Evaluation of a minimal services treatment track for noncompliant patients in opioid substitution treatment.

Abstract

Opioid substitution treatment (OST) is the most widely used treatment for opiate dependence.1,2 The preponderance of evidence suggests that retention in OST is associated with decreased opiate use and criminality.3–5 However, continued illicit drug use among patients in OST is common.6–8 Program responses to ongoing use vary widely,9 though discharge is a frequent response. Some patients nevertheless are unable or unwilling to cease illicit use despite the threat of treatment termination. Unfortunately, outcomes for out-of-treatment opiate addicts are very poor.3 Recently published OST guidelines recommend that programs find alternatives to treatment termination for ongoing drug use.10 For treatment programs, such a no-discharge policy poses certain dilemmas. If a program retains patients despite ongoing drug use, harm may be reduced for that subset of patients. However, the potential benefits of retention of drug-using patients in treatment could be offset if illicit use were to increase among other patients in the program who might have otherwise been motivated to cease or reduce their use by the threat of discharge. The value of a putative harmreduction strategy is determined not only by its effectiveness in reducing harm among members of the target group (i.e., microharm) but also by the extent to which it does not inadvertently increase harm among members of other groups or the larger population (macroharm).11 In April 1998, the OST program at the Veterans Affairs Puget Sound Health Care System (VAPSHCS) in Seattle, Washington, instituted a minimal services (MS) treatment track as an alternative to discharge for patients who continued to use illicit drugs. MS was designed to retain these patients in treatment. MS also was designed to introduce additional contingencies that 1) encouraged abstinence and 2) simultaneously minimized demands on clinic and staff resources and opened additional treatment slots to reduce the waiting list for new patients. The components of the MS program are listed in Table 1 ▶. After the MS program was in place for 1 year, the new policy’s impact on both MS patients and the clinic population at large was assessed by means of a program evaluation. TABLE 1— Components of the Minimal Services Treatment Track