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.     

Heroin addiction,renal failure,and methadone maintenance: A follow-up report

In a previous article the authors reported renal transplantation in a male veteran heroin addict being treated with methadone maintenance. They now report the 5-year follow-up of this patient and his subsequent renal transplant rejection.     

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.     

Contingency contracting and systematic desensitization for heroin addicts in methadone maintenance programs

The use and effectiveness of contingency contracting and systematic desensitization with heroin addicts being treated in methadone maintenance programs are discussed. Both behavior therapies can be practically implemented in methadone maintenance programs to supplement methadone pharmacotherapy. Contingency contracting has been effectively employed to reduce illicit drug use and to manage patients in the clinic. Systematic desensitization has less effect on actual heroin usage yet effectively reduces the fear of withdrawal and general anxiety, while improving self-image, assertiveness, and adjustment in the community. A clinic protocol that incorporates all three therapies-methadone maintenance, contingency contracting, and systematic desensitization-is proposed.     

Chronic heroin use during methadone treatment: a test of the efficacy of high maintenance doses

A pilot study was conducted at two maintenance programs to test the effect of increasing the methadone dose of clients who continue chronic heroin use after stabilization on methadone. Program 1 subjects (Group 1) received substantial dose increases for a 14-week period; Program 2 subjects (Group 2) received no dose modifications during the same period. Results show Group 1 reported an alleviation of physical and psychological complaints but did not decrease illicit opiate use. Group 2 maintained the low level of complaints reported at baseline and, unexpectedly, decreased opiate abuse. Because the two maintenance programs differed in clinical practices and in enforcement of rules, it was concluded that clients who continue chronic heroin use need not only long-term dosage increases, but also clear, consistently applied program policies.     

Patterns of heroin use in the methadone programme in Sydney, 1986-1987

A study was undertaken to examine patterns of heroin use by clients attending New South Wales Health Department methadone maintenance units in Sydney. The study group included those clients who commenced taking methadone between January 1986 and January 1987 and who remained on individual programmes until December 1987. A total of 16 800 urinalysis results from 346 clients were examined. Data were correlated vertically so as to examine heroin use by all clients beginning with their first dose of methadone. Contrary to expectation, the data indicate that heroin use did not decline as a function of time. The data were further examined within a numerically stable group, which had been sub-classified according to the number of morphine positive urine samples over a period of 12 months. These data indicated the existence of two major groups; those whose continued use of heroin could be described as occasional and another heavy using group. The latter constituted 51% of the study population and contributed almost 90% of the morphine positive urines. The use of urinalysis data to identify the heavy and occasional-user groups could assist in a study to define those factors which could be responsible for the continued use of heroin whilst on a methadone maintenance programme.     

Diversion in Drug Related Cases—A View From the Defense

Abstract

The use and effectiveness of contingency contracting and systematic desensitization with heroin addicts being treated in methadone maintenance programs are discussed. Both behavior therapies can be practically implemented in methadone maintenance programs to supplement methadone pharmacotherapy. Contingency contracting has been effectively employed to reduce illicit drug use and to manage patients in the clinic. Systematic desensitization has less effect on actual heroin usage yet effectively reduces the fear of withdrawal and general anxiety, while improving self-image, assertiveness, and adjustment in the community. A clinic protocol that incorporates all three therapies—methadone maintenance, contingency contracting, and systematic desensitization—is proposed.     

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.     

Richard Lane:

After a long and courageous battle with cancer, Richard Lane died in 1994. He had been a long-term heroin addict and spent 12 years in prisons. After commencing treatment with methadone, he began to work with other addicts and helped to start Man Alive, the first methadone program in Baltimore. He later became Executive Director of Man Alive and a national leader in the effort to improve and expand methadone maintenance treatment. Among the innovations he promoted within the methadone program were onsite alcoholism treatment, protocols for poly-drug abuse, services for patients with acquired immune deficiency syndrome, improved pain management for methadone patients, and fewer restrictions for socially rehabilitated patients on methadone. He fought tirelessly for acceptance of methadone maintenance treatment by those in medicine, law enforcement, and politics. His accomplishments can inspire all in the addiction field to continue their efforts to improve the care of the addict.     

影响美沙酮维持治疗依从性的因素

目的研究影响美沙酮维持治疗依从性的因素。方法研究对象为100名在我院美沙酮维持门诊治疗的海洛因依赖者。根据其在维持治疗门诊中服药时间的长短分为两组。I组服药时间不足3个月退出治疗者,II组为服药时间超过6个月仍在维持治疗者。分析两组海洛因依赖者的社会人口学特征、药物依赖及治疗剂量、治疗时间等影响美沙酮维持治疗依从性的因素。结果年轻的、单身、男性、无业、文化程度低、无家人支持、多药物滥用者是影响美沙酮维持治疗依从性的危险因素。结论临床上对影响维持治疗的危险因素进行甄别,并采用相应的干预措施,能有效提高美沙酮维持治疗效果。     

An exploration of prisoners' and prison staff 's perceptions of the methadone maintenance programme in Mountjoy Male Prison, Dublin, Republic of Ireland

This study, which was based in Ireland's main committal prison, used semi-structured interviews and a focus group to explore the perceptions of staff and prisoners towards methadone maintenance within the prison setting. Although the research subjects identified advantages and disadvantages associated with methadone prescribing within the prison, they were generally positive in their assessment of Mountjoy's methadone programme. Prisoners perceived it as leading to an improvement in their relationships with their families, while staff viewed it as facilitating a more stable and safer working environment. However, although prisoners' use of heroin had reportedly declined since the advent of the methadone maintenance programme in the prison, their use of other drugs had not. There were negative views expressed by both groups about the manner in which methadone is dispensed within the prison, and also because methadone was viewed as being as addictive as heroin. Regarding perceptions of the purpose of methadone maintenance, there was a spectrum of interpretations among the interviewees. Five purposes were identified. These were: (1) to ensure continuity of harm-reduction policies from the community; (2) to reduce the supply of heroin in the prison; (3) to prevent needle sharing and the spread of blood-borne infections; (4) to treat heroin addiction; and (5) to control prisoners and maintain order and discipline within the prison. Apropos the latter, there was a widely held perception within the total sample that this latent function of methadone maintenance could be seen as of greater importance than the more conventional harm-reduction functions that were also identified.     

Determinants of methadone treatment assignment among heroin addicts on first admission to public treatment centres in Italy

AIMS: To identify factors associated with entering any methadone treatment at first admission at an NHS treatment centre in Italy and to investigate determinants of receiving detoxification or maintenance methadone treatments. METHODS: Data were analysed from 565 heroin addicts who entered for the first time one of 90 NHS treatment centres in 12 Italian regions between September 1998 and March 2001. Subjects were interviewed at admission by the centre's staff and followed-up for 18 months. Details on treatments provided were recorded using a standardised form. Random effects logistic regression analysis was applied. RESULTS: Factors positively associated with any methadone treatment assignment were: being younger than 25 years and using heroin more than twice a day, having been recently incarcerated, and living with a partner. Independent predictors of admission to methadone maintenance were injecting heroin, having sex without a condom in the previous six months, being HIV positive and having been enrolled at a NHS TC where a psychiatrist was present. Using heroin once a day or more and using cocaine were factors associated with enrollment into detoxification treatment. A significant heterogeneity between centres was observed. CONCLUSIONS: Results from this study give an insight into different patient profiles who are enrolled in methadone treatments. The observed heterogeneity between centres indicates the need to develop and implement common guidelines for the access of heroin addicts to substitution treatment.     

Twenty-Five Basic Joining Techniques in Family Therapy

Abstract

Attitudes of opioid users toward methadone maintenance were studied using semistructured field interviews. One hundred and sixty-one heroin and speedball users in San Antonio, Texas, were interviewed between 1989 and 1992. Users were classified according to whether or not they had ever been on methadone maintenance. Opioid users who had never been on methadone maintenance were more likely to express a negative attitude toward methadone maintenance than users who had been on it (50% versus 30%). Sources of negative attitudes fell into the following categories: (1) general societal disapproval of addictive drugs, including methadone; (2) prior experience with 12 Step groups or abstinence-based treatment programs; (3) previous forced rapid detoxification from methadone in jail; and (4) observation of methadone maintained peers who continued to use drugs. Very few respondents reported adverse effects from methadone itself as a source of negative attitudes. Sources of positive attitudes included: (1) prior successful treatment with methadone; and (2) observation of methadone patients who stopped using drugs.     

An exploration of prisoners’ and prison staff 's perceptions of the methadone maintenance programme in Mountjoy Male Prison,Dublin, Republic of Ireland

This study, which was based in Ireland's main committal prison, used semi-structured interviews and a focus group to explore the perceptions of staff and prisoners towards methadone maintenance within the prison setting. Although the research subjects identified advantages and disadvantages associated with methadone prescribing within the prison, they were generally positive in their assessment of Mountjoy's methadone programme. Prisoners perceived it as leading to an improvement in their relationships with their families, while staff viewed it as facilitating a more stable and safer working environment. However, although prisoners’ use of heroin had reportedly declined since the advent of the methadone maintenance programme in the prison, their use of other drugs had not. There were negative views expressed by both groups about the manner in which methadone is dispensed within the prison, and also because methadone was viewed as being as addictive as heroin. Regarding perceptions of the purpose of methadone maintenance, there was a spectrum of interpretations among the interviewees. Five purposes were identified. These were: (1) to ensure continuity of harm-reduction policies from the community; (2) to reduce the supply of heroin in the prison; (3) to prevent needle sharing and the spread of blood-borne infections; (4) to treat heroin addiction; and (5) to control prisoners and maintain order and discipline within the prison. Apropos the latter, there was a widely held perception within the total sample that this latent function of methadone maintenance could be seen as of greater importance than the more conventional harm-reduction functions that were also identified.     

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.     

Methadone maintenance reduces heroin- and cocaine-induced relapse without affecting stress-induced relapse in a rodent model of poly-drug use.

Although it is well established that methadone can be an effective treatment for opiate addiction, it is not clear how methadone maintenance affects cocaine use and cravings in individuals who self-administer both opiates and cocaine. In our attempt to explore the effect of methadone maintenance on the effects of cocaine, we first assessed the locomotor stimulatory effects of cocaine in rats maintained on methadone (0, 10, 20, or 30 mg/kg/day, via osmotic minipumps). Chronic methadone elevated baseline locomotion in a dose-dependent manner and did not reduce the direct stimulatory effects of cocaine (5 mg/kg). We then investigated the effects of the highest methadone maintenance dose (30 mg/kg/day) on heroin and cocaine seeking in extinction, and when it was precipitated by exposure to heroin, cocaine, or foot-shock stress in rats trained to self-administer both drugs in the same experimental context (heroin 0.05 mg/kg/inf; cocaine 0.5 mg/kg/inf, eight 3-h sessions each). In tests of reinstatement, rats responded selectively on the appropriate drug-associated lever after priming injections of heroin (0.25 mg/kg) or cocaine (20 mg/kg). Methadone maintenance blocked both cocaine- and heroin-induced reinstatement, but not stress-induced reinstatement, which was not lever selective. These results suggest that although methadone maintenance may not reduce the direct stimulatory effects of cocaine, it has the potential to reduce both spontaneous and cocaine-primed cocaine-seeking behavior.     

The effects of the opioid pharmacotherapies methadone, LAAM and buprenorphine, alone and in combination with alcohol, on simulated driving

While methadone is currently the primary pharmacotherapy used in the treatment of heroin dependence in Australia, levo-alpha-acetyl-methodol (LAAM) and buprenorphine are new pharmacotherapies that are being examined as alternatives to methadone maintenance treatment. The aim of this research is to consider the effects of the methadone, buprenorphine and LAAM, as used in maintenance pharmacotherapy for heroin dependence, upon simulated driving. Clients stabilised in methadone, LAAM and buprenorphine treatment programs for 3 months, and a control group of non-drug-using participants, took part in this study which involved operating a driving simulator over a 75 min period. All participants attended one session without alcohol and one session with alcohol at around the 0.05% blood alcohol level. Simulated driving skill was measured through standard deviations of lateral position, speed and steering wheel angle, and reaction time to a subsidiary task was also measured. While alcohol impaired all measures of driving performance, there were no differences in driving skills across the four participant groups. These findings suggest that typical community standards around driving safety should be applied to clients stabilised in methadone, LAAM and buprenorphine treatment. The findings are important in terms of the widespread implementation of these treatment options in Victoria given that a large proportion of pharmacotherapy clients drive.     

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.     

Controlled use of heroin in patients on methadone maintenance treatment

The efficacy of methadone maintenance treatment was evaluated on 93 patients after 10 years of therapy. On the basis of therapeutic compliance, patients were divided into three groups: (a) 40 Total-Agreement subjects on weekly take-home methadone; (b) 28 Partial-Agreement subjects, who regularly attended the clinic daily but presented episodic positive urinalysis; (c) 25 No- Agreement patients, who were absent from the clinic more than twice a monthand had a high rate of urinalysis positive for morphine. Statistical analysis, based on social adjustment improvement and criminality rate decrease, divided the 93 patients into 2 distinct categories. The first category, characterized by high social adjustment and low criminality score, included the Total- and Partial- agreement groups. The second, characterized by significantly lower social adjustment and higher criminality score, included all No-Agreement patients. This suggests that methadone treatment was able to dissociate heroin use from low social functioning. It was concluded that, in a condition of adequate compliance the episodic use of heroin is of no harm to patients on methadone maintenance therapy, that is, methadone maintenance treatment permits a controlled use of heroin.