Methadone Take-home Doses Research Articles

Impact of the COVID-19 pandemic on the provision of take-home doses of opioid agonist therapy in Ontario, Canada: A population-based time-series analysis.

BackgroundIn March 2020, the Ontario government declared a state of emergency due to the growing risk of COVID-19. In response, new guidance for the management of opioid agonist therapy (OAT) was released, which included the expansion of eligibility for take-home doses. We investigated the impact of these changes on trends in the distribution of take-home doses of OAT.MethodsWe conducted a population-based time series analysis among residents of Ontario, Canada who were dispensed OAT between June 25, 2019 and November 30, 2020. For each week of the study period, we calculated the percentage of people dispensed (a) methadone and (b) buprenorphine/naloxone by the number of take-home doses received. We used interventional autoregressive integrated moving average models to estimate changes in the percentage of people dispensed each category of take-home doses in the weeks following the declaration of the state of emergency and release of the OAT dispensing guidance.ResultsFollowing the state of emergency and release of the OAT dispensing guidance, there was a significant increase in the percentage of Ontarians dispensed 7 to 13 (3.6% increase; p = 0.033) and 14 or more (0.8% increase; p<0.001) take-home doses of methadone, and in the percentage of people dispensed 7 to 13 (4.3% increase; p = 0.001), 14 to 27 (2.8% increase; p<0.001), and 28 or more (0.3% increase; p = 0.008) take-home doses of buprenorphine/naloxone. There were significant decreases in the percentage of Ontarians receiving daily dispensed buprenorphine/naloxone (-3.1%; p = 0.001), as well as the percentage dispensed 1 to 6 take-home doses of methadone (-4.5%; p = 0.001) and buprenorphine/naloxone (-4.9%; p = 0.001).ConclusionThe new guidance for dispensing OAT in Ontario resulted in increases in the duration of take-home doses of methadone and buprenorphine/naloxone supplied. However, given that changes were small, strategies to improve retention in OAT and ensure equitable access to take-home dosing should continue.

Association Between Increased Dispensing of Opioid Agonist Therapy Take-Home Doses and Opioid Overdose and Treatment Interruption and Discontinuation

During the COVID-19 pandemic, modified guidance for opioid agonist therapy (OAT) allowed prescribers to increase the number of take-home doses to promote treatment retention. Whether this was associated with an increased risk of overdose is unclear. To evaluate whether increased take-home doses of OAT early in the COVID-19 pandemic was associated with treatment retention and opioid-related harm. A retrospective propensity-weighted cohort study of 21 297 people actively receiving OAT on March 21, 2020, in Ontario, Canada. Changes in OAT take-home dose frequency were assessed between March 22, 2020, and April 21, 2020, and individuals were observed for up to 180 days to assess outcomes (last date of follow-up, October 18, 2020). Exposure was defined as extended take-home doses in the first month of the pandemic within each of 4 cohorts based on OAT type and baseline take-home dose frequency (daily dispensed methadone, 5-6 take-home doses of methadone, daily dispensed buprenorphine/naloxone, and 5-6 take-home doses of buprenorphine/naloxone). Primary outcomes were opioid overdose, interruption in OAT, and OAT discontinuation. Among 16 862 methadone and 4435 buprenorphine/naloxone recipients, the median age ranged between 38 and 42 years, and 29.1% to 38.2% were women. Among individuals receiving daily dispensed methadone (n = 5852), initiation of take-home doses was significantly associated with lower risks of opioid overdose (6.9% vs 9.5%/person-year; weighted hazard ratio [HR], 0.73 [95% CI, 0.56-0.96]), treatment discontinuation (51.0% vs 63.6%/person-year; weighted HR, 0.80 [95% CI, 0.72-0.90]), and treatment interruption (19.0% vs 23.9%/person-year; weighted HR, 0.80 [95% CI, 0.67-0.95]) compared with no change in take-home doses. Among individuals receiving daily dispensed buprenorphine/naloxone (n = 662), there was no significant difference in any outcomes between exposure groups. Among individuals receiving weekly dispensed OAT (n = 11 010 for methadone; n = 3773 for buprenorphine/naloxone), extended take-home methadone doses were significantly associated with lower risks of OAT discontinuation (14.1% vs 19.6%/person-year; weighted HR, 0.72 [95% CI, 0.62-0.84]) and interruption in therapy (5.1% vs 7.4%/person-year; weighted HR, 0.69 [95% CI, 0.53-0.90]), and extended take-home doses of buprenorphine/naloxone were significantly associated with lower risk of interruption in therapy (9.5% vs 12.9%/person-year; weighted HR, 0.74 [95% CI, 0.56-0.99]) compared with no change in take-home doses. Other primary outcomes were not significantly different between groups. In Ontario, Canada, during the COVID-19 pandemic, dispensing of increased take-home doses of opioid agonist therapy was significantly associated with lower rates of treatment interruption and discontinuation among some subsets of patients receiving opioid agonist therapy, and there were no statistically significant increases in opioid-related overdoses over 6 months of follow-up. These findings may be susceptible to residual confounding and should be interpreted cautiously.

The impact of relaxation of methadone take-home protocols on treatment outcomes in the COVID-19 era

ABSTRACT Background Background: In response to the COVID-19 pandemic, the US Substance Abuse and Mental Health Services Administration (SAMHSA) allowed for an increase in methadone take-home doses for the treatment of Opioid Use Disorder (OUD) in March 2020. Objective To evaluate the effects of the SAMSHA exemption on methadone adherence and OUD-related outcomes. Methods A convenience sample of 183 clients (58% female) were recruited from a methadone clinic in the fall of 2019 for a cross-sectional survey. Survey data was linked to clinical records, including urine drug testing (UDT) results for methadone and emergency department (ED) visits at the local hospital. Participants were on stable methadone dosing for 9 months prior to and following March 2020. Methadone adherence was assessed by UDTs; OUD-related outcomes were assessed by overdose events and ED visits. Logistic regression was used to assess the association between change in take-home methadone doses and outcomes. Results Mean take-home doses increased nearly 200% (11.4 doses/30 days pre-COVID-19 vs. 22.3 post-SAMHSA exemption). ED visits dropped from 74 (40.4%) pre-COVID-19 to 56 (30.6%) post-SAMHSA exemption (p = <0.001). No significant changes were observed in either the number of clients experiencing overdose or those who experienced one or more methadone negative UDTs in the post-SAMHSA exemption period. Adjusted models did not show a significant association between changes in take-home doses and associated outcomes. Conclusions Despite a near-doubling of take-home methadone doses during the COVID-19 exemption period, the increase in take-home doses was not associated with negative treatment outcomes in methadone-adherent clients.

Changes in methadone take-home dosing before and after COVID-19

IntroductionIn response to the COVID-19 pandemic, a federal exemption allowed stable and less stable patients greater take-home doses of methadone. We assessed the adoption of increased take-home medication during COVID-19 and whether increased take-home doses is associated with clients' characteristics. MethodologyWe completed a pre-post study of adults receiving methadone for OUD from an OTP in Spokane, Washington. Our outcome was the change in the number of take-home methadone doses three months before and three months after the March 2020 take-home medication exemption. Clients' characteristics included age, gender, ethnicity, education level, homelessness, spatial access to the clinic, and methamphetamine use. ResultsThe study included 194 clients in treatment for a median of three years. All study participants experienced an average increase in take-home medication of 41.4 in the three-month period after the COVID-19 exemption. In the final adjusted models, clients who reported using methamphetamine in the last 30 days experienced a significantly larger increase in take-home dosage (55.6 days) compare to clients who did not use methamphetamine (p ≤0.001). Most of the clients who reported using methamphetamine were also likely to be homeless. All other variables were not associated with a change in take-home doses. ConclusionThese results suggest that the Spokane OTP quickly expanded take-home medication dosing in response to the COVID-19 exemption and broadly expanded take-home dosing among established clients. Clients with concurrent methamphetamine use were allowed fewer take-home doses prior to COVID-19, but after the exemption the clinic provided them the same number of take-home doses as clients who had not used methamphetamine.

Use of an electronic pillbox to increase number of methadone take-home doses during the COVID-19 pandemic

This study describes use of the commercially available Medminder electronic pillbox at a community substance use disorder treatment program to safely increase the number of methadone take-home doses administered during the COVID-19 pandemic. The pillbox contains 28 cells that lock independently and can be opened only during preprogrammed time windows. This study provided patients (n = 42) deemed vulnerable to take-home mismanagement or more severe symptoms from COVID-19 infection the pillbox and observed them for 11 weeks. A telephone support line was staffed daily to manage technical issues. Overall, patients received about 14 more take-home doses per month after receiving the pillbox. Most medication was dispensed within scheduled windows. The study observed few incidents of suspected tampering, though five patients had their pillbox rescinded to allow more intensive on-site clinical monitoring. The study supports use of an electronic pillbox with a telephone support line to help vulnerable patients to better observe stay-at-home guidelines during the COVID-19 pandemic. The pillbox may offer public health and clinical benefits that extend beyond the pandemic by increasing program treatment capacity and patient satisfaction.

Clinician perspectives on methadone service delivery and the use of telemedicine during the COVID-19 pandemic: A qualitative study

ObjectivesDuring the COVID-19 pandemic, opioid treatment programs (OTPs) in the U.S. were granted new flexibility in methadone dispensing and the use of telemedicine. To explore the impact of the pandemic and accompanying policy changes on service delivery, we asked OTP clinicians about changes in care patterns and perceptions of impacts on access and quality. MethodsIn May–June 2020, we completed semistructured telephone interviews with 20 OTP clinicians (physicians, physician assistants, and nurse practitioners) from 13 U.S. states. The study recruited participants through Medscape, an online platform where clinicians access clinical content. We used rapid thematic analysis, a qualitative approach, to summarize participants' expressed views related to the research objectives. ResultsClinicians identified a range of changes to methadone and ancillary service delivery as a result of COVID-19. Most clinicians reported that OTPs were prescribing more take-home doses of methadone and providing psychosocial services and medication management via telemedicine. Many also reported reducing the frequency of urine toxicology screening and accepting fewer new patients. While some clinicians expressed support for the increased flexibility around dosing and use of telemedicine, others expressed concern about increased risk of medication diversion and overdose. Clinicians reported several advantages and disadvantages of the changes due to the pandemic and that continued reimbursement would be required to maintain telemedicine services. ConclusionsThe COVID-19 pandemic dramatically altered the delivery of methadone treatment in the U.S. This study's findings suggest that OTPs may have reduced their methadone treatment during the early months of the pandemic and that the flexibilities that policy changes offered may not have resulted in changes in care delivery for all patients. Careful consideration and additional analysis should inform which changes OTPs should maintain long-term.

Take-home dosing experiences among persons receiving methadone maintenance treatment during COVID-19

PurposeMethadone maintenance treatment is a life-saving treatment for people with opioid use disorders (OUD). The coronavirus pandemic (COVID-19) has introduced many concerns surrounding access to opioid treatment. In March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued guidance allowing for the expansion of take-home methadone doses. We sought to describe changes to treatment experiences from the perspective of persons receiving methadone at outpatient treatment facilities for OUD. MethodsWe conducted an in-person survey among 104 persons receiving methadone from three clinics in central North Carolina in June and July 2020. Surveys collected information on demographic characteristics, methadone treatment history, and experiences with take-home methadone doses in the context of COVID-19 (i.e., before and since March 2020). ResultsBefore COVID-19, the clinic-level percent of participants receiving any amount of days' supply of take-home doses at each clinic ranged from 56% to 82%, while it ranged from 78% to 100% since COVID-19. The clinic-level percent of participants receiving a take-homes days' supply of a week or longer (i.e., ≥6 days) since COVID-19 ranged from 11% to 56%. Among 87 participants who received take-homes since COVID-19, only four reported selling their take-home doses. ConclusionsOur study found variation in experiences of take-home dosing by clinic and little diversion of take-home doses. While SAMSHA guidance should allow expanded access to take-home doses, adoption of these guidelines may vary at the clinic level. The adoption of these policies should be explored further, particularly in the context of benefits to patients seeking OUD treatment.

Medication-assisted Treatment for Opioid Use Disorder in Rhode Island: Who Gets Treatment, and Does Treatment Improve Health Outcomes?

Since the early 2000s Rhode Island has been among the states hardest hit by the opioid crisis. In response, the state has made it a priority to expand access to medication-assisted treatment (MAT) for opioid use disorder (OUD), which refers to the use of the FDA-approved medications methadone, buprenorphine, and/or naltrexone in conjunction with behavioral therapy. MAT is strongly supported by scientific evidence and endorsed by US public health officials and yet fails to reach many OUD patients. Using administrative data covering medical treatments and selected health outcomes for more than three-quarters of the Rhode Islanders covered by health insurance from mid-2011 through mid-2019, this report considers MAT’s efficacy in preventing opioid overdoses in Rhode Island and sheds light on the barriers to receiving MAT. The authors find evidence that MAT, as practiced in Rhode Island, appears to reduce the risk of opioid overdose: Among patients who had an initial (nonfatal) overdose, those who had received MAT in the preceding three months were less likely to experience a second overdose. In addition, federal policies that allowed a broader set of health-care providers to prescribe buprenorphine for OUD and enabled each prescriber to treat more patients with that drug are shown to have had some success in expanding the set of patients receiving MAT in Rhode Island.Unfortunately, we observe significant disparities in access to MAT across different groups within Rhode Island. Among individuals diagnosed with opioid dependence, those living in places with elevated poverty rates are less likely to receive buprenorphine, but they are also somewhat more likely to receive methadone. Because a treatment regimen involving methadone is much less convenient for the patient compared with one involving buprenorphine, ideally patients should have similar access to both drugs. Having Medicaid insurance as opposed to some other form of insurance is associated with a much greater chance of receiving methadone treatment, a finding that supports policies that would incentivize the expansion of Medicaid in states that have not yet done so. Women are somewhat less likely than men to receive either methadone or buprenorphine.This research demonstrates that recent federal policies helped to increase the number of Rhode Islanders who were prescribed buprenorphine for OUD. Raising patient-number limits enabled select prescribers to serve more patients and expand the total patient pool; however, more people could be helped if more prescribers took full advantage of their prescribing limits. This research and similar findings from other states reveal that the typical buprenorphine prescriber has a caseload that is well below the maximum number of patients they could treat. A separate policy that enabled mid-level practitioners (such as physician assistants) to train to prescribe buprenorphine was also found to draw in new patients, particularly those in high-poverty Zip codes. The research also underscores the urgency of helping more OUD patients receive methadone and/or buprenorphine treatment quickly following an overdose (in hospitals, for example) and to maintain that treatment over time for a sufficient duration.Some additional policies that could promote greater access to MAT include allowing pharmacists to prescribe buprenorphine, relaxing restrictions on the use of telehealth for obtaining buprenorphine prescriptions, and revisiting the rules about allowing take-home doses of methadone. Additional research is required on these interventions before specific recommendations can be made, but consideration of further policy adjustments is critically important given the ongoing scourge of opioid abuse and the proven ability of MAT to help those suffering from opioid use disorder. In response to the COVID-19 pandemic there has in fact been a temporary loosening of policies related to MAT in order to minimize patients’ exposure to the virus while helping them to get on or stay on medications, thus offering an opportunity to evaluate the efficacy and safety of the revised measures.

Another silver lining?: Anthropological perspectives on the promise and practice of relaxed restrictions for telemedicine and medication-assisted treatment in the context of COVID-19.

As a response to the COVID-19 pandemic, the United States Drug Enforcement Administration (DEA) has temporarily relaxed restrictions to serve people who are opioid dependent during social distancing mandates. Changes include allowing patients to take home more doses of methadone and buprenorphine rather than coming to the clinic every day (for methadone) or weekly (for buprenorphine) and relaxed restrictions on telehealth delivery. Telemedicine Program representatives have described the relaxing of federal regulations as a "silver lining" to the COVID-19 pandemic. Drawing from medical anthropology approaches to epidemic surveillance and understandings of risk, we critically evaluate media representations of recent changes to telemedicine, prescribing, and opioid treatment delivery. Ethnographic research with providers and stakeholders in Arizona from 2017 to the present add insight to our analysis of media reports on these topics. Our findings demonstrate that media portrayal of access to medication-assisted treatment (MAT) as the key to preventing both COVID-19 and overdose among people who are opioid dependent misses important risks and potential inequities. Applied social science questions raised by the new guidelines include: who receives take-home doses of methadone and buprenorphine and why; and how media representations of risk and benefit rationales shape real-world policy and practice.

Technology-assisted methadone take-home dosing for dispensing methadone to persons with opioid use disorder during the Covid-19 pandemic

IntroductionCovid-19 confers substantial risk for the >400,000 patients who receive methadone for the treatment of opioid use disorder (OUD) and methods for safely dispensing large quantities of methadone to patients are lacking. MethodsThis study evaluated the MedMinder “Jon”, an electronic and cellular-enabled pillbox that provides real-time monitoring to remotely manage take-home doses of methadone using a 12-week, within-subject, Phase II (NCT03254043) trial. We transitioned all participants from liquid to tablet methadone one week prior to randomization. Participants completed both treatment-as-usual and electronic pillbox conditions before choosing a condition in a final “choice phase”. We assessed feasibility, satisfaction, and safety outcomes during the exit interview. ResultsOverall, we randomized 25 participants, 24 (96.0%) completed >1 study session, and 21 (84.0%) completed the exit interview. We dispensed 167.92 g (1,974 doses) of methadone. Participants would use the pillbox again (86.3%) and recommend it to others (95.4%). Overall, 52.4% selected the pillbox in the choice condition and those who did not cited issues related to study requirements. Less than 1% of pillbox alerts were for medication being consumed outside the dosing window and we observed no evidence of actual or attempted methadone diversion. DiscussionWe were able to adequately manage patients who would not otherwise qualify for large quantities of take-home methadone when we dispensed methadone tablets via a secure pillbox. The integration of a commercially available pillbox into routine clinic operations increases opportunity for dispensing medication. Our data support remote monitoring of methadone take-home doses and may inform clinic practices related to Covid-19.

Increased flexibility in methadone take-home scheduling during the COVID-19 pandemic: Should this practice be incorporated into routine clinical care?

In the context of the COVID-19 pandemic and the state of emergency that the government of Spain declared, the rapid adaptation of health services is of paramount importance to preserve access to and continuity of service delivery. This research note underscores the importance of ensuring a sufficient quantity of methadone take-home doses for patients on methadone maintenance treatment (MMT) to maximize their adherence to government-imposed lockdown restrictions and social distancing measures designed to curtail the spread of SARS-CoV-2. We evaluate the impact of COVID-19 on take-home medication (number of days provided) in a methadone clinic in Barcelona (Catalonia, Spain). This work conveys that we should consider maintaining the take-home practices that we adopted in response to the pandemic, even after the pandemic has abated.

Patients seeking treatment for opioid use disorder face more challenges during pandemic

Patients seeking treatment for opioid use disorder face more challenges during pandemic

COVID-19 Could Change the Way We Respond to the Opioid Crisis-for the Better.

COVID-19 Could Change the Way We Respond to the Opioid Crisis-for the Better.

A Crisis Within a Crisis: The Extended Closure of an Opioid Treatment Program After Hurricane Sandy

Disruptions in opioid treatment programs (OTPs) are common after major disasters. Highly regulated OTPs confront challenges when responding to extended closures following disaster. Following Hurricane Sandy in 2012, an OTP located at the Manhattan Veteran Affairs Medical Center (VAMC) closed for 5 months. Semistructured interviews were conducted with clinicians and administrators who participated in the evacuation of the Manhattan VAMC, including the co-located OTP program. The Manhattan OTP preemptively dispensed emergency take-home methadone doses. Following closure, emergency guest-dosing arrangements were made for approximately 100 Veterans with Veterans Affairs (VA) and non-VA OTPs throughout New York City. Fortuitously, a retired VA OTP at another facility was reopened and accredited expeditiously. OTPs must improve contingencies for emergency response. However, disruptions in methadone delivery and threats to patient safety are likely to continue until agencies with oversight authority of OTPs describe specifications for emergency alternate care sites during long-term disaster recovery.

Irma: Florida OTP patients got take‐home methadone doses

Alcoholism & Drug Abuse WeeklyVolume 29, Issue 36 p. 4-5 Articles Irma: Florida OTP patients got take-home methadone doses Alison Knopf, Alison KnopfSearch for more papers by this author Alison Knopf, Alison KnopfSearch for more papers by this author First published: 18 September 2017 https://doi.org/10.1002/adaw.31706Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume29, Issue3618 September 2017Pages 4-5 RelatedInformation

Methadone "callbacks" within a veterans affairs opioid treatment program: Detecting methadone misuse.

A "callback" requires patients to bring in take-home methadone doses for inspection. An opioid treatment program (OTP) quality-improvement project examined random versus "for-cause" callbacks. Eighty-two random callbacks and 60 for-cause callbacks were conducted among patients enrolled in an OTP (N = 183). Among patients with more take home doses, 6% of random callbacks versus 44% of for-cause callbacks were failed. Among patients with fewer take home doses, 36% of for-cause callbacks were failed. For-cause callbacks are more useful than random ones. For-cause callbacks based on clinical judgment detect methadone misuse. (Am J Addict 2017;26:50-52).

Achievement of take-home dose privileges is associated with better-perceived sleep and with cognitive status among methadone maintenance treatment patients

Objectives. Methadone maintenance treatment (MMT) patients may achieve up to a 2-week privilege of methadone take-home doses (THD), which is associated with considerable responsibility. MMT patients are characterized as having poor sleep quality and low cognitive states. We studied sleep indices and cognitive status with respect to THD privileges. Methods. A sample of 123 MMT patients stratified by THD groups was studied. Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and the cognitive Clock Drawing Test (CDT) were performed. Results. Thirty-one of 123 patients never had any THD and 92 did (25 had the maximum of 2 weeks). The never THD had history of longer duration of opiate usage and a shorter period in MMT. They had the highest rates of poor sleep (80.6%, PSQI > 5), daily sleepiness (“fall asleep while talking”) (41.9%), and impaired cognitive status (58.1%, CDT < 3), while those who had 2-week privileges had the lowest (56, 8, and 28%, respectively). Logistic regression characterized THD patients as no-benzodiazepine and no-cocaine, short opiate usage duration, low ADHD scores, and no cognitive impairment (CDT = 3) and its interaction with treatment duration. Conclusion. Privileges that reflect patients’ abstinence and rehabilitation were also expanded to be associated with better cognitive states. These finding confirm the THD dispensing performance. Including CDT as part of the decision for dispensing THD may be considered.

Opioid-Addiction Treatment: Maintenance or Abstinence Better?

Opioid-Addiction Treatment: Maintenance or Abstinence Better?

Abstinence-contingent reinforcement and engagement in non-drug-related activities among illicit drug abusers.

Methadone-maintained cocaine abusers (N = 78) were randomly assigned to 1 of the following 52-week interventions: (a) usual care only (UC), (b) take-home methadone doses contingent on cocaine- and opiate-negative results (THM), or (c) take-home methadone doses for cocaine- and opiate-negative results and monetary-based vouchers contingent on cocaine-negative urinalysis results (THM + V). Cocaine use was assessed by urinalysis on a thrice-weekly schedule. Frequency and enjoyability of non-drug-related activities were assessed with the Pleasant Events Schedule (PES) at baseline, midtreatment, and end of treatment. The THM + V condition achieved the greatest abstinence from cocaine and opiate use, followed by the THM and UC conditions. The THM + V condition had the highest PES frequency ratings at midtreatment and at the end of treatment, followed by the THM and UC conditions. There were significant differences between the THM + V and UC conditions on 10 of 12 PES-derived subscales. Analyses revealed that abstinence mediated the effects of treatment condition on frequency ratings. There were no significant differences in enjoyability ratings. These results suggest that when contingency-management interventions increase abstinence from drug abuse, they also increase engagement in non-drug-related activities in naturalistic settings.

A 12-month controlled trial of methadone medical maintenance integrated into an adaptive treatment model

Methadone medical maintenance (MMM) reduces the reporting schedule for stable and well-functioning methadone maintenance patients to once a month, with counseling provided by medical staff. We report on the 12-month outcomes of 92 highly stable methadone maintenance patients randomly assigned to one of three study conditions: routine care, MMM at the methadone maintenance program, and MMM at a physician's office. Methadone medical maintenance patients received a 28-day supply of methadone, whereas routine care patients received five or six take-home methadone doses each week. All patients performed a medication recall once a month and submitted two urine samples each month. An adaptive stepped-care system of treatment intensification was used for patients who failed recall or who had drug-positive urine specimens. Seventy-seven patients completed the 12-month study period. Dropout was caused primarily by problems with handling methadone and disliking the recall frequency. There were low rates of drug use or failed medication recall. Treatment satisfaction was high in all groups, but the MMM patients initiated more new employment or family/social activities than did routine care patients over the study period. The stepped-care approach was well tolerated and matched patients to an appropriate step of service within a continuum of treatment intensity.