Methadone Maintenance Patients Research Articles

Effects of reinforcer magnitude on data-entry productivity in chronically unemployed drug abusers participating in a therapeutic workplace.

The Therapeutic Workplace is a substance abuse treatment wherein patients are hired and paid to work in a job contingent on daily drug-free urine samples. The present study examined data-entry productivity of 6 unemployed methadone patients who demonstrated relatively variable and low data-entry response rates. A within-subject reversal design was used to determine whether increasing reinforcement magnitude tenfold could increase response rates. Four of the 6 participants showed the highest rates of responding in the high magnitude reinforcement condition. Two participants, who had the lowest overall response rates, showed less robust changes to the magnitude manipulation. The results suggest that reinforcement magnitude can be used to improve productivity in Therapeutic Workplace participants. Chronic unemployment is a common problem among individuals with long histories of drug abuse. Unemployment rates among methadone maintenance patients have been estimated to be 50% to 80% (French, Dennis, McDougal, Karuntzos, & Hubbard, 1992). It is not surprising that unemployment among drug abusers has been shown to be associated with continued drug use, poor treatment outcome, and criminal activity (Platt, 1995).

Latent Structure of the Davis Interpersonal Reactivity Index in Methadone Maintenance Patients

The latent structure of Davis's 28-item Interpersonal Reactivity Index (IRI) measure of empathy was examined in 241 methadone maintenance (MM) patients using factor analytic procedures and the divergent and convergent reliability of the derived structure was determined. Contrary to the four-factor structure determined for the IRI previously, three factors, comprised of 18 items, were found to best represent the construct of empathy in MM patients—an Empathy factor (nine items) combining the Empathic Concern and Perspective Taking factors originally described by Davis, and Fantasy (four items) and Personal Distress (five) factors. Canonical correlation analysis undertaken to determine concurrent validity of the IRI's revealed latent structure supported the validity of the derived Empathy factor as a measure of empathy, but indicated that Personal Distress appeared to be associated with neuroticism. These findings are consistent with more recent factor analytic and validity findings for the IRI.

Improving On‐Time Counseling Attendance in a Methadone Treatment Program: A Contingency Management Approach

Two studies were conducted to investigate the effectiveness of contingency management techniques in promoting punctual counseling attendance among methadone maintenance patients. In Study 1, 50 participants were recruited from an inner‐city methadone maintenance program. Study 1 used an A–B–A design with baseline, intervention, and return‐to‐baseline phases. On‐time attendance was reinforced during the intervention phase with a voucher that was redeemable for a draw out of a box containing 100 tokens with values varying from $0.00 to $100.00. Methadone maintenance patients who exhibited poor attendance during baseline showed a significant positive response during the contingency management intervention phase. Study 2 used the same design as Study 1 except that the 52 participants were randomized into reinforcement groups that received either the variable rate of reinforcement as in Study 1 or a fixed value reinforcer of $3.25. As in Study 1, Poor Attenders significantly improved counseling attendance during the intervention. There were no differences between the variable and fixed reinforcement groups. Overall, results suggest that targeting Poor Attenders with contingency management techniques may be a cost‐effective method of improving counseling attendance. Targeting Poor Attenders early in treatment may be especially important for improving treatment outcomes.

A staging system to predict prognosis among methadone maintenance patients, based on admission characteristics

As U.S. general internists play an increasing role in providing opioid maintenance therapy in practice offices, they are having to face the challenge of identifying patients who need specialized services especially at the outset of treatment. In methadone maintenance treatment, prognostic studies have failed to find robust predictors on the basis of single predictive variables. We hypothesize that a multivariable staging system will predict treatment outcome more accurately than single variables. We reviewed baseline and treatment data regarding 226 consecutive patients admitted to a methadone maintenance program in New Haven, Connecticut, from January 1, 1993 to March 28, 1994, and followed until December 1, 1996. The staging system was developed from the data on the first 112 patients, confirmed in the remaining 114 patients, and then applied to the entire cohort of 226 patients. Retention was the main outcome measure used in developing the staging system. The staging system was also validated as a predictor of illicit drug use during treatment and adverse discharge. In the staging system one point is scored for each of the following: use of more than two bags of heroin daily, previous prison term, previous period in reform school, and a history of diseases related to substance use, e.g., endocarditis, hepatitis, abscesses, and overdose. The total score classifies patients as Stage I (0 and 1 points), Stage II (2 points), or Stage III (3 and 4 points). This staging system was significantly associated with retention in a proportional‐hazards model, and no other variable added any additional predictive influence. The specific stage was also found to be a significant predictor of adverse discharge. Although additional validation is necessary in other populations, we found the staging system to be a useful and simple way of identify ing patients at risk for early attrition and adverse discharge.

Identifying Alcohol Problems Among Methadone Maintenance Patients

Abstract Alcohol consumption and patterns of use were examined in a cohort of 108 patients in methadone maintenance treatment in South London. Measures of alcohol consumption, alcohol dependence, liver dysfunction and blood alcohol levels were taken. The aim of the study was to identify the prevalence of alcohol problems among methadone maintenance patients and to consider resource implications in assessing and monitoring these problems. Although 42% had been abstinent from alcohol for the previous month, mean alcohol consumption among drinkers was 33.5 units of alcohol in the last week, with 25 patients (23%) drinking at levels that may be regarded as dangerous (more than 50 standard units of alcohol per week). Positive correlations were found between self-reported measures of alcohol use, severity of alcohol dependence and breathalyser scores. Associations between self-report alcohol measures and physiological indices of liver dysfunction were positive but weak. A minority of methadone maintenance patie...

Self-detoxification attempts among methadone maintenance patients: What methods and what success?

In a study of patients attending a methadone maintenance clinic in South London, 66 of 114 (58%) had previously attempted to detoxify themselves from opiates without medical assistance. The total number of self-detoxification attempts was 237, an average of 3.6 attempts per individual. Forty subjects (61%) reported attempting self-detoxification with the help of drugs or alcohol. The drugs most commonly used were diazepam, alcohol, and cannabis. The most commonly reported reasons for attempting self-detoxification were “fed-up with the lifestyle” (61%) and “for their family” (12%). The reasons given for why patients had decided to detoxify themselves rather than access treatment services included 23% who reported that “they could cope on their own and that they didn't need any help.” The short-term success rate (abstinent for at least 24 hours) was moderate, at 41% (97/237). Patients who had been unsuccessful were asked why their last self-detoxification attempt had not resulted in abstinence, with 27% reporting that they were “tempted to use again” and 23% reported that they “didn't know why they started using again.” The prevalence of both attempts and success suggests that, for some opiate users, self-detoxification may be a pathway to abstinence.

Cognitive impairment in methadone maintenance patients

Few well-controlled studies have examined psychomotor and cognitive performance in methadone maintenance patients (MMP). In the present study, performance of 18 opioid-dependent MMP was evaluated relative to that of 21 control participants without substance abuse histories. The MMP and control groups were balanced with respect to gender, race, age, years of education, current employment status, current reading level, and estimated IQ score. Recent drug abstinence was verified by urine testing. Participants with a urine screen positive for benzodiazepines or a breathalyzer test positive for alcohol prior to performance testing were excluded. To avoid testing under conditions of acute heroin or cocaine intoxication, but without testing under conditions of acute withdrawal, participants with current use of heroin or cocaine were only required to abstain for 24 h prior to performance testing. MMP exhibited impairment relative to controls in psychomotor speed (digit symbol substitution and trail-making tests), working memory (two-back task), decision making (gambling task), and metamemory (confidence ratings on a recognition memory test); results also suggested possible impairment in inhibitory mechanisms (Stroop color-word paradigm). MMP did not exhibit impairment in time estimation, conceptual flexibility or long-term memory. The wide range of impaired functions is striking, and may have important implications for daily functioning in MMP. Further research is necessary to determine the clinical significance of the impairments in laboratory-based tests for daily performance in the natural environment, as well as to differentiate impairments due to acute methadone dosing, chronic methadone maintenance, chronic poly-drug abuse, and other factors.

Treating hepatitis C in methadone maintenance patients: an interim analysis

Objective: This study evaluates the safety, tolerability, and efficacy of interferon/ribavirin combination therapy in methadone maintenance (MM) patients with active hepatitis C (HCV). End-of-treatment results are presented as an interim analysis of efficacy. Methods: Fifty eligible MM patients with active HCV and concomitant liver fibrosis were treated with interferon/ribavirin combination therapy using standard dosing regimens. Patients with active drug or alcohol use at the start of treatment, severe or untreated psychiatric illness, and/or decompensated liver disease were excluded. Results: Treated MM patients were older, had a longer history of HCV infection, a high prevalence of psychiatric illness, and had substantially more liver fibrosis than in previous studies of HCV treatment in non-opioid-dependent populations. Seventy-eight percent completed the 6–12 month course of treatment. The end-of-treatment virologic response rate was 64% in patients completing treatment and 54% on an intent-to-treat basis. Conclusion: Methadone maintenance patients exhibit a number of factors that make HCV treatment more difficult: they are older, have a higher prevalence of psychiatric illness, and show evidence of more advanced liver disease. Despite this, their end-of-treatment response rate to interferon/ribavirin combination therapy is similar to that of patients without a history of IDU. Further analysis of the sustained virologic response (SVR) rate is planned at the study's completion. These preliminary results show that MM patients are in need of timely HCV diagnosis, and should be considered good candidates for referral and HCV treatment.

The brief abstinence test: Effects of continued incentive availability on cocaine abstinence.

This study compared the effects of 4 voucher incentive conditions of a brief abstinence test on continuous cocaine abstinence. In 3 conditions, cocaine-abusing methadone patients could earn $100 for 2 days of cocaine abstinence; 2 of these conditions offered, on either a continuous or interrupted schedule, an additional $300 for evidence of sustained abstinence over the next 9 days. In the 4th condition, no incentives were available. In incentive conditions, 70-80% of patients initiated abstinence, compared with 48% in the no-incentive condition. Both continuing reinforcement conditions produced higher rates of sustained abstinence than the single and no-voucher conditions. The study confirmed the utility of quantitative urine-testing methods combined with high valued incentives to promote cocaine abstinence initiation in methadone maintenance patients.

Clinical Use of Methadone

Methadone hydrochloride is a mu-opioid agonist that has been used for the treatment of pain and for the management and maintenance of opioid withdrawal for over 50 years. Several characteristics make methadone a useful drug. However, these same characteristics and wide interpatient variability can make methadone difficult to use safely. A MEDLINE search was conducted on publications between January 1996 and May 2001 to identify literature relevant to this subject. Those publications were reviewed, and from them, other literature was identified and reviewed. Published studies demonstrate methadone's efficacy in pain management and in opioid withdrawal. However, interpatient variability in pharmacokinetic variables of methadone produces difficulties in developing guidelines for methadone use. Clinicians should not be deterred from use of this drug which has been shown to benefit patients in both pain management and methadone maintenance, but an individualized patient approach must be taken to use methadone safely.

A multicenter randomized evaluation of methadone medical maintenance

Methadone medical maintenance (MMM) is a rational, cost-effective method to match treatment intensity to level of needed services. In the present study, 73 highly stable methadone maintenance patients were randomly assigned to either a routine methadone treatment, MMM — a once monthly reporting schedule — at the methadone maintenance program or MMM at a physician office. A ‘stepped care’ intensified treatment approach was used for patients who had drug-positive urine specimens or failed the medication recall procedure. Patients left two urine specimens for analysis each month (at least one on a random basis) and responded to one medication recall each month. Results are presented for the first 6 months of the 1-year trial. Only 1% of urine specimens were positive for illicit drugs, there was no evidence of methadone diversion and there were very low rates of medication misuse, with no between group differences. MMM patients initiated more new employment or family/social activities than the routine care patients. MMM patients were more satisfied with their treatment than the routine treatment patients, but all patients rated themselves satisfied or very satisfied with their treatment. Stepped care was well-tolerated and helped match patients to an appropriate intensity of service. The good outcomes observed with the present sample suggest that MMM can be implemented effectively as part of a continuum of care in clinic and office-based sites.

A randomised, controlled trial of fluoxetine in methadone maintenance patients with depressive symptoms

Background: Depression and antidepressant use are prevalent in methadone maintenance patients (MMPs). However, antidepressant efficacy is not well established in this population. This study examined the efficacy of fluoxetine in improving depressive symptoms and reducing substance use in MMPs. Methods: Stabilised MMPs scoring over 21 on the Beck Depression Inventory were randomised to receive fluoxetine or placebo over 12 weeks. Results: Forty-nine subjects were randomised. In both groups, significant improvements were observed in depression, life functioning, and social impairment over 12 weeks. Poly-drug use improved in completers only. No fluoxetine effects were observed. Conclusions: Little evidence supports use of fluoxetine as a treatment for depressive symptoms in MMPs.

Effects of program and patient characteristics on retention of drug treatment patients

Objective: To examine effects of program and patient characteristics on patient retention in residential drug treatment programs, outpatient drug-free programs (ODF), and methadone maintenance (MM) programs. Data sources/study setting: Patient data were based on admission and discharge records for individuals entering treatment programs in Los Angeles County during 1992 and 1993. Program data were collected from program directors via a mail survey. The study sample included 26,047 patients in 87 programs. The dependent variable was patient completion of a critical threshold of treatment (360 days for MM and 180 days for the other two modalities). We applied logistic regression hierarchical linear modeling analysis for each modality. Principal findings: Threshold retention rates were generally low in all three modalities (18.1% for residential programs, 22.9% for ODF, and 13.6% for MM). An articulated programmatic focus and low caseload increased patient retention in residential programs. A lower level of group therapy focus increased patient retention in ODF programs. A low programmatic focus and a low percentage of recovering staff were associated with high retention rates among MM patients. For ODF programs, none of the slopes showed random effects, while for residential and MM programs, some program factors contributed to the explanation of the random effects in several slopes (e.g., drug use severity). Conclusion: Program practice and service provision played important roles in determining patient retention in treatment. Service providers and planners should consider these key factors to improve retention of patients, which is likely to increase overall treatment effectiveness and efficiency.

The relationship between suicide and heroin overdose among methadone maintenance patients in Sydney, Australia.

To examine the relationship between attempted suicide and non-fatal heroin overdose among methadone maintenance patients. Cross-sectional survey. Sydney, Australia. Two hundred and twenty-three methadone maintenance patients. Forty per cent of participants reported a history of at least one suicide attempt. Females were significantly more likely than males to have attempted suicide (50% vs. 31%), and to have done so on more than one occasion (28% vs. 15%). There was a large difference between males and females in the onset of attempted suicide. Females reported an initial attempt, on average, 6 years earlier than males (18.3 vs. 24.7 years), and were significantly more likely than males to have attempted suicide prior to the onset of heroin use (69% vs. 11%). While heroin overdose was common among the sample (66%), the most common methods employed for suicide attempts were overdose of a non-opioid drug (21%) and slitting of wrists (20%). A deliberate heroin overdose as a means of attempted suicide was reported by 10% of participants. Heroin overdoses appeared overwhelmingly to be accidental. Ninety-two per cent of those who had overdosed reported that their most recent overdose was accidental. Attempted suicide presents a major clinical problem to staff at drug treatment programmes, but one distinct from heroin overdose. While both overdose and suicide present increasing clinical problems, they are separate problems, and require different responses.

The validity of the interviewer severity ratings in groups of ASI interviewers with varying training.

This study evaluated the hypothesis that the subjective interviewer severity rating (ISR) summary indices of the intake Addiction Severity Index (ASI) of less trained interviewers are less valid than those of more highly trained interviewers. Baseline ASIs from three completed studies whose interviewers varied in degree of initial ASI training and subsequent quality assurance monitoring were examined. Associations between baseline ISRs and three other sets of ASI summary indices not based on interviewer ratings-composite scores, clinical indices and evaluation indices-were compared for three groups of interviewers with varying amounts of training. The assumption underlying these analyses was that more reliable ISRs, found in more trained interviewers, would be more highly associated with the other more objective indices. Methadone maintenance patients in the Philadelphia and New York City areas. Thirty-five interviewers with the most intense training who administered 295 interviews; 10 interviewers with an intermediate level of training who administered 763 interviews; and eight identified (and other unidentified) least trained interviewers who administered a total of 276 interviews. Measurements and methods. Four sets of summary indices from the above ASIs. Both bivariate and multivariate analyses were performed. The study found that the validity of the validity of ISRs was greater in more trained interviewers. Greater training and subsequent monitoring of ASI interviewers generally appears to be associated with increased ISR validity.

Predictive validity of the Addiction Severity Index's composite scores in the assessment of 2-year outcomes in a methadone maintenance population.

The current research tested the predictive validity of 6 of the 7 Composite Scores (CSs) of the Addiction Severity Index (ASI) in 310 methadone maintenance patients assessed at treatment entry using the ASI and other measures, and followed for 2 years. Logistic regression was used to estimate the sensitivity and specificity of the CSs at intake in predicting their respective validity criterion measures at follow up. Except for the Medical CS, each of the other 5 CS measures significantly predicted its validity criterion measure. The CSs measuring drug use, alcohol abuse, psychopathology, and legal problems had high specificity (88% [corrected] for the Drug CS, 91% for the Alcohol CS, 96% for the Legal CS, and 100% for the Psychological CS). The CSs measuring employment problems had high sensitivity (76%). The results support the predictive validity of most of the ASI CSs as measures of specific problems as well as the validity of the multidimensional construct on which the ASI is based.

Social relationships and intravenous drug use among methadone maintenance patients

This study examined the extent to which social relationships were associated with continued injection drug use and needle sharing among 252 methadone maintenance patients. Logistic regression analyses indicated that drug use was highest among persons who had a substance using live-in partner and among those with more drug-using social relationships. Among injectors, whites and those who had more people present during IV drug use were more likely to share needles, while those with more emotional support were less likely to do so. These findings suggest that personal relationships strongly influence continued injection drug use and that methadone programs should help patients develop social networks of non-users.

Methadone maintenance patients are cross-tolerant to the antinociceptive effects of morphine

We have previously shown that methadone maintenance patients are hyperalgesic. Very little is known about the antinociceptive effects of additional opioids in these patients. This study (1) compared the intensity and duration of antinociceptive responses, at two pseudo-steady-state plasma morphine concentrations ( C SS1 and C SS2), between four patients on stable, once daily, doses of methadone and four matched control subjects; and (2) determined, in methadone patients, whether the antinociceptive effects of morphine are affected by changes in plasma R(−)-methadone concentration that occur during an inter-dosing interval. Two types of nociceptive stimuli were used: (1) a cold pressor test (CP), (2) electrical stimulation (ES). Morphine was administered intravenously to achieve the two consecutive plasma concentrations. Blood samples were collected, concurrently with nociceptive responses, to determine plasma morphine concentrations. Methadone patients achieved mean C SS1 and C SS2 of 16 and 55 ng/ml respectively; those of controls were 11 and 33 ng/ml. Methadone patients were hyperalgesic to pain induced by CP but not ES. Despite significantly greater plasma morphine concentrations, methadone patients experienced minimal antinociception in comparison with controls. Furthermore in methadone patients, the antinociception ceased when the infusion ended. In comparison, the duration of effect in control subjects was 3 h. The fluctuations that occurred in plasma R(−)-methadone concentration during an inter-dosing interval had little effect on patients’ responses to morphine. Our findings suggest that methadone patients are cross-tolerant to the antinociceptive effects of morphine, and conventional doses of morphine are likely to be ineffective in managing episodes of acute pain amongst this patient group. Further research is needed to determine whether other drugs are more effective than morphine in managing acute pain in this patient population.

Outcomes after methadone maintenance and methadone reduction treatments: two-year follow-up results from the National Treatment Outcome Research Study

This paper provides a detailed analysis of the 2-year outcomes for 351 drug misusers allocated on an intention-to-treat basis to methadone maintenance or methadone reduction treatments. Both groups showed substantial reductions in their use of illicit drugs and in other outcome areas. However, whereas most methadone maintenance patients received maintenance, only about one third of those allocated to methadone reduction received methadone reduction, and many actually received a form of methadone maintenance. Reduction patients were more likely to receive low doses of methadone, and were less likely to remain in treatment. For maintenance patients, higher doses and retention in treatment were both associated with improvements in illicit heroin use at 2 years. For the reduction patients, the more rapidly the methadone was reduced, the worse the heroin use outcomes. For patients in both treatment conditions, reductions in heroin use were associated with improvements in other outcome areas. The more severely dependent patients showed better outcomes in methadone maintenance. Methadone reduction treatment processes were associated with poor outcomes, and many patients who were allocated to methadone reduction treatment did not receive reduction treatment as intended. This calls into question the appropriateness of either the initial treatment planning process or the treatment delivery process, or both. A clearer distinction should be made between methadone maintenance and methadone reduction. Treatment goals should be made explicit both to the patient and to the clinical staff at the start of treatment. We suggest the need for a reappraisal of the goals and procedures of methadone reduction treatment.

Hyperalgesic responses in methadone maintenance patients

Opioid substitution treatment for dependence may alter sensitivity to pain. Previous studies on pain sensitivity in methadone maintenance patients have yielded contradictory results. This study compared nociceptive responses between 16 patients on stable, once daily, doses of methadone and 16 matched control subjects. Two types of nociceptive stimuli were used: (1) electrical stimulation; and (2) a cold pressor test. Two parameters were measured: detection for onset of pain, and pain tolerance. Methadone patients were tested over an inter-dosing period: at the time of trough plasma methadone concentration (0 h), and 3 h after their daily dose. Control subjects were tested twice 3 h apart. Blood samples were collected to determine plasma methadone concentration. In methadone patients, trough to peak increases in mean R-(−)- and S-(+)-methadone concentrations (118 and 138 ng/ml to 185 and 259 ng/ml, respectively) resulted in significant increases in pain detection and tolerance values for both nociceptive stimuli. Using electrical stimulation, methadone patients' pain tolerance values were lower than controls at 0 h, but higher than controls at 3 h; no significant differences in pain detection values were found. For the cold pressor test, methadone patients detected pain significantly earlier than controls at 0 h, and were also substantially less pain tolerant than controls at both 0 and 3 h. There were no significant differences in pain detection values between the two groups at 3 h. Pain tolerance to pain detection ratios for methadone patients were significantly lower than controls for the cold pressor test at 0 and 3 h, and for electrical stimulation at 0 h only. In summary, the relative pain sensitivity of methadone maintenance patients is determined by the nature of the nociceptive stimulus (e.g. cold pressor test versus electrical stimulation), the plasma methadone concentration (trough versus peak plasma concentration), and whether thresholds are determined for detection of pain or pain tolerance. Although responding to changes in plasma methadone concentration, maintenance patients are markedly hyperalgesic to pain induced by the cold pressor test.