Treatment Satisfaction Among Clients Enrolled in Methadone Maintenance Treatment (MMT) Program in Myanmar: A Cross-sectional Study

To address the long-standing opioid abuse problem, Myanmar has established the methadone maintenance treatment (MMT) program in 2006. This study aims to determine client’s treatment satisfaction towards MMT program in Myanmar. A total of 210 clients who have registered in MMT program with a minimum of six-month treatment history were recruited for this cross-sectional study across Myanmar. The Verona Service Satisfaction Scale for Methadone-Treatment (VSSS-MT) was administered to objectively measure methadone treatment satisfaction.


Abstract Background
To address the long-standing opioid abuse problem, Myanmar has established the methadone maintenance treatment (MMT) program in 2006. This study aims to determine client's treatment satisfaction towards MMT program in Myanmar.

Method
A total of 210 clients who have registered in MMT program with a minimum of six-month treatment history were recruited for this cross-sectional study across Myanmar. The Verona Service Satisfaction Scale for Methadone-Treatment (VSSS-MT) was administered to objectively measure methadone treatment satisfaction.

Result
The majority (89%, n=186) were satis ed with the current methadone treatment program. Speci cally, 89.5% (n=187) claimed to be highly satis ed with the clinic staff professional skills (e.g. doctor, nurse, etc.), (91.9%, n=192) satis ed with the basic interventions (instruction between visits, side-effects etc.), and (74.6%, n=156) satis ed with speci c interventions (e.g. individual rehabilitation and psychotherapy, group therapy etc.) categories. Among the different characteristics of the respondents, higher quality of life on physical, psychological, social and environmental categories, respondents who satis ed on current marital status and current leisure status, respondents who were on alcohol were associated with higher treatment satisfaction on methadone (p<0.05). The result of stepwise binary logistic regression showed alcohol use and physical health had signi cantly association with treatment satisfaction.

Conclusion
Despite the high methadone treatment satisfaction, treatment providers must make an attempt to address service limitations in order to maintain clients' participation in MMT program especially for speci c intervention categories (e.g. individual rehabilitation and psychotherapy, group therapy etc).

Background
Global Health Observatory data from the World Health Organization (WHO) mentioned in 2014 that 50% of the 152 responding countries have methadone available for maintenance treatment of opioid dependence. Meanwhile, 45% of the 147 responding countries have methadone available for detoxi cation treatment of opioid dependence (methadone 2014).
World Drug Report 2020 estimated that 57.8 million are opioid users in 2018 around the world and losing 80% of 42 million years of "healthy life lost" by the implication due to opioid drug use. Drug dependence is mentioned as multi-factorial health disorder with relapsing and remitting in nature. Myanmar is still accounting for 7% of the world's total opium production (UNODC 2020). So, comprehensive intervention packages for harm reduction interventions were also addressed in Myanmar. Methadone programme started and enrolled 260 patients in 2006 in Myanmar according to the report of Drug Dependency   Treatment and Research Unit (DDTRU 2015). Since then, 19,991 People who inject drugs (PWID) were treated with methadone for opioid substitution in 2019, which is 21% of estimated 93,000 PWIDs (T. G. Myanmar 2020). Meanwhile, harm reduction works were being advocated to the administrative and legislative community for desensitization of drug uses alongside the expansion of opioid substitution therapy by the National Drug Abuse Prevention and Control Programme. However, it is important to identify the service satisfactory of the methadone programme to assess the performance of the service delivery, clients' experience on each components of services and types of services they received. The identi cation of satisfaction can be useful in retaining of the clients in the methadone programme and future planning of quality service expansion after identifying service gaps.
Methadone treatment is effective and associated with the less opioid use (YI, et al. 2016) and improved the quality of life of the patients at 6 months after treatment among Malaysian patients (Fei, et al. 2016), as well as 6 month and 12 month follow up among Taiwan patients (Chou, et al. 2013). The methadone program were expanded in China and South East Asia countries like Myanmar and Malaysia after 2000, understanding methadone treatment satisfaction becomes vital to treatment providers. Several validated tools have been designed to assess client's treatment satisfaction. Among the commonly used tools include Client Satisfaction Questionnaire (CSQ-8) (Larsen, et al. 1979), the Service Satisfaction Scale (SSS-30) (Attkisson and Green eld. 1996) and the Verona Service Satisfaction Scale (VSSS-32) (Rugger, et al. 1996). Furthermore, there are also other modi ed tools to use in the methadone services like modi ed (Satisfaction with HIV/AIDS Treatment Interview Scale) SATIS instrument; a 10-item scale instrument to measure three dimensions of methadone services: "services quality and convenience", "health workers' capacity and responsiveness" and "inter-professional care", as well as "con dentially" and "responsiveness" were included in observation. Taking a long-term methadone treatment compared to 3, 6 and 12-month treatment is signi cantly bene cial and less positive urine drug tests, reducing commercial sex activities among drug users compared to baseline (Zhang, et al. 2013). Historically, a short methadone programme review in 2013, the following challenges were reported; inconvenient operational hours, long distance to travel for MMT patients, lengthy registration process, ongoing injecting among a signi cant number of patients, long induction period, and lack of con dentiality (U. Myanmar 2015). So, based on different satisfactory assessments, this study used the VSSS-MT because results of VSSS-MT measures would multi-dimensionally suggest methadone patient satisfaction with methadone treatment centres on social worker and psychologist skills, basic interventions and speci c interventions respectively. Thus, methadone patients who are at least on 6-month methadone maintenance would identify the service satisfaction on methadone treatment experience in the programme were assessed with VSSS-MT tools to identify the treatment satisfaction comprehensively.

Study design, respondents and location
This study determines the treatment satisfaction situation and parameters associated with the methadone service satisfaction of patients enrolled methadone treatment in Myanmar. Methadone patients who were at least six months on treatment were recruited from all States and Regions where methadone services were provided. Sample collection sites from each State and Region were selected with strati ed random sampling. A total of 210 respondents were recruited in the survey with 42 from each selected cities, Yangon, Mandalay, Lashio from Shan State, Kawlin from Saging Region and Mohnyin from Kachin State for primary data and sample collections.

Inclusion and exclusion criteria
Inclusion criteria of the survey is a) above 18 years of age, b) self-reported as a methadone user who is currently enrolled in a formal methadone programme in Myanmar, and c) must have at least a minimum of six-month methadone treatment history. The exclusion criteria is self-reported to have current psychological problems or were observed to be under serious medical conditions which could ultimately affect the study participation. The responses were coded with Likert's 5 point scale (1 for the worst satisfaction ranging to 5: the most satis ed situation for each characteristic questions). These satisfactory responses were grouped into 3 categories of the methadone service programme clinic staff professional skills (e.g. doctor, nurse, counsellor etc.), basic intervention (instruction between visits, side-effects etc.) and speci c intervention (e.g. individual rehabilitation and psychotherapy, group therapy etc) categories.

Urinalysis
Urinalysis included identi cation of methadone and common illicit drugs in the urine. Those respondents who consented for agreement to take part in the study were veri ed with methadone test kit and con rmed their participation. Further urine tests for illicit drug use status (Morphine, Cannabis, Methamphetamine, Amphetamine, and Benzodiazepine) were processed alongside with physical measurements, interview survey questionnaires to identify demographic data, reported infectious disease status, methadone treatment pro le, their perception on methadone programme and their satisfaction level on methadone treatment.

Statistical analysis
VSSS-MT Treatment satisfaction was analysed. For identifying association of differences between categorical variables of patient characteristics with VSSS-MT Treatment satisfaction, chi-square test was done. Comparing the differences between mean scores of the interested parameters (VSSS scores) was done with t-tests. Binary logistic regression was done for identifying the predictors to the outcome "VSSS scale" at p = 0.05 to recheck the stepwise regression output while controlling the confounding variables. With the availability of cross-sectional data, treatment satisfaction was further estimated with cox

Demographic Characteristics
Respondents' average age is 33.3 years (ranging from 20 to 76 years). Majority of the respondents were male 98.6% and 1.4% were female. As the majority, 209 took methadone daily from the methadone dispensing sites and 1 (0.48%) had take-home dose and all reported their history of opioid abuse.
Majority of methadone patients are their rst time of treatment for methadone 173 (83%) and getting more than one time treatment is 35 (17%) and treatment frequency of methadone ranges from 1 to 6 times. The average methadone dose is 83mg (with a range of 20mg to 300mg) and their average duration on treatment is 28 months (range: 6 to 127 months). Meanwhile, almost two thirds (63%, n = 132) had methadone dose less than or equal 80mg daily dose while 75 (37%, n = 76) had more than 80mg daily dose. Their average Body Mass Index (BMI) is 20.5 (range from14.0 to 33.3). More than two thirds; 159 (75.57%) had primary through high school education and 45 (21.43%) had college level while only 6 (2.86%) had non-formal education. Almost half; 96 (46.38%) were single/ divorced and 84 (40.58%) were married while 27 (13.04%) were separated. Their historic working status within 3 years showed that the majority; 192 (93.43%) had recent jobs (previous 3-year period) and 18 (8.57%) were in no-job categories (including disabled, students). However, 28 (13.46%) had received their income from the drug negotiation within 30 days. Twenty-nine (13.81%) were working as outreach workers or peereducators for drug users. The VSSS scale was mentioned based on responses to each question in Table 1. Treatment satisfaction rating differed with study sites, lower in the big cities (Yangon, Mandalay) and higher in the small cities (Kawlin, Lashio and Mohnyin). Satisfaction with methadone service (VSSS-MT score) was reported as 100 for average and ranging from 58 to 131 whereas over 80 as "much satisfaction"; rated 3 above Likert scale of 5 for all questionnaires. A total of 88.57% (n = 186) were "much satis ed" with methadone service. However, VSSS-MT score rated professional skill items (doctor, nurse, counsellor and worker) as 3.89 out of 5, basic intervention items as 3.83 and speci c intervention items as 3.42. Those on high methadone dose with more than 80mg gave higher satisfaction rating than low dose personnel (p = 0.0276).

Differences of VSSS scales with respondents' characteristics
There are VSSS domain scale differences with the characteristics of methadone patients as described in Table 2. Among the different characteristics of the respondents, higher quality of life on physical, psychological, social and environmental categories, respondents who satis ed on current marital status and current leisure status, respondents who were on alcohol were associated with higher treatment satisfaction on methadone, over 80 as "much satisfaction"; (p < 0.05) as mentioned in Graph 1.

Stepwise regression analysis
After considering signi cant associated characteristics in the model affecting to the VSSS service satisfaction scale, stepwise binary logistic regression was done among the signi cant parameters in the model to identify nal predictors to the outcome group for "VSSS service satisfaction scale" in Table 3. Stepwise binary logistic regression, p value: **signi cance < 0.05, ***signi cance < 0.001 Retention in logistic regression was predicted the associated characteristics which impacted on the VSSS service satisfaction scale.
In the analysis of binary logistic regression, this analysis estimated the association of independent variables to the outcome variable of VSSS service satisfaction scale category of the methadone patients after controlling the potential confounding variables for adjustment. Alcohol alone had 6 times (aOR 5.57, 95% CI; 1.20-25.88, p = 0.029) while respondents in good physical health (with higher score in physical quality of life) had 12 times (aOR 11.87, 95% CI; 4.29-32.84, P = 0.000) in contributing to the high VSSS service satisfaction scale. When checking for the multi collinearity, mean variance in ation factor (vif) was 1.61 and none of the variable has more than 10. The regression model alpha ratio is set at 0.05.

Reported Infection status of the patients
Among the methadone respondents, just above one-third (36.5%, n = 76) received high-dose (more than 80mg/ day) and the rest 63.5% (n = 132) received low-dose on methadone (less than 80mg/ day). Almost Higher rate of satisfaction incidence was 1.49% among HIV negative respondents and 0.72% among HIV positive respondents after adjusting for methadone dose (p = 0.000). Higher dose was associated with increased satisfaction scales (p = 0.037) in HIV negative respondents.
Difference of higher satisfaction incidence was showed in 1.2% among non-co-infected patients and 0.71% among co-infected patients with adjusted doses. Co-infected patients were less likely to get satisfaction compared to non-co-infected patients (p = 0.000).

Discussion
This study elaborates factors associated with methadone treatment satisfaction VSSS scale. Besides basic methadone services and staff interaction of the methadone service providers, some of the factors that signi cantly in uences on satisfaction of speci c service provision of methadone are recent heroin injections, respondents taking benzodiazepine, those infected with HCV, those who had higher addiction severity index on alcohol and family/ social status, etc. So, it is highly important that ancillary services of methadone programme; counselling, medical services, psycho-social services, and psychiatric care will enhance the outcome for methadone treatment. It is also aligned with treatment satisfaction is higher among methadone clinics with other healthcare services than methadone service alone (Tran, et al. 2015). Treatment progression (estimate = 0.227, SE = 0.019, p < 0.01) and counselling rapports (estimate = 0.229, SE = 0.016, p < 0.01) had positive associations with treatment satisfaction (Li, et al. 2017).
Meanwhile, responses from Malaysian clients raised that dosing area; waiting area and staff shortage were most desired changes from the methadone clients (Aziz and Chong 2015). Another analysis result from Spain, multiple linear regression showed methadone satisfaction depended on methadone dispensing hour, in uence on methadone dose change, number of patients per centre, perceived frequency of receiving information about methadone dose changes, and social dysfunction subscale of GHQ-28 (General Health Questionnaire-28; lower social dysfunction was related to higher satisfaction) (p < 0.05) (Trujols, et al. 2012).
The result of stepwise binary logistic regression showed alcohol use and physical health has signi cantly associated with treatment satisfaction. So, alcohol usage along with methadone is also an important factor to consider the drug rehabilitation programme and measures. Higher satisfaction was also shown when methadone treatment is provided with other associated healthcare services than treating only with methadone. The satisfaction results from Vietnam re ected that comprehensive care clinics services with physical, psychological and HIV related care are important in the service provision. Meanwhile, treatment satisfaction for "staff category" of methadone treatment was high in Myanmar and it was also seen in Vietnamese study of Tran study which also showed the highest in "capacity of health workers & responsiveness" with lowest proportion in "Quality" (49.0%) and "Convenience" (51.1%) (Tran, et al. 2015).
This study also has a few limitations as the respondents were recruited who are taking methadone currently and those who are not satis ed with the services can be omitted unintentionally from the recruitment process. Based on the cross-sectional data, estimation of the service satisfaction among patients with infection status has methodology limitation due to the data availability other than the cohort nature. Furthermore, due to the sample size limitation, it is expected that limitations in the conclusion for respondents with speci c characteristics. As the respondents are the current patients taking on methadone, the patients can be under Hawthorn's effect and can avoid the unexpected risk of answering pessimistic views although there was a proper explanation for ensuring their con dentiality in answering their opinion.
There were other factors to consider for evaluation of methadone services like early drop-outs and refusals to participate, which could contribute uncertainty of the results obtained and a threat to the internal validity and generalizability of such results.
To ensure the re ective answer for methadone patients, those who were retained at least six-month in the programme were set as a criterion for inclusion in the survey. Meanwhile, in terms of drug e cacy in retention of the patients compared to other opioid substitution, it was reported in the Cochrane review that methadone maintenance is superior in retaining patients in opioid substitution therapy compared to buprenorphine at low xed dose (Mattick, et al. 2014).
Respondents on methadone were generally satis ed with the services they received. It was clear in the results that speci c intervention works were necessary to expand and improved for treatment satisfaction. As the speci c intervention works focuses on individual and group counselling, family support, centre supports at home, the methadone intervention is more effective if it integrated with individual and/or group counselling, employment or family services (Opioid Addiction 2018). This nding was higher than a study result from Spain and average total score was 3.4 (SD = 0.6); with Basic Interventions mean scores 3.5 (SD = 0.7), Speci c Interventions scores 3.1 (SD = 0.8), Social Worker Skills 3.5 (SD = 1.0), and Psychologist Skills 3.6 (SD = 0.9) (Trujols, et al. 2012).

Conclusion
Pharmacological response from urine drug results also encouraged that optimal dose of methadone based on the clinical pro le of patient was also effective in reducing the illicit opioid drug injection among methadone patients. Furthermore, community based approach with the individual rehabilitation with family support, individualized care from the treatment centres are recommended in delivering effective methadone treatment and prevention of further illicit drug use and infections for strengthening of speci c intervention category of methadone treatment. Treatment of the people who inject drugs (PWID) and their family members at their place are also important for expansion among harm reduction organizations and early access of interventions will prevent further infections and get the treatment earlier in a social integrated approach.