Question 13: Are there program characteristics associated with the success of methadone maintenance treatment?

Answer: Yes. There are several program characteristics associated with a variety of improved treatment outcomes in patients receiving methadone maintenance. These program characteristics are as follows:

• Establishment of evidence-based dosing policies and dose ranges
• Availability of a variety of psychosocial services for those who require them
• Attention to staff training and quality
• When possible, integration of medical, counseling, and administrative services

Research Highlights

• A meta-analysis of 12 trials involving 981 people comparing varying levels of psychosocial treatment added to methadone maintenance showed additional benefit in adding any psychosocial treatment to standard methadone maintenance treatment in relation to the use of heroin during the treatment; relative risk was 0.69 (95% CI 0.53 to 0.91). However, no statistically significant additional benefit was shown in terms of retention in treatment–relative risk was 0.94 (95% CI 0.85 to 1.02)–or proportion of patients retained or abstinent at followup–relative risk was 0.90 (95% CI 0.76 to 1.07) (Amato, Minozzi, Davoli, et al., 2004).
• Ball and Ross (1991) noted wide differences among the six methadone maintenance clinics studied with respect to the reduction of injection drug use by patients. Factors that account for treatment success include (1) adequate dosing; (2) participation in programs that had high retention rates, high rates of scheduled attendance, low treatment staff turnover, and a close, consistent, and enduring relationship between staff and patients; (3) an effective treatment director; (4) combined medical, counseling, and administrative services; (5) experienced counselors providing comprehensive counseling services; and (6) staff/patient agreement about the status of patients and their treatment needs.
• In a United Kingdom study of 262 patients who were admitted to and retained in methadone treatment programs at 6 months, structural equation models were used to evaluate relationships between treatment process variables and heroin use at 1 and 6 months. Patients' perceptions of program characteristics and methadone dose were related to reduced heroin use at 1 month. In addition, early engagement with treatment services was associated with decreased heroin use at 6 months (Gossop, Stewart, and Marsden, 2003).
• Studies comparing methadone treatment in general practice or primary care with treatment in specialty treatment clinics are limited, but at least two have demonstrated similar treatment outcomes between these two locations of care (Fiellin, O'Connor, Chawarski, et al., 2001).
• The Treatment Outcome Perspective Study (TOPS) examined a sample of 606 methadone maintenance treatment patients from 21 different clinics to identify treatment process factors related to improved patient retention rates. Results showed higher patient retention rates for programs (1) using organized and professional staff to diagnose problems and define treatment plans, (2) meeting and satisfying the needs perceived as important by clients, and (3) using higher methadone doses (Joe, Simpson, and Hubbard, 1991).
• A 6- to 7-year followup study of 347 methadone maintenance treatment patients examined different retention policies. Two programs had a high-dose, long-retention policy in which involuntary termination was used as a last resort. A third program had a low-dose, 2-year retention policy with strict terminations for program violations. Retention rates were longer in the two less structured programs (means of 4.3 and 3.2 years) than in the more structured program (mean of 2.2 years) (McGlothlin and Anglin, 1981).
• One study randomly assigned 69 patients at admission to structured and unstructured treatment groups. Structured groups had limits on illicit drug use that, if exceeded, resulted in withdrawal from methadone. The unstructured groups had no limits on illicit drug use. At the end of 1 year, 53 percent of the patients in structured groups remained in treatment, but only 30 percent of the patients in unstructured groups remained in treatment (McCarthy and Borders, 1985).
• A nationwide U.S. telephone survey of a randomized and stratified representative sample of 172 outpatient methadone units found that relatively high methadone dosage levels and patient participation in dosage decisions are related to higher retention rates (D’Aunno and Vaughn, 1992).
• According to Center for Substance Abuse Treatment, 1993).

The Effects of Dosage on Methadone Maintenance Treatment–Research regarding methadone dosage levels clearly establishes that low average doses are inappropriate in methadone maintenance treatment. No single level is effective for all patients, although NIDA-supported research has suggested that the minimum effective dosage for most methadone maintenance patients is 60 mg per day. The specific dosage for a patient cannot be determined arbitrarily because patients metabolize methadone at different rates. In addition, the appropriate dosage can change over time or in response to specific situations such as pregnancy or the use of other medications. Overall, methadone dosage should be based on the patient’s individual needs, goals of treatment, and progress in treatment.

In the Ball and Ross studies (1991), illicit opioid use was directly related to methadone dosage levels. In methadone maintenance patients on dosages of about 71 mg per day, no heroin use was detected, but methadone maintenance patients on dosages below 46 mg were 5.16 times more likely to use heroin than those on higher dosages.

Ball and colleagues (1988) found that 18.6 percent of 490 patients who were in methadone maintenance treatment for 6 months to 4.5 years used heroin within the last 30 days, but use correlated strongly with methadone dosage level. At doses of 75 mg per day and above, the continuing use of heroin stopped altogether. In contrast, 64 percent of patients maintained on 10 mg per day or less continued frequent heroin use. A dose of 40 mg per day seemed to be the cutoff point for a large decrease in heroin use.

Despite recent attention to the importance of adequate methadone dosages, a large-scale survey of methadone maintenance treatment programs conducted in the United States in 1992 found that 50 percent of patients nationwide receive suboptimum methadone doses (D’Aunno and Pollack, 2002).

In an exhaustive review of 22 studies that compared the effects of different methadone dosages on outcomes such as patient retention, continuing illicit opioid use, and symptoms, Hargreaves (1983) concluded that daily methadone doses of 100 mg were superior to those of 50 mg during the first 5 to 10 months of methadone maintenance treatment for a sizeable subgroup (10 percent to 30 percent) of opioid addicts.

In a study of 2,400 patients enrolled in methadone maintenance over a 15-year period, those patients maintained on a daily dose of 60 mg or more had longer retention in treatment; less use of heroin and other drugs, including cocaine; and a lower incidence of HIV infection and AIDS (Hartel, Selwyn, and Schoenbaum, 1988a and 1988b).

In a multiclinic study of 12 Veterans Administration hospitals, methadone maintenance treatment patients were assigned to two dosage levels of methadone: 50 mg and 100 mg. The percentage of patients retained for 10 months was higher in the 100-mg group (52 percent) than in the 50-mg group (42 percent), but the difference was not statistically significant (Ling, Charuvastra, Kaim, et al., 1976).

Studies that examined the relationship between methadone maintenance treatment dosage and retention suggest that, although many patients will continue in treatment on methadone doses of less than 50 mg, some patients need higher doses. In a review of five well-designed dose-retention studies, three found statistically nonsignificant trends toward increased retention with higher doses and two did not (Maddux, Vogtsberger, Desmond, et al., 1993).

In a study of 180 methadone maintenance treatment patients randomly assigned at admission to three groups that received doses of 30 mg, 50 mg, and 100 mg, the percentages retained for 53 weeks were as follows: 45 percent of the 30-mg group, 55 percent of the 50-mg group, and 35 percent of the 100-mg group. The 100-mg group had the lowest retention rate, but the differences were not statistically significant (Garbutt and Goldstein, 1972).

A study of 322 methadone maintenance treatment patients receiving an average daily dose of 30 mg demonstrated a high dropout rate. Only 17 percent of the sample remained in treatment at the end of 6 months, and only 10 percent remained by the end of a year. Moreover, patients who dropped out within the first 30 days had the same drug-using behavior as they did before treatment (Craig, 1980).

Methadone dose should not be rapidly increased or decreased–or used in contingency management–because such changes tend to disrupt the normalization of physiological function achieved by steady dose treatment. If the stabilized methadone dose/plasma levels are disrupted, drug hunger and drug-seeking behaviors are likely to reappear (Kreek, 1991;Kreek, 1992).

Need for Comprehensive Services in Methadone Maintenance Treatment–In a study of 351 daily or weekly heroin users who were admitted to 1 of 17 publicly funded methadone maintenance treatment programs, nearly all (85 percent) reported having difficulty in at least one of the following problem areas: medical or physical; mental health or emotional; family or friends; police or legal; job, work, or school; and financial or money. Nearly one-half (44 percent) reported having difficulties in more than three of these areas (Condelli, 1993).

Program Characteristics Associated With Success of Methadone Maintenance Treatment–Other program characteristics that appear to improve treatment success include having sufficient staff, low staff turnover and high staff stability, sufficient staff training, and close and enduring relationships between staff and patients.

Figure 27 illustrates the program characteristics, identified by numerous research studies, that contribute to methadone maintenance treatment success (Joe et al., 1991).

Figure 28 illustrates that in a recent study, 102 patients were divided into three groups: (1) minimum methadone maintenance treatment services (methadone alone); (2) standard methadone maintenance treatment services (methadone plus counseling); and (3) enhanced methadone maintenance treatment services (methadone, counseling, and onsite medical, psychiatric, employment, and family therapy services). At 24 weeks, methadone alone resulted in minimal improvements; methadone plus counseling resulted in significant improvements over methadone alone; and enhanced services, including a broad range of psychosocial services plus methadone, had the best outcomes of all (McLellan et al., 1993). Patients receiving the most comprehensive array of treatment services were the most likely to have opioid-free urine tests for the 24 weeks of the study. Patients receiving minimal services were the most likely to have urine tests that were positive for illicit opioids. Note: These patients were removed from participation in the study because of drug use and psychiatric difficulties. Additional treatment services were made available.

References

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Ball JC, Lange WR, Meyers CP, Friedman SR. Reducing the risk of AIDS through methadone maintenance treatment. Journal of Health and Social Behavior 1988;29:214-26.

Ball JC, Ross A. The Effectiveness of Methadone Maintenance Treatment: Patients, Programs, Services, and Outcomes. New York: Springer-Verlag, 1991.

Center for Substance Abuse Treatment. State Methadone Treatment Guidelines. Treatment Improvement Protocol Series 1. Rockville, MD: Center for Substance Abuse Treatment, 1993.

Condelli WS. Strategies for increasing retention in methadone programs. Journal of Psychoactive Drugs1993;25(2):143-47.

Craig RJ. Effectiveness of low dose methadone maintenance for the treatment of inner city heroin addicts.International Journal of the Addictions 1980;15(5):701-10.

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D'Aunno T, Vaughn TE. Variations in methadone treatment practices. Results from a national study. JAMA1992;267(2):253-58.

Fiellin DA, O'Connor PG, Chawarski M, Pakes JP, Pantalon MV, Schottenfeld RS. Methadone maintenance in primary care: a randomized controlled trial. JAMA 2001;286(14):1724-31.

Garbutt GD, Goldstein A. Blind comparison of three methadone maintenance dosages in 180 patients. In:Proceedings of the Fourth National Conference on Methadone Treatment. New York: National Association for the Prevention of Addiction to Narcotics, 1972, pp. 411-14.

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Hartel D, Selwyn PA, Schoenbaum EE. Methadone maintenance treatment and reduced risk of AIDS and AIDS-specific mortality in intravenous drug users. Abstract No. 8546. Fourth International Conference on AIDS, Stockholm, Sweden, June 1988a.

Hartel D, Selwyn PA, Schoenbaum EE. Temporal patterns of cocaine use and AIDS in intravenous drug users in methadone maintenance. Abstract 8526. Fourth International Conference on AIDS. Stockholm, Sweden, June 1988b.

Joe GW, Simpson DD, Hubbard RL. Treatment predictors of tenure in methadone maintenance. Journal of Substance Abuse 1991;3(1):73-84.

Kreek MJ. Rationale for maintenance pharmacotherapy of opiate dependence. In: O’Brien CP, Jaffe JH (eds.).Addictive States. New York: Raven Press, 1992.

Kreek MJ. Using methadone effectively: achieving goals by application of laboratory, clinical, and evaluation research and by developing of innovative programs. In: Pickens RW, Leukefeld CG, Schuster CR (eds.). Improving Drug Abuse Treatment. NIDA Research Monograph Series 196. Rockville, MD: National Institute on Drug Abuse, 1991.

Ling W, Charuvastra VC, Kaim SC, Klett CF. Methadyl acetate and methadone as maintenance treatments for heroin addicts. Archives of General Psychiatry 1976;33:709-20.

Maddux JF, Vogtsberger KN, Desmond DP, Esquivel M. Program changes and retention on methadone. Journal of Substance Abuse Treatment 1993;10:585-88.

McCarthy JJ, Borders OT. Limit setting on drug abuse in methadone maintenance patients. American Journal of Psychiatry 1985;142(12):1419-23.

McGlothlin WH, Anglin MD. Shutting off methadone: cost and benefits. Archives of General Psychiatry 1981;38:885-92.

McLellan AT, Arndt IO, Metzger DS, Woody GE, O’Brien CP. The effects of psychosocial services in substance abuse treatment. JAMA 1993;269(15):1953-59