Methadone maintenance counseling: Definition,principles, components

Counseling has been a major service component of methadone maintenance since its inception. Yet, there is no consensus about what methadone counseling is or how it should be practiced. This paper proposes a definition of professional methadone counseling as a specialized modality of addiction therapy and rehabilitation. Five principals of methadone counseling are reviewed: (1) coordination of care, (2) use of the counseling relationship, (3) attention to the stage of recovery, (4) structure and flexibility, and (5) facilitation of patient resourcefulness and social recovery. Fifteen components of methadone counseling are also reviewed. These include interventions focused on (1) the initial phase of treatment, (2) the treatment itself, and (3) the work of rehabilitation. General counseling issues are considered, such as counselor education, the role of the counselor in the program, the methadone controversy, as well as the impact of HIV disease and “crack/ cocaine”. In closing, the advantages of the proposed model are stressed.     

Predictors of engagement in vocational counseling for methadone treatment patients

Employment enhances the outcomes of substance dependency treatment. Unfortunately, although unemployed methadone treatment patients frequently state they are interested in a job, many fail to participate in vocational services when available. Unless patients become engaged, vocational services do not have an opportunity to be effective. This is the first study to explore a broad array of factors that may be associated with differential engagement in vocational services among methadone patients. The study was conducted in two methadone programs in New York City during 2001-2004. Unemployed methadone patients (n = 211) were voluntarily randomly assigned to either of two vocational counseling programs (standard vs. experimental) and followed for 6 months. The sample was 59% male, 75% minority group, aged 45 years on average, and in methadone treatment for 5 years on average. Being engaged in the vocational counseling programs was defined as five or more sessions with the counselor in the first 6 months after study entry. In multivariate analysis, the factors associated with higher engagement in vocational counseling were being non-Hispanic, having more education, a drug injection history, a crack use history, having chronic emotional/mental problems, better work attitudes, and assignment to the experimental vocational program. The results indicate that it is often the most "needy" unemployed methadone patients who become more engaged in vocational counseling. A vocational counseling model which emphasizes assertive outreach and attends to nonvocational clinical issues as well is more likely to engage patients.     

Richard Lane:

After a long and courageous battle with cancer, Richard Lane died in 1994. He had been a long-term heroin addict and spent 12 years in prisons. After commencing treatment with methadone, he began to work with other addicts and helped to start Man Alive, the first methadone program in Baltimore. He later became Executive Director of Man Alive and a national leader in the effort to improve and expand methadone maintenance treatment. Among the innovations he promoted within the methadone program were onsite alcoholism treatment, protocols for poly-drug abuse, services for patients with acquired immune deficiency syndrome, improved pain management for methadone patients, and fewer restrictions for socially rehabilitated patients on methadone. He fought tirelessly for acceptance of methadone maintenance treatment by those in medicine, law enforcement, and politics. His accomplishments can inspire all in the addiction field to continue their efforts to improve the care of the addict.     

Assessing the effectiveness of an Internet-based videoconferencing platform for delivering intensified substance abuse counseling

Enhanced schedules of counseling can improve response to routine opioid-agonist treatment, although it is associated with increased time demands that enhance patient resistance and nonadherence. Internet-based counseling can reduce these concerns by allowing patients to participate from home. This study assesses treatment satisfaction and response to Internet-based (CRC Health Group's e-Getgoing) group counseling for partial responders to methadone maintenance treatment. Patients testing positive for an illicit substance (n = 37) were randomly assigned to e-Getgoing or onsite group counseling and followed for 6 weeks. Patients in both conditions responded favorably to intensified treatment by achieving at least 2 consecutive weeks of abstinence and 100% attendance to return to less-intensive care (e-Getgoing: 70% vs. routine: 71%, ns). Treatment satisfaction was good and comparable across conditions. E-Getgoing patients expressed a preference for the Internet-based service, reporting convenience and increased confidentiality as major reasons. Integrating Internet-based group counseling with on-site treatment services could help expand the continuum of care in methadone maintenance clinics.     

Bridges and barriers to recovery: Clinical observations from an opiate recovery project

Clinical issues are described in opiate addicts attempting to taper off methadone maintenance, and techniques are suggested to help this patient population. The observations were generated in an experimental “Tapering Network” project, in which opiate addicts on methadone maintenance had the opportunity to receive individual and group counseling, relapse prevention training, self-help groups, and other services. Vignettes illustrate clinical problems with intimacy and social isolation, identity as a former addict, and a “post methadone syndrome” characterized by vulnerability, dramatic swings in mood, and disordered thinking for a period of up to six months after detoxification. To counteract these barriers to recovery, a program model is suggested that uses curricula available in the emerging literature on treatment of substance abuse. These techniques can provide bridges to recovery.     

A randomized trial of 6-month methadone maintenance with standard or minimal counseling versus 21-day methadone detoxification

BACKGROUND: Important questions remain regarding the necessary duration and intensity for methadone treatment to be effective. METHODS: As part of a clinical trial of tuberculosis chemoprophylaxis [Batki, S.L., Gruber, V.A., Bradley, J.M., Bradley, M., Delucchi, K., 2002. A controlled trial of methadone treatment combined with directly observed isoniazid for tuberculosis prevention in injection drug users. Drug Alcohol Depend. 66 283-293. doi:10.1016/S0376-8716(01)00208-3], patients with opioid dependence were recruited from an outpatient 21-day methadone detoxification program and were randomly assigned to one of three treatment conditions: (1) continuation in 21-day methadone detoxification; (2) transfer to 6-month methadone maintenance with only minimal counseling; or (3) transfer to 6-month methadone maintenance with standard twice monthly counseling and as-needed social work and psychiatric services. Both the 6-month maintenance treatments were followed by 1.5 months of detoxification. Urine drug tests and self-report measures were collected at baseline, months 1-6, and month 8.5. RESULTS: Compared to 21-day methadone detoxification, 6-month methadone maintenance with either minimal or standard counseling resulted in fewer opiate positive urine tests and days of self-reported heroin and alcohol use. There was no change in cocaine use or other outcome measures. The increased counseling available in the standard counseling condition did not appear to reduce heroin use further than the minimal counseling condition, in contrast to the effect found for more structured counseling in long-term methadone maintenance (McLellan et al., 1993). CONCLUSIONS: Six months of methadone maintenance, even with minimal counseling, reduces heroin and alcohol use more than 21-day methadone detoxification.     

Effectiveness of psychotherapeutic counseling in methadone maintenance

Therapeutic counseling has been widely adovacted with methadone maintenance, but its effectiveness has not been demonstrated. A review of the literature revealed a dearth of scientific investigations comparing treatment outcomes with and without counseling services. The few studies which have been reported seem to suggest that counseling does not significantly change treatment outcomes as measured by the usual indicators of illicit drug use, arrests, employment, and retention in the program. These studies suffered from a number of methodological flaws, however, including failure to adhere to research design, small sample size, poorly matched control groups, inadequate outcome criteria, and absence of post-treatment follow-up. Previous investigators have been nearly unanimous in calling for further studies of this issue. Since the cost of counseling services represents a major portion of treatment program budgets, there is an urgent need to document the effectiveness of these services with definitive studies.     

Biofeedback Application to Drug Addiction in the University of Colorado Drug Rehabilitation Program

Biofeedback was used as a means to relieve stress and anxiety for methadone patients. The hypothesis was that biofeedback could substitute for the use of drugs that were previously used to relieve stress and anxiety. Biofeedback was found to be an effective substitute for opiates and also a tool for insight into behavior. The addict learned to use his own abilities to improve his well-being and control over his life situations. The goal of maintaining a drug-free life with the help of biofeedback techniques was supported in this study.     

Use of a low-cost incentive intervention to improve counseling attendance among methadone-maintained patients

Despite the importance of counseling in methadone maintenance treatment, many patients do not take advantage of these services. Incentives for attending group counseling were offered to methadone-maintained patients during an orientation phase of treatment or during required attendance at a relapse group later in treatment. Upon attending each counseling session, patients could draw for prizes under an escalating draw system with a 50% probability that draws would result in a prize. Incentives included small ($1), moderate ($5), and large ($20) prizes, with chances of winning inversely related to prize costs, and a maximum possible total of $160 per patient. It was anticipated that this policy would provide a relatively low-cost approach to improving counseling attendance in our methadone clinic. The incentive policy significantly increased the percent of counseling sessions attended (52% vs. 76%) and promoted periods of continuous attendance. These data further support the effectiveness of low-cost incentive programs in enhancing counseling attendance among methadone patients.     

An addiction treatment program in Laos: the first year's experience

In late 1972 a treatment program for narcotic addicts was begun in Vientiane, Laos. Medical and social treatment modalities were emphasized: withdrawal from narcotic drugs, care for chronic health problems, a highly structured milieu program with explicit rules, and careful discharge planning with family counseling. Patients were accepted on a voluntary basis only. The first year's patient population were mostly married, employed, addicted to opium, and from rural areas. They comprised a diversity of ethnic groups. A smaller group of young, single, male heroin addicts (a type of addict new to Laos) also appeared in this group of patients. This treatment program proved highly acceptable to a large number of addicted people from various age groups and ethnic backgrounds. It was successfully undertaken by medical personnel who had minimal or no experience in the addiction field prior to work at this facility. Among opium addicts, twice-a-day methadone dosage for withdrawal treatment was superior to once-a-day dosage. Opium addicts required a longer detoxification regimen than did heroin addicts.     

香港美沙酮治疗计划的小组辅导及支持服务

香港美沙酮治疗计划自1972年推行以来面对不少困难,包括服药人士对美沙酮的误解、社会人士的偏见、计划的形象危机、职员间团队精神的磨合不足以及缺乏支持服务等。但香港美沙酮治疗计划仍然不断优化自强。自2000年起全面加强小组辅导及支持服务,得到服药人士良好的反应及积极支持,并在预防吸毒人群感染艾滋病病毒方面取得优异的成绩,每天约有7000人前往接受治疗。我们采用具有香港特色的“医药、社会及心理合—治疗模式”帮助服药人士。本文分享香港推行美沙酮治疗计划所经历的一些问题及解决方法,以期这项计划能发挥最佳治疗效益。     

美沙酮维持治疗辅助康复训练前后病人的应对方式和社会支持变化

目的:探讨美沙酮维持治疗辅助康复训练对海洛因依赖病人应对方式和社会支持的影响。方法:对50名接受美沙酮维持治疗的病人进行了5个月的康复训练,康复训练以接受美沙酮维持治疗病人的需求、所处的康复阶段及接受能力为中心,包括强化戒毒治疗动机、减少吸毒造成的危害、复吸预防等各种技能训练。康复训练前后测量应对方式和社会支持。结果:康复训练后美沙酮维持治疗病人幻想、退避、自责等不成熟型应对方式分值下降,而求助的分值增加,社会支持增加。结论:美沙酮维持治疗辅助康复训练能够改善门诊病人的社会支持和应对方式。     

A psychoeducational approach to methadone maintenance treatment

Methadone maintenance has become the treatment of choice for heroin addiction because of its beneficial effects on illicit opiate use and criminality. Yet methadone maintenance falls short in a variety of ways; methadone clients continue to use drugs, experience high rates of psychopathology and alcoholism, and fail to become employed and integrated into the community. These problems are endemic in addicts, but also can be attributed to a host of strategic and tactical failures in methadone maintenance treatment itself. Traditional counseling is an inadequate and confused way to provide clients with the living skills, psychotherapy, and limit setting they need. S.T.A.R. is a methadone program in Portland, Oregon, that emphasizes direct training of educational, recreational, and personal skills. Group treatment is employed to create social support for clients while psychotherapy and crisis counseling are available on an as-needed basis. Implementation of the model has caused some difficulties and has led to creative and promising results.     

Clonidine Versus Long- and Short-Term Methadone-Aided Withdrawal from Opiates. An Uncontrolled Comparison

Twelve heroin addicts and one methadone addict began withdrawal from street opiates, under clonidine cover, in a general psychiatric ward. Ten (80%) of them completed it within 6 days. Clonidine doses used were lower than in similar studies and all patients were alert and mobile throughout withdrawal. Two other groups of opiate addicts, of similar age and sex, were withdrawn on standard methadone regimens. Clonidine and methadone withdrawal had similar acceptability and attrition rates. Self-reports of subjective discomfort were higher in the clonidine group without affecting compliance with treatment. Withdrawal under clonidine cover deserves further study, in view of the need for postwithdrawal treatment to prevent relapse to opiate use.     

Predictors of Engagement in Vocational Counseling for Methadone Treatment Patients

Employment enhances the outcomes of substance dependency treatment. Unfortunately, although unemployed methadone treatment patients frequently state they are interested in a job, many fail to participate in vocational services when available. Unless patients become engaged, vocational services do not have an opportunity to be effective. This is the first study to explore a broad array of factors that may be associated with differential engagement in vocational services among methadone patients. The study was conducted in two methadone programs in New York City during 2001–2004. Unemployed methadone patients (n = 211) were voluntarily randomly assigned to either of two vocational counseling programs (standard vs. experimental) and followed for 6 months. The sample was 59% male, 75% minority group, aged 45 years on average, and in methadone treatment for 5 years on average. Being engaged in the vocational counseling programs was defined as five or more sessions with the counselor in the first 6 months after study entry. In multivariate analysis, the factors associated with higher engagement in vocational counseling were being non-Hispanic, having more education, a drug injection history, a crack use history, having chronic emotional/mental problems, better work attitudes, and assignment to the experimental vocational program. The results indicate that it is often the most “needy” unemployed methadone patients who become more engaged in vocational counseling. A vocational counseling model which emphasizes assertive outreach and attends to nonvocational clinical issues as well is more likely to engage patients.     

Education and counseling in the methadone treatment setting improves knowledge of viral hepatitis

The aim of this study was to evaluate the effectiveness of an educational method of providing viral hepatitis education for methadone maintenance patients. Four hundred forty participants were randomly assigned to either a control or a motivationally-enhanced viral hepatitis education and counseling intervention. Viral hepatitis A (HAV), B (HBV), and C (HCV) knowledge tests were administered at baseline, following each of two education sessions (post-education), and at a 3-month follow-up assessment. Results indicated a significant increase in knowledge of HAV, HBV, and HCV over time. No differences were found in knowledge between the intervention groups in knowledge acquisition regarding any of the hepatitis viruses suggesting that a motivational interviewing style may not augment hepatitis knowledge beyond standard counseling. A two-session viral hepatitis education intervention effectively promotes hepatitis knowledge and can be integrated in methadone treatment settings.     

Historical Note: Escalation to Tea

Commonly agreed upon goals in conjunction with methadone maintenance have been (1) a return to legitimate employment, (2) cessation or substantial reduction in criminal behavior, (3) reduction in the amount of time spent in drug-seeking behavior, (4) involvement with a social system in which there is a positive reinforcement for relating to people, and (5) furnishing a motivation for healthy living. Furthermore, many methadone programs have reported high retention rates of addicts remaining in the program. Thus, as a result of these retention rates, methadone maintenance programs should have a higher degree of success in achieving the above-mentioned goals as compared to other alternative forms of treatment that do not have high retention rates (Senay and Renault, 1971). Indeed, the present findings reveal that for matched groups of addicts admitted to a methadone program, those addicts who remain in methadone treatment longer than 3 months showed improved behaviors in seeking and gaining meaningful employment, attitudes about themselves, reduction in time spent seeking illegal drugs, interpersonal relationships, and a higher motivation for carrying on a more useful and productive life. In addition, these same addicts in methadone treatment revealed a steady reduction in criminal behavior. These findings are similar to those reported by others (Rosenberg, Davidson, and Patch, 1972).

Despite these findings, it should be pointed out that the success reported here involves a sample which reflects only 35% of the addicts remaining in methadone treatment out of all the addicts who originally applied for the program. As such, a substantial problem still remains. It appears that many addicts who do not accept treatment or who drop out of treatment early may be lost to treatment for a long period of time. Furthermore, dropouts appear to be a high risk to return to criminal behaviors to support their habit. There seems to be no one single reason why addicts drop out of treatment, but rather the problem is a multidimensional one. That is, addicts who do not accept treatment or drop out early may be more influenced by peer group dynamics, deprived physical and emotional family backgrounds, or find it easier to obtain “street” methadone, all of which encourage addiction rather than abstinence and treatment. Finally, although a large number of addicts remain a problem, there is hope that for those addicts who accept and remain in methadone treatment, the first critical steps are being taken toward providing themselves with a degree of stability whereby improved social, psychological, and personal growth can take place. Thus it seems imperative that meth-adone treatment programs continue research into gaining a better understanding of the complex forces and interaction of forces that contribute to the heroin addict not accepting or dropping out of treatment. Only through such understanding can better alternatives be offered to a larger segment of the addict population.     

Patients' perspective on the process of change in substance abuse treatment

Understanding how methadone patients view treatment for their cocaine dependence and the process of recovery from cocaine addiction, is important in helping to design treatment strategies that will effectively motivate and engage these patients. There has been little development or testing of treatment approaches for cocaine-dependent, methadone-maintained patients and research on the effectiveness of outpatient cocaine treatment has excluded the perspectives of patients. This article presents the patient's view, using ethnographic interviews with 17 patients enrolled in a relapse prevention treatment program for cocaine dependence, that was set up in an inner-city methadone maintenance clinic. Findings suggest that despite initial ambivalence or resistance, patients became highly engaged by the positively reinforcing treatment intervention. In addition, patients found the highly structured nature of the program and the cognitive behavioral techniques critical in reducing their cocaine use. Finally, patients responded positively to the psychodynamic issues addressed within a cognitive behavioral format, and reported improvements in certain areas of psychological functioning.     

Staff and Client Attitudes toward Methadone Maintenance

Samples of two client groups, one electing to be treated with methadone maintenance and one electing to be treated on an abstinent basis, were compared with each other and with the staff of the multi-modality setting at which those clients were being treated in terms of their characterizations (1) of an addict on heroin, (2) of an addict who has given up all drugs, and (3) of an addict being maintained on methadone. The Adjective Check List was employed. Each group characterized the addict who has given up all drugs as functioning significantly more effectively than the addict being maintained on methadone, with the latter seen by all groups as functioning significantly more effectively than the addict using heroin. These results suggest that methadone maintenance is not yet fully accepted as a long-term treatment device by clients, even by those clients asking to be placed on methadone, or by the staff that administers such treatment. Several reasons are suggested to explain this phenomenon, and exploration is made of the various techniques administrators might employ to deal with it.     

美沙酮维持治疗社区综合干预的前瞻性研究——120例疗效分析

目的：观察美沙酮维持治疗疗效,探索社区综合戒毒康复干预模式。方法：选择二家美沙酮维持治疗（MMT）门诊病例120例开展纵向研究。采用MMT常规干预、社会心理干预（各种宣教培训、集体／个体心理辅导和咨询）及社会帮教监管等综合干预方法。于干预前,干预5月、10月后分别评估患者自愿就诊保持率、多项社会心理测试指标（FAD、SSRS、SAS、SDS）,并逐月检测尿液吗啡含量,观察综合干预效果。结果：干预后：①自愿就诊保持率提高（58．7％→79．2％,P〈0．001）。②社会家庭功能、焦虑情绪获得改善（P〈0．001,P〈0．001）;“社会支持”评分无统计学意义改善（P〉0．05）;但继发抑郁略加重（均分提高0．03）。③尿检阳性率逐月降低,即尿检阴性率明显提高（59．2％→81．9％,P〈0．001）。提示偷吸毒品现象得到有效控制。结论：社会心理综合干预对提高MMT门诊病人的治疗依从性和自愿就诊保持率,帮助病人适应和回归社会将起到积极和重要的作用;建议将综合性社会心理干预作为美沙酮维持治疗的一个重要基础性工作,在有条件的区、县开始施行,从管理要求、队伍建设、人员培训和工作机制等方面不断完善、健全。