Psychotherapy/Counseling for Opiate Addicts: Strategies for Use in Different Treatment Settings

The authors review evidence from outcome studies of psychotherapy for opiate addicts and make recommendations regarding the use of psychotherapy on the basis of the findings. The place of psychotherapy is evaluated for three types of treatment settings: outpatient drug-free treatment, narcotic antagonist treatment, and methadone maintenance. The heterogeneity of opiate addicts is emphasized, as is the need for multidimensional assessment of clients in order to maximize the effectiveness of psychotherapies offered. In each of the treatment settings evaluated, psychotherapy appears to be most promising for a subgroup of those seen. For outpatient drug-free treatment, psychotherapy appears to be most useful for the new client with no treatment history, the successful client graduating from a more intensive program, the client who has temporarily relapsed, and the client leaving jail or a hospital. In a narcotic antagonist program, psychotherapy appears to be most useful for clients entering the program from illicit heroin use and not for those switching from methadone maintenance to a narcotic antagonist program. Moreover, in the maintenance phase of the program, preliminary evidence suggests the value of family therapy for aiding treatment retention. Regarding psychotherapy in the context of a methadone maintenance program, it appears to be best reserved for those addicts who present to treatment with relatively severe levels of psychiatric symptoms.     

A psychoeducational approach to methadone maintenance treatment

Methadone maintenance has become the treatment of choice for heroin addiction because of its beneficial effects on illicit opiate use and criminality. Yet methadone maintenance falls short in a variety of ways; methadone clients continue to use drugs, experience high rates of psychopathology and alcoholism, and fail to become employed and integrated into the community. These problems are endemic in addicts, but also can be attributed to a host of strategic and tactical failures in methadone maintenance treatment itself. Traditional counseling is an inadequate and confused way to provide clients with the living skills, psychotherapy, and limit setting they need. S.T.A.R. is a methadone program in Portland, Oregon, that emphasizes direct training of educational, recreational, and personal skills. Group treatment is employed to create social support for clients while psychotherapy and crisis counseling are available on an as-needed basis. Implementation of the model has caused some difficulties and has led to creative and promising results.     

538例海洛因成瘾者美沙酮维持治疗情况

目的了解538例美沙酮维持治疗者的治疗情况。方法按照国家工作组规定的入组标准,收治自愿参加美沙酮维持治疗试点的患者,对受治者进行问卷调查。结果在538例中,能坚持维持治疗者429例(79.7%),脱失109例(20.3%);经过美沙酮维持治疗后,482例(89.6%)保持操守;静脉注射毒品和违法犯罪现象得到控制;社会功能有所恢复,有104例(25.7%,104/404)找到了工作;检测出的HIV感染者6例全部进入美沙酮维持治疗。结论美沙酮维持治疗在改善吸毒者的社会功能、降低毒品危害方面成效显著。     

Time of day of methadone consumption and illicit heroin use

One hundred clients receiving methadone substitution treatment participated in an investigation of the relationship between methadone dose, time of daily self-administration and reported illicit heroin and other drug use. The study was conducted at two outpatient clinics operating from a single site at the Maudsley Hospital, London. Forty-seven per cent of clients reported using illicit heroin on one or more occasions in the week before interview. Multivariate analysis of methadone dose, time of methadone administration and duration of treatment indicated that the time of methadone administration was the most important predictor of illicit heroin use. Clients who took their methadone before 1500 h were less likely to use heroin than those who consumed methadone later in the day. This finding suggests the possibility of reducing illicit heroin use by methadone maintenance clients through the structuring of treatment programmes so that supervision of methadone consumption occurs during the early part of the day.     

Neuropsychological functioning in opiate-dependent subjects receiving and following methadone maintenance treatment

OBJECTIVE: An accumulating body of research suggests that former heroin abusers in methadone maintenance therapy (MMT) exhibit deficits in cognitive function. Whether these deficits are present in former methadone maintained patients following discontinuation of MMT is unknown. This study tests the hypothesis that former heroin users who have detoxified from methadone maintenance therapy and are drug-free have less pronounced cognitive impairment than patients continuing long-term MMT. METHOD: A series of neuropsychological tests were administered to three groups of subjects: 29 former heroin addicts receiving methadone maintenance treatment, 27 former heroin addicts withdrawn from all opiates, and 29 healthy controls without a history of drug dependence. Testing included Wechsler Adult Intelligence Scale-Revised Vocabulary Test, the Stroop Color-Word Test, the Controlled Oral Word Association Test, the Benton Visual Retention Test, and a Substance Use Inventory. FINDINGS: Both methadone-maintained and abstinent subject groups performed worse than controls on tasks that measured verbal function, visual-spatial analysis and memory, and resistance to distractibility. Abstinent subjects performed worse than their methadone maintained counterparts on tests measuring visual memory and construct formation. Cognitive impairment did not correlate with any index of drug use. CONCLUSIONS: We confirmed previous findings of neuropsychological impairment in long-term MMT recipients. Both patients receiving MMT and former heroin users in prolonged abstinence exhibited a similar degree of cognitive impairment. Cognitive dysfunction in patients receiving methadone maintenance may not resolve following methadone detoxification.     

罗定市海洛因吸毒人群应用美沙酮维持治疗的生活质量调查与相关危险因素分析

目的探讨海洛因吸毒人群应用美沙酮维持治疗的生活质量,并分析其相关危险因素。方法选择2011年6月～2013年2月本院收治的海洛因吸毒患者200例作为观察组（采用美沙酮维持治疗）,同期选择在本院进行住院治疗的非吸毒患者200例作为对照组。两组均进行生活质量与一般情况的调查。结果观察组的躯体功能、角色功能、认知功能、情绪功能与社会功能评分均明显低于对照组（P〈0．05）;多因素条件Logistic回归分析结果显示,获得社会家庭接纳与支持、拥有适当职业、吸毒时间是影响生活质量的主要独立危险因素（P〈0．05）。结论海洛因吸毒人群应用美沙酮维持治疗的生活质量还比较差,要严格根据危险因素加强预防与管理。     

Staff and Client Attitudes toward Methadone Maintenance

Samples of two client groups, one electing to be treated with methadone maintenance and one electing to be treated on an abstinent basis, were compared with each other and with the staff of the multi-modality setting at which those clients were being treated in terms of their characterizations (1) of an addict on heroin, (2) of an addict who has given up all drugs, and (3) of an addict being maintained on methadone. The Adjective Check List was employed. Each group characterized the addict who has given up all drugs as functioning significantly more effectively than the addict being maintained on methadone, with the latter seen by all groups as functioning significantly more effectively than the addict using heroin. These results suggest that methadone maintenance is not yet fully accepted as a long-term treatment device by clients, even by those clients asking to be placed on methadone, or by the staff that administers such treatment. Several reasons are suggested to explain this phenomenon, and exploration is made of the various techniques administrators might employ to deal with it.     

Acceptability of methadyl acetate (LAAM) as compared with methadone in a treatment program for heroin addicts

Heroin addicts who had been maintained for at least three months on LAAM (levo-alpha-acetylmethadol, methadyl acetate) and at least three months on methadone were asked to compare the two drugs on a number of criteria. The responses were highly selective, indicating that a desire to please the investigators was not an important factor. Overwhelmingly, the majority of patients reported that LAAM provided better heroin "blockade", that it was more effective in reducing craving, and that actual use of heroin was less on LAAM than on methadone. In other respects, such as sexual performance, sleep, and appetite, most patients perceived no difference between the drugs. In no respect was methadone preferred by a majority, although methadone was viewed more favorably on some criteria by some patients. These findings indicate that for most heroin addicts LAAM will be an acceptable maintenance drug.     

Reducing benzodiazepine self-administration with contingent reinforcement.

The purpose of the present study was to determine whether drug self-administration by methadone maintenance clients can be influenced by offering methadone clinic privileges contingent upon reductions in drug use, and to compare the reinforcing efficacy in this regard of two different clinic privileges. Eight methadone maintenance clients who had histories of supplemental benzodiazepine use participated. In order to transfer illicit drug use to the treatment clinic, clients were prescribed diazepam, 20 mg/day, at the methadone clinic dispensary. Following assessment of baseline diazepam use, clients were offered, during 6-week blocks of time, either the chance to obtain a single methadone take-home dose or the chance to self-regulate their methadone dose for a single day. These privileges were contingent upon refusing prescribed diazepam at the clinic. During baseline weeks, 95.6% of available diazepam doses were requested. When take-home privileges were available, only 11.2% of diazepam doses were requested, while when dose self-control was available, 69.7% of doses were requested. The study showed that the supplemental drug use of methadone maintenance clients can be influenced by clinic privileges which are available contingent upon reductions of drug use. The medication take-home privilege was more effective as a reinforcer than was limited methadone dosage self-control. Methadone clinic privileges can be used as intervention tools to promote desirable therapeutic behavior change in drug addicts, and in particular to promote reductions in supplemental drug use.     

影响重庆市海洛因成瘾者美沙酮维持治疗保持和脱失因素研究

目的:了解影响重庆市海洛因成瘾者社区美沙酮维持治疗保持和脱失的主要因素。方法:于2008年8月-2009年1月,调查重庆市社区美沙酮维持治疗门诊点参加美沙酮维持治疗的成瘾者300例,分析其社会人口学、药物滥用情况、美沙酮维持治疗情况,比较脱失者与维持者之间的差异。结果:研究对象在文化程度、吸毒年限、参加社区美沙酮维持治疗的时间和与毒友来往程度等方面对维持治疗保持和脱失有影响(P<0.05)。结论:针对影响美沙酮维持治疗的主要因素对参与治疗者开展相应的干预服务,以提高维持治疗的保持率。     

Student Drug Use and the Perceived Peer Drug Environment

The psychopharmacological rationale and clinical effectiveness of the methadone maintenance treatment program was subjected to critical theoretical and methodological analysis. It was concluded (1) that the MMTP constitutes and perpetuates an immature coping mechanism; i.e., “subliminal euphoria”—pervasive pharmacological shielding of addicts from the inevitable discomforts attending adaptation to the real world; (2) that it does not satisfy so-called tissue craving for florid euphoria because most “stabilized” clients actively seek and obtain same from heroin, methadone itself, and/or other potentially euphorogenic drugs; (3) that the source of this craving resides in the addict's personality rather than in his tissues; (4) that official evaluation studies of the MMTP grossly exaggerate its clinical effectiveness; and (5) that the MMTP has inadvertently created incomparably more primary methadone addicts than it has cured heroin addicts.     

The effects of methadone maintenance treatment on heroin addicts with response inhibition function impairments: Evidence from event-related potentials

Response inhibition has been a core issue in addictive behavior. Many previous studies have found that response inhibition abilities are damaged in those with drug dependence. However, whether heroin addicts who are treated with methadone maintenance have an abnormal response inhibition ability is not clear. In order to investigate the response inhibition functions in heroin addicts who were treated with methadone maintenance, electroencephalography (EEG) was used to examine 14 heroin addicts treated with methadone maintenance (HDM), 17 heroin addicts (HD), and 18 healthy controls (HC) in an equiprobability Go\NoGo task. The reaction times (RTs) for the Go stimuli in the HD group were slower than those in the HDM and HC groups. Event-related potential (ERP) measurements showed that NoGo stimuli elicited larger N2 amplitudes than Go stimuli in the HDM and HC groups. However, for the HD group, the N2 amplitudes were similar for the two conditions. In addition, the HDM and HD groups were associated with longer P3 latencies. Our results demonstrated that methadone maintenance treatment might ease the deficits in response inhibition that result from long-term drug abuse. However, compared to normal people, HDM patients have serious problems evaluating and inhibiting inappropriate behaviors.     

Differences in heroin addicts seeking inpatient detoxification, ambulatory detoxification, or methadone maintenance

Fifteen psychosocial characteristics of 300 male and 90 female heroin addicts admitted for inpatient detoxification, ambulatory detoxification, and methadone maintenance within the same multiphasic drug-abuse program were compared to determine whether or not their characteristics differentiated those seeking each type of treatment approach; there were 100 men and 30 women randomly drawn to represent each of the three approaches. Only two variables differed among the three approaches for both men and women--length of daily heroin use and educational attainment. The ambulatory detoxification patients had started using heroin daily at a later age than the inpatients who, in turn, had started using heroin daily at a later age than the methadone maintenance patients, and the ambulatory detoxification patients were more educated than the inpatients. The other variables differentiating the three approaches for each sex were discussed, and the conclusion was drawn that addicts with higher socioeconomic levels preferred ambulatory detoxification over methadone maintenance.     

Structural-level factors affecting implementation of the methadone maintenance therapy program in China

This study identifies structural-level factors influencing methadone maintenance therapy (MMT) program implementation in China. Twenty-eight service providers and 560 randomly selected clients from 28 MMT clinics in the study area underwent face-to-face interviews. Number of clients, retention rate, coverage, and structural-level factors were collected from a survey of service providers. Individual-level factors and self-reported illicit drug use information were obtained from clients. Urine specimens were collected from the client participants to test for heroin use. Clinics affiliated with the local Centers for Disease Control and Prevention (CDC) had more clients, higher retention rates, and broader coverage than those not affiliated with the CDC. Longer operating hours, incentive for compliant clients, and comprehensive services were positively associated with client recruitment and coverage. Comprehensive services and incentives for compliant clients were negatively associated with concurrent illicit drug use. Comprehensive services should be incorporated into the MMT program. Extended operating hours and incentives for compliant clients should be implemented.     

美沙酮维持治疗150例海洛因依赖者对海洛因渴求度的变化及影响因素分析

目的:了解哈密市美沙酮治疗对药物成瘾者海洛因渴求度的控制情况,探讨美沙酮维持治疗患者接受治疗6个月后对海洛因渴求程度的改变情况以及影响渴求改变的可能因素。方法:采用《海洛因渴求问卷》分别在患者入组治疗时和治疗6个月后随访调查,分析美沙酮维持治疗前后患者对海洛因等毒品的渴求程度以及影响渴求程度改变的因素。结獉果獉:MMT患者治疗6个月后的海洛因渴求水平比基线时普遍下降,除"自我控制"外其他各因子得分差异均有统计学意义。150例MMT患者中有70例患者在治疗6个月后渴求总分得到改善,改善率为46.7%。结论:美沙酮维持治疗能够减少海洛因成瘾者对海洛因的渴求感,患者吸毒年限、文化程度和是否戒过毒是影响渴求的主要因素。     

A Comparison of Abstinence-Oriented and Indefinite Methadone Maintenance Treatment

Advantage was taken of a natural experiment to compare the outcome of abstinence-oriented and indefinite methadone maintenance. Subjects assigned to an abstinence-oriented program were significantly more likely than those assigned to indefinite maintenance to use heroin (OR 1.3) and amphetamines (OR 2.8) during the first 2 years of methadone treatment but less likely to use benzodiazepines (OR 0.7). Subjects discharged from the abstinence-oriented program were significantly more likely to relapse and return to maintenance treatment (RR, first 6 months, 4.2). The abstinence-oriented program was also less able to attract heroin addicts into maintenance treatment.     

Five Patterns of Darvon Abuse

The “United Kingdom Statistics of Drug Addiction and Criminal Offences Involving Drugs” (published by the Home Office) gives the following data as of 31st December 1969: of the total number of 1466 known drug addicts (namely, addicts to hard drugs), 499 were taking heroin, and more than double that number, namely 1011, were taking methadone (either alone or with other drugs). A footnote explains that “as a result of a deliberate policy adopted by Hospital Clinics in the treatment of heroin addiction, of weaning patients from heroin on to methadone, methadone has supplanted heroin as the drug most commonly used by addicts.” What is meant by the phrase “most commonly used by addicts” is probably, “most commonly prescribed to addicts,” as, of course, the number of abusers or addicts buying “Chinese heroin” or English heroin or methadone on the black market is unknown. There is, in fact, a certain amount of black market dealing in these and other drugs going on.     

Buprenorphine in the treatment of opioid dependence.

Buprenorphine has become of increasing interest to be an alternative to methadone in the treatment of heroin addicts. The aim of the paper is to review, from a clinical perspective, the current status of what is known about the pharmacology of buprenorphine, with a particular emphasis on the issues of maintenance therapy in heroin addiction. A systematic review of published follow-up data, from observational and experimental studies was done. Electronic databases Medline and PSYNDEXplus were searched from their earliest entries. Buprenorphine appears to be a well-tolerated drug, with a benign overall side effect. Buprenorphine is an additional treatment option for heroin dependent patients, especially for those who do not wish to start or continue with methadone or for those who do not seem to benefit from adequate dosages of methadone.     

A comparison of thrice weekly LAAM and daily methadone in employed heroin addicts

Forty-eight employed heroin addicts were maintained on daily doses of methadone for four months and then randomly assigned to continue methadone maintenance or be switched to thrice weekly levo-alpha-acetylmethadol (LAAM). LAAM patients had significantly less illicit drug use and longer treatment retention times than those remaining on methadone. They also preferred LAAM to methadone on nine of 15 criteria such as the dosage schedule, feeling ‘normal’, and reduction of craving for heroin. LAAM may be particularly useful with employed patients owing to the reduced frequency of clinic visits.     

Comparative Treatment Effectiveness: Effects of Program Modality and Client Drug Dependence History on Drug Use Reduction

This study examined treatment outcome as a function of program modality, clients’ lifetime patterns of drug dependence, and their interaction, controlling for current level of drug use at treatment intake. Data were based on 2,966 clients who were interviewed at intake and at 1-year follow-up as part of the Drug Abuse Treatment Outcome Study (DATOS), which included programs of four major modalities. Subjects’ lifetime patterns of drug dependence were classified into nine groups according to Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association; 1987) diagnostic criteria and time of onset of drug use career. Outcome measure was the reduction of heroin use or cocaine use at follow-up from levels at intake. The results showed that rates of lifetime drug dependence and current drug use at DATOS admission were highest among methadone maintenance clients and lowest among outpatient drug-free clients. Drug use reduction was observed for all modalities. The presence of dependence diagnosis was associated with less improvement when current use level at intake was controlled. Clients dependent on heroin but not currently daily users benefited most from inpatient and residential programs. Methadone programs were also relatively ineffective in reducing cocaine use. Characteristics of the client’s drug dependence history, in addition to the current or presenting drug problem, should be assessed to guide treatment planning. The high rate of cocaine dependence among methadone clients, most of whom were dependent on heroin, poses considerable challenge to contemporary opiate substitution treatments. Published by Elsevier Science Inc.