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Integrating Methadone Services Into Primary Care in Ukraine: Two-Year Outcomes From a Randomized Trial
Eteri Machavariani1, Denise Esserman2, Kostyantyn Dumchev3
1Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, and Center for Interdisciplinary Research on AIDS, Yale University, New Haven, Connecticut, and New York University School of Global Public Health, New York University, New York, New York (E.M.).
Background:
Opioid use disorder (OUD) drives high morbidity and mortality, but access to opioid agonist therapy (OAT) is limited in low- and middle-income countries. Integrating OAT into primary care may expand access and improve comorbidity management, although provider discomfort remains a barrier.
Objective:
To compare health care use among persons with OUD receiving methadone in specialty clinics versus primary care centers in Ukraine (January 2018 to December 2023).
Design:
Two-group randomized controlled trial with 2:1 allocation to intervention and control. (ClinicalTrials.gov: NCT04927091).
Setting:
Thirteen cities in Ukraine: Cherkasy, Dnipro, Kramatorsk, Kropyvnytskyi, Kryvyi Rih, Kyiv, Lviv, Mariupol, Mykolaiv, Odesa, Rivne, Sloviansk, and Zhytomyr.
Participants:
A total of 1459 adults with OUD (950 intervention, 509 control) initiating or receiving methadone.
Intervention:
Methadone delivered in primary care aided with telementoring, an Extension for Community Healthcare Outcomes-like model that is adapted to the Ukraine context, versus standard specialty clinic care.
Measurements:
Primary outcome: difference in composite quality health indicator (QHI) scores between groups at 24 months, representing access to 17 guideline-concordant services (9 primary care and 8 specialty care) received, assessed through surveys and ranging from 0 to 100. Secondary outcomes: domain-specific QHI scores and methadone treatment indicators.
Results:
Participants in primary care settings achieved higher composite QHI scores than those in specialty clinics, with a mean difference of 9.1 percentage points (95% CI, 6.9 to 11.2 percentage points) at 24 months. Results were similar for primary care QHI (12.3 percentage points [CI, 9.0 to 15.6 percentage points]) and specialty care QHI (5.2 percentage points [CI, 0.2 to 10.3 percentage points]). Methadone retention among new patients at 24 months was 67.2% in primary care versus 64.7% in specialty clinics.
Limitations:
Quality health indicators reflect health care use rather than health outcomes. Quality health indicators were equally weighted despite differing clinical significance.
Conclusion:
Integrating methadone treatment into primary care settings improves adherence to guideline-concordant health care without compromising methadone retention and treatment quality.
Primary Funding Source:
National Institute on Drug Abuse.
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