Take-home Privileges Research Articles

Prolonged diacetylmorphine take-home during the COVID-19 pandemic-Results of a retrospective cohort study.

Legal regulations for dispensing in Swiss heroin-assisted treatment were relaxed during the COVID-19 pandemic, allowing prolonged take-home of up to 7 days instead of two to reduce patient contact and the risk of infection. Our study aimed to measure the consequences of this new practice. This was a retrospective cohort study set in Switzerland's largest outpatient centre for opioid agonist therapy. One hundred and thirty-four (72.4%) of the 185 patients receiving oral diacetylmorphine (DAM) participated in the study. Through the utilization of electronic medication prescription and dispensing software, as well as the electronic medical record, the following data were extracted to explore the potential consequences: dose of DAM, the number of antibiotic therapies, emergency hospitalizations and incarcerations. Age, gender, prescriptions for psychotrophic drugs and additional prescription for injectable DAM were tested to assess an increased risk of losing prolonged take-home privileges. Data in the year since prolonged take-home (period 2) were compared with data from the equivalent prior year (period 1). DAM take-home was not associated with a change in DAM dose (P = 0.548), the number of emergency hospitalizations (P = 0.186) or the number of incarcerations (P = 0.215); 79.1% of all patients were able to maintain their extended take-home privileges. However, patients who had injectable DAM experienced significant reductions in their prolonged take-home privileges. Allowing patients to take home oral diacetylmorphine for up to 7days as treatment for opioid use disorder does not appear to pose any demonstrable health risk. It is generally manageable for the large majority of patients. However, careful consideration of prolonged take-home for patients with additional injectable diacetylmorphine is recommended, as these patients are more likely to lose take-home privileges.

Pilot investigation of an electronic pillbox at a community opioid treatment program

ABSTRACT Background: Opioid treatment programs (OTPs) permit patients to ingest daily methadone doses unsupervised and away from the clinic, a strategy that enhances treatment access and convenience but has the potential for mismanagement. Objective: This retrospective review, conducted during the COVID-19 pandemic (5/2020–1/2022), evaluates the feasibility and acceptability of a commercially available electronic pillbox to safely administer methadone take-home tablets in a large community-based OTP (census >500 people). Methods: Study participants (n = 24; 54% male, 46% female; M age = 63 years) had recently received more take-homes per visit to support national social distancing directives, and were instructed that they could maintain these privileges by agreeing to use the pillbox. Results: Results demonstrate good demand feasibility as most participants (71%) agreed to use the pillbox. Good implementation feasibility was observed through safe and reliable delivery of most take-home tablets, with a staff support line to resolve technical issues. Acceptability was modest as six participants (25%) requested to return the pillbox despite losing some take-home privileges. Conclusion: Results support continued use and study of the electronic pillbox to safely deliver and increase access to methadone take-home doses.

Spatial access to opioid treatment program and alcohol and cannabis outlets: analysis of missed doses of methadone during the first, second, and third 90 days of treatment

ABSTRACT Background: The burden of access to opioid treatment programs (OTPs) may change as clients become eligible for take-home privileges. Our previous study showed clients who lived more than 10-miles away from an OTP were more likely to miss methadone doses during the first 30 days of treatment. Proximity to alcohol and cannabis outlets may also negatively influence treatment adherence. Objective: To examine the association between access to this OTP, alcohol and cannabis outlets, and the number of missed methadone doses during the first, second, and third 90 days of treatment. Methods: The number of missed methadone doses was calculated for 752, 689, and 584 clients who remained in treatment, respectively, for at least 3, 6, and 9 months (50% female). Distance between client’s home and the OTP, alcohol, and cannabis outlets was measured. Generalized linear models were employed. Results: Shorter distance from a client’s residence to the OTP was associated with a decreased number of missed methadone doses during the first 90 days of treatment. Shorter distance to the closest cannabis retail outlet was associated with an increased number of missed methadone doses during the first and second 90 days of treatment. Shorter distance to the closest off-premise alcohol outlet was associated with an increased number of missed methadone doses during the third 90 days of treatment. Conclusions: Improving spatial accessibility of OTPs are essential to ensure treatment opportunities are available for individuals so affected. Exploring to what extent residing in areas that facilitate alcohol and cannabis availability can influence treatment adherence is warranted.

Treatment Outcome Unaffected by Initiation of Full Weekend Closure of Methadone Maintenance Treatment Clinic

After changing the weekend closure of our methadone maintenance clinic from 1 to 2 days, we compared patients’ retention in treatment, discount payment privileges, take-home doses, and rate of drugs in urine tests during the 6 months before and after the change. No differences were found in the 6-month retention rate (94.6% and 95.4%, respectively), take-home dose privileges (60.9% and 58%, respectively), or the rate of urines positive to all substance abuse. Expanding closure of the clinic for a 2-day weekend had no adverse effect on treatment parameters, suggesting that a methadone maintenance clinic may keep the same hours as other hospital's outpatient clinics.

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.

Earning “Take-Home” Privileges and Long-Term Outcome in a Methadone Maintenance Treatment Program

This observational prospective study aimed to determine whether duration to the earning of privileges of "take-home" methadone doses (as a part of behavioral enforcement) reflects long-term outcome of patients in methadone maintenance treatment (MMT). All 657 former heroin addicts admitted to our MMT clinic between June 1993 and June 2008 were prospectively studied and followed up. Duration from admission to first take-home dose (until October 2008), to leaving (retention, until June 2009), and to dying (survival, until June 2008) was calculated. Most patients (n = 435; 66.2%) ever achieved take-home privileges. Retention was longest (10 years, 95% confidence interval [CI]: 8.8 to 11.2) for 110 patients who achieved their first take-home dose after 3 to 6 months, followed by 9 years (95% CI: 7.7 to 10.3) for 98 patients who achieved it after >6 months and ≤1 year, and 8.3 years (95% CI: 7.2 to 9.4) for 127 patients who managed to achieve it only after >1 year. Retention was lower among patients who were given exceptional take-home doses (not respecting policy regulations) <3 months since admission: 5.1 years (95% CI: 3.4 to 7.8) for 30 patients (who got it for medical reasons), 9 years (95% CI: 6.7 to 11.3) for 14 patients admitted from another MMT, and 6.3 years (95% CI: 5 to 7.6) for 56 patients who got it for unjustified (mistakes) reasons. The shortest retention in MMT was 2.2 years (95% CI: 1.8 to 2.7, P < 0.0005) for 222 patients who never managed to achieve any take-home privileges. Survival was longer among patients who ever versus never received take-home privileges (13.2 years [95% CI: 12.8 to 13.6] vs 12.3 years [95% CI: 11.5 to 13.1], respectively; P = 0.04) and longest (14.1 years [95% CI: 13.4 to 14.7]) among those who received take-home privileges after 3 to 6 months. The group with the shortest time (3 to 6 months) to the achievement of first take-home dose had the best outcome. Further studies are needed to characterize this group.

Kontingenzmanagement in der Substitutionsbehandlung Opiatabhängiger

The majority of opiate-dependent patients in substitution treatment show additional substance-related disorders. Concomitant use of heroin, alcohol, benzodiazepines or cocaine compromises treatment success. Concomitant drug use may be treated by using contingency management (CM) which is based on learning theory. In CM, abstinence from drugs, as verified by drug screenings, is reinforced directly and contingently. Reinforcers used in CM studies with substituted patients were, amongst others, vouchers and take-home privileges. Studies in the USA show a medium average effect of CM on drug consumption rates and abstinence. The effects decrease markedly after the end of the intervention. We discuss whether CM is applicable within the German substitution treatment system and how it can be combined with other interventions such as selective detoxification treatments or cognitive-behavioural programmes.

Evaluation of ongoing oxycodone abuse among methadone-maintained patients

Prevalence of prescription opioid abuse has increased dramatically in recent years in the United States generally, and a similar pattern of increasing prescription opioid use has also been noted among patients seeking treatment for opioid dependence. This study presents results from an internal quality assurance project conducted by an outpatient methadone maintenance (MM) treatment clinic which sought to examine the extent of ongoing oxycodone abuse among patients that might be going undetected with current urinalysis-testing methods. One hundred five MM patients provided 437 urine samples over a 6-week period. Samples were analyzed using the clinic's usual enzyme multiplied immunoassay test (EMIT) opiate assay (300 ng/ml opiate cutpoint) and a supplemental oxycodone test strip (100 ng/ml oxycodone cutpoint). The EMIT assay identified only 6% (20/437) of samples as positive for oxycodone, whereas the oxycodone test strip indicated that 19% (83/437) tested positive for recent oxycodone use. Inspection of patient characteristics revealed that oxycodone users were more likely to report a prescription opioid as their primary drug at intake, be in MM treatment for a significantly shorter duration, and provide significantly more opioid- and cocaine-positive urine samples. Overall, these data illustrate the potential importance of monitoring for ongoing oxycodone use in MM clinics. Although future efforts should examine this question using more rigorous experimental methods, findings from this initial project have implications for clinical issues such as evaluating patient stability in treatment, making medication-dosing decisions, and determining patient eligibility for methadone take-home privileges.

Maintaining the Viability and Safety of the Methadone Maintenance Treatment Program

The purpose of this article is to describe a methadone maintenance treatment (MMT) program and address how such programs can maintain their viability in the community as well as the safety of the clinic environment for patients and staff. The complex nature of the MMT patient is described including social, legal and psychiatric issues. Diversion (selling of methadone) is discussed and examples of how to combat diversion are explored, including monitoring of take-home privileges. The safety of the clinic setting may be ensured through the utilization of toxicology screens and breathalyzers as well as through limit-setting, enforcement of program rules and the maintenance of professional therapeutic boundaries.

Urine testing in methadone maintenance treatment: applications and limitations

We consider here the applications and limitations of urine testing schedules used in methadone maintenance treatment programs. We show that for patients attending clinic daily, any practical testing schedule will only reliably detect those who are using heroin or other illicit drugs very frequently (e.g., daily). For patients with take-home privileges no testing schedule can effectively detect either skipped doses or use of illicit drugs. Consequently, whether for patients attending clinic daily or for patients with take-home privileges, some programs, as measured by urine test results, may actually be less successful than they appear to be.

Use of Methadone Take-Home Contingencies with Persistent Opiate and Cocaine Abusers

This study investigated conditions under which methadone patients with urinalysis evidence of persistent multiple drug abuse would respond to take-home incentive procedures. Study subjects submitted > or = 80% opiate and/or cocaine positive urines during a 5-week baseline period (M, W, F urine testing) while maintained on 60 mg methadone. Doses were raised to 80-100 mg methadone under blind conditions and subjects were randomly assigned to receive methadone take-home doses under one of three conditions: (a) earn a 1-day take-home privilege for each opiate and cocaine-free test delivered (daily contingent condition), (b) three negative test results required for the first take-home privilege, with each subsequent negative test earning one take-home dose; a positive test reset the contingency back to three again (weekly contingent condition), or (c) a control group that did not receive take-home privileges (no take-home control). Five of 21 subjects (24%) assigned to a contingent take-home intervention (2 from condition a, 3 from condition b) showed marked reductions in drug use and delivered 4 or more consecutive weeks of drug-free urines during a 16-week intervention. No subject in the control group met these criteria. Percent positive urines decreased by 14% and 18% from baseline in daily and weekly contingency groups, respectively, compared to a decline of 2% in the no take-home control group (planned contrast of means p < .07 and .05, respectively). Thus, the study demonstrated that take-home incentives can be effective for reducing during-treatment use of opiates and cocaine in methadone patients with a poor prognosis related to their persistent multiple drug use.

Patient outcomes after initiation of Sabbath closure of a methadone maintenance clinic in Israel.

The study examined whether closing of a methadone maintenance clinic in Israel on the Sabbath was associated with adverse patient outcomes. One take-home dose of methadone was given to all patients for that day regardless of whether they had earned take-home privileges. No difference was found in dropout rates for the six-month periods before and after Saturday closure was initiated. Results of random, twice-weekly urinalyses for all patients did not indicate increased use of heroin. The findings suggest that closure of a methadone clinic at least one day a week does not jeopardize patient outcome. Cutting hours of operation would reduce workload and enable clinics to function more economically.

Treatment Process and Relapse to Opioid Use During Methadone Maintenance

A general framework for studying drug abuse treatment process factors is presented, and components are then used to predict relapse to opioid use during treatment in methadone maintenance. Major domains of the treatment process research framework include client variables at entry, program characteristics, treatment events, and client outcomes. The analyses rely on the use of proportional hazards models to identify significant outcome predictors in a sample of 590 methadone maintenance clients from 21 clinics in the Research Triangle Institute/Treatment Outcome Prospective Study (RTI/TOPS) data system who remained in treatment at least 3 months. The analyses were performed on the total sample and separately on clients from three groups of clinics classified on the basis of the distribution of client relapse rates and tenure in treatment. Relapse rates were related to dosage level, client monitoring with urinalyses, and methadone take-home privileges in some clinics, and hence, these time-varying treatment events were important factors in treatment outcomes. Even at entry to treatment, some measures were found to be related to how the client later performed during treatment. Finally, it was also found that the particular area of professional speciality of the staff making client diagnosis at intake and preparing treatment plans was associated with client outcomes.

Contingency management in methadone maintenance: effects of reinforcing and aversive consequences on illicit polydrug use

Treatment outcomes were compared for an intervention emphasizing reinforcement for abstinence from illicit drug use and an alternative intervention which combined the same reinforcement contingencies with aversive consequences for unauthorized drug use. Sixteen polydrug abusing methadone maintenance patients were randomly assigned to one of two treatment groups. Both groups received the opportunity to take methadone doses away from the clinic (take-home dose) as reinforcement for submitting urines testing negative for illicit substances. A regular weekly take-home dose of methadone could be earned for every 2 weeks of verified abstinence from unauthorized drugs, up to a maximum of three take-home doses per week. The combined intervention group had an additional contingency which involved a reduction in methadone dose as an aversive consequence for submitting urine samples testing positive for illicit substances. Specifically, 10% of the patient's daily methadone dose was lost for each week in which two of three urines tested positive for illicit drugs. An examination of the urinalysis results indicated no between group differences. Overall, 8% of the 12-week baseline urinalysis results tested negative for illicit substances while 42% tested negative for unauthorized substances during the 20 weeks of treatment intervention. At the end of the intervention period, nine subjects remained in treatment with three patients in each group receiving at least once weekly take-home privileges. Of the seven subjects no longer in treatment, five were in the combined intervention group. The study supports previous work from this laboratory demonstrating that reinforcement based interventions as compared to procedures emphasizing aversive consequences produce an equivalent number of treatment successes while avoiding dropout among patients who fail to respond to treatment.

The Accuracy of Drug Use Monitoring in Methadone Treatment

Patients' urinalysis results are used in methadone maintenance programs to help make decisions about methadone dosage, medication take-home privileges, referrals for employment and job training and detoxification from methadone. Little systematic research exists, however, addressing the adequacy of the procedures used to detect illicit drug use. This study examined the accuracy of patients' clinic thin-layer chromatography (TLC) urinalysis profiles by comparing these with two independent measures of drug use; patient self-reports of drug use and urinalysis using a more sensitive test, enzyme immunoassay (EMIT). A representative sample of 229 patients in three methadone clinics was studied. The study found that drug use as measured by self-reports or by EMIT is 2.5 times higher than use as measured by TLC. The level of agreement between self-reports and EMIT was high, while the levels of agreement between these measures and clinic TLC urinalysis were low. Clinic decisions about take-home medication were shown to be correlated with clinic urinalysis results. The study examines the causes and consequences of inaccurate drug screening and discusses possible alternative responses to the problem for the methadone treatment field.

Contingent methadone take-home privileges: effects on compliance with fee payment schedules.

Contingent methadone take-home privileges: effects on compliance with fee payment schedules.

Reducing benzodiazepine self-administration with contingent reinforcement

Abstract The purpose of the present study was to determine whether drug self-administration by methadone maintenance clients can be influenced by offering methadone clinic privileges contingent upon reductions in drug use, and to compare the reinforcing efficacy in this regard of two different clinic privileges. Eight methadone maintenance clients who had histories of supplemental benzodiazepine use participated. In order to transfer illicit drug use to the treatment clinic, clients were prescribed diazepam, 20 mg/day, at the methadone clinic dispensary. Following assessment of baseline diazepam use, clients were offered, during 6-week blocks of time, either the chance to obtain a single methadone take-home dose or the chance to self-regulate their methadone dose for a single day. These privileges were contingent upon refusing prescribed diazepam at the clinic. During baseline weeks, 95.6% of available diazepam doses were requested. When take-home privileges were available, only 11.2% of diazepam doses were requested, while when dose self-control was available, 69.7% of doses were requested. The study showed that the supplemental drug use of methadone maintenance clients can be influenced by clinic privileges which are available contingent upon reductions of drug use. The medication take-home privilege was more effective as a reinforcer than was limited methadone dosage self-control. Methadone clinic privileges can be used as intervention tools to promote desirable therapeutic behavior change in drug addicts, and in particular to promote reductions in supplemental drug use.

Self-regulation of dose in methadone maintenance with contingent privileges

Abstract The effect of giving methadone maintenance clients the opportunity to regulate their dosage and of offering take-home doses as an incentive for dose reduction was studied. Subjects (116) were randomly assigned to one of three conditions: self-regulation ofdose (SR-1); self-regulation of dose with incentive for reduction (SR-2) and standard treatment (control). Dependent variables were dosage and use of illicit drugs (measured by urinalyses). Results for the first four months show SR-1 subjects increased dose and maintained themselves at dosages significantly greater than the SR-2 or control groups while having significantly less use of illicit opiates during certain time periods. SR-2 subjects were not different from controls. Findings indicate subjects behaved responsibly under self-regulation and that this regimen is clinically feasible. Nevertheless, an increase in take-home privileges was an insufficient incentive to yield major reductions in dosage in SR-2 as a group.

Contingency management in a methadone maintenance program: availability of reinforcers.

A survey was conducted to identify clinic privileges that might serve as reinforcers for a group of methadone maintenance clients. Fifty-three clients ranked nine clinic privileges according to their desirability. The opportunity to take medication home from the clinic on 4 days of the week was ranked as most desirable, on the average, followed by receiving cash payments ($30 and $10) and the opportunity for limited dosage self-control. Medication take-home privileges appear to be the most potent potential reinforcer available in the context of a methadone clinic.

Medication take-home as a reinforcer in a methadone maintenance program.

The opportunity to take methadone doses home from the clinic can be used as a reinforcer in contingency management procedures to promote desirable behavior among a population of methadone maintenance clients. This was demonstrated by delivering take-home privileges contingent upon attendance at counseling sessions. Sixteen methadone maintenance clients were selected on the basis of their low attendance rates at individual counseling sessions. During five successive 2-month periods, weekend (2 days) medication take-home privileges were either contingent upon attendance at a weekly counseling session lasting at least 45 min or were given to clients non-contingently. During periods of contingent delivery of the take-home privilege, counseling attendance increased significantly above levels observed during period of non- contigent delivery.