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      Twenty years of the methadone treatment protocol in Ireland: reflections on the role of general practice

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          Abstract

          Background

          Opioid dependence, characterised by socio economic disadvantage and significant morbidity and mortality, remains a major public health problem in Ireland. Through the methadone treatment protocol (MTP), Irish general practice has been a leader in the introduction and expansion of Irish harm reduction services, including opioid substitution treatment (OST), needle and syringe programs (NSP) and naloxone provision. These services have been effective in engaging opiate users in treatment, reducing human deficiency virus (HIV) and hepatitis C virus (HCV) transmission and reducing-drug related morbidities. Challenges remain in relation to choice of substitution treatments, timely access to OST services, adequate coverage of NSP, naloxone provision and increasing drug-related deaths.

          Methods

          A narrative review was conducted and designed to present a broad perspective on the Irish MTP and to describe its history and development in terms of clinical care, stakeholder views and changing trends.

          Results

          Three themes emerged from the analysis; The History of the Methadone Treatment Protocol, Service User and Provider Views and Challenges and Developments. Despite the initial concern about methadone maintenance treatment (MMT) in Ireland, increased participation by Irish GPs in the treatment of opioid dependence is observed over the last two decades. There are now over 10,000 people on methadone treatment in Ireland, with 40% treated in general practice. The MTP provides structure, remuneration and guidance to GPs and is underpinned by training, ongoing education and a system of quality assurance provided by the Irish College of General Practice (ICGP). Challenges include the negative views of patients around how methadone services are delivered, the stigma associated with methadone treatment, the lack of choice around substitution medication, waiting lists for treatment in certain areas and rates of fatal overdose.

          Conclusion

          Twenty years of the MTP has been the mainstay of harm reduction services in Ireland. It has provided a network of specially trained GPs who provide methadone to over 10,000 patients across Ireland within a structured framework of training, quality assurance and remuneration. With the ongoing commitment of Irish specialists in the field of addiction medicine, further improvements to support and treat patients can be made.

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          Most cited references41

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          “Don’t Judge a Book Its Cover”: A Qualitative Study of Methadone Patients’ Experiences of Stigma

          INTRODUCTION Despite its efficacy and widespread use, methadone maintenance treatment (MMT) continues to be widely stigmatized. Reducing the stigma surrounding MMT will help improve the accessibility, retention, and treatment outcomes in MMT. METHODS Semi-structured interviews were conducted with 18 adults undergoing MMT. Thematic content analysis was used to identify overarching themes. RESULTS In total, 78% of participants reported having experienced stigma surrounding MMT. Common stereotypes associated with MMT patients included the following: methadone as a way to get high, incompetence, untrustworthiness, lack of willpower, and heroin junkies. Participants reported that stigma resulted in lower self-esteem; relationship conflicts; reluctance to initiate, access, or continue MMT; and distrust toward the health care system. Public awareness campaigns, education of health care workers, family therapy, and community meetings were cited as potential stigma-reduction strategies. DISCUSSION AND CONCLUSION Stigma is a widespread and serious issue that adversely affects MMT patients’ quality of life and treatment. More efforts are needed to combat MMT-related stigma.
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            A national study of the retention of Irish opiate users in methadone substitution treatment.

            Retention in treatment is a key indicator of methadone treatment success. The study aims to identify factors that are associated with retention. To determine retention in treatment at 12 months for Irish opiate users in methadone substitution treatment and to indicate factors that increase the likelihood of retention. National cohort study of randomly selected opiate users commencing methadone treatment in 1999, 2001, and 2003 (n = 1269). Sixty-one percent of patients attending methadone treatment remained in continuous treatment for more than 1 year. Retention in treatment at 12 months was associated with age, gender, facility type, and methadone dose. Age and gender were no longer significant when adjusted for other variables in the model. Those who attended a specialist site were twice as likely to leave methadone treatment within 12 months compared with those who attended a primary care physician. The most important predictor of retention in treatment was methadone dose. Those who received <60 mg of methadone were three times more likely to leave treatment. Retention in methadone treatment is high in Ireland in a variety of settings. The main factors influencing retention in methadone treatment was an adequate methadone dose and access to a range of treatment settings including from primary care physicians. Providing an adequate dose of methadone during treatment will increase the likelihood of treatment retention. Methadone treatment by the primary care physician is a successful method of retaining opioid users in treatment.
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              Methadone as HIV prevention: high volume methadone sites to decrease HIV incidence rates in resource limited settings.

              R Bruce (2010)
              The link between injection drug use and HIV has been extensively described. Despite worldwide prevention efforts, injection drug use continues to be a risk factor for HIV transmission and both HIV and injection drug use continues to spread across the globe. Although methadone has demonstrated multiple health benefits including the reduction in injection drug use and HIV acquisition, the utilisation of methadone in many areas of the world remains one of secondary, rather than primary, HIV prevention. As a result, many who finally begin methadone enter treatment having accumulated medical and mental health problems as a result of delayed treatment. Rapid access to treatment and a more aggressive policy that realizes that methadone can help reduce opioid drug use is necessary if methadone is effectively going to act as primary HIV prevention. To delay access to methadone only increases the probability that the individual will acquire an infectious disease that is more costly to the individual in terms of morbidity and mortality and more costly to society as a whole. Copyright (c) 2009 Elsevier B.V. All rights reserved.
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                Author and article information

                Contributors
                ide.delargy@icgp.ie
                des.crowley@icgp.ie
                m.c.vanhout@ljmu.ac.uk
                Journal
                Harm Reduct J
                Harm Reduct J
                Harm Reduction Journal
                BioMed Central (London )
                1477-7517
                17 January 2019
                17 January 2019
                2019
                : 16
                : 5
                Affiliations
                [1 ]Irish College of General Practitioners, Dublin, Ireland
                [2 ]ISNI 0000 0004 0368 0654, GRID grid.4425.7, Public Health Institute, , Liverpool John Moores University, ; Liverpool, UK
                Author information
                http://orcid.org/0000-0002-0018-4060
                Article
                272
                10.1186/s12954-018-0272-4
                6337760
                30654803
                0ff180fb-b8b9-4250-b57d-133b519bb55c
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 22 September 2018
                : 11 December 2018
                Categories
                Review
                Custom metadata
                © The Author(s) 2019

                Health & Social care
                ireland,general practice,methadone,opioid dependence,harm reduction
                Health & Social care
                ireland, general practice, methadone, opioid dependence, harm reduction

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