Pre-treatment characteristics, program philosophy and level of ancillary services as predictors of methadone maintenance treatment outcome

Predictors of methadone maintenance treatment outcome have not been extensively studied as they relate to variations in program philosophy, nor have such predictors received much examination among recently treated, older cohorts of opioid addicts for whom drug use patterns have changed. Predictors of outcome were examined at 18 months post-treatment entry for 353 admissions to methadone maintenance who received random assignment to one of three counseling conditions: (1) medication only, (2) standard counseling and (3) enhanced services; and one of two contingency conditions: (1) no contingencies, and (2) contingency contracting in a six-cell 3x2 design. Subjects in contingency contracting conditions were placed on contingency contracts for positive urine toxicology results and ultimately discharged for unremitting drug use. All subjects completed the Addiction Severity Index (ASI) and provided weekly urine specimens. Predictors of urinalysis results and treatment retention were determined using bivariate and multivariate techniques. Interactions between subject characteristics by experimental condition assignment were also examined as predictors. Higher rates of total positive urine specimens were predicted by younger age, greater pre-treatment frequency of smoking cocaine, lower ASI psychiatric composite scores, and higher ASI legal composite scores. Higher rates of opiate positive specimens were predicted by younger age, lower pre-treatment frequency of alcohol intoxication, higher ASI legal and lower ASI employment and psychiatric composite scores, and assignment to medication only/no contingencies condition. Higher rates of cocaine positives were predicted by younger age, black race, lower ASI psychiatric composite score, greater pre-treatment frequency of intravenous and smoked cocaine use, less pre-treatment frequency of marijuana use, and lower methadone dose level. Assignment to enhanced/contingency contracting predicted lower rates of cocaine positives. Treatment retention was predicted by older age, non-black race, lower ASI legal composite score, higher methadone dose level and assignment to non-contingent conditions. While subject variables over which treatment providers have little control were, thus, related to outcome, type of treatment provided and methadone dose also influenced outcome.     

Investigating the influence of treatment philosophy on outcome of methadone maintenance

This study is based on a ‘natural experiment’ in which a cohort of heroin users was assessed at one unit, then referred on geographic grounds for treatment to one of two clinics—one orientated to long-term maintenance (Clinic 2, with 61 subjects), the other to time-limited treatment aimed at achieving abstinence from all drugs including methadone (Clinic 1, 141 subjects). The outcome measure was heroin use as measured by urine testing performed regularly at both clinics. Overall, 25% of urine tests from Clinic 1 were positive for heroin compared to 18% in Clinic 2. This difference reflected in part a high rate of heroin use during the period of mandatory withdrawal from treatment in Clinic 1. Statistical models were developed to identify factors associated with heroin use. There was a strong association between methadone dose and heroin use; relative to a daily dose of 40 mg, a dose of 80 mg/day of methadone was less likely to be associated with a heroin-positive urine (OR 0.55, 95% CI [0.45,0.68]). Average doses prescribed in Clinic 1 were lower, reflecting the clinic's orientation to abstinence. Adjusting for dose, and for the fact that certain individuals tend to use heroin heavily while others do not, there was no difference between the clinics in risk of heroin use during maintenance treatment. The higher rates of heroin use in the abstinence-orientated clinic were attributable to time-limited treatment and the use of lower doses of methadone. This finding confirms that in investigating the effects of treatment factors, the powerful influence of methadone dose needs to be taken into account.     

Effect of psychiatric severity on the outcome of methadone maintenance treatment

While psychiatric comorbidity has been shown to produce a negative impact on the outcome of opioid use disorders, longitudinal studies carried out in the context of methadone maintenance treatment programs (MMTP) to evaluate outcomes strictly linked to methadone efficacy have not demonstrated a similar negative influence. To verify whether results obtained considering psychopathology in terms of formal psychiatric diagnoses were replicated when assessing psychopathology in terms of global psychiatric severity, a retrospective cohort study was designed. 259 patients commencing methadone maintenance treatment were divided into two groups on the basis of SCL-90 severity score and compared for retention in treatment, toxicological urine test results and psychological/psychiatric status throughout a one year period of observation. The results of the study suggest that patients in MMTP with high psychiatric severity are not characterized by a lower retention in treatment or higher substance use than those with low psychiatric severity. Moreover, during treatment high severe psychiatric patient status appears to improve significantly for all psychological/psychiatric dimensions explored by SCL-90. These results are consistent with those obtained in previous studies on the efficacy of MMTP, comprehensive of psychiatric care, irrespective of the severity of psychopathology exhibited by patients at the beginning of treatment.     

The effect of stimulant and sedative use on treatment outcome of patients admitted to methadone maintenance treatment

While methadone maintenance treatment (MMT) has been demonstrated to be an effective treatment for opiate dependence, its impact on the treatment outcome of other illicit drug abuse is not as clear. Using the initial urine drug screen (UDS) and follow-up UDS at 1, 6, 12, and 24 months, 167 patients consecutively admitted to MMT were evaluated for opiate, sedative (predominantly benzodiazepine), and stimulant (predominantly cocaine) use. Retention for the opiate only group was 97.32 days longer on average than for patients using opiates along with stimulants, sedatives, or both stimulants and sedatives. Patients abusing opiates only had the greatest decrease in drug use; however, MMT was also associated with decreases in cocaine and sedative use over the 24 month follow-up period. There was no evidence that patients "switched" their drugs of abuse with time in treatment. The negative impact of non-opiate drug use on outcome in MMT and its implications for treatment planning are discussed.     

Predictors of patient retention in a newly established methadone maintenance treatment programme

Aims. To identify predictors of patient retention in methadone maintenance. Design. Prospective study. Setting. Methadone maintenance treatment programme newly established in Geneva, Switzerland. Participants. All patients who initiated treatment between February 1991 and January 1995. Measurements. Baseline patient characteristics, dose of methadone, year of enrollment and retention in treatment. Findings. Overall, 111 patients contributed 164.4 person-years of follow-up. The retention rate was 84% after 12 months. In multivariate analysis, the risk of dropping out was significantly higher for patients who had been using opioids for 7 years (relative hazard (RH) 3.0, 95% confidence interval (CI) 1.2-7.4), and for patients who had no stable income at baseline (RH 3.3, 95% CI 1.2-9.1). Dropouts were less frequent at the highest doses of methadone (65-110 mg/day, RH 1.0) than at middle doses (45-60 mg/day, RH 2.0, 95% CI 0.7-5.5) but, quite unexpectedly, dropouts were least likely at the lowest doses (15-40 mg/day, RH 0.5, 95% CI 0.1-1.8). Dropouts were more likely among patients who enrolled in the first (RH 6.2, 95% CI 2.3-16.7) and second (RH 1.9, 95% CI 0.6-5.6) years of the programme, compared with subsequent years (RH 1.0). Conclusions. Patients who have a long history of drug use and who have a stable income were more likely to stay in methadone maintenance treatment. Independent of patient characteristics, retention improved dramatically in the first years of programme functioning, suggesting that patient retention is a sensitive indicator of programme performance.     

Abstinence following detoxification and methadone maintenance treatment

During an 11 year overview of methadone treatment, 161 (72 per cent) of 225 patients who completed detoxification were followed up to eight years. Fifty-one (22.6 per cent) of those were classified as stable and narcotic free 2.9 years after detoxification. Of 89 self-selected patients who had undergone a planned, supported, “therapeutic” detoxification, 37 (42 per cent) were classified narcotic-free; whereas many fewer were so judged after other methods of detoxification. Relapse to nonprescribed opioid use, detected in 34 (38.7 per cent) of those traced, was inversely related to time since detoxification. Relapse potential was very low after three years of apparent continuous narcotic-free existence; three years should be a minimal time for successful detoxification. Some subjects had several cycles of methadone treatment and detoxification. Most patients with combined alcohol-methadone dependencies did poorly, whether or not detoxification from opiolds was undertaken. Since the frequency of enduring narcotic-free state was only 9.7 per cent of 522 patients in the treatment sample, detoxification should not be a realistic goal for all patients who enter treatment.     

Withdrawal from methadone maintenance treatment. Reasons for not trying to quit methadone

Although factors associated with successful termination of methadone maintenance treatment (MMT) have been well studied, the question of why certain methadone patients try to taper off methadone while others do not is still unanswered. Those patients who wish to continue MMT should of course be allowed to stay in treatment. However, even if only a small portion of the MMT patients wish to quit maintenance treatment, they should be offered all possible support by the treatment staff to maximize the possibility of a successful outcome. In the present study, we compared two groups of well-functioning MMT patients with respect to background factors, methadone-related factors, drug-related factors and psychological characteristics: one group consisted of patients who were trying to terminate their MMT (group 1) and the other group consisted of patients who were not trying (group 2). Each of the groups contained 25 well-rehabilitated subjects matched by age, gender and the number of years in MMT. The results show that the patients who were not trying to terminate MMT (in comparison to group 1) were not influenced by others to try to quit methadone, had a long history of opiate use as well as mixed drug use prior to MMT, had a higher methadone dose and reported a lower degree of anticipated abstinence symptoms. According to the statements of the subjects in group 2, the most important reason for not quitting treatment was the belief that they needed the methadone. The fact that they knew others who had failed to quit MMT and low confidence in succeeding were other common answers. Further, our results suggest that patients who were satisfied with their overall drug situation were less inclined to make a withdrawal attempt.     

Cost and cost-effectiveness of standard methadone maintenance treatment compared to enriched 180-day methadone detoxification

Aims To compare the cost and cost‐effectiveness of methadone maintenance treatment and 180‐day methadone detoxification enriched with psychosocial services. Design Randomized controlled study conducted from May 1995 to April 1999. Setting Research clinic in an established drug treatment program. Participants One hundred and seventy‐nine adults with diagnosed opioid dependence. Intervention Patients were randomized to methadone maintenance (n = 91), which required monthly 1 hour/week of psychosocial therapy during the first 6 months or 180‐day detoxification (n = 88), which required 3 hours/week of psychosocial therapy and 14 education sessions during the first 6 months. Measurements Total health‐care costs and self‐reported injection drug use. A two‐state Markov model was used to estimate quality‐adjusted years of survival. Findings Methadone maintenance produced significantly greater reductions in illicit opioid use than 180‐day detoxification during the last 6 months of treatment. Total health‐care costs were greater for maintenance than detoxification treatment ($7564 versus $6687; P < 0.001). Although study costs were significantly higher for methadone maintenance than detoxification patients ($4739 versus $2855, P < 0.001), detoxification patients incurred significantly higher costs for substance abuse and mental health care received outside the study. Methadone maintenance may provide a modest survival advantage compared with detoxification. The cost per life‐year gained is $16 967. Sensitivity analysis revealed a cost‐effectiveness ratio of less than $20 000 per quality‐adjusted life‐year over a wide range of modeling assumptions. Conclusions Compared with enriched detoxification services, methadone maintenance is more effective than enriched detoxification services with a cost‐effectiveness ratio within the range of many accepted medical interventions and may provide a survival advantage. Results provide additional support for the use of sustained methadone therapy as opposed to detoxification for treating opioid addiction.     

The structure of heroin communities (in relation to methadone maintenance).

The sociocultural structure of contemporary urban heroin-using communities is delineated using the dimensions "being hooked," "scoring," and "hustling" on "the street." A concentric ring model is constructed with four rings: (innermost) the street dealing network, other criminal hustles, employed addicts, and a peripheral "recruitment" area (outermost). The model is used to define differential intentions toward and responses to methadone maintenance treatment among members of the heroin community.     

Arrest record and retention in methadone maintenance treatment

It was found that when compared with those who stay in methadone maintenance treatment for less than 18 months, those who remain at least 18 months have a lower pretreatment and a lower in-treatment arrest record. It is questioned, however, if this group entered with a favorable bias and would have responded better to any form of treatment, including simple dispensation of methadone.     

Ten years of methadone maintenance treatment: some clinical observations

Ten years of methadone maintenance were reviewed in all 547 patients admitted to one clinic in New York City. High retention rates, reduced but still high mortality rates, increased employment, and minor degrees of recognized opiate abuse characterized those remaining in treatment. The treated patients appeared to evolve into a unique social and economic class, partly in the drug subculture and partly outside the drug world. Many were dependent on public assistance for living expenses, methadone treatment, and medical care. An interesting finding was their heavy demands for inpatient hospital care, often for drug-related reasons. A segment of New York City narcotic addicts was sequestered in an open-ended treatment process with considerable benefits to themselves and to society. Only a small fraction appeared to gravitate toward full economic support, to discontinuation of methadone, and to an enduring narcotic-free state.     

Ventilatory responses to hypoxia and hypercapnia in stable methadone maintenance treatment patients

RATIONALE: Methadone is a long-acting mu-opioid and is an effective treatment for heroin addiction. Opioids depress respiration, and patients receiving methadone maintenance treatment (MMT) have higher mortality than the general population. Few studies have investigated ventilatory responses to both hypercapnia and hypoxia in these patients. STUDY OBJECTIVES: We measured hypercapnic ventilatory response (HCVR) and hypoxic ventilatory response (HVR) and investigated possible factors associated with both in clinically stable patients receiving MMT. DESIGN AND SETTING: Patients receiving long-term, stable doses of methadone recruited from a statewide MMT program, and normal, non-opioid-using subjects matched for age, sex, height, and body mass index were studied with HCVR and HVR. RESULTS: Fifty MMT patients and 20 normal subjects were studied, and significantly decreased HCVR and increased HVR were found in MMT patients compared to normal subjects (HCVR [mean +/- SD], l.27 +/- 0.61 L/min/mm Hg vs 1.64 +/- 0.57 L/min/mm Hg [p = 0.01]; HVR, 2.14 +/- 1.58 L/min/% arterial oxygen saturation measured by pulse oximetry [Sp(O2)] vs 1.12 +/- 0.7 L/min/% Sp(O2) [p = 0.008]). Respiratory rate and not tidal volume changes were the major physiologic responses contributing to both HCVR and HVR differences between the groups. Variables associated with HCVR in the MMT patients are as follows: obstructive sleep apnea/hypopnea index (t = 5.1, p = 0.00001), Pa(CO2) (t = - 3.6, p = 0.001), body height (t = 2.6, p = 0.01) and alveolar-arterial oxygen pressure gradient (t = 2.5, p = 0.02). Variables associated with HVR in MMT patients are body height (t = 3.2, p = 0.002) and Pa(CO2) (t = - 2.8, p = 0.008). CONCLUSIONS: Stable long-term MMT patients have blunted central and elevated peripheral chemoreceptor responses. The mechanisms and clinical significance of these findings need further investigation.     

美沙酮维持治疗患者脱失的影响因素研究

目的 了解美沙酮维持治疗(MMT)门诊患者脱失的影响因素. 方法 将在天心区和衡阳市MMT门诊参治的353名患者,按维持时间长短分为脱失组和对照组,分析两组患者人口学、治疗前吸毒情况、治疗中情况、心理状况、接受家庭帮教情况之间的差别,分析影响患者脱失的因素. 结果 影响MMT门诊患者脱失的主要人口学因素有患者婚姻状况及家庭关系;影响MMT门诊患者脱失的吸毒行为因素有同居者吸毒状况;影响MMT门诊患者脱失的社会学因素有参加MMT后与吸毒朋友交往情况及是否实施社会帮教;影响MMT门诊患者脱失的心理学因素主要是焦虑状况和患者自尊状况. 结论 门诊对影响患者脱失的因素提前进行干预,能有效减少患者脱失,提高门诊治疗效果.     

Alcoholism and methadone treatment: consequences for the patient and program

The data on alcoholism presented in this paper were extracted from a major follow-up study of active and discharged methadone patients conducted from 1974 through 1977 in New York City. Alcoholism is a factor in 26% of the terminations from methadone treatment. It is also the leading cause of death in treatment and the second leading cause of death, following complications with opiates, in the post-treatment Also, patients with episodes of excessive drinking have markedly lower survival rates over a 10-year period when compared to patients who are social or moderate drinkers.     

海洛因成瘾者对美沙酮维持治疗的态度及相关因素

美沙酮维持治疗虽已有接近50年的历史,但是医疗机构与海洛因成瘾者双方依然存在对于美沙酮维持治疗态度的差异,主要表现在对于美沙酮治疗方式、美沙酮性质、不良反应、治疗效果等方面的不同认识。美沙酮这种多年来逐渐被医疗机构认为需终生维持的药物,海洛因成瘾者看来更应该作为短期内通过剂量递减方式实现戒断海洛因目的的药物,海洛因成瘾者同时认为美沙酮存在较强的不良反应和戒断症状。海洛因成瘾者形成此种态度的现状,则主要受到医生对于维持治疗方式的支持程度、本人是否参加过美沙酮维持治疗以及其他海洛因成瘾者参加治疗失败的经历的影响。     

Street-level drug law enforcement and entry into methadone maintenance treatment

Aims. To test the hypothesis that drug law enforcement encourages entry into methadone maintenance treatment. Design. Survey conducted as face-to-face interviews in methadone clinics, at needle exchange centres and on the street, in areas of widespread heroin dealing and use. Setting. Sydney, Australia. Participants. Heroin users. Measurements. Self-reported data on personal characteristics, and experience of drug law enforcement and methadone maintenance treatment. Findings. Although keeping their relationship/family together emerged as the most important reason given by respondents for entering treatment, avoiding more trouble with police/courts was also rated by the majority of respondents as an important or very important reason for entering treatment. The results of logistic regression analysis show that, after controlling for other factors, heroin users who have had a friend or family member imprisoned are more likely to have tried methadone maintenance treatment. A heroin user's own experience of arrest and imprisonment was also found to increase the likelihood of having tried treatment but only when age and length of time as a regular user (which were related to the user's experience of arrest and imprisonment) were excluded from the set of control variables. Despite having extensive histories of contact with the police and criminal justice system, however, Asian, Middle Eastern and Aboriginal respondents showed less proclivity to enter treatment than Caucasian respondents. Conclusion. Drug law enforcement may have a role to play in heroin demand reduction but its effects are not evident for all ethnic groups and the separate effects of contact with police, age and time spent in the heroin market remain unclear.