Program Quality Effects on Patient Outcomes during Methadone Maintenance: A Study of 17 Clinics

This study was designed to replicate Ball and Ross's benchmark research, which was the first to identify a set of program quality factors for methadone maintenance programs and relate them to patient outcomes. Ball and Ross's treatment domain variables were measured in a new and larger sample of methadone clinics, and eight candidate program quality factors were derived. Both studies found that program factors defined by more frequent counseling contacts, higher director involvement with treatment. and more director experience were associated with lower drug use by patients during treatment. Several patient and counselor characteristics also were associated with drug-use outcomes.     

Drug abuse treatment retention and process effects on follow-up outcomes

After finding that retention in methadone treatment for a year or longer was a highly significant predictor of patient outcomes following discharge, measures of pretreatment motivation and early therapeutic engagement were examined as predictors of program retention. Personal interviews were conducted with a sample of 435 patients 12 months after discharge from three methadone treatment programs. Logistic regression results showed several patient attributes—i.e. over 35, lower injection frequency before admission, and higher motivation for treatment—were each associated with twofold increases in the likelihood of having favorable follow-up outcomes on illicit drug use, alcohol use, and criminal involvement. Patients staying in treatment a year or longer, however, were nearly five times more likely to have better outcomes. Further analyses established that length of treatment stay was predicted by higher patient motivation at intake and early program involvement. The findings suggest that more comprehensive models of patient attributes, therapeutic process, and environmental influences are needed, and that treatment enhancement efforts should focus on such during-treatment measures as interim criteria for improving posttreatment outcomes.     

Outcomes after methadone maintenance and methadone reduction treatments: two-year follow-up results from the National Treatment Outcome Research Study

This paper provides a detailed analysis of the 2-year outcomes for 351 drug misusers allocated on an intention-to-treat basis to methadone maintenance or methadone reduction treatments. Both groups showed substantial reductions in their use of illicit drugs and in other outcome areas. However, whereas most methadone maintenance patients received maintenance, only about one third of those allocated to methadone reduction received methadone reduction, and many actually received a form of methadone maintenance. Reduction patients were more likely to receive low doses of methadone, and were less likely to remain in treatment. For maintenance patients, higher doses and retention in treatment were both associated with improvements in illicit heroin use at 2 years. For the reduction patients, the more rapidly the methadone was reduced, the worse the heroin use outcomes. For patients in both treatment conditions, reductions in heroin use were associated with improvements in other outcome areas. The more severely dependent patients showed better outcomes in methadone maintenance. Methadone reduction treatment processes were associated with poor outcomes, and many patients who were allocated to methadone reduction treatment did not receive reduction treatment as intended. This calls into question the appropriateness of either the initial treatment planning process or the treatment delivery process, or both. A clearer distinction should be made between methadone maintenance and methadone reduction. Treatment goals should be made explicit both to the patient and to the clinical staff at the start of treatment. We suggest the need for a reappraisal of the goals and procedures of methadone reduction treatment.     

The impact of ongoing illicit drug use on methadone adherence in illicit drug users receiving treatment for HIV in a directly observed therapy program

INTRODUCTION: Studies evaluating the effectiveness of opioid agonist therapy programs typically evaluate drug abstinence or treatment retention as their primary outcomes. However, in many circumstances (e.g. directly observed therapy (DOT) programs within methadone maintenance programs), methadone adherence is an extremely relevant clinical outcome. We sought to evaluate the impact of ongoing illicit drug use on methadone adherence within a DOT program for the treatment of HIV-infection. METHODS: Patients were enrolled in a DOT program, where methadone and HIV medication are co-administered by a community pharmacist. Drug use (amphetamines, benzodiazepines, cocaine, and opiates) was assessed by repeated urinalysis results. Methadone adherence was calculated as the fraction of days methadone was administered. RESULTS: Ongoing drug use, and poly-substance use was common, with only 4 of 60 patients abstaining from all illicit drug use. Overall methadone adherence was 84.5%. Amphetamine use (without benzodiazepine and cocaine use), benzodiazepine use (without amphetamines) and higher methadone doses were associated with higher methadone adherence. When patients used benzodiazepines or cocaine, any positive effect associated with amphetamine use was negated. In addition, opiate use was associated with decreased methadone adherence. DISCUSSION: The effect of many illicit drugs on methadone adherence may differ from reports using other treatment outcomes.     

Program Factors and Treatment Outcomes in Drug Dependence Treatment: An Examination Using Meta-Analysis

In comparison with studies of client characteristics and treatment processes, limited research has been conducted on how program features of drug dependence treatment programs may affect client outcomes. Of particular interest are those characteristics of programs that may have a clinically significant impact on outcomes and that are amenable to change within programs. This study examines the impact of various program factors on client outcomes using data from a meta-analysis of drug dependence effectiveness studies (n = 143). Because of heterogeneity among studies, the data are analyzed in terms of type of outcome variable (drug use and crime), type of design (single-group and treatment-comparison group), and type of treatment (methadone maintenance, therapeutic communities, outpatient drug free, and detoxification). For the more valid treatment-comparison group studies, the weighted mean effect size was 0.29 for drug use outcomes and 0.17 for crime outcomes. Program factors found to be significantly correlated with effect size in one or more modalities were decade of treatment, researcher involvement in treatment delivery, maturity of the program, counselor/client ratio, treatment implementation, treatment exposure, and methadone dosage.     

Program factors and treatment outcomes in drug dependence treatment: an examination using meta-analysis

In comparison with studies of client characteristics and treatment processes, limited research has been conducted on how program features of drug dependence treatment programs may affect client outcomes. Of particular interest are those characteristics of programs that may have a clinically significant impact on outcomes and that are amenable to change within programs. This study examines the impact of various program factors on client outcomes using data from a meta-analysis of drug dependence effectiveness studies (n = 143). Because of heterogeneity among studies, the data are analyzed in terms of type of outcome variable (drug use and crime), type of design (single-group and treatment-comparison group), and type of treatment (methadone maintenance, therapeutic communities, outpatient drug free, and detoxification). For the more valid treatment-comparison group studies, the weighted mean effect size was 0.29 for drug use outcomes and 0.17 for crime outcomes. Program factors found to be significantly correlated with effect size in one or more modalities were decade of treatment, researcher involvement in treatment delivery, maturity of the program, counselor/client ratio, treatment implementation, treatment exposure, and methadone dosage.     

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.     

The Effects of Community Structure on During-Treatment Outcomes of Methadone Maintenance Programs

This study examines the effects of selected community factors on aggregated during-treatment outcomes of methadone maintenance programs in 27 cities. The basic premise of the study is that methadone maintenance (MM) program outcomes on such measures as drug use, criminality, and productive activities are significantly affected by factors in the community environment. The results indicate that community measures are associated with outcomes on drug use (opiate and nonopiate), productive activities, and criminality but not with alcohol use. Another finding is that global measures such as overall quality of life of a community are not clearly related to outcomes of MM programs. It is also found that property crime rates, which are frequently used as indicators of prevalence of drug use, are not related to during-treatment program outcomes of drug use and criminality.     

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.     

TREATING COCAINE-USING METHADONE PATIENTS: PREDICTORS OF OUTCOMES IN A PSYCHOSOCIAL CLINICAL TRIAL

Cocaine-using methadone patients in two clinics were assigned to 8 months of enhanced methadone treatment—primarily cognitive-behavioral therapy (CBT) for cocaine use—while similar patients in two “sibling” clinics were assigned to standard methadone treatment during 1995–1998. Cocaine use declined significantly from baseline to 4- and 12-month follow-ups. Patients receiving CBT rated the quality of their counseling relationship higher and obtained more supportive services than those receiving standard treatment. However, study treatment condition itself was not associated with outcome. Baseline measures associated with poorer outcomes across both treatment conditions were: currently enrolled in methadone treatment (in contrast to being newly enrolled), higher cocaine use frequency, greater cocaine use associated problem recognition, and an ambivalent attitude toward methadone. The results are consistent with some previous clinical trials showing that psychosocial treatments of different intensities result in similar declines in cocaine use. The findings indicate that methadone maintenance treatment can help dually-addicted patients reduce their cocaine use.     

Treating cocaine-using methadone patients: predictors of outcomes in a psychosocial clinical trial

Cocaine-using methadone patients in two clinics were assigned to 8 months of enhanced methadone treatment-primarily cognitive-behavioral therapy (CBT) for cocaine use-while similar patients in two "sibling" clinics were assigned to standard methadone treatment during 1995-1998. Cocaine use declined significantly from baseline to 4- and 12-month follow-ups. Patients receiving CBT rated the quality of their counseling relationship higher and obtained more supportive services than those receiving standard treatment. However, study treatment condition itself was not associated with outcome. Baseline measures associated with poorer outcomes across both treatment conditions were: currently enrolled in methadone treatment (in contrast to being newly enrolled), higher cocaine use frequency, greater cocaine use associated problem recognition, and an ambivalent attitude toward methadone. The results are consistent with some previous clinical trials showing that psychosocial treatments of different intensities result in similar declines in cocaine use. The findings indicate that methadone maintenance treatment can help dually-addicted patients reduce their cocaine use.     

Effect of Methadone Dose on Maintenance Treatment and Health Consequences Among Heroin Addicts in South China

A retrospective cross-sectional study was conducted with a convenience sample of 197 adults receiving methadone maintenance treatment in Kunming city, South China, in 2010. The aim of the study was to determine the association of methadone maintenance dose on a variety of treatment outcomes. Treatment modalities, the adverse reactions to methadone treatment, the physical and mental outcomes of the treatment, and risk behavior changes were assessed. Multilevel negative and logistic binomial regression analyses were carried out, which demonstrated that methadone maintenance dose in this sample was not associated with improved treatment adherence or with quality of life. We concluded that dose had a small, if negligible, influence on the changes in adverse effects of methadone. Further research in dose differences between the genders should be conducted.     

QT interval screening in methadone maintenance treatment: report of a SAMHSA expert panel

In an effort to enhance patient safety in opioid treatment programs, the Substance Abuse and Mental Health Saervices Administration convened a multi-disciplinary Expert Panel on the Cardiac Effects of Methadone. Panel members (Appendix A) reviewed the literature, regulatory actions, professional guidances, and opioid treatment program experiences regarding adverse cardiac events associated with methadone. The Panel concluded that, to the extent possible, every opioid treatment program should have a universal Cardiac Risk Management Plan (incorporating clinical assessment, electrocardiogram assessment, risk stratification, and prevention of drug interactions) for all patients and should strongly consider patient-specific risk minimization strategies (such as careful patient monitoring, obtaining electrocardiograms as indicated by a particular patient's risk profile, and adjusting the methadone dose as needed) for patients with identified risk factors for adverse cardiac events. The Panel also suggested specific modifications to informed consent documents, patient education, staff education, and methadone protocols.     

Patient and program factors in obtaining supportive services in DATOS

This study examined patient and program factors that influenced the receipt of scheduled supportive services in the Drug Abuse Treatment Outcome Studies (DATOS). Patients (N = 2,932) in 21 long-term residential (LTR) programs, 27 outpatient methadone treatment (OMT), and 25 outpatient drug-free programs were interviewed at admission and at 3 months during treatment. A hierarchical regression analysis was used to examine the relationship between patient-level and program-level factors associated with receiving supportive services in seven categories (medical, psychological, family, legal, educational, vocational, and financial). LTR patients received more services on average than outpatients (especially OMT), but patients overall received few services in the first 3 months of treatment. The patient-level likelihood of receiving services was related to being female and to having higher problem severity at intake. At the program level, outpatient clientele with higher problem severity received more services if they entered a program whose other enrolled patients were less troubled on average.     

QT prolongation and torsades de pointes among methadone users: reports to the FDA spontaneous reporting system

BACKGROUND: Recent case series have associated the synthetic opioid, methadone, with QT prolongation and torsades de pointes (TdP) ventricular arrhythmia. STUDY OBJECTIVE: To review and analyze adverse events (QT prolongation and TdP) reported to the Food and Drug Administration (FDA) to determine the patient characteristics, dosages of methadone, and outcomes of methadone-treated patients. METHODS: The study design was a retrieval and retrospective analysis of reports of adverse events associated with methadone voluntarily reported to the FDA MedWatch program from 1969 to October 2002. Reports were accessed via QSCAN (DrugLogic, Reston, VA), a commercially available software interface. RESULTS: In a total of 5,503 reports of adverse events associated with methadone, 43 (0.78%) noted the occurrence of TdP and 16 (0.29%) QT prolongation. Doses were reported in 42/59 (71%) of cases; mean dose was 410 +/- 349 mg/day (median 345, range 29-1680). The dosages for 10 of the 42 cases (29%) were within the recommended range for methadone maintenance treatment, 60-100 mg/day. Female gender, interacting medications, hypokalemia, hypomagnesemia, and structural heart disease, risk factors previously identified with other drugs known to cause TdP, were found in 44 (75%) cases. Most adverse events required hospitalization or resulted in prolonged hospitalization (28/59, 47%) and 5/59 (8%) were fatal. CONCLUSIONS: Cases of TdP associated with methadone have been reported to the FDA MedWatch system. Analysis of the cases provides evidence that prolonged QT and TdP can occur over a wide range of dosages including those usually recommended for addiction treatment.     

Patterns in admission delays to outpatient methadone treatment in the United States

Waiting lists for methadone treatment have existed in many U.S. communities, but little is known nationally about what patient and service system factors are related to admission delays that stem from program capacity shortfalls. Using a combination of national data sources, this study examined patterns in capacity-related admission delays to outpatient methadone treatment in 40 U.S. metropolitan areas (N = 28,920). Patient characteristics associated with admission delays included racial/ethnic minority status, lower education, criminal justice referral, prior treatment experience, secondary cocaine or alcohol use, and co-occurring psychiatric problems. Injection drug users experienced fewer delays, as did self-pay patients and referrals from health care and addiction treatment providers. Higher community-level utilization of methadone treatment was associated with delay, whereas delays were less common in communities with higher utilization of alternative modalities. These findings highlight potential disparities in timely admission to outpatient methadone treatment. Implications for improving treatment access and service system monitoring are discussed.     

A 5-year evaluation of a methadone medical maintenance program

Methadone medical maintenance (MMM) is a model for the treatment of opioid dependence in which a monthly supply of methadone is distributed in an office setting, in contrast to more highly regulated settings where daily observed dosing is the norm. We assessed patient characteristics and treatment outcomes of an MMM program initiated in the Bronx, New York, in 1999 by conducting a retrospective chart review. Participant characteristics were compared with those of patients enrolled in affiliated conventional methadone maintenance treatment programs. Patients had diverse ethnicities, occupations, educational backgrounds, and income levels. Urine toxicology testing detected illicit opiate and cocaine use in 0.8% and 0.4% of aggregate samples, respectively. The retention rate was 98%, which compares favorably with the four other MMM programs that have been reported in the medical literature. This study demonstrates that selected patients from a socioeconomically disadvantaged population remained clinically stable and engaged in treatment in a far less intensive setting than traditional methadone maintenance.     

Determinants of methadone treatment assignment among heroin addicts on first admission to public treatment centres in Italy

AIMS: To identify factors associated with entering any methadone treatment at first admission at an NHS treatment centre in Italy and to investigate determinants of receiving detoxification or maintenance methadone treatments. METHODS: Data were analysed from 565 heroin addicts who entered for the first time one of 90 NHS treatment centres in 12 Italian regions between September 1998 and March 2001. Subjects were interviewed at admission by the centre's staff and followed-up for 18 months. Details on treatments provided were recorded using a standardised form. Random effects logistic regression analysis was applied. RESULTS: Factors positively associated with any methadone treatment assignment were: being younger than 25 years and using heroin more than twice a day, having been recently incarcerated, and living with a partner. Independent predictors of admission to methadone maintenance were injecting heroin, having sex without a condom in the previous six months, being HIV positive and having been enrolled at a NHS TC where a psychiatrist was present. Using heroin once a day or more and using cocaine were factors associated with enrollment into detoxification treatment. A significant heterogeneity between centres was observed. CONCLUSIONS: Results from this study give an insight into different patient profiles who are enrolled in methadone treatments. The observed heterogeneity between centres indicates the need to develop and implement common guidelines for the access of heroin addicts to substitution treatment.