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.     

Diazepam use among methadone maintenance patients: Patterns and dosages

Methadone maintenance patients who use benzodiazepine drugs were interviewed about the dosage levels, patterns, frequency and motives for their use of these drugs. The sample was drawn from two treatment clinics, one in Baltimore (N = 12) and one in Philadelphia (N = 17). Benzodiazepine use was prevalent at both of these clinics — 65–70% of maintenance patients had positive urinalysis tests during a single month. Ninety-three per cent of survey participants identified diazepam as the drug which they used most often. The median value of the usual daily dose was 40–45 mg, 31% reported usual daily doses between 70 and 300 mg and 62% had experience with doses of 100 mg and higher. The majority of the sample reported taking diazepam in a single daily dose within one hour of the time that they ingested their daily methadone; 72% of the sample indicated that diazepam boosts the effects obtained from the daily methadone dose. Another sample of addicts who reported extensive experience with both benzodiazepines and barbiturates indicated that diazepam increases the effects of methadone while barbiturates produce no change in the effects of methadone. Results of this study suggest that patterns and dosages of diazepam use among methadone maintenance patients are primarily abusive rather than therapeutic.     

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.     

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.     

Allowing methadone clients control over dosage: A 48-week controlled trial

Two strategies for client self-regulation of dosage in methadone maintenance were examined in a 48-week randomized clinical trial. Subjects assigned to the two experimental conditions (SR-1 and SR-2) were able to regulate their dosage weekly. In addition, SR-2 subjects could earn additional take-home dose privileges by reducing dosage. A total of 85 subjects were randomly assigned to either SR-1 (n = 28), SR-2 (n = 31), or a standard treatment control condition (n = 26). An anomalous trend for female control subjects to lower their dosage was observed, but otherwise dosage trends over time were similar in all treatments. Nevertheless, control subjects showed more illicit opiate use than either self-regulation group. Results confirm that methadone maintenance clients act responsibly when given the ability to regulate their own dosage. The opportunity for an increased number of take-home doses and the convenience of less frequent clinic visits seems not to be an adequate incentive to induce clients to significantly decrease their ongoing maintenance dosage.     

Self-regulation of dose in methadone maintenance with contingent privileges.

The effect of giving methadone maintenance clients the opportunity to regulate their dosage and of offering take-home doses as an incentive for dose reduction was studied. Subjects (116) were randomly assigned to one of three conditions: self-regulation ofdose (SR-1); self-regulation of dose with incentive for reduction (SR-2) and standard treatment (control). Dependent variables were dosage and use of illicit drugs (measured by urinalyses). Results for the first four months show SR-1 subjects increased dose and maintained themselves at dosages significantly greater than the SR-2 or control groups while having significantly less use of illicit opiates during certain time periods. SR-2 subjects were not different from controls. Findings indicate subjects behaved responsibly under self-regulation and that this regimen is clinically feasible. Nevertheless, an increase in take-home privileges was an insufficient incentive to yield major reductions in dosage in SR-2 as a group.     

Reducing drug use among methadone maintenance clients: Contingent reinforcement for morphine-free urines

This study assessed the impact on supplemental heroin use by seven methadone maintenance patients of providing extrinsic reinforcement contingent upon morphine-free urinalysis results. Reinforcement was available for morphine-free urine samples during randomly selected weeks. Reinforcement consisted of a choice between $15, two methadone take- home privileges, and two opportunities to self-regulate methadone dosage. The monetary reinforcer was chosen on 95% of reinforcement occasions. During contingent reinforcement the rate of morphine-positive urinalyses declined significantly below pre-study levels (Wilcoxon Test, P<0.01). The morphine-positive rate during the randomly intermixed non-reinforcement weeks also declined, and did not differ significantly from that during reinforcement weeks. The post-study morphine-positive rate increased to a level not significantly different from the prestudy level. These data suggest generalization of the reinforcement effect to the non-reinforcement weeks, and indicate the need for further studies to determine the specific impact of the reinforcement procedure. Clinically, these data support the utility of contingent reinforcement for drug-free biological samples as a treatment modality for substance abuse.     

Pharmacists' provision of methadone to intoxicated clients in community pharmacies, Victoria, Australia

This paper concerns pharmacists dispensing methadone to intoxicated clients, drawing on both questionnaire and focus-group data from a 1996 evaluation of the community-based methadone programme in Victoria, Australia. The questionnaire was sent to registered community methadone pharmacies in Victoria (N = 188). The response rate was 84% and 148 questionnaires were analysed. Pharmacists were asked how they would respond to clients who presented intoxicated for their methadone dose. Results indicated that 32% of pharmacists said that they would provide a client who presented intoxicated with his or her usual methadone dose. The analyses suggested that pharmacists who were male and those pharmacists whose number of methadone clients exceeded 10 were more likely to dispense methadone to an intoxicated client than female pharmacists and those pharmacists with less than 10 clients. Pharmacists who would withhold the methadone dose were more likely to inform the client's prescribing doctor at the time (74%) than pharmacists who would provide the usual or modified dose (41%). In order to understand the social processes underlying provision of methadone to intoxicated clients this theme was later taken up in a focus group with pharmacists. Reasons given by pharmacists to explain the dispensing of methadone to intoxicated clients were: insufficient communication between prescribers and pharmacists; a down playing of the pharmacological dangers; personal beliefs and values; a fear of retribution from the client if thedose was refused; difficulty in recognizing intoxication; lack of education and training. The results raise concerns about the basis on which pharmacists make decisions about providing methadone to intoxicated clients. [Koutroulis GY, Kutin JJ, Ugoni AM, Odgers P, Muhleisen P, Ezard N, Lintzeris N, Stowe A, Lanagan A. Pharmacists' provision of methadone to intoxicated clients in community pharmacies, Victoria, Australia. Drug Alcohol Rev 2000;19:299-308]     

A naturalistic study on ending blind dosing in a methadone maintenance clinic in Israel

Since many methadone maintenance treatment (MMT) clinics in the United States do not share with patients, information concerning their methadone dosage, we aimed to investigate the impact of patients being informed of their methadone dosage and the influence of ending blind dosing on treatment outcome. Seventy-four patients who were unaware of their methadone dosage took part in this study. We compared changes in opiate abuse, levels of methadone dosage and patients' perceptions of dosage adequacy before and after they were informed of their dosage. Data on opiate abuse were based upon bi-weekly randomly taken and observed urine tests provided the data on opiate abuse. Records on methadone dosage were kept and a short questionnaire on dosage-related attitudes, devised for this study, was administered. Most patients expressed the desire to know their dosage, but there were no significant changes in opiate abuse, methadone dosage or the patients' perceptions of dosage adequacy after they knew what it was. We conclude that informing patients of their methadone dosage and thereby ending blind dosing does not seem to have any negative effect on treatment outcomes. We believe that this policy is in accord with the patients' rights and expressed will to know their dosage and this justifies putting an end to blind dosing policies.     

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.     

Human methadone self-administration: effects of dose and ratio requirement

The effects of response requirement and small doses of methadone on human oral self-administration of methadone were examined. Three methadone maintenance patients stabilized at a dose of 80mg methadone per day were recruited as subjects. Completing a response requirement, fixed ratio (FR) of 32, 64 or 128 responses (FR32, FR64, FR128) on one button dispensed 10ml of drug solution. Completing the equivalent response requirement on a second concurrently available response button dispensed 10ml of vehicle. The opportunity to respond was unavailable until the drug or vehicle had been consumed. Each 10ml of drug solution contained methadone doses of 0.027, 0.054 or 0.108mg/ml. The frequency of deliveries was limited so that subjects could not ingest more than 54mg of methadone; the difference between the 80mg daily methadone dose and the methadone consumed in session was administered 30min post-session. At FR64 and FR128 the frequency of deliveries decreased, at the 0.054 and 0.027mg/ml doses, relative to the frequency of deliveries at FR32. The amount of methadone consumed increased with increases in methadone dose and decreased with increases in FR size. These results demonstrate the reinforcing effects of small unit doses of methadone. This procedure provides a sensitive baseline for examining effects of other pharmacological interventions on methadone ingestion in humans.     

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.     

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.     

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.     

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.     

Choice of blind methadone dose increases by methadone maintenance patients

In the present study, a choice procedure was used in an outpatient methadone maintenance clinic to examine preferences for different double-blind methadone dose increases in 5 male patients. Subjects chose between 50 mg vs. 50 mg, 60 mg, 75 mg and 100 mg of methadone. In the 50 mg vs. 50 mg condition, each alternative was selected equally often. Percent selection of the higher doses (60, 75 and 100 mg) over the 50 mg dose of methadone increased in a dose-related fashion. Subject self-reports were consistent with methadone's opiate-like properties with dose-related trends being noted in most scales (e.g. opiate effects, drug liking). Overall, the results show that a choice procedure can be used successfully to assess the reinforcing properties of drugs in methadone maintenance patients and that methadone dose increases can function as a reinforcer in this population even under blind dosing conditions.     

A qualitative study exploring the reason for low dosage of methadone prescribed in the MMT clinics in China

Objectives

Dosage of methadone maintenance therapy (MMT) is an important factor influencing retention in methadone treatment. MMT clients in China received lower dosages of methadone compared with those provided in other countries. The objective of this study is to elucidate the reason for the low methadone dosage prescribed in MMT clinics in China.

Methods

Twenty-eight service providers were recruited from the MMT clinics in Zhejiang and Jiangxi Provinces, China. Qualitative in-depth interviews were conducted to ascertain the procedure for prescribing methadone in the MMT clinics.

Results

The average dosage prescribed in the 28 clinics was 35 mg/person/day. Four major themes resulting in low dosage of methadone were identified: (1) the service providers fear the liability resulting from large doses of methadone in combination with other substances which might result in overdose fatalities, (2) lack of understanding of harm reduction which resulted in low acceptance of the long term maintenance treatment approach, (3) break-down in communication between clients and service providers about dosage adjustment, and (4) dosage reduction is perceived by most service providers as an effective way to treat the side-effects associated with MMT.

Conclusions

The findings of the study highlighted the necessity to formulate clear guidelines concerning individualized dosage management and to improve training among service providers’ in MMT clinics in China.     

An evaluation of community methadone services in Victoria, Australia: results of a client survey

One hundred and ninety-five metropolitan clients enrolled in the community-based methadone programme in Victoria, Australia were surveyed in order to evaluate client perspectives of methadone treatment delivered from primary health care settings. Results indicated that the average daily methadone dose was 41 mg, ranging from 7 mg to 140 mg. The majority of clients were satisfied with the programme and the services delivered by dispensing pharmacies and prescribing doctors. Most clients were found to have reduced their heroin use and criminal activity since commencing methadone. A number of concerns about the programme were identified, however, including the high proportion of weekly income spent on methadone-related activities and a high use of tranquillizers by clients on higher methadone doses. In general the community-based methadone programme was found to be an acceptable methadone of service delivery to metropolitan clients in Victoria, Australia.     

Correlates of methadone client retention: a prospective cohort study in Guizhou province, China

BackgroundMethadone client retention levels and treatment doses of patients vary widely in methadone clinics across China. Because methadone clinics have been available in China only recently, this study explored the relationship between methadone dosage and client retention in methadone maintenance programmes in Guizhou province.MethodsThe study used a prospective cohort study design. Injecting and non-injecting heroin-using clients who had been treated for no more than two and half months in one of eight methadone maintenance treatment clinics in Guizhou province were recruited into the cohort, beginning on 3 June 2006 and followed up until 1 June 2007. A total of 1003 participants were enrolled. Face-to-face interviews were conducted to collect baseline information, and clients’ daily doses were recorded.ResultsThe 14-month retention rate was 56.2%. Controlling for other covariates in the multivariate Cox model, a higher methadone dose was found to predict higher client retention. Retention was also associated with intention to remain in treatment for life and the clinic attended.ConclusionClients need to receive an adequate methadone dose to assure continued retention. Patients who expect to be treated for life have higher retention rates than patients who anticipate only short-term treatment. Key factors associated with successful clinics in China need to be elucidated.     

Excusing exclusion: Accounting for rule-breaking and sanctions in a Swedish methadone clinic

BackgroundMethadone maintenance treatment has been subjected to much debate and controversy in Sweden during the last decades. Thresholds for getting access are high and control policies strict within the programmes. This article analyses how professionals working in a Swedish methadone clinic discuss and decide on appropriate responses to clients’ rule-breaking behaviour.MethodsThe research data consist of field notes from observations of three interprofessional team meetings where different clients’ illicit drug use is discussed. A micro-sociological approach and accounts analysis was applied to the data.ResultsDuring their decision-oriented talk at the meetings, the professionals account for: (1) sanctions, (2) nonsanction, (3) mildness. In accounting for (2) and (3), they also account for clients’ rule-breaking behaviour. Analysis shows how these ways of accounting are concerned with locating blame and responsibility for the act in question, as well as with constructing excuses and justifications for the clients and for the professionals themselves.ConclusionIn general, these results demonstrate that maintenance treatment in everyday professional decision-making, far from being a neutral evidence-based practice, involves a substantial amount of professional discretion and moral judgements. Sanctions are chosen according to the way in which a deviance from the rules is explained and, in doing so, a certain behaviour is deemed to be serious, dangerous and unacceptable – or excusable.