-two percent reported high interest in coming off treatment in the next 6 months. High interest was associated with having discussed coming off treatment with a greater number of categories of people (OR=1.72), not citing concern about heroin relapse (OR=3.18), and shorter duration of current treatment episode (OR=0.99). Seventy-one percent reported previous withdrawal attempts and 23% had achieved opioid abstinence for ≥3 months following a previous withdrawal attempt. Attempts most commonly involved jumping off (59%), and doctor-controlled (52%) or self-controlled (48%) gradual reduction. For future attempts respondents were most interested in doctor-controlled (68%) or self-controlled (41%) gradual reduction. Concerns regarding coming off treatment included withdrawal discomfort (68%), increased pain (50%), and relapse to heroin use (48%)., Conclusion: While some patients may require lifetime maintenance, the issue of coming off treatment is important to many patients and should be discussed regularly throughout treatment and where appropriate supported by a menu of clinical options., (Crown Copyright © 2010. Published by Elsevier B.V. All rights reserved.)

A survey of 448 clients receiving opioid treatment in public clinics in Australia was conducted during 2005, exploring diversion and injection of supervised methadone and buprenorphine, frequency and reported effects of injecting, and the cost and availability of street-purchased pharmacotherapies. The rates of diversion in the preceding 12 months were over three times higher among participants receiving supervised buprenorphine (15.3%) than among those receiving supervised methadone (4.3%). While 26.5% of participants currently prescribed buprenorphine had ever injected buprenorphine, 65.9% of those prescribed methadone reported ever injecting methadone. The majority of participants did not appear to have extensive experience of injecting their medication and most expressed a preference for taking it as directed. Further research is required to determine the optimal approach for the supervised administration of buprenorphine that maximizes the benefits of treatment and minimizes harm and the risk of diversion. The study's limitations are noted.

This study aimed to identify the practices of community pharmacists regarding the provision of buprenorphine for opioid dependence and explore behaviors pharmacists considered indicative of buprenorphine diversion. A cross-sectional survey of 669 community pharmacists authorized to dispense buprenorphine or methadone was conducted in New South Wales and Victoria, Australia. There was wide variation between pharmacies in the level of supervision provided during supervised buprenorphine dosing and a lack of clarity between pharmacists regarding what behaviors are examples of buprenorphine diversion. Compared to New South Wales, a higher proportion of Victorian pharmacists detected 1 or more episodes of buprenorphine diversion in the past year (65% vs. 28%; p < .001) and in the past month (20% vs. 7%; p < .001). Detection of buprenorphine diversion was associated with the administration of crushed tablets (odds ratio = 2.77), broken tablets (odds ratio = 2.69), and having more buprenorphine clients (odds ratio = 1.24). Future research investigating the prevalence of buprenorphine diversion should include a clear definition of what behaviors constitute diversion.

Background: This study explored the attitude towards, and experiences of, injection site examination among injecting drug users in opioid treatment and the potential impact of this routine examination on information disclosure and future injection practices., Methods: A self-complete, anonymous, cross-sectional questionnaire was used with 153 patients recruited from three public clinics in Sydney, Australia., Results: The vast majority (97%) had ever injected in their upper limb, 19% in their leg, 16% in their neck, and 7% in their groin. The majority were 'happy to have their sites inspected' (78%), and felt it was an 'appropriate part of routine examination' (72%). Seventy-seven percent said they would be more honest about recent injecting, and 25% would inject in other sites if upper limb inspection occurred at every clinical review., Conclusions: The examination of injecting sites can provide useful corroboration of self-reported injecting drug use and an opportunity to offer harm reduction advice. The inspection of injecting sites was acceptable to most patients and should form part of routine clinical reviews.

This study aimed to develop a better understanding of the motives for suspected buprenorphine diversion during supervised dosing. Structured interviews were conducted with clients after 71 episodes of diversion at 3 opioid substitution treatment clinics in Sydney, Australia. Interviews were conducted by the clinic manager. An equivalent number of suspected episodes involved diversion via removal of buprenorphine from the mouth (n = 35), and secretion of buprenorphine in the mouth (n = 32). Denial of diversion occurred in 45% of suspected episodes and was significantly associated with secretion of buprenorphine in the mouth (P < .0001), suggesting a possible misunderstanding between clinicians and clients to what constitutes diversion. Motivations for diversion included "stockpiling" for later sublingual use (n = 15), discarding buprenorphine (n = 11), and giving it to another person (n = 5). A consistent definition of diversion of supervised dosed of buprenorphine is required. Diversion of supervised doses may represent a single episode of nonadherence to dosing instructions or more significant ambivalence over treatment. Responses to suspected diversion should aim to minimise harm and maximise treatment outcomes.

Background: This study aimed to investigate the prevalence of diversion and injection of methadone and buprenorphine among clients receiving opioid pharmacotherapy treatment at community pharmacies in New South Wales (NSW), Australia., Methods: A multi-site cross-sectional survey design was utilised using a self-complete questionnaire. Participants were 508 clients receiving supervised methadone (n=442) and buprenorphine (n=66) at 50 community pharmacies. Participants were surveyed about whether they had diverted their currently prescribed pharmacotherapy, whether they had injected methadone or buprenorphine, the frequency, desirability and duration of action of injecting, and the ease of availability of street-purchased pharmacotherapies., Results: The prevalence of recent diversion was more than 10 times higher among those receiving buprenorphine compared to methadone, with 23.8% of buprenorphine-maintained participants reporting diverting their dose in the preceding 12 months. Seventeen percent of methadone clients had injected methadone in the preceding 12 months compared with 9.1% of buprenorphine clients over the same time period., Conclusion: The higher prevalence of buprenorphine diversion compared to methadone diversion is likely to be due to its sublingual tablet formulation and difficulty associated with supervising its consumption compared to that of an oral liquid. Methadone diversion is also less prevalent likely due to the high levels of methadone take away provision, which also helps to explain the higher levels of recent methadone injecting compared to buprenorphine injecting. A clearer understanding of the motivations for diversion and injection of opioid pharmacotherapies, and the relationship between them is required.

Introduction and Aims: A consumer satisfaction survey was conducted among clients receiving methadone or buprenorphine treatment for opioid dependence. The survey aimed to assess client perceptions across a number of treatment domains, including the clinic environment, service provision, clinical relationships, medication and treatment outcomes., Design and Methods: Participants were 432 clients receiving treatment at nine public clinics in New South Wales, Australia. An interviewer-administered questionnaire was utilised, designed by the researchers. Participation was voluntary and anonymous. All participants received $10 remuneration., Results: Seventy-eight per cent of participants were on methadone treatment. Overall satisfaction with treatment was high (mean: 3.8; very satisfied = 5). Participants were mainly satisfied with service provided by the clinic, although had concerns over the inflexibility associated with the clinic atmosphere, frequency of clinic attendance, dosing hours and lack of takeaway doses. While relationships with prescribers and case managers were rated positively, 16% and 21% of participants wanted to see their prescriber and case manager more often, respectively; 53% reported that they did not have input into their care plan. Regarding the helpfulness of case managers in assisting clients with problems experienced in identified domains of case management (e.g. drug use, physical and mental health, psychosocial supports), the mean rating was 5.2 (excellent = 10)., Discussion and Conclusions: While participants reported being mainly satisfied with their treatment, results must be viewed within the context of what a consumer reasonably expects to receive from a service. The concept of 'expectation' and 'relative experience' is crucial in measuring consumer satisfaction among pharmacotherapy consumers.

Introduction and Aims: Clients in opioid substitution therapy often have considerable unmet health-care needs. The current study aimed to explore health problems related to opioid substitution therapy among clients on methadone and buprenorphine treatment., Design and Methods: A self-complete, cross-sectional survey conducted among 508 patients receiving methadone and buprenorphine treatment at community pharmacies in New South Wales (NSW), Australia., Results: The most common problems for which participants had ever sought help were dental (29.9%), constipation (25.0%) and headache (24.0%). The most common problems for which participants would currently like help were dental (41.1%), sweating (26.4%) and reduced sexual enjoyment (24.2%). There were no significant differences between those currently on methadone and those currently on buprenorphine for any of the health problems explored, nor differences for gender or treatment duration. Participants on methadone doses 100 mg or above were significantly more likely to want help currently for sedation., Discussion and Conclusions: The considerable unmet health care needs among participants in this study suggest that treatment providers should consider improving the detection and response to common health problems related to opioid substitution therapy.

Introduction and Aims: The introduction of buprenorphine - naloxone in Australia in April 2006 has permitted the revision of takeaway policies in many states and has introduced the possibility of unsupervised treatment. This study explored the implications of the introduction of buprenorphine - naloxone in terms of cost to patients through a survey of pharmacists' intended pricing practices. The aim of the research was to examine the intentions of pharmacists in relation to fees for buprenorphine - naloxone and study the potential implications to patients when compared with the existing fee structure for methadone and for buprenorphine alone., Design and Methods: A self-complete questionnaire was mailed to every community pharmacy in New South Wales (NSW) (n = 593) dispensing methadone or buprenorphine to people with opioid dependence. A response rate of 68.6% (n = 407) was achieved after three mailouts., Results: The majority of pharmacies charged a flat weekly fee for methadone (92.2%; mean = $31.90) and buprenorphine (74.8%; mean = $31.00). The mean intended fees for buprenorphine - naloxone according to different dosing and takeaway regimens ranged from $19.19 per week for no supervised doses and fortnightly takeaways to a $30.88 per week flat fee. There appeared to be little variation in fee structure irrespective of the takeaway regimen, until reaching the 2 weeks' unsupervised dose regimen., Discussion and Conclusions: This study highlights the importance of the early dissemination of unambiguous information regarding the introduction of a new medication, especially where supervised dispensing through community pharmacies is essential to the provision of treatment. The potential impact upon the successful rollout of a new treatment paradigm that was developed to benefit stable patients in the community may be jeopardised when such processes are not followed.

Aims To explore service provision and the range of problems that New South Wales (NSW) and Victoria (VIC) community pharmacists providing opioid substitution treatment (OST) have experienced with clients and prescribers. Design Cross-sectional postal survey. Setting All community pharmacies providing OST in NSW ( n = 593) and VIC ( n = 393), Australia. Participants Completed questionnaires were received from 669 pharmacists (68% response rate). Measurements The questionnaire addressed pharmacy characteristics, recent problems experienced with clients including refusal to dose, provision of credit for dispensing fees, termination of treatment, responses of pharmacists to problems experienced with clients, as well as problems experienced with OST prescribers. Findings In the preceding month, 41% of pharmacists had refused to dose a client for any reason, due most commonly to expired prescriptions (29%), or ≥3 missed doses (23%). Terminating a client's treatment in the past month was reported among 14% of respondents, due most commonly to inappropriate behaviour and missed doses. Treatment termination was reported by a significantly higher proportion of pharmacists in VIC ( P < 0.001). Treatment termination in last month was predicted having more clients ( P < 0.001), the provision of buprenorphine treatment ( P = 0.008), having a separate dosing area ( P = 0.021), and being a female pharmacist ( P = 0.013). Past month refusal to dose was predicted by the pharmacy being in VIC ( P < 0.001) and having more clients ( P < 0.001). Problems experienced most commonly in the past month with prescribers were difficulty contacting prescriber (21%) and provision of takeaway doses to clients considered unstable by the pharmacist (19%) (higher in VIC: both P < 0.001). Conclusions This study highlights the range of problems experienced by community pharmacists in the delivery of OST and the consequences for people in treatment. Particular attention should be focused upon considering number of clients per pharmacy and improving professional communication between pharmacists and prescribers. [ABSTRACT FROM AUTHOR]

Aims: There are currently 39,000 people on methadone or buprenorphine treatment in Australia, representing approximately one third of the opioid-dependent population. An educational DVD, entitled Access All Areas, was developed to inform, attract and engage opioid-dependent drug users into treatment, with a view to increasing users' understanding of the benefits and risks of treatment and factors impacting the way treatment is delivered. Methods: A pilot evaluation of the draft DVD was conducted with 99 opioid users recruited from two public opioid treatment clinics and four Needle Syringe Programs (NSP). Participants viewed a 1-hour segment of the DVD and completed a pre- and post-test knowledge questionnaire, and an evaluation questionnaire. Findings: After viewing the DVD, the majority of participants had a 'better understanding of the benefits of treatment' (95%), and were 'more likely to ask about hepatitis C treatment' (69%). Among participants not on opioid treatment, 37% were 'more interested in the idea of treatment' after viewing the DVD. The mean number of correct responses to knowledge questions increased marginally after viewing the DVD (14/28 vs. 15/28; p <.05). However, there were considerable increases in the proportion of participants who responded correctly to questions regarding pregnancy and opioids, the dental effects of methadone, and hepatitis. Conclusions: This study provides preliminary evidence of the benefits of this educational resource to people with opioid dependence. Future research is planned evaluating the DVD in a controlled trial exploring treatment engagement, retention, and other outcomes. [ABSTRACT FROM AUTHOR]

Aims: To ascertain the level of knowledge about some of the effects of methadone and buprenorphine among 956 clients receiving treatment for opioid dependence at 9 public clinics and 50 community pharmacies in New South Wales, Australia. Methods: A cross-sectional survey using both research-administered and self-complete questionnaires assessed medication-specific knowledge (derived from a literature review and information contained within client treatment information booklets), answered only by those receiving that treatment type. Assessment of knowledge was performed by asking participants to agree or disagree with four statements about their medication. Findings: The majority of methadone clients were aware of the risks of overdose when methadone is taken by non-tolerant people and when methadone is mixed with other CNS depressants. Methadone clients were less aware of the protective effects of methadone in overdose and most believed that it rotted their teeth. Almost 50% of those on buprenorphine were not aware of the effects of dose increase on duration of action nor its relatively good safety profile compared to methadone. Buprenorphine clients were well informed about the importance of sublingual absorption and the risks of precipitated withdrawal. Conclusions: This study identifies significant gaps in the knowledge that opioid-dependent clients have about methadone and buprenorphine that may lead to suboptimal use of medications and ambivalence over treatment. In addition to the provision of written material service providers need to consider systems to ensure that clinical information concerning treatment is received and understood by clients. [ABSTRACT FROM AUTHOR]