Question 7: What components of methadone maintenance treatment account for reductions in AIDS risk behaviors?

Answer: Reductions in drug use and related AIDS risk behaviors among methadone-maintained individuals have been associated with both physiological and psychosocial factors. Recent studies have confirmed that adequate methadone dose levels are required to achieve significant reductions in opioid abuse. At the same time, research has demonstrated that methadone alone will have, at best, limited impact. Additional psychosocial support services are needed to maximize the effectiveness of methadone maintenance treatment.

Research Highlights

• A study examining the impact of psychosocial services in methadone treatment found that outcomes were significantly improved for those injection drug users who received services in addition to methadone (McLellan, Arndt, Metzger, et al., 1993). In this study, methadone patients were randomly assigned to one of three groups that received either: (1) methadone alone with no other services, (2) methadone and regular counseling, or (3) methadone with counseling and medical/psychiatric services, employment services, and family therapy. Although methadone doses were the same in each group, outcomes were significantly better in the groups that also received psychosocial services. Sixty-nine percent of the methadone-only group had to be “protectively transferred” due to unremitting use of opiates or cocaine or medical/psychiatric emergencies.
• Counseling programs specifically designed to reduce HIV risk behavior among methadone-maintained patients have been shown to be effective (Margolin, Avants, Warburton, et al., 2003).
• Patients with comorbid psychiatric disease are less likely to decrease their HIV risk behaviors during methadone maintenance treatment, compared with those without, although both groups receive benefit (King, Kidorf, Stoller, et al., 2000).
• A study of 291 patients that evaluated a high-intensity day treatment along with methadone versus enhanced methadone treatment saw decreases in drug use and HIV risk behavior in both groups; however, the study was unable to detect a significant difference in these outcomes between treatment groups (Avants, Margolin, Sindelar, et al., 1999).
• Similarly, a study that compared methadone dose (50 mg vs. 80 mg) and visit frequency (two visits per week vs. five visits per week) saw reductions in HIV risk behavior with methadone maintenance treatment but was unable to demonstrate a difference in HIV risk reduction between the four groups (Rhoades, Creson, Elk, et al., 1998).
• Hartel, Schoenbaum, Selwyn, et al. (1995) examined the drug use patterns and treatment characteristics of 652 methadone patients receiving treatment from the Montefiore Methadone Treatment Program in New York. The study found that those who were maintained on less than 70 mg per day of methadone were 2.1 times (p < .005) more likely to be using heroin. It is important to note that the observed effects of higher doses were found even after controlling for the length of time in treatment.
• A meta-analysis of HIV risk reduction interventions in substance abuse treatment programs found that these programs succeeded in changing knowledge, attitudes, and beliefs; sexual behavior; and injection practices. The impact of the intervention programs was negatively correlated with the presence of ethnic/minority samples and positively correlated with the number of intervention techniques used, the intensity of the intervention, interventions that were delivered within methadone treatment, and specific intervention techniques (Prendergast, Podus, Chang, et al., 2002).

References

Avants SK, Margolin A, Sindelar JL, Rounsaville BJ, Schottenfeld R, Stine S, et al. Day treatment versus enhanced standard methadone services for opioid-dependent patients: a comparison of clinical efficacy and cost. American Journal of Psychiatry 1999;156(1):27-33.

Hartel DM, Schoenbaum EE, Selwyn PA, Kline J, Davenny K, Klein RS, et al. Heroin use during methadone maintenance treatment: the importance of methadone dose and cocaine use. American Journal of Public Health1995;85:83-88.

King VL, Kidorf MS, Stoller KB, Brooner RK. Influence of psychiatric comorbidity on HIV risk behaviors: changes during drug abuse treatment. Journal of Addictive Diseases 2000;19(4):65-83.

Margolin A, Avants SK, Warburton LA, Hawkins KA, Shi J. A randomized clinical trial of a manual-guided risk reduction intervention for HIV-positive injection drug users. Health Psychology 2003;22(2):223-28.

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.

Prendergast ML, Podus D, Chang E, Urada D. The effectiveness of drug abuse treatment: a meta-analysis of comparison group studies. Drug & Alcohol Dependence 2002;67(1):53-72.

Rhoades HM, Creson D, Elk R, Schmitz J, Grabowski J. Retention, HIV risk, and illicit drug use during treatment: methadone dose and visit frequency. American Journal of Public Health 1998;88(1):34-39