Development of a Brief Treatment Instrument for Routine Clinical Use with Methadone Maintenance Treatment Clients: The Methadone Treatment Index

Routine measurement of treatment outcome between clinician and client in alcohol and drug user treatment services is an important quality improvement initiative. It is particularly important for clients receiving long-term treatment such as methadone maintenance treatment, as fluctuations in substance use, functioning, and health are to be expected. Although there are a number of standardized alcohol and drug user treatment outcome instruments available for research and clinical use, a key challenge is to develop clinical instruments that will actually be used routinely in busy practice settings by a range of staff. Such instruments need to be brief, acceptable to staff and clients, easy to use, provide immediate feedback, and meet adequate psychometric requirements. This report describes development work undertaken in three studies of the Methadone Treatment Index (MTI). The MTI is a brief instrument comprising measures of recent substance use, aspects of social and behavioral functioning, and physical and psychological health. The MTI was designed in consultation with clinicians and clients for use in monitoring treatment progress with clients receiving methadone maintenance treatment. Key findings were that the MTI was acceptable to clients, produced clinically relevant information, and has satisfactory psychometric properties, although it was not used to measure change in this study. Further evaluation of the MTI on a longitudinal basis is supported.     

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]     

Patterns of improvement after methadone treatment: 1 year follow-up results from the National Treatment Outcome Research Study

One year outcomes for substance use behaviours, health and criminal behaviour, and variation in treatment response, are reported for patients recruited to methadone maintenance and methadone reduction treatment programmes as part of NTORS. Significant reductions in the use of all illicit target drugs were found at follow-up for patients recruited to the methadone maintenance and methadone reduction modalities. Because of similarities in the treatments received by clients in the two modalities we caution against interpreting these findings as showing that methadone maintenance and reduction treatments lead to similar outcomes. At this stage, it is suggested that these outcomes be regarded as reflective of exposure to some general methadone substitution treatment. Further investigation of the outcomes for the two modalities will be conducted. Cluster analyses were used to classify patients according to level of improvement in drug use. Four groups were identified. Two groups (59% of cases) showed substantial reductions in their illicit drug use and criminality as well as reduced physical and psychological symptoms. Twenty two percent of cases showed poor outcomes across a range of measures. Results for alcohol consumption were less satisfactory for patients in all groups. A majority of patients achieved widespread improvements across a range of outcome measures after treatment in existing methadone treatment services. These changes represent important clinical benefits to the individual clients, to their families and to society.     

Development and validation of a brief instrument for routine outcome monitoring in opioid maintenance pharmacotherapy services: the brief treatment outcome measure (BTOM)

AIM: To develop a brief, multi-dimensional instrument for routine, on-going treatment outcome monitoring in alcohol and other drug (AOD) services in Australia and examine the underlying psychometric properties. This study focuses on opioid maintenance pharmacotherapy (OMP) services. DESIGN: Researcher-administered test-retest interviews and clinician administered interviews. SETTING: The test-retest interviews took place in two private and two public OMP clinics in Sydney, Australia. The clinician-administered interviews took place in 37 metropolitan, rural and prison OMP services in New South Wales, Australia. PARTICIPANTS: One hundred and sixty current OMP clients for the test-retest interviews and 2004 clients commencing OMP treatment for the clinician-administered interviews. MEASURES: Thirty-two items across the domains of dependence, blood-borne virus exposure risk, drug use, health/psychological functioning and social functioning. FINDINGS: The internal reliability of the brief treatment outcome measure (BTOM) is satisfactory. Retest reliabilities for the scales and drug use scores are good to excellent indicating their consistency with multiple measurements across time and different interviewers and concurrent validation of BTOM scales with analogous scales from similar instruments yielded acceptable agreement. Average completion times of the BTOM were 14.5 min, when administered in a research context and 21 min in a clinical context. CONCLUSIONS: A brief, valid and reliable questionnaire has been developed for monitoring treatment outcome over the range of OMP services. The BTOM contains a core set of outcome measures, which can be easily adapted for integration into routine clinical practice across the range of AOD services.     

Adapting problem-solving therapy for depressed older adults in methadone maintenance treatment

Late-life depression is prevalent in older adults who are dependent on opiates. Depressive disorders among opiate abusers have detrimental effects on their well-being and ability to refrain from illegal drugs. There are numerous barriers to the provision of appropriate mental health care to older adults receiving methadone maintenance treatment. This article focuses on problem-solving therapy (PST) and presents evidence that PST may be a promising nonpharmacological treatment for older methadone clients with comorbid depressive disorders that can be applied within the staffing and resource limits of methadone maintenance treatment facilities. The advantages of PST relative to other behavioral therapies for this population are based on evidence that PST is less cognitively demanding for an older adult population with mood and substance use disorders. A properly modified PST for an older adult substance-dependent population with subsyndromal or diagnosed depression may be a viable option for methadone maintenance programs with limited resources.     

Satisfaction with methadone as a medication: psychometric properties of the Spanish version of the treatment satisfaction questionnaire for medication

There is a manifest lack of psychometrically sound instruments designed for specific and multidimensional assessment of satisfaction with methadone as a medication within the context of methadone maintenance treatment. Therefore, it may be worthwhile to assess the pertinence and utility of using a generic and multidimensional medication satisfaction instrument that has not been specifically developed for use in methadone maintenance treatment.The aim of this study was thus to explore the psychometric properties of the Spanish version of the Treatment Satisfaction Questionnaire for Medication (TSQM version 1.4 [Health Qual Life Outcomes. 2004;2:12]) in a sample of methadone-maintained heroin-dependent patients.Two hundred three methadone-maintained patients filled out the TSQM and other several measures related to the construct of patient satisfaction (eg, Verona Service Satisfaction Scale for methadone treatment). Dimensionality of the TSQM was assessed by means of a confirmatory factor analysis. Internal consistency was examined using the ordinal coefficient α. Spearman correlations were used to explore the relationship between the TSQM and the measures conceptually related to patient satisfaction.Regarding the dimensionality of the TSQM, its original factor structure adequately fitted the data (Satorra-Bentler χ58, 72.14 [P = 0.100]; root-mean-square error of approximation, 0.045; comparative fit index, 0.978). All but 1 of the 4 TSQM subscales showed acceptable to good internal consistency values (0.78-0.89). The dimensions of the TSQM were differentially and congruently correlated with related measures.The results strongly suggest the TSQM value as a brief, generic, and psychometrically sound instrument to assess satisfaction with methadone as a medication in a multidimensional manner. Notwithstanding, more research is needed not only to assess the generalizability of these findings but also to provide pieces of evidence for other psychometric properties, especially the TSQM predictive validity.     

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.     

Improving family functioning and child outcome in methadone maintained families: the Parents Under Pressure programme

Twelve families responded to posters displayed in a methadone clinic for inclusion in a pilot study assessing the viability and potential utility of an intensive, multi-component family-focused intervention, the Parents Under Pressure programme. The programme was designed to improve child behaviour, decrease parental stress and improve family functioning in methadonemaintained families by targeting affect regulation, mood, views of self as a parent, drug use and parenting skills. Nine of the families completed the programme delivered in their homes; eight were recontacted at 3 months. Each family reported significant improvements in three domains: parental functioning, parent - child relationship and parental substance use and risk behaviour. In addition to the changes in family functioning, the majority of families reported a decrease in concurrent alcohol use, HIV risktaking behaviour and maintenance dose of methadone. The families reported high levels of satisfaction with the programme. It is recommended that future studies include independent measures (e.g. behavioural observations) of child outcome and parental functioning. The results were optimistic and provided the impetus to evaluate the treatment programme using a randomized controlled trial. [Dawe S, Harnett PH, Rendalls V, Staiger P. Improving family functioning and child outcome in methadone maintained families: the Parents Under Pressure programme. Drug Alcohol Rev 2003;22:299 - 307]     

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.     

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.     

Characteristics of clients receiving treatment in Australian drug and alcohol agencies: a national census

The first Australian national census of clients of drug and alcohol treatment agencies was undertaken to document the characteristics of clients attending these facilities. Of the agencies surveyed nationwide, 431 (85.2%) completed and returned census forms describing demographic and drug use details of their clients. A total of 6175 clients were reported to have received services (beyond methadone maintenance alone) in the responding agencies on the census day. Ninety percent of the clients seen were substance users, and 10% of clients were relatives or friends of a substance user. The mean age of the clients was 34 years and two-thirds were male. The majority were Australian born, with 10% described as Aborigines or Torres Strait Islanders. The majority of the clients were not in paid employment. Fifty-five percent of all clients received treatments services on a non-residential basis. The most frequent presenting drug problem reported was alcohol, followed by opiates and tobacco. Thirty-three percent of the substance users were reported to have injected illicit drugs in the past 12 months.     

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 treatment: outcomes from the Otago methadone programme

AIM: To provide information on methadone treatment outcomes for opiate-dependent individuals. METHODS: Questionnaires and random urine tests were completed for 112 Otago clients comparing outcomes before and during methadone maintenance treatment. RESULTS: Treatment retention rates were high, with 86% of clients remaining on the programme six months or more. The number of clients on benefits reduced by almost 30% during treatment, with employment rates doubling from 19% to 40% (including attendance at educational programmes). For the 89 clients injecting opiates daily at initial presentation, 64% reported no opiate use in the three months prior to review. Of the remaining 36%, opiate use reduced significantly. Rates of sharing injecting equipment reduced by almost 90%. Almost 50% of cannabis users reduced their use from daily to less than daily use. Clients reporting no current use of illicit benzodiazepines increased by 85%. Heavy binge drinking weekly or more reduced by almost 75%. Use of other illicit drugs reduced by almost 90%. Drug-related convictions reduced by almost 60%, while accidental drug overdoses reduced by over 90%. CONCLUSION: The widespread benefits of methadone maintenance treatment demonstrated underline the importance of making quality methadone programmes readily accessible within the health system. Currently, there are long waiting lists and many individuals cannot gain access to active treatment. We believe the health system urgently needs to look at expanding existing services and/or establishing private methadone clinics similar to those in New South Wales.     

Lifetime multiple substance use pattern among heroin users before entering methadone maintenance treatment clinic in Yunnan,China

Introduction and Aims. Multiple substance use leads to greater levels of psycho‐behavioural problems, unsafe sex, and therefore a high risk of contracting sexually transmitted diseases, and is also more difficult to treat. This study aims to determine pattern of lifetime multiple substance use among Chinese heroin users before entering methadone maintenance treatment clinic. Design and Methods. A survey to obtain retrospective longitudinal data on lifetime multiple substance use was conducted among 203 heroin users in two of the biggest methadone maintenance clinics in Kunming City, Yunnan province. Results. All participants used more than one substance in their lifetime. Most of them used four or more substance groups (range two to seven groups). The most common substance patterns in lifetime use were alcohol, tobacco, opiates and depressants. Approximately 80% of them had a history of simultaneous substance use (co‐use). The most common combination of co‐use pattern was heroin with depressant. Common reasons for co‐use were to get high, to experiment, to sleep and to increase the potency of other drugs. Determinants of co‐use were education, marital status and family relationship. Discussion and Conclusions. Multiple substance use is highly prevalent among Chinese heroin users. Depressants are the most common substances used in combination with heroin.[Li L, Sangthong R, Chongsuvivatwong V, McNeil E, Li J. Lifetime multiple substance use pattern among heroin users before entering methadone maintenance treatment clinic in Yunnan, China. Drug Alcohol Rev 2010]     

Pilot randomised controlled trial of community pharmacy administration of buprenorphine versus methadone

Objectives The established regime for opiate substitute prescribing for drug misusers is daily methadone administered under supervision in community pharmacies. Buprenorphine has recently been introduced as an alternative. However there is a lack of evidence of the effectiveness of buprenorphine maintenance therapy (BMT) in the UK treatment setting. This study aimed to assess methods for a randomised controlled trial (RCT) and the feasibility of pharmacy‐based supervised self‐administration (SSA) of buprenorphine compared to methadone. Setting Specialist substance misuse service, general practices and community pharmacies in Aberdeen, Scotland. Method The design was a pilot RCT. Opiate‐dependent drug misusers, newly referred for maintenance treatment were randomised to receive BMT or methadone maintenance therapy (MMT). Clients and pharmacists were interviewed at baseline and at the end of a 12‐week intervention period. Clients completed the quality of life measure EQ‐5D. Pharmacy activities were timed. Key findings Twenty‐one opiate‐dependent clients were recruited (BMT = 11, MMT = 10). Recruitment levels improved as the trial progressed. Clients' treatment preferences were evident. Withdrawals occurred early with BMT. Clients found SSA of buprenorphine acceptable, but found daily administration more manageable than three times weekly. Pharmacists found the dispensing of buprenorphine to be an acceptable role, but felt less certain of ensuring against diversion with buprenorphine than they were with methadone. Pharmacy activities associated with buprenorphine took longer than those associated with methadone (mean = 7 min 25 s versus mean = 3 min 27 s, respectively). Conclusion Recruitment to a trial comparing MMT to BMT for opiate‐dependent clients within a UK treatment setting is feasible. Clients and pharmacists found buprenorphine acceptable.     

Cost-utility analysis of methadone maintenance treatment: a methodological approach

Economic considerations influence the substance user treatment system. These considerations influence who gets treatment and for how long, as well as determining what services they receive and in what setting. Current medical literature argues that maintenance treatment reduces risk-taking behavior, such as injection drug use and needle sharing. Treatment also reduces the mortality associated with abuse of opiates by injection and can cause decreases in costs incurred by the criminal justice system and social services agencies. This suggests the need for complex economic evaluations of a maintenance treatment to find out the optimum treatment program. This paper describes methods of economic evaluation in health care and reviews the methodology of cost-utility analysis in economic evaluations of methadone maintenance treatment.     

Smoking cessation interventions among individuals in methadone maintenance: A brief review

Background

Individuals in methadone maintenance treatment are motivated to quit smoking and are interested in smoking cessation treatment. However, few studies have assessed the efficacy of smoking cessation treatment for individuals undergoing methadone maintenance. The purpose of this article is to review interventions for tobacco use cessation among individuals in methadone maintenance with a particular emphasis on the components of such interventions and their effect on smoking cessation/reduction and drug use.

Methods

A comprehensive search of six databases in June 2008 retrieved 584 research studies, which addressed smoking cessation interventions among individuals in substance use treatment. Of the retrieved articles, eight studies addressed smoking cessation among individuals undergoing methadone maintenance treatment. These studies were examined for effect of intervention on smoking cessation/reduction, gender differences in treatment outcomes, and the effect of the smoking cessation intervention on substance use behaviors.

Results

Few studies demonstrated successful smoking abstinence among individuals in methadone maintenance treatment. Most interventions were associated with significant smoking reduction from baseline. Few studies assessed differences between men and women in smoking cessation treatment outcome. Smoking cessation treatment was not associated with increased substance use.

Conclusions

To date, interventions among individuals in methadone treatment have been largely unsuccessful in achieving sustained smoking abstinence. However, smoking cessation treatment does not worsen substance use. Future studies are necessary to determine intervention designs and components that can enhance smoking cessation among individuals in methadone maintenance.     

Drug and alcohol offenders coerced into treatment: a review of modalities and suggestions for research on social model programs.

Outcome studies on drug and alcohol offenders coerced into treatment by the criminal justice system were reviewed. Positive outcomes were found for therapeutic community, methadone maintenance, and unspecified residential and outpatient programs. No outcome studies were found for court-mandated clients coerced into social model recovery programs. When developing studies, researchers should consider how clients perceive legal mandates and whether they are receiving pressures to enter treatment from other sources, such as family members, employers, friends or the welfare system. Use of the Social Model Philosophy Scale (SMPS) is suggested to correlate program characteristics and processes with outcome.     

Use of non-prescribed methadone and other illicit drugs during methadone maintenance treatment

Patterns of illicit and non-prescribed drug use among a cohort of 100 patients in methadone maintenance treatment were tracked over a 6-month period. While there were no statistically significant changes in alcohol or heroin use, there were significant increases in the frequency of crack cocaine and cannabis use. Use of non-prescribed methadone had also increased. Twenty-one percent reported non-prescribed methadone use at follow-up who had not done so at the first interview, with increases also in the mean quantities used. Non-prescribed methadone use at the second interview was strongly associated with the amounts of both methadone and diazepam prescribed at each of the data collecting points.