Thread by @tdbrothers

Our commentary on patient-centred care for opioid agonist therapy is published today in @CMAJ

Written by me (a doctor who prescribes OAT) & the incredible @m_bonnxx of @HANDUPhfx, @HepNSabc, & @needleexchange2 (an expert w/ lived experience)

A THREAD ⬇️

cmaj.ca/content/191/17…

The evidence is clear that opioid agonist treatment with methadone or buprenorphine reduces the risk of death and infection with HIV and hepatitis C
virus (HCV) among people who inject opioids. In many places, OAT isn't available at all and should be implemented urgently.

But even for people with access to OAT, not all OAT is equal

Meta-analyses of multiple RCTs established minimum effective doses for methadone (60mg or higher)

cochrane.org/CD002208/ADDIC…

and buprenorphine (16mg or higher)

cochrane.org/CD002207/ADDIC…

This is reflected in international clinical practice guidelines, including from the World Health Organization

who.int/substance_abus…

Unfortunately many patients receive doses lower than these thresholds

In one recent study of admin data in US by @haroldpollack & colleagues, 23% of patients had methadone doses under 60mg

sciencedirect.com/science/articl…

While the randomized clinical trials tested clinical outcomes related to different milligram doses of methadone or buprenorphine, none of them have really asked patients whether they felt their dose was adequate or not

Our commentary refers to an important observational study today in @CMAJ by Artenee, Bruneau, and colleagues that exploring whether OAT's perception of dosage adequacy is associated with health outcomes (in this case, new infections of Hepatitis C)

cmaj.ca/content/191/17…

The authors recruited a cohort of people who inject drugs in Montreal who did not have hepatitis C, and asked how many were on opioid agonist therapy (with methadone or buprenorphine), what is their dose, and whether they felt their dose is adequate

Compared with people who inject drugs (PWID) who are not on OAT, people who were on clinically recommended doses AND who also felt their doses of OAT were adequate were at LESS THAN HALF the risk of contracting hepatitis C (aHR 0.43)

But this benefit seemed to be lost if PWID on OAT were on doses lower than clinically recommended or on doses felt to be inadequate by the patients themselves

And disturbingly, PWID on OAT who were doses lower than clinically recommended AND that they themselves felt were inadequate, they were at TWO TIMES HIGHER risk of contracting hepatitis C compared to PWID who were not on OAT at all (aHR 1.94)

The reasons for this still need to be figured out -- but in short, we (an expert with lived experience and a doctor who prescribes OAT) believe active patient involvement in treatment decisions may be essential to improving health outcomes, including HCV

There are other potential explanations, including that PWID who feel their OAT is inadequate (no matter the dose) might be more likely to contract HCV related to their substance use or injecting behaviours

& multiple different factors contributing to OAT dose increases and decreases are COMPLEX. See, eg:

ncbi.nlm.nih.gov/pubmed/23803718
by Sanders & colleagues

ncbi.nlm.nih.gov/pubmed/25875323
by @rs_mcneil, Chereece Kewatin, & colleagues

& it is relatively common for people to want to stay on a low dose of OAT so that they will more quickly be able to taper off

But we are concerned about OAT care that is not patient- or client-centred, and may lead to inadequate doses, and be causing harm

For example, punitive methadone dose tapers (@Hawkfeather333)

https://twitter.com/LeoBeletsky/status/1051543679259668480

Or forced tapers (@AliciaSVentura)

https://twitter.com/AliciaSVentura/status/1052372956968640519

.@LeoBeletsky has collected a thread of harmful OAT policies here:

https://twitter.com/LeoBeletsky/status/1051543679259668480

Overall we feel we prescribers & patients should partner together in the design and delivery of care for addictions and substance use disorders - people with lived experience are experts in their needs & how they can be best served

(& let me know if you're 🔒& want the PDF!)