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. Author manuscript; available in PMC: 2017 Aug 1.
Published in final edited form as: Drug Alcohol Depend. 2016 Jun 17;165:213–220. doi: 10.1016/j.drugalcdep.2016.06.011

Determinants of Willingness to Enroll in Opioid Agonist Treatment among Opioid Dependent People Who Inject Drugs in Ukraine

Iuliia Makarenko 1, Alyona Mazhnaya 1, Maxim Polonsky 2, Ruthanne Marcus 2, Martha J Bojko 2, Sergii Filippovich 1, Sandra Springer 2, Sergii Dvoriak 3, Frederick L Altice 2,4
PMCID: PMC5094181  NIHMSID: NIHMS800700  PMID: 27370527

Abstract

Background

Coverage with opioid agonist treatments (OAT) is low (N=8,400, 2.7%) for the 310,000 people who inject drugs (PWID) in Ukraine. In the context of widespread negative attitudes toward OAT in the region, patient-level interventions targeting the barriers and willingness to initiate OAT are urgently needed.

Methods

A sample of 1,179 opioid dependent PWID not currently on OAT from five regions in Ukraine was assessed using multivariable logistic regression for independent factors related to willingness to initiate OAT, stratified by their past OAT experience.

Results

Overall, 421 (36%) PWID were willing to initiate OAT. Significant adjusted odds ratios (aOR) for covariates associated with the willingness to initiate OAT common for both groups included: higher injection frequency (previously on OAT: aOR=2.7; never on OAT: aOR=1.8), social and family support (previously on OAT: aOR=2.0; never on OAT: aOR=2.0), positive attitude towards OAT (previously on OAT: aOR=1.3; never on OAT: aOR=1.4). Among participants previously on OAT, significant correlates also included: HIV-negative status (aOR=2.6) and depression (aOR=2.7). Among participants never on OAT, however, living in Kyiv (aOR=4.8) or Lviv (aOR=2.7), previous imprisonment (aOR=1.5), registration at a Narcology service (aOR=1.5) and recent overdose (aOR=2.6) were significantly correlated with willingness to initiate OAT.

Conclusions

These findings emphasize the need for developing interventions aimed to eliminate existing negative preconceptions regarding OAT among opioid dependent PWID in Ukraine, which should be tailored to the needs of specific characteristics of PWID in geographically distinct setting, higher injection frequency, prior incarceration, and psychiatric and HIV status.

Keywords: opioid agonist treatments, drug injection, opioid use disorder, HIV, Ukraine

1. INTRODUCTION

Opioid agonist treatments (OAT) for opioid dependence with buprenorphine (BMT) or methadone (MMT) maintenance therapy effectively reduces HIV and hepatitis C virus (HCV) transmission (Gibson et al., 1999; Gowing et al., 2006; Van Den Berg et al., 2007), illegal drug use, HIV risk behaviors (Magura et al., 1998; Wong et al., 2003), and criminal activity (Sun et al., 2015). For patients with HIV or tuberculosis (TB), it also improves health-related outcomes, retention in treatment (Kamarulzaman and Altice, 2015; Morozova et al., 2013; Tran and Nguyen, 2013), and decreases mortality (Nolan et al., 2015). Globally, access to OAT is underscaled, including in Ukraine. The majority of people who inject drugs (PWID) remain out of treatment, although PWID continue to drive the HIV epidemic in Ukraine (Bojko et al., 2013; Wolfe et al., 2010; World Health Organization, 2013) and elsewhere.

Treatment of opioid dependence with BMT was first introduced in Ukraine in 2004, with MMT added in 2008 (Bruce et al., 2007; Schaub et al., 2010). Currently nearly 8400 patients receive OAT, primarily MMT, through public medical facilities (Ukrainian Centers for Disease Control (UCDC), 2015). In order to receive OAT, opioid dependent persons must officially become registered at a specialty addiction treatment center operated by the Narcology Service. This name-based registration process has been documented as a barrier to treatment due to restrictions in employment and harassment by police (Bojko et al., 2015, 2016; Izenberg et al., 2013). For the past five years, the number of patients on OAT in Ukraine has not increased appreciably with OAT coverage (2.7% of the estimated 310,000 PWID in Ukraine; Nieburg and Carty 2012; Ukrainian Centers for Disease Control (UCDC), 2015) nearly 10-fold lower than the recommended 25% needed to effectively reduce HIV transmission (Alistar et al., 2011). Despite the target of enrolling 20,000 PWID on OAT by 2015 (Verkhovna Rada of Ukraine 2014a) and planned funding to enroll them, the majority of out-of-treatment PWID have not initiated treatment. Many individual and structural barriers to expanding OAT in Ukraine and throughout other countries of Eastern Europe and Central Asia have been described (Altice et al., 2016; Bojko et al., 2013, 2016; Cohen, 2010; Elovich and Drucker, 2008; Polonsky et al., 2015; Samet, 2011) and influenced greatly by nearby Russia where OAT remains banned mostly based on myths and prejudices against it rather than on extensive scientific evidence (Elovich and Drucker, 2008; Latypov, 2011).

While patient-, clinic- and structural-level factors constrain OAT expansion, patient-level decisions by PWID to enter OAT are often associated with significant social, medical and psychological problems that occur as a result of illicit drug use (Stover, 2011). Globally, numerous factors have been associated with OAT initiation including: older age (Fairbairn et al., 2012; Lloyd et al., 2005; Reynoso-Vallejo et al., 2008; Shah et al., 2000; Shin et al., 2007; Yen et al., 2011), social support through marriage or living with a partner (Lloyd et al., 2005; Schutz et al., 1994), being female (Kerr et al., 2005; Schutz et al., 1994; Shah et al., 2000; Springer et al., 2015) and living with children (Lundgren et al., 2003). Other factors related to the individual’s drug use also facilitate the decision to initiate OAT including a substantial duration (Schutz et al., 1994; Schwartz et al., 2008) and frequency of drug injection (Booth et al., 1998; Reynoso-Vallejo et al., 2008; Zule and Desmond, 2000), overdose experience (Callon et al., 2006), prior history of drug treatment (Booth et al., 2003, 1998; Schutz et al., 1994; Zule and Desmond, 2000) and needle/syringe program (NSP) attendance (Shah et al., 2000). In addition, having been incarcerated or homeless (Reynoso-Vallejo et al., 2008; Schutz et al., 1994; Shah et al., 2000), and being HIV-infected (Kerr et al., 2005; Zule and Desmond, 2000) influence OAT entry, and there is evidence that PWID with mental health problems are more likely to be enrolled in OAT (Amodeo et al., 2004; Reynoso-Vallejo et al., 2008).

The most commonly reported reasons for enrolling in treatment also reflect the perceived benefits of OAT by PWID. These include the desire to improve health, change social networks, avoid criminal activity, and reduce illicit drug use (Stover, 2011). Many patients are attracted to treatment as the financial burden of illicit drug use becomes too costly (Booth et al., 1998). Previous studies found that expressed interest in treatment is a significant predictor of future participation in OAT (Booth et al., 2003; Zule and Desmond, 2000). Our study aimed to assess the determinants of willingness to initiate OAT among out-of-treatment opioid dependent PWID in Ukraine, to help guide tailored interventions to improve OAT entry and scale-up in Ukraine and throughout the region.

2. MATERIALS AND METHODS

2.1 Data collection

Data for this study were derived from a cross-sectional survey of 1,613 opioid dependent PWID from 5 cities in Ukraine with the highest burden of addiction and HIV that assessed the prevalence of barriers to OAT access and retention. Specifically, three groups of PWID meeting ICD-10 criteria for opioid dependence were recruited: a) never on OAT; b) previously on OAT; and c) currently on OAT. Recruitment occurred sequentially (approximately 60–90 days per city) between 2014–2015 in Kyiv, Mykolaiv, Odesa, Dniptopetrovsk and Lviv. For the purpose of this analysis, we included only data on participants who were previously or never on OAT.

2.2. Sampling procedures

PWID meeting criteria for opioid dependence who had never been on OAT were recruited utilizing respondent driven sampling (RDS). Those who were previously on OAT were recruited using random sampling from pre-existing OAT patient lists. An additional 26 PWID recruited through RDS were re-classified as previously on OAT based on their baseline survey. Eligibility criteria included: ≥18 years; met ICD-10 criteria for opioid dependence; lived/worked in the city surveyed; able to provide informed consent; and willingness to undergo rapid HIV and HCV testing. Initial participants (“seeds”) for RDS were selected from community outreach sites where PWID interface (e.g., NSP) and included for each city the following of at least one: female; age 18–25 years; and PWID with less than 2 years of injecting.

2.3. Measures

All participants completed a computer-assisted, self-administered instrument (CASI) survey using a Qualtrics® web-based platform. Results of exploratory qualitative phase analyses (Bojko et al., 2015, 2016; Mazhnaya et al., 2016) were used to develop sections of the questionnaire related to OAT experience to assess facilitators and barriers of OAT entry and retention, and attitudes of OAT-naïve study participants towards OAT. In addition to identifying OAT facilitators and barriers in qualitative focus groups, we also developed survey content areas using previously validated instruments or from previous research conducted in Ukraine. The survey domains included: demographic characteristics, addiction history and drug treatment experience, self-reported HIV status, HIV testing experience, assessment of alcohol use disorders (AUDIT; Saunders et al., 1993), depression (CES-D; Radloff 1977), addiction severity (DAST-10; Gavin et al., 1989), health-related quality of life (SF-12v2), sex and injection risk behaviors. HIV and HCV testing and post-test counseling were conducted using rapid tests (CITO TEST HIV 1/2/0 and CITO TEST HCV) by qualified and trained medical staff (i.e., nurse or doctor).

The primary outcome was defined as willingness to initate OAT with methadone or/and buprenorphine in response to the question: “Are you interested in starting methadone or buprenorphine treatment now?” All analyses of the primary outcome were stratified by those who had previously and never been on OAT. Education was categorized by whether they had completed high school or not, while employment included full- or part-time versus not employed. Stable housing was defined as living in one’s own home or renting an apartment, or living with family or friends, but not describing themselves as being homeless, living at a shelter, or any other temporary housing. Income was stratified based on the minimum poverty level (1200 UAH/150USD; Verkhovna Rada of Ukraine, 2014b) and average monthly wage (3500 UAH/437 USD; State Statistics Service of Ukraine, 2014) for Ukraine in 2014. Duration of drug injection was stratified at >5 years or ≤5 years and frequency of drug injection in the last 30 days was divided at 20 days. Other factors were chosen from our qualitative analysis that appeared as a barrier to OAT including official registry at a Narcology center and previous experience with drug treatment (Bojko et al., 2016). Having an alcohol use disorder was defined using the AUDIT, with cutoffs of ≥8 for men and ≥4 for women (Babor et al., 2001; Caviness et al., 2009). Moderate to severe depression was coded for CES-D scores >10 (Andresen et al., 1994; Zhang et al., 2012). In addition, we created two continuous composite variables reflecting attitudes toward OAT. Having “positive” attitudes was created from10 questions (5 about buprenorphine and 5 about methadone) related to benefits of OAT that included OAT: a) is a very good way to treat opioid addiction; b) improves your quality of life; c) helps you stay out of prison; d) reduces the injection of drugs; and e) is less stressful than using other narcotics. The composite “negative” attitude variable included 6 questions (3 about buprenorphine and 3 about methadone) related to negative myths and beliefs that OAT is: a) only replacing one addiction for another; b) bad for a person’s health; and c) people should try to get off of OAT as soon as they can. For participants who were unwilling to start OAT, they were asked to choose the primary reason (from a list of 24 statements) of why they did not want to start methadone or buprenorphine treatment. The reasons were presented stratified by city separately for previously OAT and never OAT participants.

2.4. Statistical analysis

Frequencies of socio-demographic characteristics, injection-related behavior, incarceration history, self-reported HIV status, and alcohol use disorders of study subjects were preliminarily analyzed with descriptive statistics using chi-square test to compare differences between those who reported interest in starting OAT and those who did not. Comparisons of continuous variables (age, positive and negative attitudes towards OAT) by the outcome of interest were analyzed using Wilcoxon two-sample test for data that does not meet the assumption of normality. A multivariable logistic regression model was used to evaluate independent correlates of willingness to receive OAT. Variables were selected for inclusion in a primary multivariable model if they were significantly associated with the outcome during bivariate testing (p<0.1). Variables were retained in the final model, only if they were significantly associated with the outcome in the adjusted model (p<0.05). Both, backward elimination and forward selection approaches were used to define the final model. Further, the final model was assessed for effect modification by OAT experience using interaction terms and likelihood ratio tests. Results of regression analyses were presented stratified by OAT experience. The model fit was assessed using a Chi-square goodness-of-fit test. As a sub-analysis among participants who did not report interest in starting OAT, the reasons for unwillingness to start the treatment were stratified by city separately for previously and never having been on OAT groups. Differences in frequencies of the reasons for unwillingness to start OAT, controlling for city of enrollment, were analyzed using a chi-square or Fisher’s exact tests. Only the most prevalent reasons (i.e., reported by >50% of respondents) were included in the results. Statistical analysis was performed using SAS 9.3 (SAS Institute Inc., Cary, NC, USA).

The study was approved at institutional review boards at Yale University and the Gromashevskiy Institute at the National Academy of Medical Sciences, Kyiv, Ukraine.

3. RESULTS

3.1. Participant Characteristics

Table 1 presents overall characteristics of the 1,179 participants stratified by their willingness to start OAT. Males comprised 75.7% of the study sample, median age was 35 years (inter-quartile range [IQR]=30–40 years), 33.7% of the study participants lived with spouse or partner, and 51.1% had children. Most of the respondents (83.8%) had completed high school, and 46.6% had a full- or part-time job. Almost one-quarter (21.3%) had income at or above the average income level in Ukraine in 2014 (State Statistics Service of Ukraine 2014) and almost one third (32%) had less than the minimum Ukrainian wage (<1200 UAH or 120 USD). Nearly all participants (95.3%) had stable housing. Thirty-six percent reported a history of incarceration in their lifetime.

Table 1.

Characteristics of study subjects by their willingness to initiate opioid agonist therapy

Characteristic Willing to start OAT
Yes (N=421) No OST (N=758) Total (N=1179) p-value
N (%) N (%) N (%)
City <0.0001
 Kyiv 142 (33.7) 135 (17.8) 277 (23.5)
 Odesa 46 (10.9) 122 (16.1) 168 (14.2)
 Mykolaiv 56 (13.3) 183 (24.1) 239 (20.3)
 Dnipropetrovsk 79 (18.8) 187 (24.7) 266 (22.6)
 Dnipropetrovsk 98 (23.3) 131 (13.3) 229 (19.4)
 Lviv
Gender (Male) 328 (77.9) 565 (74.5) 893 (75.7) 0.1957
Age – Median (IQR) 35 (30–41) 35 (29–42) 35 (30–40) 0.9408
Living with spouse/partner (yes vs. no) 152 (36.1) 246 (32.5) 398 (33.7) 0.2040
Have children 219 (52.0) 384 (50.7) 603 (51.1) 0.6546
Completed high school or higher 359 (85.3) 629 (83.0) 988 (83.8) 0.3062
Employment 0.2375
 Full time/Part time permanent job 182 (43.2) 366 (48.3) 548 (46.5)
 Temporary/Seasonal/Day laborer 68 (16.2) 116 (15.3) 184 (15.6)
 Not employed 171 (40.6) 276 (36.4) 447 (37.9)
Income 0.5485
 <1200 UAH 132 (31.4) 245 (32.3) 377 (32.0)
 1200–3499 UAH 192 (45.6) 359 (47.4) 551 (46.7)
 ≥3500 UAH 97 (23.0) 154 (20.3) 251 (21.3)
Stably housed 404 (96.0) 720 (95.0) 1124 (95.3) 0.4468
Has been previously incarcerated 174 (41.3) 250 (32.9) 424 (36.0) 0.0042
OAT experience 108 (25.7) 171 (22.6) 279 (23.7) 0.2311
Injected drugs > 5 years 377 (89.6) 632 (83.4) 1009 (85.6) 0.0038
Frequent drug injecting (>20 days) in the last 30 days 244 (58.0) 342 (45.1) 586 (49.7) <0.0001
Poly-substance use (including alcohol) in the last 30 days 186 (44.2) 294 (38.8) 480 (40.7) 0.0709
Poly-substance use (excluding alcohol) in the last 30 days 177 (42.0) 241 (31.8) 418 (35.4) 0.0004
Overdose in the last 6 months 52 (12.4) 49 (6.5) 101 (8.6) 0.0005
Official registered at a Narcology addiction treatment center 207 (49.2) 327 (43.1) 534 (45.3) 0.0463
Prior drug treatment experience 272 (64.6) 435 (57.4) 707 (60.0) 0.0153
Alcohol use disorder 201 (47.7) 377 (49.7) 578 (49.0) 0.5120
Self-reported HIV status 0.0603
 Positive 127 (30.2) 252 (33.3) 379 (32.1)
 Negative 177 (42.0) 266 (35.1) 443 (37.6)
 Unknown 117 (27.8) 240 (31.7) 357 (30.3)
Moderate to severe depression 271 (64.4) 391 (51.6) 662 (56.1) <0.0001
Family members/friends who live with respondent support OAT 184 (43.7) 162 (21.4) 346 (29.3) <0.0001
Positive attitude towards OAT (0–10 scale) – Median (IQR) 8 (5–10) 3 (0–6) 5 (1–8) <0.0001
Negative attitude towards OAT (0–6 scale) – Median (IQR) 3 (2–5) 5 (3–6) 4 (2–6) <0.0001
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The study sample included 279 (23.7%) PWID who had previously received OAT with buprenorphine or methadone; 346 (29.3%) respondents said that family members or friends who live with them supported OAT. Most (85.6%) of our sample had injection drug use experience for more than 5 years, and almost half (49.7%) had injected drugs frequently (20 days or more) in the last 30 days. The proportion of respondents who were officially registered as drug users at a Narcology center was 45.3%. The majority (60.0%) had at least one drug treatment attempt. According to the AUDIT assessment almost half (49.0%) had harmful or hazardous alcohol use. Positive HIV status was reported by 379 (32.1%) of respondents. Over half (56.1%) of study sample had symptoms of moderate to severe depression.

3.2. Willingness to initiate OAT

Overall, 421 (35.7%) of the 1179 PWID were interested in initiating OAT. In the bivariate analyses, the response differed significantly (p<0.0001) by city with more interested respondents in Kyiv (33.7%) and Lviv (23.3%). There was no difference in interest to receive OAT by gender, age, marital status, having children, education, employment situation and income level, as well as by housing situation, previous experience of OAT, alcohol use, and self-reported HIV status. Those who indicated that they would be willing to initiate OAT had previously been in prison (41.3% vs. 32.9%, p-value=0.0042), injected drugs longer (89.6% vs. 83.4%, p-value=0.0038), injected drugs more frequently in the last 30 days (58.0% vs. 45.1%, p-value<0.0001), and more likely to have experienced overdose in the last 6 months (12.4% vs. 6.5%, p-value=0.0005). Among those interested in OAT there were more PWID who were officially registered at a Narcology center (49.2% vs. 43.1%, p-value=0.0463), and a higher proportion had previous drug treatment experience (64.6% vs. 57.4%, p-value=0.0153). Depression symptoms were also more frequent among those interested in OAT (64.4% vs. 51.6%, p-value<0.0001). Drug users were willing to receive OAT if their family/friends supported participation in OAT (43.7% vs. 21.4%, p-value<0.0001), had higher score related to positive attitude towards OAT (median score=8, IQR=5–10 vs. median=3, IQR=0–6), and lower score related to negative attitude towards OAT (median=3, IQR=2–5 vs. median=5, IQR=3–6).

Results of the multivariable analysis stratified by OAT experience are presented in Table 2. Factors independently associated with a willingness to initiate OAT among those who had never been on OAT included: city (Kyiv vs. Mykolaiv: adjusted odds ratio [aOR]=4.8, 95% confidence interval [CI]=2.5–9.2; Lviv vs. Mykolaiv: aOR=2.7, 95% CI=1.4–5.3), previous imprisonment (aOR=1.5, 95% CI=1.0–2.2), registration at a Narcology center (aOR=1.5, 95% CI=1.0–2.3), overdose in the last 6 months (aOR=2.6, 95% CI=1.5–4.5), frequent drug injecting during the last 30 days (aOR=1.8, 95% CI=1.3–2.6), family/friends who support participation in OAT (aOR=2.0, 95% CI=1.4–3.0), positive attitudes towards OAT (aOR=1.4, 95% CI=1.4–1.5). Among those previously on OAT, correlates of OAT willingness are the following: frequent drug injecting during the last 30 days (aOR=2.7, 95% CI=1.4–5.3), self-reported negative HIV status (aOR=2.6, 95% CI=1.4–4.9), depression (aOR=2.7, 95% CI=1.5–5.0), positive attitudes towards OAT (aOR=1.3, 95% CI=1.2–1.4). PWID from both OAT groups with negative attitudes towards OAT were less likely to be willing to enroll into OAT.

Table 2.

Multivariable logistic regression of willingness to initiate OAT stratified by previous experience with opioid agonist therapy

Never OAT Previously OAT
Adjusted OR 95% CI P-value Adjusted OR 95% CI P-value
City
 Mykolaiv Ref.
 Kyiv 4.8 2.5–9.2 <0.0001
 Odesa 1.3 0.7–2.7 0.4099 - - -
 Dnipropetrovsk 1.4 0.8–2.8 0.2579
 Lviv 2.7 1.4–5.3 0.0024
Has previously been incarcerated
 No Ref. - - -
 Yes 1.5 1.0–2.2 0.0354
Official registration at a Narcology addiction treatment center
 No Ref. - - -
 Yes 1.5 1.0–2.3 0.0451
Overdose in the last 6 months
 No Ref. - - -
 Yes 2.6 1.5–4.5 0.0009
Frequency of drug injection in the last 30 days
 ≤20 days Ref. Ref.
 >20 days 1.8 1.3–2.6 0.0016 2.7 1.4–5.3 0.0039
Family/friends who live with respondent support participation in OAT
 No Ref. Ref.
 Yes 2.0 1.4–3.0 0.0003 2.0 1.1–3.6 0.0200
Positive attitude towards OAT (0–10 scale score) 1.4 1.4–1.5 <0.0001 1.3 1.2–1.4 <0.0001
Negative attitude towards OAT (0–6 scale score) 0.7 0.7–0.8 <0.0001 0.8 0.7–0.9 0.0034
Self-reported HIV status
 Positive Ref.
 Negative - - - 2.6 1.4–4.9 0.0030
 Unknown 1.8 0.7–4.9 0.2297
Depression
 No - - - Ref.
 Yes 2.7 1.5–5.0 0.0009
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As shown in Table 3 and Table 4, the most common reasons for unwillingness to receive OAT reported by study participants were related to negative attitudes toward OAT caused by PWID’ myths and beliefs regarding OAT. The 587 PWID who had never taken OAT and who were not interested in the treatment believed that OAT only replaced one addiction for another (80.2%), was bad for their health (77.0%), would not treat their addiction (74.1%), and had bad side effects (73.3%). Two thirds (66.3%) reported that they had heard negative things about OAT. Many respondents (69.8%) mentioned that they were not ready to begin OAT, were afraid of OAT treatment (61.0%), or they could stop using drugs on their own (60.5%). Other reasons frequently reported by PWID who had never been on OAT were program-level barriers that included: unwillingness to be registered as a drug user at Narcology center (62.5%), fear of not being able to detox from OAT (59.6%), and unwillingness to go to the OAT site every day (57.2%). Lack of family support of participation in OAT was also an important reason for not being interested in taking OAT (58.4%).

Table 3.

Reasons for unwillingness to initiate OAT in people who inject drugs who have never been in an OAT program

Total
N=587		 Kyiv
N=91		 Odesa
N=114		 Mykolaiv
N=117		 Dnipropetrovsk
N=150		 Lviv
N=115		 P-value
N (%) N (%) N (%) N (%) N (%) N (%)
I believe OAT only replaces one addiction for another 471 (80.2) 69 (75.8) 97 (85.1) 99 (84.6) 129 (86.0) 77 (67.0) 0.0005
I believe OAT is bad for my health 452 (77.0) 63 (69.2) 91 (79.8) 100 (85.5) 125 (83.3) 73 (63.5) <0.0001
I do not believe OAT will treat my addiction 435 (74.1) 69 (75.8) 85 (74.6) 85 (72.6) 121 (80.7) 75 (65.2) 0.0786
I believe OAT has bad side effects 430 (73.3) 56 (61.5) 90 (79.0) 96 (82.1) 120 (80.0) 68 (59.1) <0.0001
I am not ready to begin OAT 410 (69.8) 57 (62.6) 90 (78.9) 81 (69.2) 109 (72.7) 73 (63.5) 0.0491
I have heard negative things about OAT 389 (66.3) 55 (60.4) 85 (74.6) 89 (76.1) 114 (76.0) 46 (40.0) <0.0001
I do not want to register as a drug user with the Narcology center 367 (62.5) 61 (67.0) 77 (67.5) 62 (53.0) 90 (60.0) 77 (67.0) 0.0944
I am afraid of OAT treatment 358 (61.0) 44 (48.3) 72 (63.2) 77 (65.8) 107 (71.3) 58 (50.4) 0.0006
I can stop using the drugs on my own 355 (60.5) 57 (62.6) 69 (60.5) 83 (70.9) 92 (61.3) 54 (47.0) 0.0062
I will not be able to detox from OAT 350 (59.6) 47 (51.6) 75 (65.8) 75 (64.1) 105 (70.0) 48 (41.7) <0.0001
My family will not approve (does not want me to) participate in OAT 343 (58.4) 48 (52.8) 71 (62.3) 79 (67.5) 83 (55.3) 62 (53.9) 0.1141
I do not want to go to the site every day 336 (57.2) 44 (48.4) 74 (64.9) 72 (61.5) 91 (60.7) 55 (47.8) 0.0220
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Table 4.

Reasons of unwillingness to restart OAT among PWID who received OAT in the past

Total
N=171		 Kyiv
N=44		 Odesa
N=8		 Mykolaiv
N=66		 Dnipropetrovsk
N=37		 Lviv
N=16		 P-value
N (%) N (%) N (%) N (%) N (%) N (%)
OAT just replaces one addiction for another 108 (63.2) 30 (68.2) 8 (100.0) 50 (76.8) 13 (35.1) 7 (43.8) <0.0001
I am not interested in initiating OAT right now 93 (54.4) 17 (38.6) 2 (25.0) 46 (69.7) 19 (51.3) 9 (56.3) 0.0078
OAT is bad for my health 89 (52.1) 25 (58.8) 5 (62.5) 41 (62.1) 13 (35.1) 5 (31.3) 0.0328
OAT is too hard to withdraw from 89 (52.1) 27 (61.4) 5 (62.5) 41 (62.1) 13 (35.1) 3 (18.7) 0.0026
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Most participants who received OAT in the past and were unwilling to initiate OAT again agreed with statements that OAT replaced one addiction with another (63.2%), they were not interested in undergoing OAT treatment (54.4%), OAT was bad for their health (52.1%), and it was too hard to withdraw from OAT (52.1%). Frequencies of almost all reported reasons of unwillingness to start OAT differed by city.

4. DISCUSSION

Opioid dependent PWID who are not currently enrolled into OAT do not receive the benefits derived from this treatment (Bachireddy et al., 2014; Kamarulzaman and Altice, 2015; Morozova et al., 2013; Tran and Nguyen, 2013). They also have increased risk of HIV, sexually transmitted infections (STIs) and other infectious diseases (TB, HCV), and are more involved in criminal activities and illegal drug use (Gibson et al., 1999; Springer et al., 2011; Sun et al., 2015; Van Den Berg et al., 2007; Wong et al., 2003). Our study is the first in Ukraine to assess factors associated with willingness to receive OAT, a first step in the OAT enrollment decision-making process. According to the results of previous research, PWID who expressed interest in treatment were more likely to start OAT (Booth et al., 2003; Zule and Desmond, 2000).

A number of important findings were noted in this study. We observed that interest in receiving OAT was generally low among PWID who were not in treatment. Only 35.7% of the study sample reported willingness to enroll on OAT. Factors associated with interest in OAT differed based on their previous experience with OAT. Correlates of willingness to start OAT that were common to both PWID previously on and never on OAT included higher injection frequency, potentially a proxy of addiction severity, their family being supportive of them starting OAT, and having more positive attitudes toward OAT. Our study confirms results from elsewhere that frequent drug injecting was associated with OAT enrollment (Booth et al., 1998; Zule and Desmond, 2000). PWID who inject drugs more often are at higher risk for HIV and HCV transmission (Berbesi-Fernandez et al., 2015; Todd et al., 2011). This is potentially derived because frequent injectors perceive themselves at highest risk for HIV and, consequently, became more motivated to enter treatment (Booth et al., 1998). The findings of family support promoting willingness to start OAT have important implications for Ukraine.

Generally, attitudes toward OAT are quite negative (Bojko et al., 2015; Polonsky et al., 2016a, 2015, 2016b; Springer and Bruce 2008) and have important implications for OAT expansion and suggest that both a general social marketing about OAT is needed, but also for PWID who are contemplating OAT. Community outreach and peer-driven interventions are important grass roots strategies to change attitudes and (Heckathorn and Broadhead, 1996; Heckathorn, 1990). Such strategies have been effective in reducing HIV risk behaviors among PWID (Broadhead et al., 1998, 1995, 2006), but also in promoting antiretroviral therapy adherence among PWID (Broadhead et al., 2012, 2002). How such interventions might be expanded to reach family members, however, is unknown. Other researchers have concluded that supportive environments may improve entry into treatment and may be helpful in implementing effective interventions to encourage drug treatment entry and retention (Peterson et al., 2010; Wu et al., 2013), which speaks toward working with families in the process of facilitating OAT entry. In Ukraine, where PWID mostly remain with families even during their most problematic drug use suggests that family members may be central to OAT promotion campaigns.

Of interest is that there were differences in willingness to start OAT based on their previous experience with OAT. Interest in OAT among OAT-naïves varied significantly by city. While participants from Kyiv and Lviv were more interested in OAT than participants from Odesa, Mykolaiv and Dnipropretrovsk, this may speak to organizational factors associated with OAT programs. Problematic in these findings is that the three cities where PWID were less willing to start OAT is where the drug use and HIV epidemics are most pronounced (Zaller et al., 2015). Regional differences have also been described in attitudes towards OAT (Polonsky et al., 2015), which may in part contribute to these differences.

It is not surprising that among the OAT-naïve PWID not being “registered” at a Narcological Center was negatively correlated with interest to receive OAT. In order to receive OAT, Narcological registration is a necessary requirement (Ministry of Health of Ukraine, 2012). Official registration is associated with restrictions in type of employment, loss of driver’s license and potential targeting by police (Bojko et al., 2013; Izenberg and Altice, 2010; Izenberg et al., 2013). This finding supports qualitative research in Ukraine that until such policies are reversed, PWID are unlikely to enter OAT (Bojko et al., 2015, 2016; Mazhnaya et al., 2016) OAT.

The finding that being HIV negative and having depression were positively correlated with willingness to start OAT among those PWID who were previously on OAT is counterintuitive and worthy of further investigation. According to the Health Behavior Model for Vulnerable Populations (Gelberg et al., 2000; Stein et al., 2007), having more medical comorbidities, or predisposing factors, would promote healthcare seeking. Depression is one of the comorbidities associated with decreased motivation to seek treatment. Having depression, however, may have been severe enough that it emerged more as a need factor, similar to addiction severity, for these patients. Like our study, others have found that patients with depressive symptoms are more likely to enroll in OAT (Amodeo et al., 2004; Reynoso-Vallejo et al., 2008). But because depression is associated with poor levels of motivation, it may be that these participants had not followed through on the complex requirements to re-enter treatment despite their willingness. Consequently, routine screening for depressive symptoms and providing adequate treatment for depression may be one strategy to facilitate interest in OAT.

Regarding HIV status, others have found that being HIV-infected was associated with enrollment in OAT (Kerr et al., 2005; Zule and Desmond, 2000). Here, we found the opposite. One explanation is that at the inception of the OAT programs in Ukraine, people living with HIV (PLWH) were disproportionately enrolled such that now 37% of OAT patients are HIV-infected (Ukrainian Centers for Disease Control (UCDC), 2015). The early efforts focused on PLWH, leaving only those who were very unmotivated to start OAT, which was who we recruited for this study. Another explanation could be that HIV negative PWID perceive their risk of HIV infection and they are willing to enter OAT to stay healthy.

Similar to our findings, others have shown that lack of knowledge and negative attitudes toward OAT are significant obstacles to receiving OAT (Lin et al., 2011; Peterson et al., 2010; Polonsky et al., 2015). Among PWID who had never received OAT, the most commonly reported reasons of not being interested in treatment are mostly related to negative myths and beliefs about OAT including fears of side effects, harm for health and withdrawal symptoms from OAT. More than half of respondents endorsed the fear of detoxification after entering OAT. There is a belief that a withdrawal from methadone is much more difficult compared to any other illegal drugs (Bojko et al., 2015; Peterson et al., 2010).

Being aware of factors and characteristics of PWID who are not willing to receive OAT will help to target interventions aimed to change unfavorable attitudes of PWID towards OAT and their addictive behavior. Suggesting that most PWID are not ready to change their addictive behaviors, a motivational interview is an advisable strategy to increase motivation towards change (Miller and Rollnick, 1991; Rollnick et al., 2010). Prior studies showed that PWID who received case management consultations were much more likely to enter treatment (Havens et al., 2007; Strathdee et al., 2006). There are other approaches that have been shown to be effective to increase OAT treatment enrollment that could be applied in the Ukrainian context. These include facilitating entry into drug treatment among PWID through referral from needle/syringe programs and street outreach (Kuo et al., 2003; Riley et al., 2002; Strathdee et al., 2006). Applying principals of the Network for the Improvement of Addiction Treatment (NIATx) based on process improvement strategies (McCarty et al., 2007; Woody et al., 1975) can help identify existing problems and assist in development of strategies oriented on specific needs of a particular site or city to improve OAT delivery which may make it more attractive for PWID to enter and retain in OAT.

This study is not without limitations. First, the cross-sectional design restricts interpretation only to correlation and not causation (Carlson and Morrison, 2009). Second, self-reported data may be influenced by recall and social desirability biases (Johnson and Fendrich, 2005). Third, though RDS was used to recruit participants who have never been on OAT, the findings may be modestly imprecise since covariates from this group were unweighted (Gile and Handcock, 2010; Goel and Salganik, 2010). Despite these limitions, the sample size is large and provides the most extensive data about interest in initating OAT among PWID in Ukraine where the HIV epidemic is concentrated.

Although OAT is extremely effective for treating opioid addiction and preventing HIV, the majority of PWID in Ukraine are not willing to receive it. Here, it appears as though both individual and structural factors may be associated with the unwillingness to receive OAT. Many of these factors, however, are amenable to intervention and should be addressed and tailored to the needs of the specific programs, which appear geographically diverse. Strategies that directly address these issues, however, will be crucial to increasing the number of PWID who receive OAT. One such implementation strategy that allows each setting to solve problems unique to the program is the NIATx treatment improvement process, which defines a problem (e.g., low uptake of opioid dependent persons) and develops strategies using a rapid cycle change strategies until OAT entry (or retention) is optimized (McCarty et al., 2007). Until Ukraine overcomes such obstacles, they will be unable to effectively intervene to curb the explosive HIV epidemic and other consequences of untreated opioid addiction among PWID like high prevalence of HCV and TB, particularly multidrug-resistant TB, that persists in the region.

Highlights.

  • Interest in receiving OAT was generally low among PWIDs who were not in treatment.

  • Factors associated with interest in OAT differed based on previous OAT experience.

  • Lack of knowledge and negative OAT attitudes are significant obstacles to get OAT.

Acknowledgments

Role of Funding Source

The authors would like to acknowledge the National Institute on Drug Abuse for funding for research (R01 DA029910 and R01 DA033679 ) and career development (K24 DA017072) and the Global Health Equity Scholars Program funded by the Fogarty International Center and the National Institute of Allergy and Infectious Diseases (Research Training Grant R25 TW009338) as well as New York State International Training and Research Program through in-country training grant funded by the Fogarty International Center (D43TW000233).

We are thankful to our colleagues Iryna Pykalo, Tatiana Fomenko, and Tatiana Prokhorova who were greatly involved during data collection and dataset cleaning. We would also like to extend our gratitude to local research assistants and all the survey participants in each city for their dedication and time.

Footnotes

Contributors

I. Makarenko conducted the main statistical analysis and drafted the manuscript. F.L. Altice, A. Mazhnaya, R. Marcus, and M.J. Bojko contributed substantially to the study conceptualization and manuscript editing. M.Polonsky assisted with statistical analysis. S. Filippovich, S. Springer and S. Dvoriak provided oversight and critical feedback. All authors have read and approved the final manuscript.

Conflict of Interest

We have no conflict of interest to declare

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