Pre‐treatment characteristics, program philosophy and level of ancillary services as predictors of methadone maintenance treatment outcome

Abstract

Predictors of methadone maintenance treatment outcome have not been extensively studied as they relate to variations in program philosophy, nor have such predictors received much examination among recently treated, older cohorts of opioid addicts for whom drug use patterns have changed. Predictors of outcome were examined at 18 months post-treatment entry for 353 admissions to methadone maintenance who received random assignment to one of three counseling conditions: (1) medication only, (2) standard counseling and (3) enhanced services; and one of two contingency conditions: (1) no contingencies, and (2) contingency contracting in a six-cell 3 x 2 design. Subjects in contingency contracting conditions were placed on contingency contracts for positive urine toxicology results and ultimately discharged for unremitting drug use. All subjects completed the Addiction Severity Index (ASI) and provided weekly urine specimens. Predictors of urinalysis results and treatment retention were determined using bivariate and multivariate techniques. Interactions between subject characteristics by experimental condition assignment were also examined as predictors. Higher rates of total positive urine specimens were predicted by younger age, greater pre-treatment frequency of smoking cocaine, lower ASI psychiatric composite scores, and higher ASI legal composite scores. Higher rates of opiate positive specimens were predicted by younger age, lower pre-treatment frequency of alcohol intoxication, higher ASI legal and lower ASI employment and psychiatric composite scores, and assignment to medication only/no contingencies condition. Higher rates of cocaine positives were predicted by younger age, black race, lower ASI psychiatric composite score, greater pre-treatment frequency of intravenous and smoked cocaine use, less pre-treatment frequency of marijuana use, and lower methadone dose level. Assignment to enhanced/contingency contracting predicted lower rates of cocaine positives. Treatment retention was predicted by older age, non-black race, lower ASI legal composite score, higher methadone dose level and assignment to non-contingent conditions. While subject variables over which treatment providers have little control were, thus, related to outcome, type of treatment provided and methadone dose also influenced outcome.

A randomized trial of 6-month methadone maintenance with standard or minimal counseling versus 21-day methadone detoxification

“…In contrast, studies of the first six months of long-term methadone maintenance showed that standard counseling yielded fewer opiate positive (McLellan et al, 1993;Saxon et al, 1996) and cocaine positive urine results (McLellan et al, 1993) compared to minimal counseling.…”

“…Compared to 21-day methadone detoxification, six months of methadone maintenance appears to reduce the frequency of heroin and alcohol use, but not cocaine use. In the first six months of long-term methadone maintenance, standard counseling has been shown to help patients reduce their heroin use more than minimal counseling (McLellan et al, 1993, Saxon et al, 1996. In six-month methadone maintenance, in contrast, heroin use appears to decrease regardless of whether standard or minimal counseling is made available to patients.…”

“…In another randomized trial, standard counseling twice a month or more in the first three months of treatment was compared to minimal monthly counseling. The twice monthly counseling reduced opiate positive urine test results relative to minimal counseling (Saxon et al, 1996). Of note, both of these clinical trials comparing standard to minimal counseling were conducted with patients in their first six months of long-term methadone maintenance.…”

Mental health problems: Are they or are they not a risk factor for dropout from drug treatment? A systematic review of the evidence

“…Most of these studies used either the Addiction Severity Index subscale for psychological/psychiatric symptoms or the Symptom Check List-90. Eight studies found that the severity of a client's psychological symptoms was unrelated to retention (Epstein et al 1994;Ryan et al 1995;Saxon et al 1996;Ross et al 1997;Tidey et al 1998;McCaul et al 2001;Sayre et al 2002;Wallace and Weeks 2004). However, there is also a considerable amount of evidence that clients with more severe symptoms were more likely to leave treatment (Carroll et al 1993;Petry and Bickel 1999;Lang and Belenko 2000;Haller et al 2002;Haller and Miles 2004;Kissin et al 2004;Van Stelle and Moberg 2004).…”

Methadone treatment: relationship between dose and retention / Tratamiento con metadona: relación entre dosis y retención

“…En este sentido, Bell y Zador (2000) observan que tanto los riesgos como los beneficios del TMM dependen en gran medida del modo en que se lleva a cabo el tratamiento, instauración rápida de pretratamiento (Saxon 1996;) en la forma de realizar la incorporación en tratamiento (Favrat 2002), no limitación y participación y negociación individual de la dosis (Caplehorn 1991;Maddux 1997). Los beneficios son menores en aquellos tratamientos de poca calidad, y la calidad se asocia a la relación paciente profesional, a la actitud de los profesionales y al buen manejo clínico, …”