美沙酮维持治疗患者的健康问题和就医行为

目的:了解美沙酮维持治疗患者的健康问题和就医行为。方法:问卷调查;分项统计人数及百分比,并计算标准差、中位数、众数、极差。结果:90.1%的患者报告患有一种或一种以上疾病,其中丙型肝炎患病率为84.8%;98.4%的患者报告近3个月有健康问题,其中报告性欲减退(80.7%)、便秘(77.0%)、多汗(67.1%)的患者最多,73.0%的男性患者有勃起障碍,56.8%的女性患者月经不规则;60.4%的患者会首选咨询美沙酮维持治疗门诊医生,其次是综合医院医生(14.3%)和其他服药人员(10.2%);54.4%的患者因经济原因未能得到规范治疗,其次是因为不愿向医生坦白吸毒史(43.3%)和认为自行服药可以解决问题(39.5%)。结论:美沙酮维持治疗患者普遍存在健康问题,而患者的就医意识不强,大部分患者没有接受正规的医疗服务,应在门诊内开展积极有效的健康教育和医疗援助活动。     

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.     

Methadone dosage and retention: an examination of the 60 mg/day threshold

A National Institutes of Health (NIH) expert panel has mentioned a daily methadone dose of at least 60 mg as a best practice in methadone maintenance. The focus of this research is to estimate the percentage of outpatient methadone clients receiving this level of methadone and examine the association between treatment retention and level of methadone dosage as recommended by the NIH expert panel. A sample of 428 methadone clients discharged from methadone treatment facilities from the Alcohol and Drug Services Study (ADSS) was used, representing 109,973 methadone clients nationally. It was estimated that more than two-thirds of methadone clients nationally were receiving below 60 mg/day. While controlling for a number of client and organizational variables, a daily methadone dose of 60 mg/day or above was found to be associated with longer retention in treatment. Exploring factors affecting the utilization of the recommended daily methadone dose remains an important issue in effective delivery of methadone treatment.     

Accelerated withdrawal from methadone maintenance therapy using naltrexone and minimal sedation: a case-series analysis

The aim of this study was to measure the acceptability to stable methadone maintenance clients seeking termination of methadone treatment of accelerated withdrawal using a standardized protocol of naltrexone and minimal sedation; and to provide a first assessment of the probable demand for such treatment, characterize the withdrawal experience, and describe the outcomes for the clients using naltrexone for maintenance therapy for 3 months following withdrawal. We used an open label observational study of 14 stable, methadone maintenance programme clients within the Australian Capital Territory. We found a high degree of acceptability of the withdrawal approach to clients and staff. Three phases of withdrawal identified over a 3-week period. There was rapid attrition from naltrexone maintenance over 3 months of follow-up and a return to dependent opiate use in four clients. The protocol is a humane, effective approach to accelerated withdrawal from methadone maintenance. It is a useful modification to ultra-rapid and other rapid withdrawal techniques. Naltrexone maintenance has a limited potential role in this group of subjects. This role also needs further clarification through well-designed randomized clinical trials.     

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.     

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.     

A study of hospitalized surgical patients on methadone maintenance

It is possible that admission to hospital of methadone maintenance clients requiring treatment for pain with narcotics may result in an increase in methadone maintenance dose and affect subsequent rehabilitation of the client. The hospital admission itself may modify the subsequent outcome of the client. Fifty clients of a Methadone Maintenance Therapy Program were retrospectively evaluated. Twenty-five had been admitted to the Surgical Service of Bellevue Hospital, New York City, for a variety of conditions and for periods ranging from 2 to 43 days; twenty-five were not admitted to the Hospital. Irrespective of whether or not large amounts of narcotic analgesics had been added to the maintenance methadone, patients were discharged on the same amounts of maintenance methadone as on admission and had eventual courses and outcomes similar to the control group when followed for a mean period of 20 months.     

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 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.     

Changes in the characteristics of clients admitted to an Australian therapeutic community, "The Buttery", 1980-92

Data are presented on the characteristics of clients admitted to an Australian therapeutic community, The Buttery, between 1980 and 1992. The typical client was a 28-year-old male with a primary opioid drug problem complicated by polydrug use, particularly of alcohol and stimulants. Prior treatment experience was common, with one in three having been enrolled in methadone maintenance treatment. The average age of clients increased by about 7 months per year, and there was an increase in the prevalence of alcohol, stimulant and polydrug problems over the period of study. There was also an increase in the exposure of clients to methadone maintenance treatment prior to admission to the Buttery. Overall, the characteristics of patients in this drug-free treatment programme were strikingly similar to those observed among patients in methadone maintenance treatment over the same period.     

Withdrawal from methadone maintenance. Impact of a tapering network support program.

This study assessed the impact of providing tapering and aftercare assistance to individuals addicted to heroin maintained on methadone. Participants were clients in six outpatient methadone maintenance clinics who expressed a motivation to withdraw from methadone and who met criteria predictive of success. Fifty-eight clients in three clinics had an enriched program available, whereas 56 clients in three matched comparison clinics received written materials only. No significant differences were found in the proportion of study participants who reached 0 mg or who reduced their dose during study participation. Discussion focuses on ways to improve the quality of methadone treatment in preparation for eventual withdrawal.     

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.     

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.     

Under-utilisation of Addiction Treatment Services by Heroin users from Ethnic Minorities: Results from a Cohort Study Over Four Years

In this study the hypotheses were tested that retention rates, days spent in methadone treatment and upward mobility to outpatient and inpatient treatment modalities for heroin-dependent people in a methadone programme are lower for clients from ethnic minorities as compared with the clients from the ethnic majority (Dutch). Anonymous data for 742 heroin-dependent people who entered methadone treatment in 1996 were extracted from a psychiatric case register. Their health service utilisation was analysed over a period of four years. Results show that ethnic minorities are under-represented in the methadone programme. They also spent fewer days in the methadone programme. No differences were found between ethnic minorities and the Dutch clients in their use of outpatient treatment. However, people of Moroccan and Turkish descent were under-represented in inpatient treatment. This is of concern because fewer days in treatment predict less than optimal treatment outcomes.     

Economic cost of the therapeutic workplace intervention added to methadone maintenance

Therapeutic workplace is a novel intervention that uses access to paid training and employment to reinforce drug abstinence within the context of standard methadone maintenance. We used the Drug Abuse Treatment Cost Analysis Program as a standard method of estimating the economic costs of this intervention. In a 1-year period, the therapeutic workplace served 122 methadone maintenance clients who had a median length of stay of 22 weeks. The workplace maintained a mean daily census of 48 clients. The combined cost of methadone maintenance and the therapeutic workplace was estimated at US$362 per week. This cost is less than that of other treatments that might be used to promote abstinence in individuals who continue to use drugs during methadone treatment. Given prior evidence of effectiveness, these cost data may be useful to policy makers, social service agencies, and researchers interested in using or further developing the therapeutic workplace intervention.     

Health status of clients receiving methadone maintenance treatment using the SF-36 health survey questionnaire

This study investigated the health status of a representative sample of clients (35 Maori, 72 non-Maori) receiving methadone maintenance treatment in New Zealand, using the SF-36 health survey. The publication of New Zealand norms in 1999 enabled comparisons of the health of the Methadone Treatment Programme study participants with that of the New Zealand population. Although over 50% of participants rated their health as good, very good or excellent, 44% rated their health as fair or poor and compared with population norms, the health of the study participants was significantly poorer on all eight SF-36 scales. Male and female participants rated their health similarly to male and female clients attending another New Zealand Methadone Treatment Programme. Results highlighted the impact of a chronic disorder and co-existing health-related problems on the health and well-being and day-to-day functioning of this client group. Higher frequency of benzodiazepine use was associated with poorer social functioning, mental health and role functioning and higher frequency of cannabis use was associated with poorer role functioning due to emotional problems. Findings support routine monitoring of health status with clients receiving methadone maintenance treatment as a guide to preventative and treatment interventions and health maintenance strategies. [Deering DE, Frampton CMA, Horn J, Sellman JD, Adamson SJ, Potiki TL. Health status of clients receiving methadone maintenance treatment using the SF-36 health survey questionnaire. Drug Alcohol Rev 2004;23:273-280]     

Improvements in retention rates and changes in client group with methadone maintenance streaming

This study evaluated changes in client population and in retention rates following the introduction of a system of methadone maintenance streaming. A low intervention and low supervision stream was combined with two abstinence-orientated streams. Privileges of take-home doses and local pharmacy dose collection were contingent on successful participation in the abstinence-orientated streams. The clinic also modified policy to allow clients greater control over dose levels. The case notes of the first 100 clients entering the programme in the year prior to the changes (1991) and in the year following the changes (1993) were compared. The results showed a significant increase in retention rates. The demographic and heroin using histories did not change, but the newer programme attracted a greater proportion of clients with no previous history of methadone maintenance treatment. Mean clinic dose increased from 45 mg to 63 mg when clients were allowed to exert control over dose. These findings reveal improved outcomes in a public methadone maintenance programme as a result of policy changes designed to give clients greater control of their treatment.     

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.     

The use of token economy to reduce illicit drug use among methadone maintenance clients

The effects of a token economy in modifying the illicit polydrug use of 97 methadone maintenance clients was investigated over a period of two and a half years. Subjects' drug-free urinalysis reports were reinforced with points which could be redeemed to obtain methadone. Each subject's daily dose level varied with the point balance. A multiple baseline analysis showed that when methadone acquisition was in part made contingent upon drug-free urinalyses, illicit drug use declined rapidly. After six months, the token economy group's urines were 14% positive for illicit drugs compared to 39% in the traditional treatment group. As time in treatment increased, illicit drug use further declined. These results suggest a more effective and practical strategy for the treatment of polydrug abusing methadone maintenance clients than has previously been available.