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.     

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.     

Drug abuse treatment retention and process effects on follow-up outcomes

After finding that retention in methadone treatment for a year or longer was a highly significant predictor of patient outcomes following discharge, measures of pretreatment motivation and early therapeutic engagement were examined as predictors of program retention. Personal interviews were conducted with a sample of 435 patients 12 months after discharge from three methadone treatment programs. Logistic regression results showed several patient attributes—i.e. over 35, lower injection frequency before admission, and higher motivation for treatment—were each associated with twofold increases in the likelihood of having favorable follow-up outcomes on illicit drug use, alcohol use, and criminal involvement. Patients staying in treatment a year or longer, however, were nearly five times more likely to have better outcomes. Further analyses established that length of treatment stay was predicted by higher patient motivation at intake and early program involvement. The findings suggest that more comprehensive models of patient attributes, therapeutic process, and environmental influences are needed, and that treatment enhancement efforts should focus on such during-treatment measures as interim criteria for improving posttreatment outcomes.     

QT Interval Screening in Methadone Maintenance Treatment: Report of a SAMHSA Expert Panel

ABSTRACT

In an effort to enhance patient safety in opioid treatment programs, the Substance Abuse and Mental Health Saervices Administration convened a multi-disciplinary Expert Panel on the Cardiac Effects of Methadone. Panel members (Appendix A) reviewed the literature, regulatory actions, professional guidances, and opioid treatment program experiences regarding adverse cardiac events associated with methadone. The Panel concluded that, to the extent possible, every opioid treatment program should have a universal Cardiac Risk Management Plan (incorporating clinical assessment, electrocardiogram assessment, risk stratification, and prevention of drug interactions) for all patients and should strongly consider patient-specific risk minimization strategies (such as careful patient monitoring, obtaining electrocardiograms as indicated by a particular patient's risk profile, and adjusting the methadone dose as needed) for patients with identified risk factors for adverse cardiac events. The Panel also suggested specific modifications to informed consent documents, patient education, staff education, and methadone protocols.     

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.     

An 18-Year Follow-Up of Patients Admitted to Methadone Treatment for the First Time

ABSTRACT

An 18-year addiction career, 1985-2003, for 157 heroin dependent subjects (73% men; 49% human immunodeficiency virus seropositive) admitted for the first time to Stockholm's Methadone Maintenance Treatment program during 1989 to 1991 was analyzed with data from seven official registers and patient records. Regression analyses and incidence rates for various outcomes were calculated for subjects in first methadone maintenance treatment at the end of the observation period, discharged from first methadone maintenance treatment, in second methadone maintenance treatment, and discharged from second methadone maintenance treatment. Being human immunodeficiency virus positive (HR = 3.8), lodging (HR = 1.9) and prison sentence (HR = 1.7) predicted mortality for the 45% deceased. Approximately 70% of living subjects participated in methadone maintenance treatment at some period each year. Subjects in first or second methadone maintenance treatment had less criminality and had spent more time in methadone maintenance treatment (70% to 100%) than those discharged from first or from second methadone maintenance treatment (50%). Efforts and interventions should be intensified to increase time in treatment also for those with high problem severity.     

Integrating injectable opioid agonist treatment into a drug treatment court program: A case study

Background: A substantial proportion of individuals involved with the North American criminal justice system are convicted for drug-related activities. Drug treatment court (DTC) programs were developed as an alternative to incarceration for drug-related offences and aim to prioritize addiction treatment and improve health and social outcomes; however, only a fraction of DTC participants have access to first-line medications for opioid use disorder (OUD). Further, despite emerging evidence for the efficacy of injectable opioid agonist therapy (OAT) in treating individuals with severe OUD where past treatment attempts with first-line therapies have been unsuccessful, this treatment has never, to our knowledge, been implemented in correctional settings. Case: An individual in their 50s with a history of severe OUD, multiple interactions with the criminal justice system, and prior unsuccessful treatment attempts with methadone was initiated on injectable treatment with diacetylmorphine. The patient received 300?mg of diacetylmorphine witnessed 3 times daily at a supervised injection clinic. During a 1.5-year stabilization phase, the patient’s illicit opioid use significantly reduced. They subsequently enrolled in a DTC program for drug-related charges preceding initiation on injectable OAT and remained on this therapy during 16 months in DTC. Following graduation from DTC, the patient continued to receive treatment and returned to gainful employment in the community, with no further charges or episodes of incarceration. Discussion: This case describes the successful completion of a DTC program by an individual prescribed injectable OAT for severe OUD. The patient’s treatment plan played an integral role in DTC graduation and long-term adherence, leading to improved health and social outcomes, including cessation of illicit drug use, enhanced quality of life, and improved social functioning. The case highlights the potential benefits of a stepped and integrated approach to addiction treatment in DTC programs.     

Organizational determinants of outpatient substance abuse treatment duration in women

Longer treatment duration has consistently been related to improved substance use outcomes. This study examined how tailored women's programming and organizational characteristics were related to duration in outpatient substance abuse treatment in women. Data were from two waves of a national outpatient substance abuse treatment unit survey (n = 571 in 1999/2000, n = 566 in 2005). Analyses were conducted separately for methadone and nonmethadone programs. Negative binomial regressions tested associations between organizational determinants, tailored programming, and women's treatment duration. Of the tailored programming services, childcare was significantly related to longer duration in the nonmethadone programs, but few other organizational factors were. Tailored programming was not associated to treatment duration in methadone programs, but ownership, affiliation, and accreditation were related to longer duration. Study findings suggest evidence for how external relationships related to resources, treatment constraints, and legitimacy may influence women's treatment duration. Methadone programs may be more vulnerable to external influences.     

Persistence of heroin use despite methadone treatment: Poor coping self‐efficacy predicts continued heroin use

Aim. To evaluate the association between coping self‐efficacy and persistent use of heroin by patients enrolled in a methadone treatment program. Design and Methods. Cross‐sectional survey. One hundred and ninety‐one patients attending outpatient methadone clinics in South‐East England, United Kingdom. Validated questionnaires were used to assess drug use (Maudsley Addiction Profile), alcohol use (Alcohol Use Disorders Identification Test), mental health (Hospital Anxiety and Depression Scale) and coping self‐efficacy (brief 8‐item Drug Taking Confidence Questionnaire). Results. Half of the participants (95/191) reported heroin use in the preceding 14‐day period. Heroin use during methadone treatment was associated with financial problems (P = 0.008), spending time with other drug users (P < 0.001), cocaine use (P = 0.002), low mood (P = 0.002) and dissatisfaction with the daily methadone dose (P = 0.014). Compared with ‘Heroin‐abstinent’ patients, the ‘Heroin’ group reported significantly lower mean coping self‐efficacy scores (t = 9.8, d.f. = 182, P < 0.001, effect size 1.17). After correcting for the effects of co‐variants in a logistic regression model, the main determinants of persistent heroin use were ‘coping self‐efficacy’[B ?0.05; standard error (SE) 0.008; Wald 36.6; odds ratio (OR) 0.95, 95% confidence interval (CI) 0.94, 0.97; P < 0.001] and ‘dissatisfaction with methadone dose’ (B 0.93; SE 0.46; Wald 4.1; OR 2.5, 95% CI 1.03, 6.25; P = 0.042). Satisfaction with methadone dose showed no association with self‐efficacy. Discussion and Conclusions. While heroin use during methadone treatment can partly be explained by inadequate dosing, our data suggest a more complex picture with significant contribution from poor coping self‐efficacy. Efforts aimed at enhancing and maintaining the patients' self‐efficacy and social skills are likely to improve heroin and other drug use outcomes with added benefits for treatment completion rates and the throughput of methadone programs.[Senbanjo R, Wolff K, Marshall EJ, Strang J. Persistence of heroin use despite methadone treatment: Poor coping self‐efficacy predicts continued heroin use. Drug Alcohol Rev 2009]     

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.     

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.     

Outcomes after methadone maintenance and methadone reduction treatments: two-year follow-up results from the National Treatment Outcome Research Study

This paper provides a detailed analysis of the 2-year outcomes for 351 drug misusers allocated on an intention-to-treat basis to methadone maintenance or methadone reduction treatments. Both groups showed substantial reductions in their use of illicit drugs and in other outcome areas. However, whereas most methadone maintenance patients received maintenance, only about one third of those allocated to methadone reduction received methadone reduction, and many actually received a form of methadone maintenance. Reduction patients were more likely to receive low doses of methadone, and were less likely to remain in treatment. For maintenance patients, higher doses and retention in treatment were both associated with improvements in illicit heroin use at 2 years. For the reduction patients, the more rapidly the methadone was reduced, the worse the heroin use outcomes. For patients in both treatment conditions, reductions in heroin use were associated with improvements in other outcome areas. The more severely dependent patients showed better outcomes in methadone maintenance. Methadone reduction treatment processes were associated with poor outcomes, and many patients who were allocated to methadone reduction treatment did not receive reduction treatment as intended. This calls into question the appropriateness of either the initial treatment planning process or the treatment delivery process, or both. A clearer distinction should be made between methadone maintenance and methadone reduction. Treatment goals should be made explicit both to the patient and to the clinical staff at the start of treatment. We suggest the need for a reappraisal of the goals and procedures of methadone reduction treatment.     

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.     

Diminished Illicit Drug Use as a Consequence of Long-Term Methadone Maintenance

In the twenty-five years since its introduction as a treatment for opiate addication, methadone mainentance has generated considerable controversy regarding both its appropriateness as a treatment modality and its efficacy in diminishing opiate abuse. Given current concenrs regarding the spread of HIV amongst IV drug abusers, the role of methadone maintenance may be more important than ever. The present study was designed to examine continued illicit substance abuse by 229 patients enrolled in methadone treatment. Specifically, while 35% of the patients enrolled for less than 12 months were opiate free for the 3 month period, that value increased71% for patients enrolled for more than 4 years, and 85% for paients remaining in treatment for over 10 years. These results based on urinalysis support the conclusion of Ball and Ross (1991), based on ASI scores and criminally data, that methadone is an effective treatment modality for opiate addicted individuals.     

The Expansion of Methadone Prescribing in Ontario, 1996–1998

Various Ontario agencies have co-operated to increase the availability of methadone maintenance treatment (MMT) across Ontario. It is expected that increased availability of MMT will lead to a reduction in some of the harms of opioid use, such as HIV infection acquired through needle use. This initiative is consistent with Canada's Drug Strategy and with MMT policy changes at the federal level and is responsive to concerns of methadone patient advocates and treatment providers. When the Methadone Program at The College of Physicians and Surgeons of Ontario was established in mid-1996, there were 975 patients in MMT across Ontario. At the end of 1998 - two and a half years later - there were over 4000. This expansion is attributed to policy changes at the provincial level which were facilitated by the development of MMT guidelines compatible with both harm reduction-based and abstinence-based treatment approaches and the development of a MMT training program and supporting reference materials.     

The impact of ongoing illicit drug use on methadone adherence in illicit drug users receiving treatment for HIV in a directly observed therapy program

INTRODUCTION: Studies evaluating the effectiveness of opioid agonist therapy programs typically evaluate drug abstinence or treatment retention as their primary outcomes. However, in many circumstances (e.g. directly observed therapy (DOT) programs within methadone maintenance programs), methadone adherence is an extremely relevant clinical outcome. We sought to evaluate the impact of ongoing illicit drug use on methadone adherence within a DOT program for the treatment of HIV-infection. METHODS: Patients were enrolled in a DOT program, where methadone and HIV medication are co-administered by a community pharmacist. Drug use (amphetamines, benzodiazepines, cocaine, and opiates) was assessed by repeated urinalysis results. Methadone adherence was calculated as the fraction of days methadone was administered. RESULTS: Ongoing drug use, and poly-substance use was common, with only 4 of 60 patients abstaining from all illicit drug use. Overall methadone adherence was 84.5%. Amphetamine use (without benzodiazepine and cocaine use), benzodiazepine use (without amphetamines) and higher methadone doses were associated with higher methadone adherence. When patients used benzodiazepines or cocaine, any positive effect associated with amphetamine use was negated. In addition, opiate use was associated with decreased methadone adherence. DISCUSSION: The effect of many illicit drugs on methadone adherence may differ from reports using other treatment outcomes.     

The Effects of Community Structure on During-Treatment Outcomes of Methadone Maintenance Programs

This study examines the effects of selected community factors on aggregated during-treatment outcomes of methadone maintenance programs in 27 cities. The basic premise of the study is that methadone maintenance (MM) program outcomes on such measures as drug use, criminality, and productive activities are significantly affected by factors in the community environment. The results indicate that community measures are associated with outcomes on drug use (opiate and nonopiate), productive activities, and criminality but not with alcohol use. Another finding is that global measures such as overall quality of life of a community are not clearly related to outcomes of MM programs. It is also found that property crime rates, which are frequently used as indicators of prevalence of drug use, are not related to during-treatment program outcomes of drug use and criminality.     

Physicians' Attitudes and Retention of Patients in Their Methadone Maintenance Programs

A study was undertaken to investigate the influence of methadone prescribes' commitment to abstinence-oriented policies on retention in their maintenance programs. Two hundred and eighty patients recently enrolled in single-person, private methadone programs were interviewed and followed for 8 years. The prescribing physicians' scores on an Abstinence Orientation Scale, derived from an independent sample of methadone program staff, were significantly associated with their patients' risk of premature discharge. The influence of program orientation on retention was greater the higher the maximum dose of methadone. More attention should be paid to the effect of staff attitudes and beliefs on the effectiveness of maintenance treatment.