Slow tapering from methadone maintenance in a program encouraging indefinite maintenance

Longitudinal studies have indicated that most opioid agonist-using patients are not able to successfully complete tapering attempts. Little is known, however, about tapering within a treatment environment that is supportive of indefinite agonist treatment and medication tapering. In this study, all records of patients beginning a slow methadone taper were reviewed (N = 30). No patient successfully completed methadone tapering. Four patients (13.3%) successfully switched to buprenorphine/naloxone, one of whom tapered off buprenorphine/naloxone. Three patients (10%) were continuing their taper at the study's end. One patient transferred to another program, one was administratively discharged, and one had his taper stopped for mishandling doses. The remaining patients (n = 20, 66.7%) stopped their tapers for the following reasons: feeling unstable/withdrawal symptoms (n = 4, 13.3%), drug use/positive urinalysis results (n = 12, 40%), psychiatric instability (n = 3, 10%), and pain management (n = 1, 3.3%). Only one patient prematurely left treatment secondary to a failed taper attempt. Patients attempting tapers should be informed about the difficulty involved and be monitored closely for signs of instability. For a few patients, a taper to a lower methadone dose and a switch to buprenorphine/naloxone are obtainable. Program policies that support both tapering attempts and indefinite maintenance are described in this article.     

Contingency management in a methadone maintenance treatment program

A contingency management program was developed for in-patients induced on methadone in a methadone maintenance treatment program. Before the behavioural program started, data were collected during a 4 week base-line period. After the program had been running for one week there was an “accidental reversal” during 3 weeks, and then a 12 weeks period with the program. During the program points were given contingent on target behaviours. The points gave access to privileges such as leave, passes and visitors. The target behaviours increased in frequency during the program, decreased during the “accidental reversal” and increased again when the program was reinstated.     

Medication take-home as a reinforcer in a methadone maintenance program

The opportunity to take methadone doses home from the clinic can be used as a reinforcer in contingency management procedures to promote desirable behavior among a population of methadone maintenance clients. This was demonstrated by delivering take-home privileges contingent upon attendance at counseling sessions. Sixteen methadone maintenance clients were selected on the basis of their low attendance rates at individual counseling sessions. During five successive 2-month periods, weekend (2 days) medication take-home privileges were either contingent upon attendance at a weekly counseling session lasting at least 45 min or were given to clients non-contingently. During periods of contingent delivery of the take-home privilege, counseling attendance increased significantly above levels observed during period of non- contigent delivery.     

A menu of potential reinforcers in a methadone maintenance program

This study demonstrates the use of paired comparisons and interval scaling techniques for measuring the relative priority of program privileges available at a methadone maintenance clinic. Fifteen methadone program privileges were combined in all possible pairs (N = 105) on a reinforcer menu and administered to a group of 12 methadone patients and a second group of counselors (N = 4). Data were converted to interval scales using the law of comparative judgment to form a quantitative continuum from least to most preferable. Free methadone, free dental service, and more take-homes were ranked highest in both groups; however, patients showed less differentiation in their preference for these privileges. Dose decreases were least preferred. Results are discussed in terms of their clinical applicability in identifying privileges for potential use in modifying the behavior of drug abusers. The method of paired comparisons has excellent psychometric properties and may offer some advantages over other response scale formats.     

A 5-year evaluation of a methadone medical maintenance program

Methadone medical maintenance (MMM) is a model for the treatment of opioid dependence in which a monthly supply of methadone is distributed in an office setting, in contrast to more highly regulated settings where daily observed dosing is the norm. We assessed patient characteristics and treatment outcomes of an MMM program initiated in the Bronx, New York, in 1999 by conducting a retrospective chart review. Participant characteristics were compared with those of patients enrolled in affiliated conventional methadone maintenance treatment programs. Patients had diverse ethnicities, occupations, educational backgrounds, and income levels. Urine toxicology testing detected illicit opiate and cocaine use in 0.8% and 0.4% of aggregate samples, respectively. The retention rate was 98%, which compares favorably with the four other MMM programs that have been reported in the medical literature. This study demonstrates that selected patients from a socioeconomically disadvantaged population remained clinically stable and engaged in treatment in a far less intensive setting than traditional methadone maintenance.     

Effectiveness of prize-based contingency management in a methadone maintenance program in China

Background

Methadone maintenance treatment (MMT) has been successfully scaled up nationally in China. However, the program faces problems of poor attendance and high rates of continued drug use. We assessed whether a contingency management (CM) intervention implemented by MMT clinic staff could improve treatment attendance and drug abstinence.

Methods

Eight MMT clinics in Guangdong province were randomly selected and divided into two groups. A total of 126 participants (55 in urban clinics and 71 in rural clinics) received CM during a 12-week trial, 120 participants (83 in urban clinics and 37 in rural clinics) received usual treatment (UT). Participants in the CM group had the opportunity to draw for prizes contingent on attending treatment daily and testing negative for morphine. Clinic- and individual-level outcomes were compared between the intervention and control groups.

Results

The retention rate and negative urine testing rate were 14.2% (P = 0.010) and 10.7% (P < 0.001) higher in the CM group compared to the UT group, respectively. Compared with participants who received UT, CM participants missed on average 7.3 fewer (P = 0.008) visits and were 1.91 (95% CI: 1.53–2.39) times more likely to submit a negative urine sample. All clinic- and individual- level effects of the intervention were observed at rural clinics, but the difference in retention rate between urban CM and UT clinics was not significant.

Conclusion

Although the frequency of monitoring and value of the incentives in this study was lower than in previous studies, the CM intervention significantly improved attendance and reduced drug use in China.     

The Swedish methadone maintenance program: A controlled study

Thirty-four drug addicts, aged 20–24 years, with a history of 4–8 years of intravenous heroin abuse, were randomly assigned either to a methadone maintenance treatment (MMT) (17) or to an untreated group (17). The untreated controls could not apply for entrance to the program until two years later.It was found that after two years 12 MMT patients had abandoned their drug habits and begun work, whereas 5 had recurrent drug abuse problems. Of the controls, one was drug-free and gainfully employed, 12 were continuously abusing heroin (3 of these had incurred potentially fatal diseases in consequence), 2 were in prison and 2 had died. Two to seven years after their first visit to the Psychiatric Research Center 8 of the original control group have been accepted into the program. At present 19 (out of 25 admitted) are gainfully employed and no longer abusing drugs. Among the remaining controls 4 are dead, 3 are in prison, one in spite of a serious heart condition abuses heroin and one is drug-free.The rehabilitation rate was thus 76 per cent in the program as compared to 6 per cent among the control group. In addition, MMT obviously reduced the high morbidity and mortality rates found in a selection of heroin addicts who fulfilled the admittance criteria of the Swedish program.     

Depression among needle exchange program and methadone maintenance clients

The objective of this study was to compare the prevalence of major depression in two cohorts of injection drug users, those enrolled in a Rhode Island Methadone Maintenance Treatment Program (MMTP) and those enrolled in a Rhode Island Needle Exchange Program (NEP) using cross-sectional interviews. Symptomatic and duration criteria for major depression in the last 6 months were identified using the Structured Clinical Interview for DSM-III-R (SCID). Among 528 persons interviewed, 54% of those in NEP and 42% of those in MMTP met criteria for major depression. Using multivariate logistic regression, women (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.7–3.7), persons with alcohol use disorders (OR 1.7; 95% CI 1.1–2.7), and persons without a current partner (OR 1.8; 95% CI 1.2–2.6) were more likely to be depressed controlling for age, race, education and HIV status. Persons enrolled in MMTP were less likely to be depressed (OR 0.6; 95% CI 0.4–0.8) than NEP. Higher rates of depression were found among NEP attendees than among those enrolled in MMTP. Mental health referrals should be part of the growing number of needle exchanges in the United States.     

Detected heroin use in an Australian methadone maintenance program

A reanalysis was undertaken of survey and retrospective urinalysis data on patients remaining in an abstinence-oriented, public methadone maintenance program in Sydney, Australia. A comparison of urinalysis results with those of previous reports of Australian methadone programs suggests that the clinic's disciplinary program failed to reduce detected heroin use; morphine was detected in 27% of urine specimens. Women, those with a partner in methadone maintenance, and exprisoners were significantly more likely to submit morphine positive urines. When account was taken of subjects' General Health Questionnaire scores in a second logistic regression model, the more psychologically disturbed patients were one fifth as likely to submit a morphine positive specimen as the less disturbed. This and other findings are interpreted as indicating that psychologically disturbed patients who continued to use heroin were more likely to be expelled from or otherwise leave treatment than the less psychologically disturbed who continued to use heroin.     

Prediction of long-term outcome for heroin addicts admitted to a methadone maintenance program

Ten pre-treatment and nine during-treatment variables were correlated to outcome 5 years after admission to a methadone program for 171 subjects who were in treatment for at least 6 months. The pre-treatment variables were employment, education, criminal involvement, opiate and non-opiate drug abuse, periods of abstinence, age, sex, and ethnic group. During-treatment variables were employment, arrests or incarcerations, opiate and nonopiate drug abuse, living with an addict, marital status, and months of methadone treatment. Three measures of ‘successful’ outcome were defined. In general, subjects with more involvement with criminal justice before treatment, heavy alcohol use before or during treatment, continued daily heroin use or living with an addict during treatment, or minority ethnicity were more likely to have a poor outcome. However, the correlation coefficients for even the most significant correlations were weak; the highest was r = 0.26. We conclude that none of these 19 variables provide a basis for a priori judgment about whether or not a patient applying for admission to a methadone program is likely to have a favorable long-term outcome.     

Staying off methadone maintenance.

Methadone maintenance is again receiving attention as an intervention for needle use/sharing among intravenous drug users. A major criticism is that methadone has its own addictive properties; consequently, the client is unable to detoxify and stay off opioids permanently. Study respondents had been off methadone for several years and offered their strategies for success. Motivating forces included the freedom and rewards, such as pride and respect. The following helped individuals to get off and stay off methadone: avoidance of opioids; treatment affiliation to supply ideology and to structure and fill free time; employment; social supports, specifically family and role models; modest plans to avoid disappointment; effective coping skills to avoid depression; and aging and burning out. In addition, those individuals who had immersed themselves in the conventional world, especially those having a higher social class status, had a less difficult time staying off methadone.     

Supplementary methadone self administration among methadone maintenance clients.

The present study derives from two related questions: (1) Can methadone dose alterations act as reinforcers? (2) Do methadone dose alterations affect symptomatology of methadone maintained clients? Twenty three clients were offered six opportunities to alter their own methadone dose on a single day by as much as ±20 mg. Dose increases were selected on the vast majority of occasions (94.3%). Thus, supplemental methadone did function as a reinforcer for these clients. There was little evidence that dose increases which clients chose had any appreciable subjective effects. Neither symptomatology self reports nor judgements of dosage adequacy were significantly altered following acute methadone dose increases.The amount of supplemental methadone which clients self-administered could not be predicted by demographic characteristics, by length of time enrolled in maintenance treatment, by type or amount of illicit supplementary drug use, or by adequacy judgements of stable methadone dose. However, dosage self-regulation may have predictive potential as a measure of degree of behavioral dependence on narcotic drugs.     

Cocaine abuse sharply reduced in an effective methadone maintenance program

A comprehensive study of an urban methadone clinic with supervised urine analyses for illicit drugs was conducted over an 18 month period for a 133 patient cohort as they entered or remained in methadone maintenance for narcotic addiction. Overall retention during the study was 85%, with significantly (p < .05) higher daily methadone doses (mean 67.1 mg +/- 2.1) in those patients still in treatment at the end of the study. Predictably, illicit opioid use was dramatically reduced, to 10% as measured by urine toxicology in the last month of treatment. Moreover, significantly more patients stopped regular cocaine abuse (69%) than started using cocaine (10%, Fisher's exact test, p = .02). Thus, with effective methadone maintenance using adequate dosages, the majority of patients remain in treatment and reduce cocaine abuse as well as illicit opioid use, with implications for public health by reducing the spread of infectious diseases including hepatitis B, C, D and human immunodeficiency virus (HIV-1).     

Maintaining the viability and safety of the methadone maintenance treatment program

The purpose of this article is to describe a methadone maintenance treatment (MMT) program and address how such programs can maintain their viability in the community as well as the safety of the clinic environment for patients and staff. The complex nature of the MMT patient is described including social, legal and psychiatric issues. Diversion (selling of methadone) is discussed and examples of how to combat diversion are explored, including monitoring of take-home privileges. The safety of the clinic setting may be ensured through the utilization of toxicology screens and breathalyzers as well as through limit-setting, enforcement of program rules and the maintenance of professional therapeutic boundaries.     

心理支持提高美沙酮维持治疗效果的探讨

目的:探讨在不同阶段进行心理支持对美沙酮维持治疗的效果.方法:在美沙酮维持治疗过程中引入心理支持,在入组前、引入期和维持治疗期等不同阶段为受治者提供相应的心理支持,同时进行同伴教育的心理支持.结果:受治者改变了对药物维持治疗的认识与态度,恢复正常的生理、社会功能,提高心理健康水平,提高治疗依从性,降低脱失率.结论:在不同阶段提供心理支持能够改变受治者的高危行为和恢复其各种功能,提高美沙酮维持治疗的效果.     

Detoxification from methadone maintenance: double-blind comparison of two methods.

A well-rehabilitated group of 22 methadone maintenance patients were detoxified under ambulatory and double-blind conditions, over 42 days, either by decreasing the daily dose of methadone and supplementing it by propoxyphene napsylate (M--PN), or by decreasing the daily dose of methadone administered in two equal doses given 12 hours apart (M--M). All of 12 (100%) M--M and 5 of 10 (50%) M--PN subjects were able to temporarily withdraw from methadone maintenance, although two of the M--PN patients required maintenance with propoxyphene napsylate to cease methadone maintenance. In our experience both detoxification methods employed appear superior to the standard withdrawal technique of simply reducing the daily methadone maintenance dose in a step-wise fashion.