A novel cognitive-behavioral approach for treatment-resistant drug dependence

Despite the application of treatments that combine methadone administration, weekly counseling, and contingency reinforcement strategies, many opiate-dependent patients continue illicit drug use. In this controlled study we piloted a novel cognitive-behavioral treatment (CBT) designed to reduce illicit drug use among patients receiving methadone treatment. The treatment targeted the reduction of sensitivity to interoceptive cues associated with drug craving, and trained alternative responses to these cues. Patients (N = 23) were randomly assigned to either this novel CBT program or a program of increased counseling, such that the two programs of treatment were equated for therapist contact, assessment time, and contingency-reinforcement strategies. We found that, compared to a doubling of contact with their outpatient counselor, the new program was associated with significantly greater reductions in illicit drug use for women, but not for men. Reasons for differential performance by women and men and future directions for this new treatment are discussed.     

Predictors of engagement in vocational counseling for methadone treatment patients

Employment enhances the outcomes of substance dependency treatment. Unfortunately, although unemployed methadone treatment patients frequently state they are interested in a job, many fail to participate in vocational services when available. Unless patients become engaged, vocational services do not have an opportunity to be effective. This is the first study to explore a broad array of factors that may be associated with differential engagement in vocational services among methadone patients. The study was conducted in two methadone programs in New York City during 2001-2004. Unemployed methadone patients (n = 211) were voluntarily randomly assigned to either of two vocational counseling programs (standard vs. experimental) and followed for 6 months. The sample was 59% male, 75% minority group, aged 45 years on average, and in methadone treatment for 5 years on average. Being engaged in the vocational counseling programs was defined as five or more sessions with the counselor in the first 6 months after study entry. In multivariate analysis, the factors associated with higher engagement in vocational counseling were being non-Hispanic, having more education, a drug injection history, a crack use history, having chronic emotional/mental problems, better work attitudes, and assignment to the experimental vocational program. The results indicate that it is often the most "needy" unemployed methadone patients who become more engaged in vocational counseling. A vocational counseling model which emphasizes assertive outreach and attends to nonvocational clinical issues as well is more likely to engage patients.     

The interaction between counseling and methadone in the treatment of narcotic addicts: the challenge of the counseling relationship.

Despite the real and symbolic inportance of methadone to the drug addict, the counseling relationship is still central to the rehabilitative process. This paper discusses the unique aspects of counseling relationships in methadone programs due to the interaction of the physiological and counseling components of treatment. A point of view is presented which emphasizes the need for an open and honest discussion of the worker's role and the expectations of the program early in the treatment process as a means of establishing a therapeutic contract. Affirmation of the authority inherent in the worker's role, and in the structure of the program, lends structure to the counseling relationship and facilitates the rehabilitative process. The contract will also help the patient clarify his personal goals of treatment. It has been noted that methadone can speed up the rehabilitative process because it allows the addict to shift his attention away from the craving for drugs. While counseling staff view methadone as a tool to help patients achieve physiological stability so that psychosocial rehabilitation can occur, patients often view methadone as the primary component of treatment. This differing view of the role of methadone in treatment can lead to conflicts between patients and counselors. The skill of the counselor lies in helping the patients move away from a singular concentration on the drug (methadone), by encouraging a longer point of view and the first steps in the process of personal and social rehabilitation.     

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.     

Is there a need for "professional psychotherapy" in methadone programs?

The role of "professional psychotherapy" in methadone programs has been unclear because of its expense as compared to counseling, shortage of trained, experienced personnel, and confusion in the literature as to its efficacy. This research capsule reviews some recent studies pertaining to this and some of the methodological difficulties in arriving at a clear answer. Psychotherapy so far appears most helpful for patients with a defined psychiatric diagnosis in addition to their drug diagnosis. In addition, benefits appear to be greater if patients are treated early in their treatment program.     

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.     

Philadelphia's community based drug abuse program: broader medical and social concepts.

The rehabilitation of drug dependent people has undergone drastic changes since first attempts were made to curb the abuse of illegal drugs. The isolated law-enforcement model proved to be of no use in this area. So, too, the medical model, the psychological model and the public health model proved disappointingly low in their results. During the last ten years, a so-called "metabolic replacement model" has had its upsurge, creating a controversy still under discussion. The Drug Abuse Rehabilitation Programs of the West Philadelphia Community Mental Health Consortium, Inc. have been in the forefront with its treatment models. Established in 1968 as a purely methadone maintenance program, it has evolved into becoming a model, applying community mental health principles. This paper will explore this model further, describing the mechanics of its changes. From a municipal hospital-based methadone dispensing station, the program has developed into a multi-modality project. Three decentralized drug-free outpatient services are located in the midst of the community where the drug abuse problem is more accute. Outreach is emphasized and case-funding is applied. A possibly unique river-front motel was just acquired for the development of a community-based treatment modality. The 94 rooms were converted into a first-floor alcoholism program which also has a "highway safety program" and an intermediate care facility for alcoholics. The second floor of this facility contains outpatient services for the treatment of drug addicts, including a methadone maintenance program, counselling, family therapy and group therapy. The place where most of the emphasis has been placed is the Work Rehabilitation Center (a novel approach whereby patients will spend up to six hours in "partial hospitalization"). Clients will be tested for vocational aptitude and four workshops will be developed on the premises - carpentry, automotive, electricity and clerical. A huge cafeteria with a semi-automatic kitchen will allow further training in cooking and kitchen aids. The third floor of this renovated motel will include highly sophisticated clinical research area where computer utilization is already giving us very meaningful data. Clinical research is rapidly developing, and new drugs for the rehabilitation of drug addicts will be used. Further comments on the usefulness of methadone as a tool will be included in this paper and general comments as to the outcome of treatment further explored.     

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.     

Interim versus standard methadone treatment: A benefit–cost analysis

A benefit–cost analysis was conducted as part of a clinical trial in which newly-admitted methadone patients were randomly assigned to interim methadone (IM; methadone without counseling) for the first 4 months of 12 months of methadone treatment or 12 months of methadone with one of two counseling conditions. Health, residential drug treatment, criminal justice costs, and income data in 2010 dollars were obtained at treatment entry, and 4- and 12-month follow-up from 200 participants and program costs were obtained. The net benefits of treatment were greater for the IM condition but controlling for the baseline variables noted above, the difference between conditions in net monetary benefits was not significant. For the combined sample, there was a pre- to post-treatment net benefit of $1470 (95% CI: −$625; $3584) and a benefit–cost ratio of 1.5 (95% CI: 0.8, 2.3), but using our conservative approach to calculating benefits, these values were not significant.     

Interim methadone treatment compared to standard methadone treatment: 4-month findings

Interim methadone (IM; with emergency counseling only) is an effective but highly restricted alternative to methadone treatment program (MTP) waiting lists. However, it is not known whether IM disadvantages patients as compared with standard methadone treatment (SM). In this clinical trial, conducted in two MTPs, 230 newly admitted patients were randomly assigned to IM, SM, and “restored” methadone treatment (SM with a counselor with a reduced caseload). Data were analyzed using generalized estimating equations and generalized linear modeling. There were no significant differences among conditions in days in treatment or of heroin or cocaine use and heroin- or cocaine-positive urine drug tests. The IM as compared to the SM group had significantly fewer self-reported days of criminal activity and lower amounts of money spent on drugs and illegal income. These findings suggest that when SM is unavailable, IM should be more widely used and less restricted.     

A randomized clinical trial of methadone maintenance for prisoners: results at 1-month post-release

BACKGROUND: Despite its effectiveness, methadone maintenance is rarely provided in American correctional facilities. This study is the first randomized clinical trial in the US to examine the effectiveness of methadone maintenance treatment provided to prisoners with pre-incarceration heroin addiction. METHODS: A three-group randomized controlled trial was conducted between September 2003 and June 2005. Two hundred eleven Baltimore pre-release inmates who were heroin dependent during the year prior to incarceration were enrolled in this study. Participants were randomly assigned to the following: counseling only: counseling in prison, with passive referral to treatment upon release (n=70); counseling+transfer: counseling in prison with transfer to methadone maintenance treatment upon release (n=70); and counseling+methadone: methadone maintenance and counseling in prison, continued in a community-based methadone maintenance program upon release (n=71). RESULTS: Two hundred participants were located for follow-up interviews and included in the current analysis. The percentages of participants in each condition that entered community-based treatment were, respectively, counseling only 7.8%, counseling+transfer 50.0%, and counseling+methadone 68.6%, p<.05. All pairwise comparisons were statistically significant (all ps<.05). The percentage of participants in each condition that tested positive for opioids at 1-month post-release were, respectively, counseling only 62.9%, counseling+transfer 41.0%, and counseling+methadone 27.6%, p<.05, with the counseling only group significantly more likely to test positive than the counseling+methadone group. CONCLUSIONS: Methadone maintenance initiated prior to or immediately after release from prison appears to have beneficial short-term impact on community treatment entry and heroin use. This intervention may be able to fill an urgent treatment need for prisoners with heroin addiction histories.     

Program quality effects on patient outcomes during methadone maintenance: a study of 17 clinics.

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

Effectiveness of psychotherapeutic counseling in methadone maintenance

Therapeutic counseling has been widely adovacted with methadone maintenance, but its effectiveness has not been demonstrated. A review of the literature revealed a dearth of scientific investigations comparing treatment outcomes with and without counseling services. The few studies which have been reported seem to suggest that counseling does not significantly change treatment outcomes as measured by the usual indicators of illicit drug use, arrests, employment, and retention in the program. These studies suffered from a number of methodological flaws, however, including failure to adhere to research design, small sample size, poorly matched control groups, inadequate outcome criteria, and absence of post-treatment follow-up. Previous investigators have been nearly unanimous in calling for further studies of this issue. Since the cost of counseling services represents a major portion of treatment program budgets, there is an urgent need to document the effectiveness of these services with definitive studies.     

Methadone maintenance counseling: Definition,principles, components

Counseling has been a major service component of methadone maintenance since its inception. Yet, there is no consensus about what methadone counseling is or how it should be practiced. This paper proposes a definition of professional methadone counseling as a specialized modality of addiction therapy and rehabilitation. Five principals of methadone counseling are reviewed: (1) coordination of care, (2) use of the counseling relationship, (3) attention to the stage of recovery, (4) structure and flexibility, and (5) facilitation of patient resourcefulness and social recovery. Fifteen components of methadone counseling are also reviewed. These include interventions focused on (1) the initial phase of treatment, (2) the treatment itself, and (3) the work of rehabilitation. General counseling issues are considered, such as counselor education, the role of the counselor in the program, the methadone controversy, as well as the impact of HIV disease and “crack/ cocaine”. In closing, the advantages of the proposed model are stressed.     

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

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

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.     

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

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

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

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

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。     

A controlled trial of methadone treatment combined with directly observed isoniazid for tuberculosis prevention in injection drug users

Substance abuse is associated with high risk for tuberculosis (TB) and poor adherence to medication regimens. This study compared completion rates for isoniazid (INH) preventive therapy for injection drug users (IDUs) randomly assigned to methadone treatment combined with directly observed preventive treatment (DOPT) versus those assigned to routine TB clinic referral without methadone treatment. One hundred and eleven opioid-dependent patients with latent TB were assigned to one of three 6-month treatment conditions: standard methadone treatment including substance abuse counseling combined with daily INH DOPT (n=37); minimal methadone treatment without counseling, also combined with daily INH DOPT (n=35); or routine care referral to TB clinic for monthly INH supplies without DOPT and without methadone treatment (n=39). INH completion rates were 77.1% for minimal methadone and 59.5% for standard methadone, as compared with only 13.5% for routine care (P<0.0001). Mean duration of INH treatment retention was 5.7, 5.0 and 1.6 months, respectively (P<0.0001). TB incidence at 4-year follow-up was 0 of 54 subjects who completed preventive therapy versus 2 of 57 who failed to complete. One of these two had been assigned to routine care, and the other to minimal methadone. In conclusion, INH retention time and completion rates were significantly improved by methadone treatment combined with observed INH, whether or not substance abuse counseling was provided. The results of this study indicate that methadone treatment offers clear public health benefits when it is used to deliver preventive medical services.