Literature Review - Methadone Maintenance Treatment

4. Program Development and Design Factors

The following sections provide further information on some of the program factors that are linked to treatment outcome (see Table 4).

4.1 Emphasis on Retention

Given the link between retention in treatment and other positive treatment outcomes, an emphasis on retention is an important feature of methadone maintenance treatment programs. According to research reviewed by Ward et al. (1998b, 330), longer retention in treatment is associated with improved post-treatment outcomes including reduced opioid use and reduced criminal activity. According to Lowinson et al. (1997, 412) many studies have confirmed that a longer length of time in treatment increases reductions in criminal behaviour and also increases socially productive behaviour (e.g. employment, school, homemaking). The caveat, as Hall et al.(1998b,53) state, based on their review of the evidence, is that the benefits of methadone maintenance treatment "continue only as long as patients remain in treatment." Consequently, in their review of historical and clinical issues related to MMT, Joseph, Stancliff and Langrod (2000, 361) conclude that "it may be necessary for patients to remain in treatment for indefinite periods of time, possibly for the duration of their lives."

As noted earlier, MMT has greater rate of retention compared to other treatment options, and increased retention in treatment is associated with a number of key program factors (see Tables 1 and 4).

4.2 A Client/Patient-Centred Approach

There has been a growing emphasis on how best to meet the needs of the individual client/patient. The National Institute on Drug Abuse's (1995, 1-38) review of the evidence found that "identification and meeting of patients' treatment needs" is a program characteristic that is associated with treatment success. A client/patient-centred approach includes taking into account the needs of specific groups of clients/patients (See Part 7.0).

4.3 Integrated Comprehensive Services

According to Leshner (1999), the best treatment programs are comprehensive and multidimensional: "The most effective [drug treatment] programs either provide on-site, or are closely linked with, a wide variety of treatment elements and support services. Moreover, since recovery can often be a long and complex process, treatment providers must be able to continually assess and adjust the patient's treatment and service to ensure that it is appropriate to the individual's changing needs. In addition to behavioral and pharmacological therapies, the patient may need other medical services, family therapy, parenting instruction, vocational rehabilitation, and social and legal services."

The potential components of an integrated comprehensive approach to MMT include:

• medical care, including treatment for HIV, HCV and other blood borne pathogens, as well as other medical conditions (see Sections 7.4 to 7.6)
• other substance use treatment programs (see Section 7.1)
• counselling (See Section 4.3.1)
• mental health services (See Section 7.7)
• health promotion, disease prevention and education (See Section 7.5 and 7.6); and
• a range of other ancillary services (See Section 4.3.2).

4.3.1 Counselling

According to Kidorf, King and Brooner (1999, 166), "....the necessity of counselling to address the complex problems of drug abusers was recognized by the founders of methadone treatment, and counselling has been a standard part of this treatment modality since its inception."

According to the findings of Ball and Ross (as cited in Mattick et al., 1998, 267), the work of counsellors in MMT programs can be described by ten activities: case management; liaising with other social service agencies; assessing new applicants; one-to-one counselling; brief contacts; group therapy; family and couples therapy; assessment for psychological problems; vocational counselling; and education.⁹

Brief contacts, one-to-one counselling and group work tend to account for most of the counselling activity in methadone treatment programs In addition, counsellors as well as medical, nursing and administrative staff play an important role in providing crisis intervention for people receiving treatment ((Ball & Ross, as cited in Mattick et al., 1998, 267-268).

4.3.2 Ancillary Services

Internationally, there is wide variation in the extent to which methadone treatment programs provide ancillary supports and services. Lowinson et al.(1997, 410) describes modern U.S. treatment programs as "a full-scale medical and human service agency attempting to address major social and medical problems using a variety of techniques." For example, U.S. methadone maintenance programs usually include some non-pharmacologic aspects such as: individual counselling; group therapy; couples counselling; urinalysis; contingency contracting; vocational rehabilitation; education programs; parenting classes; HIV testing and counselling; primary medical care services; psychiatric assessments; treatment of comorbid disorders (Strain and Stoller, 1999, 10).

According to Lowinson et al.(1997, 410), the services and supports provided by treatment programs will vary, depending on the stage of treatment¹⁰:

Stabilization includes: adjustment to medication; first annual physical examination; orientation to program regulations, expectations, routines, and services offered; psychosocial history and assessment; and referrals to appropriate medical and social service agencies.

Second stage includes: review and revision of original treatment plan; implementation of vocational goals (job training or employment); ongoing medical and mental health treatment, including treatment for HIV/AIDS or serious alcohol or multiple drug problems (this is extended as long as necessary); and possible provision of take-home medication, depending on progress in treatment and functioning.

Third stage includes: continued methadone maintenance, with once weekly (or less) visits; and minimal provision of services for those who are employed and no longer require intensive services.

Given the diverse needs for support and services among people who are dependent on opioids (See Part 7.0), provision of ancillary services is a key aspect of MMT. According to Strain and Stoller (1999, 10): "The methadone clinic may be best viewed as a site for the comprehensive treatment of patients". They also note that providing services to address multiple problem areas related to drug use may be particularly important for individuals who are entering treatment.

---