Tuberculosis Prevention in Methadone Maintenance Clinics

Abstract

To determine the effectiveness and cost-effectiveness of a program to provide screening for tuberculosis infection and directly observed preventive therapy (DOPT) in methadone maintenance clinics, we determined completion rates of screening for tuberculosis infection, medical evaluation, and preventive therapy, as well as the number of active tuberculosis cases and tuberculosis-related deaths prevented, in five clinics in San Francisco, California. Between 1990 and 1995, a total of 2,689 clients (of whom 18% were HIV-seropositive) were screened at least once. Of eligible clients, 99% received tuberculin skin tests, 96% received a medical examination, 91% began isoniazid preventive therapy, and 82% completed preventive therapy. Program effectiveness was enhanced by close collaboration between public health and methadone maintenance programs and the use of incentives and enablers. Over a 3-yr follow-up period, only one verified case of tuberculosis was reported among clients with a positive tuberculin skin test, thereby preventing as much as 95% of expected tuberculosis cases. Over 10 yr, we estimate the program would prevent 30.0 (52%) of 57.7 expected cases of tuberculosis, and 7.6 (57%) of 13.4 expected tuberculosis-related deaths. The program cost $771,569, but averted an estimated $876,229, for a net savings of $104,660 (average of $3, 724 per case prevented). Our study demonstrates that when effectively implemented, screening for tuberculosis infection and DOPT in methadone maintenance clinics is a highly cost-effective approach to prevent tuberculosis.

A controlled trial of methadone treatment combined with directly observed isoniazid for tuberculosis prevention in injection drug users

“…INH completion in the routine care group was 13.1%, even lower than the 26% found among homeless clients at the same TB clinic by Tulsky et al (2000). Likewise, INH completion rates in the methadone groups were lower than in uncontrolled studies in methadone maintenance clinics that reported completion rates of 80-90% (Gourevitch et al, 1996;Gourevitch et al, 1998;Snyder et al, 1999).…”

“…A randomized trial studying the impact of location of tuberculosis screening showed that chest radiograph completion by drug users was much higher in a methadone clinic than in a nearby medical clinic (86% vs. 23%) (Umbricht-Schneiter et al, 1994). Completion rates for directly observed INH have been as high as 80-90% in methadone programs (O'Connor et al, 1992;Gourevitch et al, 1998;Snyder et al, 1999), regardless of participants' drug use (Gourevitch et al, 1996). This contrasts with other settings, where TB medication adherence among substance users has been lower than among non-users (Combs et al, 1990), even with direct observation (Burman et al, 1997;Pablos-Maendez et al, 1997;Perlman et al, 1997).…”

Facilitating entry into drug treatment among injection drug users referred from a needle exchange program: Results from a community-based behavioral intervention trial

“…Drug abuse treatment, particularly opioid agonist regimens such as methadone maintenance are effective in reducing the frequency of injection drug use, and subsequently, the incidence of HIV infection (Metzger and Navaline, 2003) and tuberculosis (Snyder et al, 1999). Since only 15-20% of IDUs are enrolled in a drug treatment program at any given time in the U.S. (Metzger and Navaline, 2003), increasing the number and proportion of drug users in treatment is an important public health goal.…”

Opioid pharmacotherapy: Treatment, regimes, constructions and control

“…In one study of patients with latent TB infection (LTBI), providing MMT with onsite DOT was associated with a four-fold improvement of isoniazid preventive treatment (IPT) completion (Batki, Gruber, Bradley, Bradley, & Delucchi, 2002). In another New York-based study, providing IPT for LTBI and DOT in MMT programs in the U.S. has been shown to be both an effective (Gourevitch, Wasserman, Panero, & Selwyn, 1996) and cost-effective TB prevention intervention (Snyder et al, 1999) among PWIDs. Description of TB treatment for patients receiving and not receiving MMT, aside from a small sample (N = 12) in the U.S. (Gourevitch et al, 1996), has not been empirically assessed until now.…”