Sociality in Methadone Treatment: understanding methadone treatment and service delivery as a social process

The overwhelming focus of research into methadone treatment has been on outcome, concentrating on the importance of issues such as dose and treatment retention. The delivery of counselling and support services has also been identified by such studies but research has yet to focus systematically on how such services are delivered and negotiated within the context of ongoing staff-client relationships. Using mainly client data we focus on the processes influencing the delivery of counselling and support services in methadone treatment, we report on findings from a 2-year ethnographic study of methadone treatment delivery in London. A key finding is that the 'sociality' of treatment is embedded within the negotiation and building of social roles and relationships more generally. These findings underscore the necessity to understand the delivery of methadone treatment services, and especially counselling and support, as a social interactional process and not merely as a medical encounter with a treatment outcome. Such a focus allows us to conclude by highlighting the practical implications of understanding 'sociality' in methadone treatment for both practice and for research.     

Sociality in Methadone Treatment: understanding methadone treatment and service delivery as a social process

The overwhelming focus of research into methadone treatment has been on outcome, concentrating on the importance of issues such as dose and treatment retention. The delivery of counselling and support services has also been identified by such studies but research has yet to focus systematically on how such services are delivered and negotiated within the context of ongoing staff-client relationships. Using mainly client data we focus on the processes influencing the delivery of counselling and support services in methadone treatment, we report on findings from a 2-year ethnographic study of methadone treatment delivery in London. A key finding is that the 'sociality' of treatment is embedded within the negotiation and building of social roles and relationships more generally. These findings underscore the necessity to understand the delivery of methadone treatment services, and especially counselling and support, as a social interactional process and not merely as a medical encounter with a treatment outcome. Such a focus allows us to conclude by highlighting the practical implications of understanding 'sociality' in methadone treatment for both practice and for research.     

The cost of methadone maintenance programs: a comparison between public hospital clinics and private practitioner programs in New South Wales

The purpose of this study is to establish the financial outlays for state and federal governments in providing methadone treatment services through public clinics and private medical practitioners authorised to prescribe methadone. This study did not assess the quality of care provided by public and private methadone programs. Three public clinics and twenty two private practitioner programs were studied. The mean cost of methadone treatment per client per month in the public clinics was $113.00, with a range of $61 to $239. This range illustrates significant variations in the costs of public methadone clinics and can be partly explained by differences in staff: client ratios and the type and frequency of clinical support services, for example, counselling provided in addition to methadone dispensing. The cost to treat one client in the most expensive public methadone clinic is more than the cost to Medicare for the treatment of one client within a private practitioner methadone program ($178 per client per month). However, the mean cost of the public clinics is considerably lower than private practitioner programs because of the high cost of urinalysis by private pathology laboratories. The mean cost for clinical management is similar for the two systems. At the level of service operating within public and private programs, the mean cost of methadone treatment would be approximately the same if private practitioners used the NSW government laboratory as their urine testing facility.     

Injection drug users' experience with and attitudes toward methadone clinics in Denver, CO

Clients' perceptions and attitudes toward methadone treatment programs are frequently overlooked in substance abuse research. Given the importance of methadone maintenance as a harm-reduction strategy and clients' concerns about treatment, it is essential to understand perceptions and attitudes toward existing programs. Using data from the 2009 National HIV Behavioral Surveillance system with injection drug users in Denver, CO, we evaluated participants' experiences with methadone clinics and examined predictive factors associated with ever being a client of a methadone clinic. Costs of services, perceptions of staff not caring about the client, and attitudes toward the counseling services seemed to be the major barriers to program retention. Besides heroin use, previous attempt at self-detoxification and being infected with hepatitis C were the strongest predictors of ever being on methadone treatment. Addressing the barriers to program retention and encouraging treatment engagement are essential to embracing methadone maintenance as a harm-reduction strategy for injection drug users.     

“It Takes Your Heart”: The Image of Methadone Maintenance in the Addict World and Its Effect on Recruitment into Treatment

Using data gathered on 368 current methadone clients and 142 narcotics users not in treatment in structured interviews and through ethnographic fieldwork, the study examines the image of methadone maintenance treatment in the drug-using community and discusses the effect of that image on recruitment of addicts into methadone treatment. The results indicate that the image of the methadone client as a “loser,” fear of the long-term effects of methadone, and the perception of treatment as an intrusion in the user's daily life make addicts often difficult to recruit and, once in treatment, ambivalent about their participation. The image of methadone is based on both misinformation about treatment and the user's contrasting of a treatment status with the stereotypic ideal of the “righteous dope fiend.” Policy implications and suggestions derived from the data are discussed.     

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。     

Programmatic,Counselor, and Client-Level Comparison of Rural Versus Urban Drug Court1 Treatment

Despite a number of recent evaluations demonstrating the effectiveness of “drug court” programs for reducing both substance abuse and criminal behavior, some authors have recently called for more thorough process evaluations (inside the “black box” of treatment) of these programs. Specifically, this article describes the need for thorough process evaluation to examine differences in program implementation across rural and urban drug courts. The delivery of substance-user treatment and allied social services is examined in a sample of four adult drug courts (two urban and two rural), using a direct observation methodology, as well as traditional surveys and interviews of treatment staff and administrators. Results reveal that there are, in fact, differences in implementation, and staff and client characteristics between courts in each type of geographic region and suggest that these differences may impact the effectiveness of the court programs in meeting their goals of reduced substance use and criminal behavior.     

Staff perspectives on methadone maintenance therapy (MMT) in a large southwestern jail

The purpose of the study was to develop and test an instrument to measure knowledge about methadone maintenance treatment, attitudes towards drug addiction, readiness to adopt a methadone maintenance program, and to determine how the staff at a large metropolitan detention center score on these domains. We developed a 45-item “Knowledge, Attitudes, and Readiness to Adopt” survey and administered it to 114 jail staff. The anonymous survey was psychometrically sound. Younger and non-medical staff generally had low knowledge scores on the survey and had negative attitudes towards methadone as a treatment for heroin addiction. Written comments indicated that many staff members have strong and often polarized opinions about drug treatment in a correctional setting. Results of this study suggest several steps towards improving the staff support for methadone maintenance therapy, which includes better education regarding opiate replacement therapy as an effective treatment for heroin addiction.     

Treatment process components and heroin use outcome among methadone patients

The study proposes and tests an integrative and directional (structural equations) model to explain how pre-treatment motivation, frequency and content of counselling services, programme perceptions, and methadone dose are related to 1 and 6 months heroin use outcomes among opiate addicts receiving outpatient methadone treatment. Data were collected as part of the National Treatment Outcome Research Study (NTORS). The sample comprised 262 patients who were admitted to, and retained in methadone treatment programmes at 6 months. Structural equation models showed several relationships between treatment process variables and heroin use outcomes at 1 and 6 months follow-up. Programme perceptions and methadone dose were related to reduced heroin use at 1 month; early engagement with treatment services was related to reduced heroin use at 6 months. Pre-treatment motivation and engagement with treatment services were indirectly related to reduced heroin use at 1 month through their association with programme perceptions. Short-term (1 month) heroin use was strongly related to heroin outcome at 6 months. In addition to direct effects, treatment factors may have important indirect effects upon subsequent outcomes through their influence upon short-term outcomes.     

Moving toward Trauma-Informed Practice in Addiction Treatment: A Collaborative Model of Agency Assessment

Abstract

Clients in substance abuse treatment need, in addition to evidence-based and sensitive treatment services in general, a system of care that takes into account the impact of trauma and violence in so many of their lives. In addition, services need to be delivered in a way that avoids triggering trauma memories or causing unintentional re-traumatization. To that end, this article describes an agency self-assessment process that combines a trauma-informed assessment, a NIATx process of “walking-through” and use of the Institute of Healthcare Improvement's Plan-Do-Study-Act (PDSA) cycles, and a user-friendly format. The trauma-informed assessment is designed to address issues of safety of clients and staff members, reduction of re-traumatization, consistency in practice, and client empowerment. It brings a non-judgmental, collaborative approach to process and practice improvement. The article describes how the assessment process can be—and has been—used to develop an Action Plan, including trainings and the identification of “trauma champions”; i.e., staff who will continue to spread trauma-informed changes and new evidence-based practices throughout the agency. As we enter a period of healthcare reform, addressing trauma as an integral part of addiction treatment also allows us to better deal with the totality of our clients’ health problems.     

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.     

Organizational Correlates of Access to Primary Care and Mental Health Services in Drug Abuse Treatment Units

Primary care and mental health services improve drug abuse treatment clients’ health and treatment outcomes. To examine the association between clients’ access to these services and the characteristics of drug treatment organizations, we analyze data from a national survey of the unit directors and clinical supervisors of 618 outpatient drug abuse treatment programs in 1995 (88% response rate). In multivariate models controlling for client characteristics and urban location, public units, units with more human resources, and methadone programs delivered more primary care services. Public units, Joint Commission on Accreditation of Health Care Organizations-accredited units, nonmethadone units, and units with more staff psychiatrists or psychologists delivered more mental health services. We conclude that organizational factors may influence drug abuse treatment clients’ access to primary care and mental health services. Changes in the treatment system that weaken or eliminate public programs, overburden staff, de-emphasize quality standards or lessen methadone availability may erode recovering clients’ tenuous access to these services.     

Interaction of Counseling Rapport and Topics Discussed in Sessions with Methadone Treatment Clients

Therapeutic rapport between counselors and clients in drug user treatment has been shown to be an important predictor of follow-up outcomes. This naturalistic study investigated the relationship of counseling rapport to drug-related topics discussed in counseling sessions in a sample of 330 clients and nine counselors. These voluntary clients had been admitted to a private, for-profit outpatient methadone treatment in Texas between September 1995 and August 1997 and received no-fee services for a year for participation in this study. The data were gathered using forms in the TCU community treatment assessments (www.ibr.tcu.edu) that measured intake information, counseling session topics, and counselor evaluation of the client. A majority were males, Hispanic, had a pending legal status and the average age was 39. Co-occurring drug dependence for these heroin users included cocaine (38%) and alcohol (31%). The results supported the hypothesis that higher rapport would be associated with addressing clients in a more “supportive approach” that emphasized relapse prevention and strengths-building while lower rapport would be associated with a punitive counseling style that stressed program rules and compliance. The influences of client background, counselor differences, and during-treatment positive urines were also examined. Although counselors differed in their general manner of dealing with clients, each also showed flexibility determined in part by client behavior (such as continued cocaine use). The findings indicate that focusing on constructive solutions is the preferred counseling approach.     

Analysis of the information and support needs generated by a community pharmacy‐based methadone treatment programme

Background — Methadone treatment has been provided in Ireland since 1998 under the methadone protocol scheme. Two liaison pharmacists were employed by the Eastern Health Board to interface between pharmacists dispensing methadone in primary and tertiary care. Objective — To analyse and review the inquiries received and addressed by one liaison pharmacist in the first year of operation of a community pharmacy‐based methadone treatment scheme. Method — Inquiries received were recorded by the pharmacist using a standard data collection form. Using content analysis, key themes were identified and each inquiry was classified. Data were analysed using standard computer software. Key findings — Two primary categories of liaison inquiry were addressed: “patient‐related” inquiries, requiring the organisation of community pharmacy‐based methadone dispensing services for patients, and “pharmacy‐related” inquiries, which were requests from community pharmacists for information or support. Two thirds of the inquiries were “patient‐related.” The primary users of the liaison service were prescribers employed by the addiction services and community pharmacists. Conclusion — The liaison pharmacy service handled diverse inquiries, with an emphasis on the facilitation of the provision of pharmaceutical care for patients requiring community pharmacy‐based methadone dispensing services. The liaison service had a significant secondary role in the provision of support and information for community pharmacists. The study findings are of relevance to those involved in developing and introducing primary care‐based services for drug misusers.     

EMCDDA INSIGHTS 11, New heroin-assisted drug treatment – Recent evidence and current practices of supervised injectable heroin treatment in Europe and beyond,John Strang,Teodora Groshkova and Nicola Metrebian

Abstract

Aims: Node-link mapping (NLM) has been strongly advocated as a cognitive tool that aims to enhance the treatment process and is supported by a large evidence-base. In one local authority area in England, NLM was systematically introduced and embedded into staff daily practice across five main services including non-statutory, NHS and young people’s services. The study aimed to assess training and adoption of NLM prior to implementation into daily practice. Methods/Results: In total, 123 staff members were trained in NLM concepts across a number of workshops. Staff responses were recorded in a Workshop Evaluation Survey that suggested a high degree of satisfaction with the training provided although “time” was identified as a pre-requisite to prepare for implementation. A random sample of staff (n?=?44) were followed-up at 6 months and were asked to complete a Workshop Assessment Follow-up schedule alongside participation in focus group interviews. Despite a commitment to NLM, there were mixed perceptions into the efficacy of node-link mapping. Staff concerns focused on lack of perceived ownership of the implementation process and a lack of confidence in using mapping on a regular basis. Managers also reflected reservations with “traditional” training methods and how to incorporate new practices into supervision processes. Implications for the dissemination of evidence-base practices are discussed.     

An Australian survey of the procedures used for the treatment of opiate users

Drug and alcohol agencies across Australia were asked to describe the services they offer to opiate users. Of the 284 agencies identified as providing treatment, 229 (81%) responded. A standard assessment procedure was used in 72% of agencies. Eighty (35%) agencies offered detoxification and had assisted 7883 clients with detoxification in the 12 months prior to March 1990. Methadone maintenance was offered in 20% of agencies with 5234 clients currently receiving this treatment. Daily doses of methadone in the range of 40-80 mg were described for most (51%) clients receiving methadone and concurrent counselling was provided in 45% of cases. Standard psychosocial interventions were provided by 60% of agencies. Out-patient or non-residential settings were most common (36%), with residential therapeutic communities being the setting for 21% of programmes. Supportive counselling was the most commonly used individual approach, and cognitive-behavioural or 12-step approaches were the most commonly used group approaches. Brief support or referral to Nar-Anon were the most popular family interventions. Procedures aimed at reducing the risk of HIV were in place at 85% of agencies. These findings are discussed in light of research evidence. Briefly, there is a diversity of treatment options available from different treatment agencies which is not reflected within the agencies, little aftercare is offered despite high rates of relapse, and doses of methadone are lower than has been found to be optimal.     

Programme factors that influence completion of residential treatment

The aim of this study was to predict retention in residential rehabilitation (RR) services for drug users, focusing on service provider factors. A national postal survey of RR services in England and Wales was carried out and information was obtained from 57 of 87 services identified (65.5%). Service managers were asked to complete a questionnaire asking about treatment philosophy, treatments provided, staff characteristics and staffing levels, as well as overall service size and funding. Services also provided information on the number of clients admitted and the number who had completed, dropped out and been asked to leave in the past year. Completion rates varied widely, from 3% to 92%, with an average of 48%. Higher completion rates were associated with lower counsellor caseloads, fewer beds, single rooms, shorter scheduled treatment durations, higher fees per client and provision of what could be termed a balanced treatment programme containing adequate amounts of individual counselling and programme-free time, and with only moderate demands for domestic duties. Programmes with more drug than alcohol users had lower completion rates, but the proportion of dual diagnosis or criminal justice referred clients did not appear to affect retention. Completion rates varied as a function of a number of service factors that are amenable to manipulation. To retain clients successfully, programmes should not be too large and should have adequate levels of therapeutic staff, a well-developed treatment schedule which is not too demanding for the client in terms of duties or overall time spent in structured activities, and which incorporates sufficient levels of individual counselling. [Meier PS, Best D. Programme factors that influence completion of residential treatment. Drug Alcohol Rev2006;25:349 - 355]     

Development of a Brief Treatment Instrument for Routine Clinical Use with Methadone Maintenance Treatment Clients: The Methadone Treatment Index

Routine measurement of treatment outcome between clinician and client in alcohol and drug user treatment services is an important quality improvement initiative. It is particularly important for clients receiving long-term treatment such as methadone maintenance treatment, as fluctuations in substance use, functioning, and health are to be expected. Although there are a number of standardized alcohol and drug user treatment outcome instruments available for research and clinical use, a key challenge is to develop clinical instruments that will actually be used routinely in busy practice settings by a range of staff. Such instruments need to be brief, acceptable to staff and clients, easy to use, provide immediate feedback, and meet adequate psychometric requirements. This report describes development work undertaken in three studies of the Methadone Treatment Index (MTI). The MTI is a brief instrument comprising measures of recent substance use, aspects of social and behavioral functioning, and physical and psychological health. The MTI was designed in consultation with clinicians and clients for use in monitoring treatment progress with clients receiving methadone maintenance treatment. Key findings were that the MTI was acceptable to clients, produced clinically relevant information, and has satisfactory psychometric properties, although it was not used to measure change in this study. Further evaluation of the MTI on a longitudinal basis is supported.     

Two Models of Integrating Buprenorphine Treatment and Medical Staff within Formerly “Drug-Free” Outpatient Programs

“Drug-free” outpatient programs deliver treatment to the largest number of patients of all treatment modalities in the U.S., providing a significant opportunity to expand access to medication treatments for substance use disorders. This analysis examined staff perceptions of organizational dynamics associated with the delivery of buprenorphine maintenance within three formerly “drug-free” outpatient treatment programs. Semi-structured interviews (N = 15) were conducted with counseling and medical staff, and respondents were predominantly African American (n = 11) and female (n = 12). Themes and concepts related to medical staff integration emerged through an inductive and iterative coding process using Atlas.ti qualitative analysis software. Two treatment clinics incorporated buprenorphine maintenance into their programs using a co-located model of care. Their staff generally reported greater intra-organizational discord regarding the best ways to combine medication and counseling compared to the clinic using an integrated model of care. Co-located program staff reported less communication between medical and clinical staff, which contributed to some uncertainty about proper dosing and concerns about the potential for medication diversion. Clinics that shift from “drug-free” to incorporating buprenorphine maintenance should consider which model of care they wish to adapt and how to train staff and structure staff communication.     

Contemporary Psychotherapy Research: Implications for Substance Misuse Treatment and Research

This article provides an overview of the major findings of psychotherapy research and discusses the possible implications of these findings for substance user treatment researchers and practitioners. While the centrality of relationship for human change processes was historically understood, twentieth century research tended to see relationship and person variables as secondary to operationalized “mechanisms of action” unique to particular psychotherapies. Interestingly, recent meta-analytic investigations have uncovered the weakness of randomized controlled trials (RCT) comparison investigations that have, until recently, represented the “gold standard” for the field. There has been a resurgent interest in the “common factors” that appear to be important across many effective psychotherapies. In addition, psychiatric anthropologists have contributed important information about the problems of client noncompliance with mental health treatment that parallel quantitative investigations. Substance misuse researchers have also found that client characteristics, especially clients' readiness to engage treatment, are important to investigate. The importance of the “therapeutic alliance” and the characteristics of clients and clinicians have become central areas for study, rather than variables to be controlled or excluded. Emphasis on these factors may represent the future for research in psychotherapy and substance user treatment, especially if researchers and community practitioners can join together to overcome methodological feasibility and dissemination problems that plague effectiveness research. However, the continued attractiveness of comparative studies and treatment efficacy studies may represent longstanding epistemological assumptions and responses to economic incentives that will be difficult to challenge.