Exploring the health concerns of people taking methadone
This article reports on a study to uncover the health concerns of clients attending a methadone maintenance programme in an addiction service in Ireland.
James, P. et al (2008) Exploring the health concerns of people taking methadone. This is an extended version of the article published in Nursing Times; 104: 35, 26–27.
Background: Health promotion is an important aspect of nurses’ work in addiction services. It encompasses a huge range of relevant topics. Previous research has demonstrated that clients with addiction problems have poor health compared with the general population. Those on methadone maintenance perceive their health negatively but continue to engage in behaviours likely to have negative health outcomes.
Aim: This article reports on a study to uncover the health concerns of clients attending a methadone maintenance programme in an addiction service in Ireland.
Method: The Health Concerns Questionnaire 3 was completed by 261 clients attending methadone maintenance clinics.
Results: The most endorsed items tended to be psychosocial health concerns, particularly mood-related items. Additional comments highlighted various health issues including hepatitis C, diet, and sexual and mental health.
Conclusion: Clients on methadone maintenance demonstrate a high level of health-related concerns. In particular, they were most concerned about mood and hepatitis C; these topics therefore merit attention from staff in addiction services. This research confirms that clients on methadone maintenance require regular screening and follow-up in relation to mood disorders and hepatitis C.
Philip James, MSc, BSc, DipN, Dip REBT, RPN, is clinical nurse specialist in child and adolescent substance misuse, YoDA Service; David Spiro, RPN, is staff nurse, both at HSE Addiction Services, Dublin; Noreen Geoghegan, BSc, RM, RGN, HDip, is assistant director of nursing; Anita Connor, RGN, is staff nurse; Gail Hawthorne, BSc, RGN, is clinical nurse specialist in hepatitis C liaison; all at HSE Addiction Services, Cherry Orchard Hospital, Dublin.
There has been a dramatic increase in the level of health promotion activities by nurses over the past 20 years. In Ireland, the Health Promotion Strategy called for a coordinated, comprehensive and integrated approach to promoting health (Department of Health and Children, 2000).
There has also been considerable emphasis on identifying key target populations and developing interventions to meet their needs. In line with this, the National Drugs Strategy indicates that health education and the promotion of healthier lifestyle choices are an important part of addressing drug misuse (Department of Tourism, Sport and Recreation, 2001).
Individuals who engage in high-risk behaviours such as injecting drugs are more susceptible to a variety of physical, social and psychological health problems (Ralston and Wilson, 1996).
Our service provides addiction treatment to approximately 1,200 clients on methadone maintenance. We noted there was a deficit in health promotion information addressing the health problems associated with illicit drug use, and members of the nursing team formed a health promotion committee to promote healthier lifestyle choices among clients. This mainly consisted of providing education and information on health-related topics but these were chosen by staff. We decided to consult clients to ensure we were addressing issues of concern to them. For this reason we chose to investigate their subjective health concerns rather than their objective health status or needs.
A literature search identified no studies attempting to measure the health concerns of people with addictions, although some had attempted to measure clients’ actual health or healthcare needs. A number of studies had examined the symptoms reported by clients with substance misuse problems (Patkar et al, 1999; Polinsky et al, 1998; Stein et al, 1998; Ryan and White, 1996).
Polinsky et al (1998) examined the symptoms of 182 people using various drugs who presented for assessment at a drug treatment service in Los Angeles. Medical concerns were high both at initial intake and six months follow-up, and the older the client the greater their medical concerns. Housing and medical needs together were also a common cluster. Psychological needs were not reported as being high, indicating a low level of concurrent psychiatric and substance misuse problems.
Patkar et al (1999) compared medical symptoms of 321 cocaine, opiate and alcohol dependent clients. Cocaine addicts reported the lowest level of symptoms across the majority of the 14 subscales. Two studies used the Medical Outcomes Study Short Form (SF) (Stein et al, 1998; Ryan and White 1996). Ryan and White (1996) interviewed 100 clients admitted to a methadone programme in Australia. At entry to the programme, heroin users reported considerably worse physical and psychological health than the general population, which is consistent with findings by Millson et al (2004). The methadone treatment clients also reported similar health-related quality of life to those with psychiatric disorders, although drug users reported their general health as worse. Meanwhile, Stein et al (1998) administered the SF-20 with 2,688 people seeking treatment for drug or alcohol difficulties in Boston. Results indicated that cocaine, heroin and alcohol have similarly negative outcomes on health and quality of life.
Two further studies were identified, one examining self-perceived health and the other the potential link between psychiatric symptoms and needle sharing. Millson et al (2004) attempted to compare the self-perceived health of 143 opiate users in Canada with the general population and other populations with long-term conditions. Clients on a methadone programme perceived their health to be worse than the other two groups. The only client population who perceived their health as negatively as opiate users were those diagnosed with psychiatric illnesses.
Lundgren et al (2005) examined whether particular psychiatric symptoms were more strongly associated with needle sharing than others in a sample of 507 intravenous drug users (IVDUs) in Boston. They found mental health problems, particularly anxiety, correlated with HIV risk behaviours.
The literature confirmed that clients receiving treatment for opiate addiction tend to perceive their health negatively, particularly from a physical perspective. However, from the studies carried out we do not know which aspects of their health clients are most concerned about. We decided to carry out a survey of our clients’ health concerns using the Health Concerns Questionnaire (HCQ-3) developed by Dush et al (1999).
Aim and method
The aim of the study was to obtain an understanding of the health concerns of clients attending the methadone maintenance clinics. The study design was quantitative using a questionnaire survey; participants also had the opportunity to mention any additional health concerns not covered in the questionnaire. All participants were aged 18 years or over and on a methadone maintenance programme for treatment of opiate addiction.
The service provides treatment for approximately 1,200 clients in its geographical catchment area. Questionnaires were distributed to clients in the clinics throughout November 2006 along with a return envelope and a letter explaining the study.
The HCQ-3 assesses respondents’ degree of concern on 66 health-related issues using a four-point Likert-type scale ranging from mild concern to very serious concern. If they are not concerned about an item they leave it blank.
The 66 ratings can be added together to give a total distress score (TDS) as well as two sub-scales for psychosocial and somatic symptoms. It is possible to work out a somatisation ratio, which is the percentage of the TDS attributable to physical complaints. The psychosocial scale contains 35 items and the somatic scale the remaining 31 items.
Dush et al (1999) and Dush and Spoth (1995) reported that the HCQ-3 has proven reliable and psychometrically robust. While untested with addiction clients, it does appear to cover a wide range of health and psychosocial concerns. We therefore believe it is a valid measure of health concerns. However, we also provided space on the questionnaire for clients to mention any additional concerns.
The ethics committee of the Drug Treatment Centre Board in Dublin granted ethical approval. Participants received written information regarding the study and a copy of the questionnaire and were able to ask the clinic nurse any further questions. A contact number for the research team was also provided.
Participants’ anonymity was assured, and we hoped this would promote honest responses and participation. Data was coded and entered into a computer using the Statistical Package for the Social Sciences (SPSS) software. Analysis mainly consisted of descriptive statistics such as means and frequencies.
Women accounted for 38.3% of our sample. Participants’ ages were 18-56 (mean 30.21), with no significant difference between genders. Almost 70% of participants had children, with women (83%) more likely to report this than men (60.4%). Over 52% of participants said they were in a long-term relationship (60.6% of women and 45.9% of men). The mean number of years of schooling completed was 11.3 and, again, there was no significant difference between genders. The average age of first heroin use was 17.95 years, with little gender difference. The average methadone dose was 80.56mg, with women on an average of 77.7mg compared with 81.6mg for men. These results are summarised in Table 1.
Table 1. Descriptive demographics of respondents
|In a long-term relationship||Yes|
|Number of years of schooling completed||Range|
|Age first used heroin||Range|
|Current methadone dose||Range|
Levels of health concern
For the entire sample (n=261) TDS was 83.62, with considerable variance between genders. Women showed a much higher mean TDS (93.03) than men (78.12). When the TDS is broken into its two broad categories, the psychosocial symptom index (PSI) and somatic symptom index (SSI), the means were 48.05 and 35.57 respectively. The somatisation ratio (SR) is the percentage of the respondents’ TDS which is accounted for by their score on the SSI. The SR reported was 43.54% and it is interesting to note that the SR for men and women is almost identical (43.30% and 43.68% respectively). These scores indicate that both genders were equally concerned about psychosocial items. The results are summarised in Table 2. There was no statistically significant relationship between age and level of health concern.
Table 2. Means for total scores and subscales
|Item/concern||Sample (n=261)||Women (n=97)||Men (n=156)|
Total distress score
Psychosocial symptom index
Somatic symptom index
Most commonly reported health concerns
The most common concerns were: worrying about health; troubled by the past; hard to trust anyone; and poor sleep. Of the 10 most endorsed health concerns (Table 3) only two – poor sleep and sweating – were physical. There was little difference between the concerns reported by men and women but men consistently scored them lower than women.
Table 3. Ten most endorsed health concerns for respondents
|Worry about health||261||2.07||1.551|
|Troubled by the past||261||1.99||1.621|
|Hard to trust anyone||261||1.89||1.602|
|Less interest in things||261||1.79||1.495|
|Dwell on problems||261||1.78||1.487|
Least commonly reported health concerns
The least endorsed health concerns were excess pain, hearing problems and swelling. In contrast to the most endorsed concerns, eight were somatic in nature. Too much alcohol and work or school problems are the only psychosocial symptoms in the 10 least endorsed concerns (Table 4).
Table 4. Ten least endorsed health concerns for respondents
|Too much alcohol||261||0.67||1.203|
|Odd skin sensations||261||0.76||1.224|
Thirty-seven per cent of the questionnaires (n=97) contained additional comments. This qualitative data was analysed to identify themes, and the frequency with which an item was reported was taken as an indication of its importance. Six broad themes were identified:
Many participants commented on a number of themes.
Physical health: This section contained the most comments (n=58) which necessitated its division into four subcategories. The first, viral infections, contained 17 comments ranging from requests for more literature and information on hepatitis C virus (HCV) and HIV to statements that the participant was worried about these viruses and about side-effects of HCV treatments. The following quote summarises the concerns:
‘I am very worried about my Hep C and how it will affect me in the future and will I die before my children grow up.’ (Q234)
The second subcategory (eight comments) related to diet, nutrition and weight management including weight gain or loss and stomach problems. The third subcategory (six comments) related to dental care, while a miscellaneous subcategory was used to capture the other comments, which highlighted concerns regarding blood pressure, deep vein thrombosis, asthma, sweating and various aches and pains.
Mental health: This category contained 14 comments, half of which related to feelings of low mood and depression, with two participants mentioning suicidal thoughts. Related to feelings of low mood was evidence of guilt, shame and low self-esteem for becoming an addict in the first place, as evidenced by the following quote:
‘I hated becoming a heroin addict and feel very stupid and angry. I have let down myself and everybody who loves me which brought an awful lot of guilt and depression.’ (Q214)
A few additional comments related to finding it difficult to cope with stress, not knowing where to go for help and feeling overwhelmed with life.
Sexual health: This category contained seven comments, four relating to the ability to have children and cope with parenthood. A particular concern appeared to be the effects of HCV and other viruses on the health of participants’ children. Concerns were also raised about various sexually transmitted infections.
Service comments: Seventeen comments related to the service; these covered a range of topics. Four pointed out good aspects including improved buildings or clinic accommodation and finding particular staff helpful. However, a number of shortfalls were highlighted, including the need for more counselling and for both male and female counsellors to be made available.
The need to offer participants the opportunity to detoxify from methadone and support when they have done so were also mentioned. Two participants commented that the rigidity of the clinic timetable made it difficult for them to get a job or live a normal life, while two recommended the services should ‘treat the whole person’ by dealing with addiction, mental health and physical problems. For example:
‘I would like more counselling. I feel I just come to the clinic, collect methadone and leave.’ (208)
Finally, two participants said they would like the opportunity to participate in further studies so they can help prevent others from making the same mistakes they made.
Drug comments: Eleven comments were made related to drugs. While one related to the harm caused by heroin, methadone was also cited as a problem by three participants who were concerned that they would be on it for the rest of their lives. A variety of other drugs were mentioned as causing problems including alcohol, cannabis, cough medicine, benzodiazepines, sleeping tablets and co-codamol. The following quote outlines the effects one respondent believed benzodiazepines were having on their life:
‘I used to take them (benzodiazepines) for a stone but now it’s like worse, I just need them to get out of bed.’ (Q35)
Stigma: Three participants stated that they are treated with less respect than other members of society because of their status as a drug user or addict. For example:
‘I think all drug addicts should be treated the same as anyone, not all drug addicts are scum or have a criminal record.’ (Q47)
Two broad health concerns emerged from this study: mood/psychosocial concerns and HCV. The top 10 concerns reported can all be closely related to depression and mood. Five of these top concerns – depressed, less interest in things, poor sleep, feeling guilty and memory problems – relate closely to five of the nine symptoms of depression listed in the Diagnostic and Statistic Manual IV (DSM-IV) (American Psychiatric Association, 2000). However, four of the five remaining concerns – worry about health, troubled by the past, hard to trust anyone and dwelling on problems – are also commonly found in people with mood or depression problems. This is not in keeping with the findings of Polinsky et al (1998), who found physical symptoms were prominent, but other studies have reported high rates of both physical and psychological symptoms in clients with substance misuse problems (Millson et al, 2004; Ryan and White, 1996).
Dush et al’s (1999) respondents reported a mean TDS of 55.32. In this study the mean TDS was 83.62, indicating a considerably higher rate of health concerns. These scores indicate that clients on methadone maintenance are more concerned about their health than those with medical problems surveyed by Dush et al (1999). Our results also found that age was not a variable in participants’ level of health concerns. This contrasts with Polinsky et al (1998), who found age was a variable, while Patkar et al (1999) found it was not. The different results may be explained by the focus of these studies on actual symptoms and not subjective concerns. Also the three studies examined different drugs of misuse.
The idea that many clients on methadone maintenance are experiencing some form of depression seems likely, as numerous studies have identified depressive symptoms among this population (MacManus and Fitzpatrick, 2007; Johnson et al, 2006; Rooney et al, 2002). Rates of depression vary from 31% to 83% of clients depending on the study, and it has been recommended that clients receiving methadone maintenance should have their mood assessed routinely (MacManus and Fitzpatrick, 2007; Havard et al, 2006; Johnson et al, 2006).
The importance of identifying those with mental health problems is emphasised by the finding that mental health symptoms are positively correlated with engaging in high-risk sexual behaviours (Lundgren et al, 2005). Havard et al (2006) reported that clients in treatment for heroin addiction who had major depression were more likely to report heavier drug use, more risk-taking behaviours and poorer physical health.
Injecting drug users are at high risk of acquiring HCV (Bolumar et al, 1996) and HIV (Madden, 1997). Despite the increasing availability of harm reduction interventions, recent studies have estimated that 52-80% of injecting opiate users are infected with HCV (Grogan et al, 2005; Smyth et al, 1998). Injecting drug users are the group most at risk of contracting HCV, so the virus will have a considerable impact on this group for the foreseeable future. Cooper and Mills (2006) outlined that concurrent substance misuse, co-morbid mental health conditions, poor socio-economic status and a complex treatment protocol that is often incompatible with lifestyles of IVDUs continue to account for poor uptake and completion of HCV treatment.
One of the biggest factors leading to unsuccessful treatment outcomes is a lack of baseline education (Corbett, 2007). The impact of social behaviours on HCV disease progression needs to be outlined to clients. For example, alcohol has been shown to increase disease progression (Freeman et al, 2001) and smokers have lower response rates to interferon-based therapy (El-Zayadi, 2006). Clients may choose not to change their behaviours, but this education will help them to make informed decisions.
It is also interesting to examine some of the potential concerns that were not strongly endorsed by participants in this study. Worry about alcohol was the fourth least endorsed concern, despite the fact that up to 56% of clients on methadone maintenance have been shown to exhibit some level of alcohol dependence (MacManus and Fitzpatrick, 2007). Similarly, smoking, while not specifically mentioned in the questionnaire, was not commented on by any participants. Research has shown that over 90% of those on methadone maintenance smoke and up to two-thirds of these expressed an interest in quitting (Clarke et al, 2001).
Conclusion and implications for practice
This study has shown that clients on a methadone maintenance programme have numerous health-related worries, particularly related to mood. Addiction services should therefore ensure clients’ mood is assessed routinely, and that appropriate interventions are implemented.
A considerable number of participants made additional comments about HCV. As outlined above, IVDUs are at particular risk of HCV and may therefore require specialist intervention in relation to this issue. Clients who have not contracted the virus require appropriate education to reduce their risk while those who have contracted it may require education and treatment to ensure they have the best outcome. The recently appointed clinical nurse specialist in HCV liaison should go some way to filling these gaps.
Finally, this research highlighted the importance of eliciting client feedback within health services. Addiction services have traditionally operated with little involvement from their users. National policy on mental health services in Ireland has already highlighted the need to involve service users and their families in service development (Government of Ireland, 2006), and service-user consultation and peer advocacy have become everyday features of the mental health services. However, this has not yet taken place within addiction services despite the fact the current drug strategy called for the development of service-user charters (Department of Tourism, Sport and Recreation, 2001). We believe there is a need for greater involvement of service users in the development of their service.
The authors would like to thank all the staff and clients of the addiction services who supported this study, in particular Jim Doyle, Patricia Carroll and Dr Eamon Keenan for their unending support. We would also like to thank the health promotion department of the Health Service Executive, which provided a grant to cover the cost of data entry.
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