Quality of life among Methadone Maintenance Treatment ( MMT ) patients with higher education

Background: One of the objective in Methadone Maintenance Therapy (MMT) which is a rehabilitation program for injecting drug users is quality of life. The purpose of this study was to determine quality of life among MMT patients Methods: The cross sectional study was conducted in Kedung Badak Primary Health Care and Bogor Timur in Bogor. Data were collected from interview and filling out WHOQOL-BREF questionnaire from April-June 2018. Analysis was performed using multiple linier regression. Results: Total subjects in this study was 62 subjects. The results showed mean scores for physical domain was 57.6; psychological domain was 57.5; social domain was 63.6; and environmental domain was 63.9. Compared with Indonesian, MMT patient scores were higher in environmental domain and lower in physical and psychological domain while social domain had no different with it. The dominant factor in determining physical and environmental domain was level of education, while the psychological domain was methadone dose, and the existence of someones to talk to was dominant factor for social domain. Conclusion: The higher level of education, will produce better quality of life in all domains. MMT patients with lower level education must be monitored to improve their quality of life. It is suggested to treat patients based on individual approaches and support from family and friends is needed to motivate clients and adherence to the therapy. (Health Science Journal of Indonesia 2018;9(2):93-9)

Drug abuse is a global problem experienced by all countries, including Indonesia.It has become one of global burden of diseases resulted disturbance in productivity with number of Disability Adjusted Life Years (DALY) in 2015 was 17 million or 0.66% of total causes of world burden, while mortality rates was 2.3 per 100,000 population.In Indonesia, it accounts for 0.2% of total DALY. 1 Based on National Narcotics Board (BNN), drug abuse prevalence in Indonesia was 2.18% in the age group of 10-59 years. 2 Ministry of Health Indonesia showed that until June 2010, the highest prevalence of Injecting Drug Users (IDU) was DKI Jakarta, West Java, East Java, South Sulawesi, and Bali. 3 Bogor was included in top 5 cities in Indonesia in terms of drug trade. 4 an anticipated precaution for the harm caused by IDU, such as HIV transmission through contaminated syringes, government developed a Methadone Maintenance Therapy (MMT) program.Methadone is a drug included in World Health Organization (WHO) essential medicines which is used to treat heroin dependence.MMT significantly reduced mortality rate among opioid dependence and reduce criminal activity. 5In Indonesia, MMT was launched in 2006 to carry out comprehensive, processable, and long-term treatment.Based on study in two hospitals namely Drug Dependency Hospital, Jakarta and Sanglah Hospital, Bali showed that IDUs who participated MMT stopped using drugs. 6e of MMT objevtive is quality of life.A study showed that low quality of life was associated with recurrent drug use among IDUs in MMT program. 6n addition, poor quality of life, unemployment, and inadequate methadone doses will cause low compliance in MMT program. 7Based on these problems, the study aimed to identify factors associated to quality of life among MMT patients.

METHODS
This cross-sectional study was conducted in purposive selected two public health care, namely Kedung badak and Bogor Timur that serves MMT program in Bogor.
The data was obtained by interview and fill out questionnaire from April-June 2018.Inclusion criterias for the study were adult (minimum 18 years old), joined MMT program at least 6 months, and able to communicate.Exclusion criterias for the study were patients with loss of consciousness, could not cooperate, referral patients who only join MMT program temporary in both public health cares, and not willing to join the study.
WHOQOL-BREF questionnaire was used to assess subjects' quality of life.There are 4 domains in this quality of life (physical health, psychological, social relationships, and environmental) that should be assessed as dependent variables.Physical health has 7 facets including activities of daily living, dependence on medical substances and medical aids, energy and fatigue, mobility, pain and discomfort, sleep and rest, and work capacity.Psychological has 6 facets including bodily image and appearance, negative feelings, positive feelings, self-esteem, spirituality/ religion/personal beliefs, and thinking, learning, memory and concentration.Social relationships has 3 facets consisting of personal relationships, social support, and sexual activity.Environment consist of financial resources, freedom, physical safety and security, health and sodial care: accessibility and quality, home environment, oppportunities for acwuiring new information and skills, participation in and opportunities for recreation/ leisure activities, physical environment (pollution/noise/traffeic/ climate), and transport.Data collected include subject characteristics, history of disease, history of heroin used, history of criminality, history of methadone therapy, and social support which became independent variables.For the purposes of this analysis, patients' occupation was divided into 2 categories (employed and unemployed).
History of heroin overdose was assessed by asking subjects history during last heroin used.It was divided into 2 gorups (no and yes).Duration of heroin use was categorized into 2 groups (less than 10 years and more than equal to 10 years).Number of incarcerations was assessed by asking subjects experiences during following MMT program.
Methadone dose was dose of methadone obtained at this time.Duration of methadone therapy was assessed by asking subjects how long they joined methadone therapy from first time until this time.Social support was evaluated by 2 questions: the presence of someone who can be talked to and someone who will lend/give money or something valuable if needed were categorized into yes and no.
As many as 62 subjects were derived from the two public health cares.Descriptive statistics were used to analyze patient characteristics and other variables.Based on normality data test, independent t-test and correlation test was performed to select appropriate variable which will be included in multivairate analysis.To identify the factors related to 4 domains quality of life multiple linier regression was used.Analysis was performed using SPSS version 16.
Ethical approval was obtained from the Ethics Committee of Faculty of Public Health Universitas Indonesia.

RESULTS
Table 1 showed characteristics of subjects.Overall, 87.1% of subjects were male, the mean (SD) age was 38.5 (4.1), and 82.3% were employed.Most subject education was university (62.9%) while most subjects were married (64.6%).Approximately 64.5% subjects had normal BMI.Approximately 40.3% were HIV positive and 43.5% had history Hepatitis-C positive.Approximately 22.6% subjects had a history of drug overdose and 75.8% had a history of heroin use more than equal 10 years.
Table 2 showed the mean scores (SD) for physical, psychological, social, and envirnmental domains of quality of life were 75.6 (8.3), 57.5 (10.2), 63.6 (15.4), and 63.9 (13.7).The mean score for MMT patients' age was 38.5 years, while the mean score (SD) for methadone dose and duration of methadone therapy were 101.8 (89.6) mg and 81.6 (41.1) months.Approximately 50% subjects comply to methadone treatment.Approximately 83.9% subjects were having someone who can be talk to and 82.3 % were able to lend money from others if needed.Table 3 showed that age had negative correlation significantly to social domain.Methadone dose had statistically negative correlation to physical, psychological, social, and environmental domains.
Table 4 showed there were significant different on physical domain to level of education and history of HIV.On psychological domain, there were significant different to marrital status and presence of someone who can be talked to.On social domain, there were significant different to subjects occupation, marrital status, and presence of someone who can be talked to.On environmental domain, there was a significant different to level of education.5 showed that physical domain was positively correlated to sex (β = 0.24) and higher level of education (β = 0.33), while methadone dose had negative correlation to physical domain (β = -0.31).On psychological domain, higher level of education had positively correlation to get better score (β = 0.26), while higher methadone dose was associated to poor score (β = -0.32).On social domain, age (β = -0.26),methadone dose (β=0.25), and no one who can be talked to (β = -0.40)were associated with poor score, while level of education was positively correlated (β = 0.24).On environmental domain, the higher level of education, will increase the score (β = 0.37).
Furthermore, the dominant factor in determining quality of life in physical and environment domain was level of education, while psychological domain was determined by methadone dose.The dominant factor in determining social domain was the presence of someone to talk to.

DISCUSSION
Several limitations must be considered in interpreting the results.The research was only conducted in two public health cares in Bogor, so it did not represent the whole region of Indonesia.In addition, magnitude of changes in quality of life scores before join MMT program can not be determined, therefore the scores only can be compared to Indonesian general population scores.History of HIV and Hepatitis C only obtained from subject recognition.Assessment of compliance to methadone therapy was based solely on drug taking records, therefore researchers could not ascertain whether the drug was actually taken by subjects.
In Indonesia, there is no quality of life score for methadone clients who have completed MMT, so these findings will be compared to the existing data (Indonesian general population score).Compared to the mean score of quality of life of Indonesian general population (physical domain = 69.23,SD = 11.49;psychological domain = 66.74,SD = 12.89; social domain = 63.13,SD = 14.38; environmental domain = 58.53,SD = 13.43), the mean score of physical and psychological domain of subjects were lower than the population. 8A person who has a history of heroin dependence tends to have chronic health problems that could weaken physical function and higher psychological pressure than healthy people, so that MMT clients will be difficult to reach healthy state as healthy population. 9The mean score of social domain was not significantly different than Indonesian population.The mean score of environmental domain had higher score than Indonesian general population.Study in Taiwan showed that after 12 months of methadone treatment, social and environmental domain scores improve significantly than before treatment.Methadone treatment can return patients to normal daily activities, so the quality of life will increase.After joined methadone treatment, patients will be more willing and able to rebuild their social relationships. 10In this analysis, age was negatively corrrelated to social domain after being controlled by other variables.As people age, many aspects of their lives change including relationships with the people around them, social context, family, and health.Many social relationships are lost by involving community and friend network. 11is study noted that level of education showed a positive correlation to quality of life in all domains.The result was in line with study in Taiwan and Malaysia. 12,13eople with higher education have better strategies to addressing social and environmental problems and higher incomes, so they will have better quality of life. 14rthermore, higher methadone dose was associated with poor physical and psychological domain.This may be occured because dose increase indicate that patients enter a maintenance phase or got another treatment therapy that require increased dose (such as HIV treatment) that need to be monitored for years including side effects and emotional condition.Increased dose result in severe side effects such as constipation, drowsiness, nausea, and sexual problems. 3In this study, the absence of social support associated with poor quality of life.Study in Taiwan also in line with this result. 15A study showed that having at least a friend has a positive effect on quality of life. 16Social support is important to improve compliance to the therapy, such as family that can assist patients in reminding to take medication. 17Social support need to be included into MMT programs to improve life satisfaction and treatment outcomes.
In conclusion, the higher level of education, will produce better quality of life in all domains.MMT patients with lower level education must be monitored to improve their quality of life.It is suggested to treat patients based on individual approaches and support from family and friends is needed to motivate clients and adherence to the therapy.

Table 2 .
Characteristics of MMT subjects (Numerical variable)

Table 3 .
Bivariate analysis: correlation test for numeric variables to qualitiy of life domains

Table 5 .
Multiple regression analysis to quality of life domains