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.     

Assessing Client Satisfaction with Treatment for Substance Use Problems and the Development of the Treatment Perceptions Questionnaire (TPQ)

This report describes the development of a brief 10-item scale to measure client satisfaction with treatment for substance use problems. The Treatment Perceptions Questionnaire (TPQ) was developed from two independent studies. The first field study recruited 123 subjects from inpatient and community treatment programmes. Each respondent completed an interviewer-administered questionnaire comprising the TPQ and other measures of personal/social functioning and treatment processes and perceptions. A sub-sample (n = 38) participated in a three-day re-test administration of the instrument with two interviewers. In a second study of outcomes from oral and injectable methadone maintenance treatment, the TPQ was administered to a further 33 patients as part of a six-month outcome evaluation. Results from these studies show that the instrument has good construct and discriminant validity, good internal reliability and acceptable test-retest reliability. The TPQ can be used in research studies of treatment process and outcome and routine programme audit activities.     

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.     

Development and validation of a brief instrument for routine outcome monitoring in opioid maintenance pharmacotherapy services: the brief treatment outcome measure (BTOM)

AIM: To develop a brief, multi-dimensional instrument for routine, on-going treatment outcome monitoring in alcohol and other drug (AOD) services in Australia and examine the underlying psychometric properties. This study focuses on opioid maintenance pharmacotherapy (OMP) services. DESIGN: Researcher-administered test-retest interviews and clinician administered interviews. SETTING: The test-retest interviews took place in two private and two public OMP clinics in Sydney, Australia. The clinician-administered interviews took place in 37 metropolitan, rural and prison OMP services in New South Wales, Australia. PARTICIPANTS: One hundred and sixty current OMP clients for the test-retest interviews and 2004 clients commencing OMP treatment for the clinician-administered interviews. MEASURES: Thirty-two items across the domains of dependence, blood-borne virus exposure risk, drug use, health/psychological functioning and social functioning. FINDINGS: The internal reliability of the brief treatment outcome measure (BTOM) is satisfactory. Retest reliabilities for the scales and drug use scores are good to excellent indicating their consistency with multiple measurements across time and different interviewers and concurrent validation of BTOM scales with analogous scales from similar instruments yielded acceptable agreement. Average completion times of the BTOM were 14.5 min, when administered in a research context and 21 min in a clinical context. CONCLUSIONS: A brief, valid and reliable questionnaire has been developed for monitoring treatment outcome over the range of OMP services. The BTOM contains a core set of outcome measures, which can be easily adapted for integration into routine clinical practice across the range of AOD services.     

Cost-Utility Analysis of Methadone Maintenance Treatment: A Methodological Approach

Economic considerations influence the substance user treatment system. These considerations influence who gets treatment and for how long, as well as determining what services they receive and in what setting. Current medical literature argues that maintenance treatment reduces risk-taking behavior, such as injection drug use and needle sharing. Treatment also reduces the mortality associated with abuse of opiates by injection and can cause decreases in costs incurred by the criminal justice system and social services agencies. This suggests the need for complex economic evaluations of a maintenance treatment to find out the optimum treatment program. This paper describes methods of economic evaluation in healthcare and reviews the methodology of cost–utility analysis in economic evaluations of methadone maintenance treatment.     

Health status of clients receiving methadone maintenance treatment using the SF-36 health survey questionnaire

This study investigated the health status of a representative sample of clients (35 Maori, 72 non-Maori) receiving methadone maintenance treatment in New Zealand, using the SF-36 health survey. The publication of New Zealand norms in 1999 enabled comparisons of the health of the Methadone Treatment Programme study participants with that of the New Zealand population. Although over 50% of participants rated their health as good, very good or excellent, 44% rated their health as fair or poor and compared with population norms, the health of the study participants was significantly poorer on all eight SF-36 scales. Male and female participants rated their health similarly to male and female clients attending another New Zealand Methadone Treatment Programme. Results highlighted the impact of a chronic disorder and co-existing health-related problems on the health and well-being and day-to-day functioning of this client group. Higher frequency of benzodiazepine use was associated with poorer social functioning, mental health and role functioning and higher frequency of cannabis use was associated with poorer role functioning due to emotional problems. Findings support routine monitoring of health status with clients receiving methadone maintenance treatment as a guide to preventative and treatment interventions and health maintenance strategies. [Deering DE, Frampton CMA, Horn J, Sellman JD, Adamson SJ, Potiki TL. Health status of clients receiving methadone maintenance treatment using the SF-36 health survey questionnaire. Drug Alcohol Rev 2004;23:273-280]     

Patterns of improvement after methadone treatment: 1 year follow-up results from the National Treatment Outcome Research Study

One year outcomes for substance use behaviours, health and criminal behaviour, and variation in treatment response, are reported for patients recruited to methadone maintenance and methadone reduction treatment programmes as part of NTORS. Significant reductions in the use of all illicit target drugs were found at follow-up for patients recruited to the methadone maintenance and methadone reduction modalities. Because of similarities in the treatments received by clients in the two modalities we caution against interpreting these findings as showing that methadone maintenance and reduction treatments lead to similar outcomes. At this stage, it is suggested that these outcomes be regarded as reflective of exposure to some general methadone substitution treatment. Further investigation of the outcomes for the two modalities will be conducted. Cluster analyses were used to classify patients according to level of improvement in drug use. Four groups were identified. Two groups (59% of cases) showed substantial reductions in their illicit drug use and criminality as well as reduced physical and psychological symptoms. Twenty two percent of cases showed poor outcomes across a range of measures. Results for alcohol consumption were less satisfactory for patients in all groups. A majority of patients achieved widespread improvements across a range of outcome measures after treatment in existing methadone treatment services. These changes represent important clinical benefits to the individual clients, to their families and to society.     

Supervised Methadone Consumption: Client Issues and Stigma

Supervised methadone consumption is an important part of methadone maintenance treatment (MMT) but may contribute to stigma for clients. Data from qualitative interviews with MMT clients (n = 64) conducted in 2002–2003 in Canada were analyzed using thematic analytic methods. Three themes dominated clients' accounts of supervised consumption (convenient access to services, relationships with pharmacists and dispensing staff, and attributes of the dispensing space) and were interwoven with experiences of stigmatization. While some dispensing contexts may help clients manage a stigmatized identity, others confer or make visible this identity. Reducing stigmatizing experiences within dispensing environments may improve MMT outcomes and decrease barriers to treatment. The study's limitations are noted.     

Characteristics of clients receiving treatment in Australian drug and alcohol agencies: a national census

The first Australian national census of clients of drug and alcohol treatment agencies was undertaken to document the characteristics of clients attending these facilities. Of the agencies surveyed nationwide, 431 (85.2%) completed and returned census forms describing demographic and drug use details of their clients. A total of 6175 clients were reported to have received services (beyond methadone maintenance alone) in the responding agencies on the census day. Ninety percent of the clients seen were substance users, and 10% of clients were relatives or friends of a substance user. The mean age of the clients was 34 years and two-thirds were male. The majority were Australian born, with 10% described as Aborigines or Torres Strait Islanders. The majority of the clients were not in paid employment. Fifty-five percent of all clients received treatments services on a non-residential basis. The most frequent presenting drug problem reported was alcohol, followed by opiates and tobacco. Thirty-three percent of the substance users were reported to have injected illicit drugs in the past 12 months.     

Association Among Outcomes in a Naturalistic Statewide Assessment of Substance User Treatment

Substance user treatment outcome measurement is important for research and policy questions, yet little literature has addressed the relationships among outcome measures of treatment success. Ideally, treatment outcomes would correlate to at least a moderate degree. The Iowa Department of Public health requires substance user treatment programs receiving public funds to provide client information. Demographic information, “substance abuse” history, current use, arrests, and hospitalizations were ascertained at admission and a 6-month follow-up for 1374 clients (from January 1999 to December 2000). Abstinence, arrests, and hospitalizations were good outcome measures of substance user treatment success. Reduction in frequency of use was negatively associated with arrests, substance use-related hospitalizations, and increased income. Full-time employment at follow-up produced different results depending on the client's sex. However, all associations among outcomes were modest. Specificity may be reasonable in some instances; however, other situations might require a broad-spectrum approach that ideally would produce a wide range of benefits.     

Methadone Maintenance Treatment for Youth: Experiences of Clients,Staff, and Parents

In order to better understand the components of effective treatment for the understudied population of opioid-dependent youth, separate focus groups were conducted in 2006 with clients, clinical staff, and clients' parents (total n = 22) at a novel methadone maintenance program for adolescents and young adults in suburban New York. Focus group sessions were audiotaped, transcribed, and analyzed for common themes. Clients, staff, and parents all reported that effective treatment for opioid addiction among young people is a long-term program, combines pharmacological and behavioral approaches, emphasizes a high degree of individual attention from staff, and incorporates clients' family members. The study's limitations were noted.     

Juggling Multiple Roles: Staff and Client Perceptions of Keyworker Roles and the Constraints on Delivering Counselling and Support Services in Methadone Treatment

Previous research on methadone treatment, including that investigating counselling and support services, has focused on the treatment outcome rather than process. This paper uses qualitative data highlighting the perceptions and experiences of clinic staff and clients to explore the processes involved in the delivery and receipt of counselling and support services. A typology of the perceived roles of keyworker staff is constructed and the different underlying tensions that constrain the deployment of some of these roles are discussed. For example, findings show that on an interactional level the extent to which staff can deploy the “counsellor” role is limited by client perceptions of them as the “gatekeeper” to methadone. Also, that issues beyond the interactional level, such as resource constraints, can mean that staff only have time to monitor client progress rather than deliver counselling and support roles. The implications for practice are then discussed.     

Opioid Addicts at Admission vs. Slow-Release Oral Morphine,Methadone, and Sublingual Buprenorphine Maintenance Treatment Participants

With use of a randomized study design, quality of life (QOL) and physical symptoms of opioid addicts at admission were compared with slow-release oral morphine, methadone, and sublingual buprenorphine maintenance program participants after 6 months of treatment. The study was conducted from February to July 2004 in the outpatient drug user treatment center at University Department of Psychiatry at Innsbruck, providing maintenance treatment programs and detoxification in Tyrol, Austria. One hundred twenty opioid users seeking treatment were compared with 120 opioid-dependent patients retained for 6 months on a slow-release oral morphine, methadone, or sublingual buprenorphine maintenance program. The German version (“Berlin Quality of Life Profile”) of the Lancashire Quality of Life Profile was used, and illicit opioid use was determined by urinalysis. Physical symptoms were measured by using the Opioid Withdrawal Scale. Urinalyses revealed a significantly lower consumption of cocaine and opioids in all three substitution groups than in patients at admission (p < 0.001 and p ≤ 0.004, respectively). Both the buprenorphine and the methadone maintenance group showed significantly more favorable values than opioid clients at admission for stomach cramps (p ≤ 0.002), muscular tension (p ≤ 0.027), general pain (p ≤ 0.001), feelings of coldness (p ≤ 0.000), heart pounding (p ≤ 0.008), runny eyes (p ≤ 0.047), and aggressions (p ≤ 0.009). Patients who received slow-release oral morphine treatment generally showed the least favorable QOL scores compared with patients at admission or sublingual buprenorphine and methadone clients. Patients in the sublingual buprenorphine or methadone program showed nearly the same QOL scores. The buprenorphine and the methadone maintenance group showed significantly more favorable values than opioid clients at admission regarding leisure time (p ≤ 0.019), finances (p ≤ 0.014), mental health (p ≤ 0.010), and overall satisfaction (p ≤ 0.010). Slow-release oral morphine is a well-established treatment for pain, but more research is required to evaluate it as a treatment for heroin dependence. The present data indicate that slow-release oral morphine could have some disadvantages compared with sublingual buprenorphine and methadone in QOL, physical symptoms, and additional consumption. The results further suggest that buprenorphine treatment is as effective as methadone in effects on quality of life and physical symptoms.     

Methadone dosage and retention: an examination of the 60 mg/day threshold

A National Institutes of Health (NIH) expert panel has mentioned a daily methadone dose of at least 60 mg as a best practice in methadone maintenance. The focus of this research is to estimate the percentage of outpatient methadone clients receiving this level of methadone and examine the association between treatment retention and level of methadone dosage as recommended by the NIH expert panel. A sample of 428 methadone clients discharged from methadone treatment facilities from the Alcohol and Drug Services Study (ADSS) was used, representing 109,973 methadone clients nationally. It was estimated that more than two-thirds of methadone clients nationally were receiving below 60 mg/day. While controlling for a number of client and organizational variables, a daily methadone dose of 60 mg/day or above was found to be associated with longer retention in treatment. Exploring factors affecting the utilization of the recommended daily methadone dose remains an important issue in effective delivery of methadone treatment.     

Intimate Partner Violence Among Individuals in Methadone Maintenance Treatment

ABSTRACT. Background: Intimate partner violence (IPV) is a highly prevalent and concerning problem among methadone maintenance populations, and previous studies have shown a relationship between a history of IPV and increased substance use and affective disturbances. Methods: The current study examined (1) the association between recent IPV victimization and alcohol and cocaine use and (2) the relationship between recent IPV victimization and depression in a sample of smokers (N = 203) in methadone maintenance treatment (MMT). Participants in this study completed a battery of assessments that included standard questionnaires of trauma, alcohol and substance use, and depression. Parallel logistic and linear regression models were used to estimate the adjusted association of IPV victimization and depressive symptoms and evaluate the adjusted association of victimization with recent substance use. Results: Participants recently victimized by partners were shown to have significantly higher mean Center for Epidemiologic Studies Depression Scale (CES-D) scores (b = 0.54, 95% confidence interval [CI]: [0.07; 1.02], P <.05) and were found to have a 6 times greater likelihood of cocaine use (odds ratio [OR] = 6.65, 95% CI: [1.61; 27.46], P <.01) after controlling for age, gender, education, opiate use, and ethnicity. Conclusions: These findings support the notion that IPV victimization can potentially increase depression and other substance use among MMT patients, which can have a deleterious impact on treatment.     

DRUG AND ALCOHOL OFFENDERS COERCED INTO TREATMENT: A REVIEW OF MODALITIES AND SUGGESTIONS FOR RESEARCH ON SOCIAL MODEL PROGRAMS

Outcome studies on drug and alcohol offenders coerced into treatment by the criminal justice system were reviewed. Positive outcomes were found for therapeutic community, methadone maintenance, and unspecified residential and outpatient programs. No outcome studies were found for court-mandated clients coerced into social model recovery programs. When developing studies, researchers should consider how clients perceive legal mandates and whether they are receiving pressures to enter treatment from other sources, such as family members, employers, friends or the welfare system. Use of the Social Model Philosophy Scale (SMPS) is suggested to correlate program characteristics and processes with outcome.     

Adapting problem-solving therapy for depressed older adults in methadone maintenance treatment

Late-life depression is prevalent in older adults who are dependent on opiates. Depressive disorders among opiate abusers have detrimental effects on their well-being and ability to refrain from illegal drugs. There are numerous barriers to the provision of appropriate mental health care to older adults receiving methadone maintenance treatment. This article focuses on problem-solving therapy (PST) and presents evidence that PST may be a promising nonpharmacological treatment for older methadone clients with comorbid depressive disorders that can be applied within the staffing and resource limits of methadone maintenance treatment facilities. The advantages of PST relative to other behavioral therapies for this population are based on evidence that PST is less cognitively demanding for an older adult population with mood and substance use disorders. A properly modified PST for an older adult substance-dependent population with subsyndromal or diagnosed depression may be a viable option for methadone maintenance programs with limited resources.     

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.     

Predicting treatment retention with a brief "Opinions About Methadone" scale

It is important to identify social conditions, program factors, and client characteristics that predict retention because time in substance abuse treatment is associated with improved health, mood, and social functioning. Treatment dropouts also are at high risk for serious harms, including relapse. Most opioid-dependent persons require long-term stabilization in methadone maintenance treatment (MMT) to normalize brain function and control withdrawal symptoms. The purpose of this study was to determine whether a client characteristic, namely, attitude toward methadone, was related to retention. Analysis of 14 opinion statements about methadone identified a reliable five-item scale with factorial validity. This scale (Opinions About Methadone; OAM-5) also predicted retention in MMT. Of 338 clients followed for one year after MMT enrollment, 48% dropped out of treatment; those who were more likely to remain had more favorable opinions. A supplementary qualitative study with MMT counselors demonstrated face validity for the OAM-5; counselors found the items easy to interpret and relevant to client attitudes towards MMT. The findings suggest that it would be worthwhile for MMT staff to assess client attitudes at intake, using the OAM-5. This would help them to identify and intervene promptly with those in greatest need of support for remaining in treatment.