TREATING COCAINE-USING METHADONE PATIENTS: PREDICTORS OF OUTCOMES IN A PSYCHOSOCIAL CLINICAL TRIAL

Cocaine-using methadone patients in two clinics were assigned to 8 months of enhanced methadone treatment—primarily cognitive-behavioral therapy (CBT) for cocaine use—while similar patients in two “sibling” clinics were assigned to standard methadone treatment during 1995–1998. Cocaine use declined significantly from baseline to 4- and 12-month follow-ups. Patients receiving CBT rated the quality of their counseling relationship higher and obtained more supportive services than those receiving standard treatment. However, study treatment condition itself was not associated with outcome. Baseline measures associated with poorer outcomes across both treatment conditions were: currently enrolled in methadone treatment (in contrast to being newly enrolled), higher cocaine use frequency, greater cocaine use associated problem recognition, and an ambivalent attitude toward methadone. The results are consistent with some previous clinical trials showing that psychosocial treatments of different intensities result in similar declines in cocaine use. The findings indicate that methadone maintenance treatment can help dually-addicted patients reduce their cocaine use.     

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.     

A Randomized,Controlled Trial of the Efficacy of an Interoceptive Exposure-Based CBT for Treatment-Refractory Outpatients with Opioid Dependence

Many patients diagnosed with opioid dependence do not adequately respond to pharmacologic, psychosocial, or combination treatment, highlighting the importance of novel treatment strategies for this population. The current study examined the efficacy of a novel behavioral treatment focusing on internal cues for drug use (Cognitive Behavioral Therapy for Interoceptive Cues; CBT-IC) relative to an active comparison condition, Individual Drug Counseling (IDC), when added to methadone maintenance treatment (MMT) among those who had not responded to MMT. Participants (N=78) were randomly assigned to receive 15 sessions of CBT-IC or IDC as an adjunct to ongoing MMT and counseling. Oral toxicology screens were the primary outcome. Results indicated no treatment differences between CBT-IC and IDC and a small, significant reduction of self-reported drug use, but no change on toxicology screens. Tests of potential moderators, including sex, anxiety sensitivity, and coping motives for drug use, did not yield significant interactions. Among opioid-dependent outpatients who have not responded to MMT and counseling, the addition of IDC or CBT-IC did not result in additive outcome benefits. These results highlight the need for more potent treatment strategies for opioid dependence, particularly among those who do not fully respond to frontline treatment.     

Patterns of substance use among methadone maintenance patients. Indicators of outcome.

Critics often cite the use of illicit drugs among methadone maintenance patients as evidence of this treatment modality's failure. The fact that methadone maintenance treatment does not lead quickly to abstinence in most clients can be a disappointment to treatment professionals and the public. By studying a cohort of 41 patients for their first year in a methadone maintenance program, this study revealed significant trends of diminished narcotic and cocaine use. However, increased benzodiazepine use was also identified. More importantly, this study patterns of drug using that predicted less drug use at the end of one year of treatment. These findings reflect the need for additional research to clarify the meaning of illicit drug use by methadone maintenance patients. In addition, the implications for providing, stopping, and determining effective drug treatment are discussed.     

Concurrent heroin use among methadone maintenance clients in China

Background

The study examined concurrent illicit heroin use among methadone maintenance clients in China and its association with clients' demographic characteristics, treatment experience, and personal social network.

Methods

Face-to-face surveys were conducted with 178 clients randomly recruited from six methadone maintenance treatment (MMT) clinics in Sichuan, China. Concurrent heroin use was measured based on self-report of heroin use during the past 30 days and a confirmatory urine morphine test. The participants' demographic characteristics and treatment factors were measured and examined. The drug use status of their family members and friends was also assessed.

Results

A total of 80 participants (44.9%) who either reported illicit heroin use in the past 30 days or had a positive urine test were defined as using heroin concurrently. Having drug-using friends was significantly associated with increased concurrent heroin use. Longer length of treatment (2 years or longer) was associated with increased concurrent heroin use. Among those who had both drug-using family members and friends, more women (71.4%) than men (50.0%) used heroin. For those who had no drug-using family members or friends, more men (34.8%) than women (20.8%) used heroin.

Discussion

Study findings indicate an urgent need to address concurrent illicit heroin use among MMT clients. Further examination of the influence of social networks on concurrent drug abuse behavior is encouraged. Results also highlight the importance of understanding gender differences in treatment seeking and behavioral changes, which is crucial to the development of gender-specific treatment strategies.     

Treating cocaine-using methadone patients: predictors of outcomes in a psychosocial clinical trial

Cocaine-using methadone patients in two clinics were assigned to 8 months of enhanced methadone treatment-primarily cognitive-behavioral therapy (CBT) for cocaine use-while similar patients in two "sibling" clinics were assigned to standard methadone treatment during 1995-1998. Cocaine use declined significantly from baseline to 4- and 12-month follow-ups. Patients receiving CBT rated the quality of their counseling relationship higher and obtained more supportive services than those receiving standard treatment. However, study treatment condition itself was not associated with outcome. Baseline measures associated with poorer outcomes across both treatment conditions were: currently enrolled in methadone treatment (in contrast to being newly enrolled), higher cocaine use frequency, greater cocaine use associated problem recognition, and an ambivalent attitude toward methadone. The results are consistent with some previous clinical trials showing that psychosocial treatments of different intensities result in similar declines in cocaine use. The findings indicate that methadone maintenance treatment can help dually-addicted patients reduce their cocaine use.     

Problem drinking in relation to treatment outcome among opiate addicts in methadone maintenance treatment

This study analyzed indicators of alcohol-related problems in opiate addicts before, during, and after leaving methadone maintenance treatment (MMT), in relation to illicit drug use and retention in treatment. The study was based on 204 patients, admitted to MMT for the first time between 1 January 1995 and 31 July 2000, and followed until 31 December 2000. Three measures were used to indicate alcohol use and alcohol-related problems; records of hospital care with an alcohol-related diagnosis, any treatment with alcohol-sensitizing drugs (disulfiram or calcium carbimide) during MMT, and results of the 5-hydroxytryptophol to 5-hydroxyindoleacetic acid ratio (5HTOL/5HIAA) in urine, a sensitive biomarker for recent drinking. Use of illicit drugs was determined by routine urine drug testing. About one third of the patients (n = 69) had a lifetime prevalence of hospital treatment for an alcohol-related diagnosis, 45 of whom had been hospitalized (mean 4.2 stays) prior to the start of MMT. There was a significant association (p<0.05) between the number of alcohol-related diagnoses prior to treatment and a positive 5HTOL/5HIAA test during MMT. The alcohol indicators first became positive on average 1.6 years after admission to treatment, compared with after about 4 months for illicit drugs. Use of cannabis or benzodiazepines was significantly associated with alcohol use. Female methadone patients with indications of alcohol-related problems relapsed more often into illicit drug use than did women without such indications (3.9 vs. 2.5 relapse periods/year; p<0.005), whereas no significant association was found for men. The results of the present study indicate that drinking problems among patients undergoing MMT is associated with an increased risk of relapse into illicit drug use and with discharge from treatment. Concurrent treatment of alcohol-related problems, including systematic monitoring of alcohol use, therefore should be recommended to reduce the risk for relapse into illicit drug use and improve overall treatment outcome in MMT.     

The effect of increased cocaine use on drug treatment

Trends in primary illicit drug use were monitored in an inpatient drug treatment program over a 10-year period, along with illicit drug used in a methadone maintenance program over a six-year period. The percentage of cocaine users admitted for inpatient treatment showed an increase for each six-month interval over the past three-year period. Cocaine was found to be the most frequently used illicit drug by methadone maintenance clients, and its continued use disrupted both inpatient and outpatient treatment. Implications for treatment are discussed.     

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.     

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.     

Active heroin injectors' perceptions and use of methadone maintenance treatment: cynical performance or self-prescribed risk reduction?

In addition to the numerous heroin users who voluntarily enter methadone treatment as a way to free themselves from illicit drug addiction and those ordered to do so by the courts, there are a large number of opioid users who enter methadone treatment with other objectives in mind. These include shorter-term goals that users do not necessarily equate with complete heroin abstinence. In this paper we report the results of a qualitative study designed to identify and describe the motivations active heroin users have for entering methadone treatment, and to suggest that many of these short-term methadone episodes may operate as self-prescribed attempts at risk reduction, and act as pilot tests for users considering or anticipating entering treatment to quit the use of illicit drugs. We argue that heroin users' motivations, perceptions about methadone, and the strategies they devise for adapting methadone treatment for their own needs should be recognized for their value in reducing the multiple risks associated with drug use.     

Consequences and costs of shutting off methadone

In the face of rising fiscal conservatism, many states and localities with sizable addict populations have reduced or eliminated public funding for methadone maintenance (MM) programs and permitted private-fee-for-service programs to replace them. The social and economic costs of these changed funding policies with reference to the California experience were analyzed. A two-and-a-half year follow-up of a sample of San Diego MM clients (195 men, 129 women) terminated from a public subsidized program compared outcome results to clients from publicly funded MM programs in Orange, Riverside and San Bernardino counties (129 men, 131 women). In a secondary analysis, San Diego clients who transferred into private (fee-for-service) treatment programs were compared with those who did not transfer. Major adverse consequences were found for clients unable or unwilling to transfer to private programs: higher crime and dealing rates, more contact with the criminal justice system, and higher rates of illicit drug use were demonstrated by nontransfer clients. Moreover, the savings resulting from a reduction of MM program costs were nearly offset by increased direct costs for incarceration, legal supervision, and other government-funded drug treatment. Indirect costs were not assessed.     

Active Heroin Injectors' Perceptions and Use of Methadone Maintenance Treatment: Cynical Performance or Self-Prescribed Risk Reduction?

In addition to the numerous heroin users who voluntarily enter methadone treatment as a way to free themselves from illicit drug addiction and those ordered to do so by the courts, there are a large number of opioid users who enter methadone treatment with other objectives in mind. These include shorter-term goals that users do not necessarily equate with complete heroin abstinence. In this paper we report the results of a qualitative study designed to identify and describe the motivations active heroin users have for entering methadone treatment, and to suggest that many of these short-term methadone episodes may operate as self-prescribed attempts at risk reduction, and act as pilot tests for users considering or anticipating entering treatment to quit the use of illicit drugs. We argue that heroin users' motivations, perceptions about methadone, and the strategies they devise for adapting methadone treatment for their own needs should be recognized for their value in reducing the multiple risks associated with drug use.     

美沙酮维持治疗受治者偷吸情况及其影响因素分析

目的：了解美沙酮维持治疗受治者毒品偷吸情况及影响因素,为进一步采取有效措施提高治疗效果提供依据。方法：对治疗时间20d以上的知情同意的受治者进行横断面问卷调查和尿液吗啡定性检测,并结合门诊记录信息进行分析.结果：毒品偷吸率54．2％（96／177）。Logistic回归分析结果显示无固定工作、接受治疗时间短、吸毒时间长和有注射吸毒史等是影响偷吸的可能因素。结论：受治者在治疗期间偷吸毒品是较常见的现象,应加强思想教育和心理辅导、增加激励机制和社会帮教等提高维持时间,减少偷吸率。     

Effectiveness of psychotherapeutic counseling in methadone maintenance

Therapeutic counseling has been widely adovacted with methadone maintenance, but its effectiveness has not been demonstrated. A review of the literature revealed a dearth of scientific investigations comparing treatment outcomes with and without counseling services. The few studies which have been reported seem to suggest that counseling does not significantly change treatment outcomes as measured by the usual indicators of illicit drug use, arrests, employment, and retention in the program. These studies suffered from a number of methodological flaws, however, including failure to adhere to research design, small sample size, poorly matched control groups, inadequate outcome criteria, and absence of post-treatment follow-up. Previous investigators have been nearly unanimous in calling for further studies of this issue. Since the cost of counseling services represents a major portion of treatment program budgets, there is an urgent need to document the effectiveness of these services with definitive studies.     

Spiritual and religious support in recovery from addiction among HIV-positive injection drug users

The current study examined the association between support and comfort derived from religion or spirituality and abstinence from illicit drugs in a sample of 43 HIV-positive injection drug users entering a methadone maintenance program. Patients with high ratings of perceived spiritual or religious support were abstinent from illicit drugs significantly longer during the first six months of methadone maintenance than were patients with lower ratings. Controlling for the influence of pretreatment variables (addiction and psychiatric severity, CD4 count, social support, and optimism), and during-treatment variables (methadone dose and attendance at counseling sessions), hierarchical regression analysis showed that strength of religious and spiritual support was a significant independent predictor of abstinence. These findings suggest that spirituality may be an important dimension of patient experience to assess in future addiction treatment outcome research.     

Using enhanced and integrated services to improve response to standard methadone treatment: Changing the clinical infrastructure of treatment networks

Outcomes are presented from opioid-dependent outpatients (N = 81) participating in a new community-based initiative designed to improve access to enhanced substance abuse and psychiatric services in a publicly supported methadone maintenance treatment network in Baltimore, MD. The initiative, entitled Community Access to Specialized Treatment (CAST), is located at the Addiction Treatment Services, a program within this network. Network programs referred patients engaged in unremitting drug use who are at risk for discharge to CAST, where they received methadone substitution, individual and group counseling within an adaptive platform, behavioral contingencies to reinforce adherence, and on-site psychiatric evaluation and care. Patients returned to their referring program after producing at least two consecutive weeks of drug-negative urine samples and full counseling adherence. CAST was well utilized by the community. Patients had high rates of adherence to scheduled individual and group counseling services (93% and 73%, respectively); 43% of referrals successfully completed the program in an average of 101 days. This community-wide service delivery approach is a novel alternative to integrating intensive substance abuse and psychiatric care at each program within a treatment network.     

Unintended impacts of regulatory changes to British Columbia Methadone Maintenance Program on addiction and HIV-related outcomes: An interrupted time series analysis

BackgroundIn February 2014, several regulatory reforms were introduced to the methadone maintenance treatment (MMT) program in British Columbia, Canada, including a switch to a ten-times more concentrated methadone formulation and restrictions in pharmacy delivery services. We evaluated possible unintended effects of these changes on illicit drug use patterns and HIV treatment outcomes among HIV-positive opioid users.MethodsData was drawn from ACCESS, a prospective community-recruited cohort of HIV-positive people who use illicit drugs in Vancouver, Canada. Interrupted Time Series Analyses were used to evaluate impacts of the policy change on monthly rates of MMT enrolment, illicit heroin injection, antiretroviral therapy (ART) adherence, and HIV viral suppression among HIV-positive opioid users between November 2012 and May 2015.ResultsA total of 331 HIV-positive opioid users were included. The MMT policy change led to a significant immediate 11.5% increase in heroin injection, and 15.9% drop in optimal ART adherence. A gradual increase in the prevalence of MMT enrolment after the policy change was also documented (0.9% per month). No changes in viral suppression rates were observed.ConclusionWe observed immediate increases in illicit heroin injection and decreases in ART adherence in the wake of regulatory changes to the local MMT program. These findings underscore the need to consider potential unintended effects of altering health programmes for vulnerable populations, the need to develop appropriate mitigation strategies, as well as to involve all relevant stakeholders in the planning and implementations of new policies.     

Impact of methadone program philosophy changes on early treatment outcomes

This paper describes the consequences of changing from methadone maintenance treatment focussed primarily on elimination of all illicit drug use and social reintegration to patient-centred care. Counselling (formerly mandatory) became optional, patients were retained in treatment despite continued illicit drug use, the ceiling on methadone doses was removed, patient input became a part of methadone prescribing and the number of patients in treatment more than doubled. Across three cohorts (before, during and after the program was redesigned) the mean daily dose of methadone increased (50.4 mg +/- 2.5, 72.6 mg +/- 2.4, 92.2 mg +/- 4.0, respectively). The number of physician visits increased linearly with cohort while the number of therapist visits was unchanged overall. Two-year treatment retention was not significantly different (73%, 69% and 67%, respectively). In all three cohorts there was a significant reduction in opioid and benzodiazepine use but not cocaine use over the first six months of treatment.