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Recent research indicates Counseling and Other Services Significantly Improve Outcomes for Methadone Patients

Methadone-maintained patients who receive counseling and professional services have dramatically better outcomes than those who receive methadone alone, according to preliminary findings of a research study supported by NIDA. Treatment with methadone alone—in the absence of even basic counseling services—was not sufficient to reduce opiate or cocaine use in most patients or to reduce their associated medical and psychiatric problems.

The study looked at whether methadone alone is adequate to produce desired changes in drug use and AIDS-related behaviors, or whether additional social services may be needed. Set up as a controlled clinical trial, the study measured the possible "dose-response" relationship between certain added services and the 24-week outcome of methadone-maintained patients in seven important areas of life adjustment—medical problems, employment, drug use, alcohol use, legal problems, family conflicts, and psychological problems.

Study methodology

Subjects were 79 male veteran volunteers admitted to the Philadephia VA Medical Center's methadone maintenance program. The majority of patients presented with significant problems in terms of medical and psychiatric conditions, crime, and family relations. The "average" subject had approximately 11 years of opiate use, 7 years of problem alcohol use, and 3 years of cocaine use.

All subjects were evaluated, given AIDS prevention instruction, and stabilized for 10 days at approximately 60-80 mg of methadone (a level widely agreed to be substantial and effective for reducing opiate withdrawal and craving). Subjects were then randomly assigned for 6 months to one of the following conditions:

• Minimum methadone maintenance (MMM), providing blocking doses of methadone and emergency counseling/referral services only (the lowest level of supervised care possible under current standards)

• Standard methadone maintenance (SMM), providing MMM services listed above plus required regular, supervised counseling and referral services using weekly urine screens as the basis for contingency management (e.g., take-home doses contingent on attendance, negative urine samples, and verifiable employment)

• Enhanced methadone maintenance (EMM), providing all SMM services listed above plus regular additional services including medical/psychiatric care, social work assistance, family therapy, and employment counseling

MMM patient outcomes. Methadone alone was clinically far less effective than standard or enhanced treatment, with MMM subjects showing substantially greater amounts of cocaine and opiate use (see charts below). Within 12 weeks, 22 of 26 patients (70 percent) had to be "protectively terminated" from the study and transferred to standard treatment because of their continuous positive urines or because of three or more serious medical/psychiatric emergencies. Following the switch to standard care with counseling, the great majority of these patients showed significant and sustained improvement in urine results, employment, and crime. Too few MMM patients remained in the study after 12 weeks for statistical analysis.

SMM patient outcomes. After 6 months of treatment, this group showed significant improvements not only in drug use but in the areas of criminal involvement, alcohol use, and family relations. During the 24-week period, 11 of 27 patients (40 percent) showed the level of continuing drug use or need for emergency services that terminated the majority of MMM patients from the study.

EMM patient outcomes. The addition of psychiatric, family therapy, and employment counseling services resulted in even more improvements for patients in the areas of drug and alcohol use, psychiatric status, and employment. Only 5 of 26 patients (20 percent) would have fallen into the protective termination category.

In subsequent analyses, Dr. A.T. McLellan and his colleagues will evaluate differences between the groups at 6 months follow-up and will test for the particular types of patients who appear to benefit most from receiving added services. The researchers are also developing a detailed paper discussing what happened to those patients who had to be protectively terminated from the minimum maintenance condition, including the specific enhancements given these patients and the resulting changes in patient status.