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Barriers to retention in methadone maintenance therapy among people who inject drugs in Bangkok, Thailand:… Hayashi, Kanna; Ti, Lianping; Ayutthaya, Prempreeda P N; Suwannawong, Paisan; Kaplan, Karyn; Small, Will; Kerr, Thomas Sep 7, 2017

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RESEARCH Open AccessBarriers to retention in methadonemaintenance therapy among people whoinject drugs in Bangkok, Thailand: a mixed-methods studyKanna Hayashi1,2,7* , Lianping Ti1,3, Prempreeda Pramoj Na Ayutthaya4, Paisan Suwannawong5, Karyn Kaplan6,Will Small1,2 and Thomas Kerr1,3AbstractBackground: Methadone maintenance therapy (MMT) is a mainstay for treating opioid use disorder and preventingand managing HIV among people who inject drugs (PWID). While previous research suggested low dosing ofmethadone and high rates of discontinuation of MMT among PWID in Thailand, little is known about patients’ livedexperiences with MMT in this setting. Therefore, we conducted a mixed-methods study to examine barriers toretention in MMT among PWID in Bangkok, Thailand, with particular attention to methadone dosing.Methods: Bivariate statistics were used to analyze quantitative survey data collected from methadone-treatedPWID between July and October 2011. Qualitative data collected through semi-structured interviews with 16methadone-treated PWID between July 2011 and June 2012 were analyzed thematically, with a focus on individual-level,social-structural, and environmental barriers to accessing MMT.Results: Among 158 survey participants, a median dosage of methadone was 30 mg/day (interquartile range 20–50). Ofthese, 15.8% reported having acquired street methadone due to low prescribed dosages of methadone and 19.0%reported recent syringe sharing. Qualitative interview data indicated some methadone provider-related barriers, includingdiscouraging patients from using methadone due to it being a Western medicine, difficulty negotiating higher doses ofmethadone, and abrupt dose reductions without patient consultation (involving the provision of non-medicated “syrup”in some cases). Social-structural and environmental barriers to optimal MMT access included intense police surveillance ofmethadone clinics; and frequent incarceration of PWID and a lack of access to methadone in prisons.Conclusions: Among our sample of methadone-treated PWID, methadone dosages were suboptimal according to theinternational guidelines. Poor adherence to international guidelines for opioid agonist therapies, aggressive lawenforcement, and a lack of methadone in prisons need to be addressed to optimize MMT and reduce harms associatedwith untreated opioid use disorder in Thailand.Keywords: Methadone maintenance therapy, Drug law enforcement, Injection drug use, Harm reduction, HIV, Thailand* Correspondence: uhri-kh@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada2Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room11300, 8888 University Drive, Burnaby, BC V5A 1S6, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Hayashi et al. Harm Reduction Journal  (2017) 14:63 DOI 10.1186/s12954-017-0189-3BackgroundOpioid agonist therapies, including methadone mainten-ance therapy (MMT), are the mainstay for treating opioiduse disorder and preventing and managing HIV amongpeople who inject drugs (PWID) [1, 2]. However, coverageof this essential service remains very low in many low-and middle-income countries, including in Southeast Asia,where injection drug use involving opioids has been a keydriver of HIV epidemics [3, 4]. The number of PWID re-ceiving opioid agonist therapies has been reported to be aslow as less than four per 100 PWID in Southeast Asia,while it was more than 60 per 100 PWID in WesternEurope [3].Moreover, while adherence to evidence-based treatmentguidelines, including adequate dosing of methadone, hasproven suboptimal in North America [5], there is limitedinformation on how methadone is provided in SoutheastAsia [4, 6]. Qualitative studies of methadone patients’ expe-riences in China and Ukraine identified some multi-levelbarriers to MMT, including service providers’ preferencefor abstinence-based treatment models, inflexible dosingregimens, fear of addiction to methadone, police harass-ment near treatment sites, and stigma, discrimination, andmistreatment by service providers [7, 8]. However, theseexperiences were not investigated alongside the methadonedoses received by patients. Available data suggest thatmethadone doses are typically low in Asia [9]. For example,a 2010 population-level study in Wuhan, China, reportedthat 69% of patients were prescribed ≥ 60 mg/day ofmethadone; however, the majority (82%) actually received< 60 mg/day of methadone [10]. These findings indicatethe importance of examining actual methadone doses re-ceived by patients and how methadone dosing influencespatients’ experiences and treatment outcomes.Thailand has been contending with a dual epidemic ofopioid injection and HIV for decades [11, 12]. While theuse of methadone for maintenance therapy was approvedin 2000 and became covered through a universal health-care scheme in 2008, available data suggest some clinics inBangkok have continued to provide inadequate doses ofmethadone [6, 13]. In Bangkok, methadone treatment isprimarily provided by the Bangkok Metropolitan Author-ity through its 17 public health centers, two hospitals,and one stand-alone clinic. A previous study docu-mented that ongoing injection drug use was commonamong methadone-treated PWID in Bangkok, indicating aneed for further research to identify gaps between inter-nationally recommended best clinical practices and the ac-tual implementation of MMT in this setting [14]. Inparticular, Thailand has traditionally relied on prohibition-based drug policy, which has involved aggressive drug lawenforcement and mass incarceration of PWID [15]. Suchpolicy environment would likely affect availability andaccessibility of MMT, as some previous studies haveindicated [15, 16]; however, details have not been fullyexamined. Therefore, we conducted a mixed-methodsstudy to examine barriers to retention in MMT amongmethadone-treated PWID in Bangkok, with particularattention to methadone dosing.MethodsStudy designData were derived from the Mitsampan Community Re-search Project, a collaborative research effort involving theMitsampan Harm Reduction Center (MSHRC; a peer-rundrop-in centre in Bangkok, Thailand), Thai AIDS Treat-ment Action Group (Bangkok, Thailand), ChulalongkornUniversity (Bangkok, Thailand), and the British ColumbiaCentre for Excellence in HIV/AIDS/University of BritishColumbia (Vancouver, Canada). Launched in 2008, thisserial cross-sectional mixed-methods study aimed to in-vestigate drug-using behaviour, healthcare access, anddrug-related harms among PWID in Bangkok [14]. Forthe present mixed-methods study, we adopted a simpletriangulation design suggested by Creswell and Clark,in which quantitative and qualitative data collection wasimplemented around the same time [17]. The study wasapproved by the research ethics boards at ChulalongkornUniversity and the University of British Columbia/Providence Health Care.Between July and October 2011, the research partnerssurveyed 440 PWID in Bangkok. Potential participantswere recruited through peer outreach efforts (on the street,near MMT clinics, etc. all over Bangkok) and word-of-mouth and were invited to attend the MSHRC orO-Zone House (another drop-in centre in Bangkok)to participate in the study. Adults residing in Bangkokor in adjacent provinces who had injected drug(s) inthe previous 6 months were eligible for participation.All participants provided informed consent and completedan interviewer-administered questionnaire eliciting arange of information, including socio-demographic char-acteristics, drug use patterns, and related exposures. Uponcompletion of the questionnaire, participants received astipend of 350 Thai Baht (approximately US$12).A qualitative arm of the project was implemented be-tween July 2011 and June 2012, involving 48 semi-structured interviews with PWID in Bangkok. The over-arching objectives of the qualitative arm were to explorePWID’s experiences with policing compulsory drug deten-tion centres and access to healthcare (including metha-done treatment). The study was informed by Rhodes’ RiskEnvironment Framework, which encourages considerationof individual, social-structural, and environmental driversof drug-related harm [18]. In relation to healthcare access,it sought to understand barriers to and facilitators of opti-mal healthcare and how they influence health outcomes[19]. Potential participants were recruited face-to-faceHayashi et al. Harm Reduction Journal  (2017) 14:63 Page 2 of 8from the concurrent quantitative arm of the project aswell as through peer-based outreach efforts and word-of-mouth and were invited to attend the MSHRC or O-ZoneHouse in order to participate in the study. While the eligi-bility criteria were consistent with those of the quantita-tive arm, we prioritized the recruitment of individualswith relevant experiences (e.g., having accessed metha-done treatment) and made efforts to attain balance in age,gender, and HIV serostatus.Two bilingual Thai interviewers conducted interviewsin Thai based on a semi-structured interview guide. Withrespect to MMT, the interview guide sought to elicit dis-cussion of experiences with MMT including how partici-pants felt about MMT and how they felt MMT could beimproved. The interview guide was reviewed by local com-munity research partners, which served to fine-tune thequestions. Interviewers were also encouraged to employadditional questions and probes to explore each individualrespondent’s experience. Throughout the data collectionprocess, the research team discussed the content ofinterview data as well as the focus and direction of sub-sequent interviews. Data collection was continued untildata reached a point of saturation. All interviews wereconducted in private rooms at the MSHRC and O-ZoneHouse, lasted between 40 and 90 min, and were audio-recorded. All participants provided informed consentand received a stipend of 450 Thai Baht (approximatelyUS $15) upon completion of the qualitative interview.Statistical analysisFor the present analysis, the sample was restricted tothose who reported having received methadone treatmentin the previous 6 months and who had complete data onmethadone dosages. First, we calculated the median dailydosage of methadone most recently received by the partic-ipants. Given a previous systematic review reporting thatat least 60 mg/day of methadone predicts favourabletreatment outcomes [20], the primary outcome of inter-est was a binary variable denoting receiving ≥ 60 mg/dayvs. < 60 mg/day of methadone. We also had the secondaryoutcome, which was a binary variable comparing >mediandose vs. ≤median dose, in order to examine any differ-ences in receiving higher or lower doses within oursample. Explanatory variables considered included age(per year older); gender (male vs. female); HIV status(positive vs. negative or unknown); daily injection of heroin,midazolam (a short-acting benzodiazepine), methadone,and methamphetamine, respectively; syringe sharing; hav-ing ever acquired street methadone because prescribed dos-ages of methadone were too low; and duration ofmethadone treatment (< 1 month vs. ≥ 1 month, < 6 monthsvs. ≥ 6 months, < 12 months vs. ≥ 12 months). All be-havioural variables referred to the previous 6 monthsunless otherwise stated. We used the Pearson’s X2 test(for categorical variables) and the Wilcoxon rank sumtest (for continuous variables) to examine bivariate as-sociations between the explanatory variables and theoutcome. Fisher’s exact test was used when one ormore of the cells contained expected values less than orequal to five. All p values were two-sided. All statisticalanalyses were performed using SAS software version9.4 (SAS, Cary, NC).Qualitative analysisThe sample was restricted to those who received metha-done treatment during the past 5 years. All audio-recorded interviews were transcribed verbatim in Thaiand translated into English. The bilingual interviewersreviewed the translated transcripts for accuracy. Further,a native English-speaking proofreader with an excellentknowledge of both Thai and English also verified theEnglish transcripts for grammatical accuracy and nuanceby comparing the English transcripts with Thai tran-scripts and audio-files. All data were entered into Atlas.ti(version 6.2).Data analysis was focused on identifying different typesof barriers to MMT, and how these function to impederetention in MMT, and was informed by the aforemen-tioned Risk Environment Framework [18]. The analysiswas conducted inductively, employing a multi-step the-matic analysis. On the first pass, KH created an initialset of codes. Subsequent reviews involved refining thecodes and assigning data segments to categories withsubstantive input from other co-authors. The analysisconsidered the range and diversity of participants’ expe-riences, as well as the negative evidence in each categoryof experience. Finally, the data were grouped into threeprimary categories: overall perceptions of MMT, metha-done provider-related barriers, and social-structural andenvironmental barriers.ResultsStatistical analysisIn total, 194 participants reported having received metha-done in the past 6 months. Of those, 36 (18.6%) did nothave data on methadone doses or duration and were ex-cluded from the analysis. There were no significant differ-ences between those excluded and included in the analysisin terms of demographic and drug use characteristics aswell as HIV-seropositivity (all p > 0.05). As shown inTable 1, among 158 eligible participants, 27 (17.1%) werewomen. The median age was 38 years (interquartile range(IQR) 34–48). Almost three-quarters (72.8%) were receiv-ing methadone for more than a year. The median dailydosage of methadone was 30 mg (IQR 20–50; minimum5; maximum 80), and 16 (10.1%) received ≥ 60 mg/day.Nearly half (48.1%) reported daily injection of midazolam,14.6% injected methadone daily, and 13.9% injected heroinHayashi et al. Harm Reduction Journal  (2017) 14:63 Page 3 of 8daily. Further, 19.0% reported syringe sharing, and15.8% reported having ever acquired street methadonebecause prescribed dosages of methadone were too low.In bivariate analyses, HIV positivity was significantlyassociated with receiving ≥ 60 mg/day of methadone(p = 0.015), whereas younger age was significantly asso-ciated with receiving > median dose (30 mg/day) ofmethadone (p = 0.027).Qualitative analysisIn total, 16 participants were included in the presentanalysis, including five women and eight HIV-positiveindividuals. Collectively, these participants accessed tendifferent methadone clinics in Bangkok during the past5 years, which covered half of all 20 methadone clinicsoperating in Bangkok [13]. Table 2 summarizes the par-ticipants’ demographic characteristics and recent druguse patterns.As shown below, we used verbal counting to highlightpatterns in the data [21]. In doing so, we operationallydefined “many” and “common” as something reportedby half or more of the participants and “some” and “afew” as something reported by less than one-third of theparticipants. However, inferences of generalizability andstatistical significance from these terms are discouraged.All names appearing below are pseudonyms.Overall perceptions of methadone treatmentMany participants negatively perceived MMT as they feltthat it did not help them reduce or stop their use ofillicit drugs. The majority of participants attributed theineffectiveness of MMT to low dosages of methadone:The methadone level is not enough. But they saythey’ve already given me a lot: 40mg per day. …Itcan’t control my body because I also use heroin.(Somsak, male, age 36)Table 1 Bivariate analyses of factors associated with methadone doses among 158 methadone-treated PWID in ThailandCharacteristic Total n (%)158 (100)Methadone dosageb p value Methadone dosageb p value≥ 60 mg/dayn(%)16 (10.1)< 60 mg/dayn(%)142 (89.9)> 30 mg/dayn(%)78 (49.4)≤ 30 mg/dayn(%)80 (50.6)Age (median, IQR) 38 (34–48) 36 (34–44) 38 (34–48) 0.273 37 (33–46) 40 (35–51) 0.027Male gender 131 (82.9) 13 (81.2) 118 (90.1) 0.739c 65 (83.3) 66 (82.5) 0.889HIV-positive 30 (19.0) 7 (43.8) 23 (16.2) 0.015c 18 (23.1) 12 (15.0) 0.196Daily heroin injectiond 22 (13.9) 1 (6.3) 21 (14.8) 0.701c 11 (14.1) 11 (13.8) 0.949Daily midazolam injectiond 76 (48.1) 8 (50.0) 68 (47.9) 0.873 39 (50.0) 37 (46.3) 0.637Daily methamphetamine injectiond 7 (4.4) 0 (0.0) 7 (4.9) N/A 4 (5.1) 3 (3.8) 0.718cDaily methadone injectiond 23 (14.6) 2 (12.5) 21 (14.8) >0.999c 13 (16.7) 10 (12.5) 0.458Syringe sharingd 30 (19.0) 2 (12.5) 28 (19.7) 0.738c 13 (16.7) 17 (21.3) 0.463Ever acquired street methadone becauseprescribed dosages of methadone weretoo low25 (15.8) 3 (18.8) 22 (15.5) 0.721c 16 (20.5) 9 (11.3) 0.111Duration of methadone treatmenta< 1 month 4 (2.5) 0 (0.0) 4 (2.8) N/A 1 (1.3) 3 (3.8) N/A≥ 1 month, < 6 months 26 (16.5) 2 (12.5) 24 (16.9) 10 (12.8) 16 (20.0)≥ 6 months, < 12 months 11 (6.7) 0 (0.0) 11 (7.7) 6 (7.7) 5 (6.3)≥ 12 month 115 (72.8) 14 (87.5) 101 (71.1) 60 (76.9) 55 (68.8)PWID people who inject drugs, IQR interquartile rangeaNumbers do not add up to 158 due to missing observations (n = 2)bAt the most recent time they received methadonecFisher’s exact testdRefers to the previous 6 monthsTable 2 Qualitative study sample characteristics (n = 16)Characteristic n (%)Male gender 11 (68.8)Age (median, IQR) 45 (36–50)HIV-positive 8 (50.0)Daily heroin injectiona 4 (25.0)Daily midazolam injectiona 13 (81.3)Daily methamphetamine injectiona 0 (0.0)Daily methadone injectiona 2 (12.5)Methadone dosage in mg/daybMedian (IQR) 35 (25–50)Minimum–maximum 12–80IQR interquartile rangeaRefers to the previous six monthsbAt the most recent time they received methadoneHayashi et al. Harm Reduction Journal  (2017) 14:63 Page 4 of 8Another common source of negative perceptions againstmethadone was the fear of experiencing methadone with-drawals, which participants believed to be more intoler-able than those of heroin. Some participants reportedabrupt methadone interruptions due to incarceration,which further fuelled their fear of methadone withdrawals.A few participants reported having been able to reducetheir heroin use while on methadone; however, it wasalso reported that midazolam use (via injection), a short-acting benzodiazepine, was either initiated or continuedto alleviate sleep disturbance while on methadone.Methadone provider-related barriersParticipant accounts revealed that the most commonlyexperienced barriers to accessing MMT stemmed frommethadone providers’ negative attitudes towards metha-done and patients who use drugs. A few participants re-ported that doctors had first discouraged them frominitiating MMT, either because it is a Western medicine,or because the doctors were concerned that the individ-uals would become addicted to methadone:I told him [i.e., a doctor who prescribed methadone]that I wanted to take the treatment. Then, he advisedme to go cold turkey and not to believe Western doctors.He said, “This drug is from the West. Westerners aretricking us.” He was quite anti-Western medicine.(Somsak, male, age 36)The doctor didn’t want me to take it [i.e., methadone]because I could become deeply addicted to it, inaddition to other drugs I had already been addictedto. He just gave me some pills so that I would just dealwith the aches. (Sompong, male, age 34)Methadone providers’ negative attitudes towards metha-done and patients who continue to use drugs most com-monly manifested themselves when participants requestedhigher doses of methadone. Except for a few isolatedcases, participants reported significant difficulty in negoti-ating higher doses, as they would be reprimanded for con-tinuing to use drugs or “relying too much on methadone.”No participant reported that methadone providers exam-ined whether ongoing drug use stemmed from inadequatedosing of methadone. Further, some participants reportedexperiencing an abrupt dose reduction without prior con-sultation. In some cases, this involved the provision ofnon-medicated ‘syrup’ that did not contain methadone.Some doctors give us just the syrup. I’ve had thatbefore. It was just the syrup, without methadone in it.As soon as I took it, I just knew! If I take methadone,my symptoms will stop. But at that time, I wasyawning so much. Then I saw another doctor. I toldhim about my symptoms and that I suspected that itwas just the syrup. Then he gave me a new glass [ofmethadone syrup]. In 10-15 minutes, my symptoms,all the yawning and goose bumps, were gone. …Somedoctors reduce the dose without telling us! How couldthey just reduce it? ...When this happened, I talked tothe head doctor. He accused me of relying too much onmethadone. (Nan, female, age 47)Participants’ narratives also indicated that a lack of trustcharacterized relationships between methadone providersand patients, which further undermined engagement withMMT. Some participants reported that, when they did notimmediately leave clinics after receiving their methadonedose, clinic staff suspected them of dealing drugs andthreaten to call the police. Peer harm reduction outreachworkers who distributed sterile syringes at methadoneclinics were also accused of promoting drug use.In response, some participants reported conflicts withclinic staff. As a consequence, they were suspended fromaccessing the clinic and transferred to another one. Thesehostile relationships served to undermine the possibility ofopen communication between methadone providers andpatients and resulted in methadone discontinuation insome cases.Social-structural and environmental barriersConsistent with previous studies in other settings [8],some programmatic barriers to MMT were noted, includ-ing difficulty maintaining full-time employment, limitedoperating hours of clinics, limited take-home privileges,and difficulty travelling to clinics. An additional barrierthat many participants referred to was the ready availabil-ity of illicit drugs in the local setting, where a previousstudy also reported significant increases in the street-levelavailability of illicit drugs despite the intensified policecrackdowns [22]. Combined with low-dose methadone,this appeared to pose challenges with staying on metha-done and not using illicit drugs. In response to these dy-namics, some participants used methadone only whenthey could not afford illicit opiates, as opposed to taking itas maintenance therapy.Some participants also witnessed drug-dealing activitiesat methadone clinics and identified encountering theirdrug-using peers at clinics as something that could triggerrelapse into drug use. Drug dealing at clinics also precipi-tated some police surveillance activities in the vicinity ofclinics. Although participants felt safe inside clinics (aslong as they did not interact with drug dealers), police har-assment, and violence around clinics provoked fear anddiscouraged some from accessing MMT.Further, because incarceration rates were high amongPWID in this setting, and methadone was not availablein prisons, some participants described incarceration asHayashi et al. Harm Reduction Journal  (2017) 14:63 Page 5 of 8a major reason for methadone discontinuation, includinga repeating cycle of interruption and re-initiation.I: How long can you stay on the methadonetreatment?P: It’s periodic. If I get arrested, I have to stop mymethadone treatment, right? After I get out of prison,I start taking it again. It’s been like that.I: Going on and off. How many times have you beenarrested?P: Around six times. Each time, about nine months inprison. (Ball, male, age 42)DiscussionThe median methadone dose (30 mg/day) among oursample of methadone-treated PWID was far below theinternationally recommended maintenance dosage range(60–120 mg/day) [23]. Many participants also reporteddifficulty negotiating dose adjustments based on their in-dividual needs. Low and inflexible methadone dosing isknown to predict suboptimal treatment outcomes [20, 24],and challenges with dose adjustments have also been docu-mented as a key barrier in other settings [8]. Not surpris-ingly, the prevalence of ongoing injection drug use andsyringe sharing was also high among our sample, indicatingthat inadequate dosing significantly compromised potentialHIV prevention benefits of MMT in this setting.The finding that HIV-positive PWID were more likelyto receive ≥ 60 mg/day of methadone suggests that someMMT providers may have appropriately increased thedose of methadone due to the interaction with antiretro-viral treatments [23]. It is imperative to ensure that allHIV-positive PWID receive an optimal dose of methadonegiven that MMT retention contributes to the optimizationof antiretroviral treatments [25]. In particular, MMT pro-viders should ensure open communications with patientsregarding HIV status and treatment. In the quantitativeanalysis, we also found that younger PWID were morelikely to receive higher doses of methadone. However, is-sues related to age did not emerge from qualitative inter-views. Future research should investigate and address thepotential age difference in methadone doses.Low dosing of methadone is common in other Asiancountries, including China [6, 10], Indonesia [6], andMalaysia [26]. A qualitative investigation of methadoneservice providers in China documented that a lack ofunderstanding of dosage management and harm reduc-tion, and poor communication with patients resulted inlow acceptance of MMT and the tendency to prescribelow dosages [27]. Our findings echo these observationsand raise ethical concerns given the reported instancesof abrupt dose reduction without appropriate patientconsultation. Collectively, these findings indicate theimportance of educating service providers about MMTand setting clear evidence-based therapeutic guide-lines. Given some concerns that methadone is a west-ern medicine, such education may best be delivered bylocal experts. Also, adding combination buprenorphine/naloxone, another evidence-based agent for opioid agonisttherapy, to treatment options will address some safetyconcerns regarding methadone as expressed elsewhere[28, 29]. As recommended by health authorities in a rangeof other settings, buprenorphine/naloxone should be con-sidered in this setting [29].Participant narratives also indicated that aggressive druglaw enforcement disrupted availability and accessibility ofMMT. Police interference of MMT has been well docu-mented in this setting [15, 16] and elsewhere [30]. Whilesome efforts to sensitize police officers to harm reductionservices for PWID have been initiated, these need to bescaled up and sustained [31]. Further, unless drug policiesthat heavily criminalize personal use of illicit drugs areeliminated, PWID continue to be at high risk of incarcer-ation. Although the World Health Organization recom-mends the provision of opioid agonist therapies incorrectional settings as a minimum standard [23], a recentreport documented that coverage of such therapies re-mains suboptimal in many countries, with only < 1% ofprisoners in need of treatment were able to access it [32].Thailand is not an exception, and methadone remains un-available in prisons even though the incarceration rateamong PWID is extremely high, and incarceration hasbeen associated with rapid spread of HIV infection in thissetting [33]. Importantly, our findings suggest that fear ofmethadone withdrawal was also fuelled by the lack ofmethadone in prisons. As many in the international scien-tific community have repeatedly called for, the incarcer-ation of PWID needs to be reduced through appropriatedrug policy reform, and voluntary opioid agonist therapiesneed to be made available for those prisoners who requiresuch treatment [32, 34].Added value of this study lies in the unique evidencegenerated through its focus on PWID in Bangkok andits mixed-methods study design, which illustrated howinadequate dosing of methadone served to compromisethe relationships between patients and service providersand the potential benefits of MMT. However, this studyalso has several limitations. First, as the sample for thequantitative study was not recruited randomly, or did notinclude non-PWID, our findings may not be generalizableto all Thai people who use drugs. Specifically, we did notrecord exact places or channels through which partici-pants were recruited. Therefore, there may be unmeas-ured geographical differences. Also, our qualitative studyfindings were based on interviews with PWID whoHayashi et al. Harm Reduction Journal  (2017) 14:63 Page 6 of 8received methadone at ten different clinics during theprevious 5 years. Therefore, experiences and views ofnon-PWID or PWID who accessed other methadoneclinics were not included, and the transferability of thefindings may be limited. Second, self-reported data maybe subjected to reporting biases. Lastly, the low countof participants receiving ≥ 60 mg/day of methadone af-fected the statistical power of some bivariate analyses;however, we feel that the mixed-method design employedis the strength of our study, which served to enhance theintegrity of our data.ConclusionsIn sum, among our sample of methadone-treated PWIDin Bangkok, methadone doses appeared too low to conferthe maximum clinical benefit. Poor adherence to inter-national clinical guidelines, aggressive law enforcement,and a lack of methadone in prisons need to be addressedto optimize opioid agonist therapies and reduce harms as-sociated with untreated opioid use disorder in this setting.AbbreviationsMMT: Methadone maintenance therapy; MSHRC: Mitsampan Harm ReductionCenter; PWID: People who inject drugsAcknowledgementsWe would particularly like to thank the staff and volunteers at the MitsampanHarm Reduction Center, Thai AIDS Treatment Action Group and O-Zone Housefor their support and Dr. Niyada Kiatying-Angsulee of the Social ResearchInstitute, Chulalongkorn University, for her assistance with developing thisproject. We also thank Tricia Collingham, Deborah Graham, and Peter Vannfor their research and administrative assistance and Arphatsaporn Chaimongkon,Sabrina K. Gyorvary, Sattara Hattirat, Orntima Kularb, and Somkiat Meetham fortheir assistance with the data collection.FundingThe study was supported by the Michael Smith Foundation for HealthResearch and Open Society Foundations (grant#20034107). Kanna Hayashi issupported by a Canadian Institutes of Health Research New InvestigatorAward (MSH-141971) and a Michael Smith Foundation for Health ResearchScholar Award.The funders have no role in study design; in the collection, analysis orinterpretation of data; in the writing of the manuscript; or in the decision tosubmit the manuscript for publication.Availability of data and materialsThe data used for this study is not publicly available. For further informationon the data and materials used in this study, please contact thecorresponding author.Authors’ contributionsTK and KH designed the Mitsampan Community Research Project. NAPconducted in-depth interviews under the supervision of TK and KH. KHconducted the analyses, drafted the manuscript, and incorporated suggestionsfrom all co-authors. All authors made significant contributions to the conceptionof the analyses, interpretation of the data, and drafting of the manuscript.All authors read and approved the final manuscript.Ethics approval and consent to participateAll participants provided informed consent for study participation. This studyreceived an ethics approval from research ethics boards at ChulalongkornUniversity and the University of British Columbia/Providence Health Care.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. 2Faculty of HealthSciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 UniversityDrive, Burnaby, BC V5A 1S6, Canada. 3Department of Medicine, Faculty ofMedicine, University of British Columbia, 317-2194 Health Sciences Mall,Vancouver, BC V6T 1Z3, Canada. 4International Reference Group onTransgender Women and HIV/AIDS, Global Forum on MSM & HIV, 436 14thStreet, Suite 100, Oakland, CA 94612, USA. 5Thai AIDS Treatment ActionGroup, 18/89 Vipawadee Rd., soi 40 Chatuchak, Bangkok 10900, Thailand.6Asia Catalyst, 1270 Broadway, Suite 1109, New York, NY 10001, USA.7Research Scientist, BC Centre for Excellence in HIV/AIDS, St. Paul’s HospitalChair in Substance Use Research and Assistant Professor, Faculty of HealthScience, Simon Fraser University, 608-1081 Burrard Street, Vancouver, BC V6Z1Y6, Canada.Received: 8 June 2017 Accepted: 30 August 2017References1. 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