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.     

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.     

An innovative job placement model for unemployed methadone patients: a randomized clinical trial

This article presents the outcomes of an innovative vocational rehabilitation model designed for methadone-maintained patients -- the Customized Employment Supports (CES) model. CES counselors work intensively with a small caseload of patients to overcome the vocational as well as non-vocational barriers that hinder employment, with the goal of attaining rapid job placement. A randomized clinical trial was implemented at two methadone treatment programs in New York City and was funded by the National Institute on Drug Abuse The study tested the hypothesis that patients assigned to the experimental (CES) condition would have better employment outcomes than those assigned to a control condition who received standard vocational counseling at the programs. The data were collected from May 2001 through April 2005. The efficacy sample for the analysis consisted of 168 patients who completed follow-up interviews. The sample was 58% male, 75% minority group, average age 45 years, and in methadone treatment for an average of five years. The results supported the hypothesis for two measures of employment; i.e., the CES group was significantly more likely than the control group to obtain both any paid employment and informal paid employment. However, there were no significant differences for competitive employment or total earnings. The study's limitations are noted. Implications of the findings for the improvement of vocational rehabilitation for addiction patients are discussed.     

An Innovative Job Placement Model for Unemployed Methadone Patients: A Randomized Clinical Trial

This article presents the outcomes of an innovative vocational rehabilitation model designed for methadone-maintained patients—the Customized Employment Supports (CES) model. CES counselors work intensively with a small caseload of patients to overcome the vocational as well as non-vocational barriers that hinder employment, with the goal of attaining rapid job placement. A randomized clinical trial was implemented at two methadone treatment programs in New York City and was funded by the National Institute on Drug Abuse The study tested the hypothesis that patients assigned to the experimental (CES) condition would have better employment outcomes than those assigned to a control condition who received standard vocational counseling at the programs. The data were collected from May 2001 through April 2005. The efficacy sample for the analysis consisted of 168 patients who completed follow-up interviews. The sample was 58% male, 75% minority group, average age 45 years, and in methadone treatment for an average of five years. The results supported the hypothesis for two measures of employment; i.e., the CES group was significantly more likely than the control group to obtain both any paid employment and informal paid employment. However, there were no significant differences for competitive employment or total earnings. The study's limitations are noted. Implications of the findings for the improvement of vocational rehabilitation for addiction patients are discussed.     

Using enhanced and integrated services to improve response to standard methadone treatment: Changing the clinical infrastructure of treatment networks

Outcomes are presented from opioid-dependent outpatients (N = 81) participating in a new community-based initiative designed to improve access to enhanced substance abuse and psychiatric services in a publicly supported methadone maintenance treatment network in Baltimore, MD. The initiative, entitled Community Access to Specialized Treatment (CAST), is located at the Addiction Treatment Services, a program within this network. Network programs referred patients engaged in unremitting drug use who are at risk for discharge to CAST, where they received methadone substitution, individual and group counseling within an adaptive platform, behavioral contingencies to reinforce adherence, and on-site psychiatric evaluation and care. Patients returned to their referring program after producing at least two consecutive weeks of drug-negative urine samples and full counseling adherence. CAST was well utilized by the community. Patients had high rates of adherence to scheduled individual and group counseling services (93% and 73%, respectively); 43% of referrals successfully completed the program in an average of 101 days. This community-wide service delivery approach is a novel alternative to integrating intensive substance abuse and psychiatric care at each program within a treatment network.     

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。     

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.     

A case study of employment case management with chronically unemployed methadone maintained clients

Employment interventions implemented in drug treatment programs have been marginally successful, but few interventions have been found to address the needs of chronically unemployed clients. Employment case management (ECM) is a comprehensive employment intervention strategy designed to motivate chronically unemployed persons to engage in work, assist in job placement, and provide post employment support through workforce integration, while maintaining progress in drug treatment. This clinical case study reports on a convenience sample of 10 chronically unemployed methadone maintained clients who voluntarily enrolled in the ECM project. Clients received individual ECM services for a period of 26 weeks. Clients were assessed at two- and eight-month follow-up intervals. Nine of the 10 clients were employed at the two-month follow-up assessment and six maintained employment at the eight-month follow-up. Moreover, three clients were able to successfully transition from welfare to competitive private sector employment. Preliminary data suggest that ECM may be an effective intervention strategy to help chronically unemployed methadone clients obtain and maintain employment. Qualitatively, clients reported that post employment intervention services such as motivational counseling, problem solving, and employer advocacy helped sustain employment.     

Services provided during methadone treatment. A gender comparison

Greater improvement in posttreatment outcomes has been shown in programs that tailor frequency and type of services to unique client needs. Using a sample of 635 clients (199 females and 436 males) admitted to three community-based methadone treatment programs, this study examined gender differences in services needed and provided during the first 3 months of treatment. Results revealed that compared to males, women entered treatment with more psychological symptoms and AIDS/HIV-risky behaviors; they also presented with less criminal activity, less alcohol use, and higher motivation. Counselors addressed psychological and crisis issues more frequently with women, and counseling strategies were more often directed toward developing problem-solving and communication skills. Counselors also made more medical referrals and reported having better rapport with females. Attention to employment issues and HIV/AIDS sexual-risk behaviors did not differ by gender, even though women had more needs in these areas.     

Risk characteristics associated with chronic unemployment in methadone clients

Relatively few methadone programs emphasize vocational skills training in their service delivery protocols. As a result, this study was conducted to determine the contribution of background demographic, vocational and clinical characteristics in differentiating chronically unemployed methadone clients from those regularly or intermittently employed over a 3-year period of time. Three-hundred eighty heroin addicts, from five urban methadone treatment programs, participated in the study. Using the multiple logistic regression approach, nine variables were found to be significantly related to unemployment risk.     

Increased caseloads in methadone treatment programs: implications for the delivery of services and retention in treatment

Changes in caseload and in the provision of counseling and comprehensive services were examined among 27 outpatient methadone programs across England between 1995 and 1999. The number of patients treated at the programs doubled during this time and average waiting times increased. More patients presented for treatment with alcohol and stimulant problems, dual diagnosis, and involvement in the Criminal Justice System. Provision of individual counseling and comprehensive services was high at both points, although services for family/relationship problems were reduced at followup. Changes were reported in disciplinary procedures. Drug positive urine tests were more likely to result in loss of patient privileges, and there was a significant increase in discharges for breaking program rules, missing appointments, and consuming alcohol. The study allows only tentative conclusions to be drawn, but these changes may be indicative of increased pressures placed on the programs and their staff.     

Combining stepped-care approaches with behavioral reinforcement to motivate employment in opioid-dependent outpatients

Employment is associated with improved treatment outcome for opioid-dependent outpatients receiving methadone (e.g., Platt, 1995). Opioid-dependent individuals typically enter treatment unemployed and many remain unemployed despite reductions in heroin use. Additional interventions are needed to motivate employment seeking behaviors and outcome. This article reports on a promising approach to reduce the chronic unemployment commonplace in treatment-seeking, opioid-dependent patients--a "stepped care" service delivery intervention that incorporates multiple behavioral reinforcements to motivate patient participation in and adherence to the treatment plan. This therapeutic approach (Motivated Stepped Care--MSC; Brooner and Kidorf (2002) was refined and modified to motivate and support a range of positive treatment behaviors and outcomes in patients with opioid-dependence (Kidorf et al. 1999), including job-seeking and acquisition. Patients who are unemployed after one year of treatment are systematically advanced to more intensive steps of weekly counseling and remain there until employment is attained. Those who remain unemployed despite exposure to at least 4 weeks of counseling at the highest step of care (Step 3, which is 9 h weekly of counseling) are started on a methadone taper in preparation for discharge, which is reversible upon attaining a job. This article describes the MSC approach and presents rates of employment for patients who were judged capable of working (n = 228). A review of medical and billing records during August--September 2002 revealed that the great majority of these patients were employed (93%), usually in full-time positions. Employment was associated with less frequent advancement to higher intensities of weekly counseling because of drug use. Further, multiple indices of improved employment stability and functioning, including months of work, hours of work, and annualized salary, were associated with better drug use outcomes. These data suggest that the MSC intervention is an effective platform for motivating and supporting both job seeking and employment in patients with chronic and severe substance use disorder.     

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.     

Characteristics and 9-month outcomes of discharged methadone maintenance clients

This study is a secondary data analysis of a clinical trial assessing the effectiveness of outreach case management (OCM) in linking discharged methadone patients back into treatment. The original trial assessed the effectiveness of the OCM intervention compared to a passive referral among methadone clients who needed treatment postdischarge but had not reengaged. The purpose of this study was to assess the characteristics and long-term outcomes of all clients who were discharged from methadone maintenance treatment including those who had reengaged in treatment. A total of 230 methadone clients were interviewed 3 months and then again at 9 months following discharge from treatment. Compared with participants who needed treatment but had not reengaged (NoTx: 56%), those who had successfully reenrolled in treatment (Tx; 44%) were more likely to be female, not married, and unemployed; had a longer history of sedative use; reported more psychiatric hospitalizations; and were originally enrolled in a community-based rather than a Veterans Administration program. Despite having more severe problems, the Tx group had fewer opioid-positive urines and reported less IV drug use at 9 months postdischarge compared to the NoTx group. The findings highlight the importance of rapid treatment reengagement.     

美沙酮长期维持治疗患者情况分析

目的通过对美沙酮维持治疗中坚持服药3年及以上服药人员情况进行分析,了解其一般情况及治疗情况。方法选取广州市荔湾区药物维持治疗点坚持服药3年及以上的46例服药人员作为研究对象,采用描述性统计方法对其人口学特征及治疗前后情况进行分析。结果长期维持治疗患者以男性为主,平均年龄(39.93±8.10)岁;大部分具有初中及以上文化程度;与家人、亲属或朋友居住,并有较好的家庭关系;93.48%的服药人员为无业或待业;97.80%的长期维持治疗人员吸毒时间10年以上,平均时间为(17.78±3.75)年;吸毒花费以100～500元者居多;82.6%的服药人员至治疗点所需时间在30min以下;大多数患者服药剂量为20～80mL;服药参与率中位数91.72%,尿检参与率中位数91.72%,尿检阳性率中位数14.12%。结论在治疗中对美沙酮维持治疗患者一般情况和治疗前后情况进行监测,并针对监测结果对患者采取相应干预措施有利于其长期维持,进而改善治疗效果。     

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.     

Combining Stepped-Care Approaches with Behavioral Reinforcement to Motivate Employment in Opioid-Dependent Outpatients

Employment is associated with improved treatment outcome for opioid-dependent outpatients receiving methadone (e.g., Platt, ). Opioid-dependent individuals typically enter treatment unemployed and many remain unemployed despite reductions in heroin use. Additional interventions are needed to motivate employment seeking behaviors and outcome. This article reports on a promising approach to reduce the chronic unemployment commonplace in treatment-seeking, opioid-dependent patients—a “stepped care” service delivery intervention that incorporates multiple behavioral reinforcements to motivate patient participation in and adherence to the treatment plan. This therapeutic approach (Motivated Stepped Care—MSC; Brooner and Kidorf () was refined and modified to motivate and support a range of positive treatment behaviors and outcomes in patients with opioid-dependence (Kidorf et al. ), including job-seeking and acquisition. Patients who are unemployed after one year of treatment are systematically advanced to more intensive steps of weekly counseling and remain there until employment is attained. Those who remain unemployed despite exposure to at least 4 weeks of counseling at the highest step of care (Step 3, which is 9 h weekly of counseling) are started on a methadone taper in preparation for discharge, which is reversible upon attaining a job. This article describes the MSC approach and presents rates of employment for patients who were judged capable of working (n = 228). A review of medical and billing records during August–September 2002 revealed that the great majority of these patients were employed (93%), usually in full-time positions. Employment was associated with less frequent advancement to higher intensities of weekly counseling because of drug use. Further, multiple indices of improved employment stability and functioning, including months of work, hours of work, and annualized salary, were associated with better drug use outcomes. These data suggest that the MSC intervention is an effective platform for motivating and supporting both job seeking and employment in patients with chronic and severe substance use disorder.     

Developing Employment Services for Criminal Justice Clients Enrolled in Drug User Treatment Programs

Approximately 80% of parolees have a history of substance abuse and nearly all are unemployed following release from prison. Common stipulations of parole require offenders to obtain employment and to not use mood-altering substances. This article explores a series of strategies implemented from 1999 to 2001 to help offenders paroled to substance user treatment to gain employment. A total of 245 paroled offenders enrolled in an outpatient substance abuse treatment program voluntarily agreed to participate in one of four different vocational intervention programs (Job Skill Development and Supported Work, Life Skill Development, Job Training, and Welfare to Work). Programmatic data (e.g., attendance, completion, job acquisition, and wage) were collected and reported for each of the vocational programs. Additionally, a 12-month pilot study examined criminal justice, substance use, and employment outcomes of 36 offenders referred to the job skill development and supported work project. Overall, 78% of the offenders enrolled in the vocational services completed the program and 134/245 (55%) were able to obtain employment. The data showed that completion of vocational services was strongly associated with obtaining employment 12 months postenrollment. Offenders identified the employment services as an integral part of their improved overall functioning. A series of practice recommendations and policy suggestions is offered to develop and manage vocational services for substance-using offenders. Employment services for parolees require considerable coordination of activities with parole officers, vocational programs, substance abuse treatment professionals, and funding systems.     

Developing employment services for criminal justice clients enrolled in drug user treatment programs

Approximately 80% of parolees have a history of substance abuse and nearly all are unemployed following release from prison. Common stipulations of parole require offenders to obtain employment and to not use mood-altering substances. This article explores a series of strategies implemented from 1999 to 2001 to help offenders paroled to substance user treatment to gain employment. A total of 245 paroled offenders enrolled in an outpatient substance abuse treatment program voluntarily agreed to participate in one of four different vocational intervention programs (Job Skill Development and Supported Work, Life Skill Development, Job Training, and Welfare to Work). Programmatic data (e.g., attendance, completion, job acquisition, and wage) were collected and reported for each of the vocational programs. Additionally, a 12-month pilot study examined criminal justice, substance use, and employment outcomes of 36 offenders referred to the job skill development and supported work project. Overall, 78% of the offenders enrolled in the vocational services completed the program and 134/245 (55%) were able to obtain employment. The data showed that completion of vocational services was strongly associated with obtaining employment 12 months postenrollment. Offenders identified the employment services as an integral part of their improved overall functioning. A series of practice recommendations and policy suggestions is offered to develop and manage vocational services for substance-using offenders. Employment services for parolees require considerable coordination of activities with parole officers, vocational programs, substance abuse treatment professionals, and funding systems.     

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.