Literature Review - Methadone Maintenance Treatment

6. Program Team and Environment

6.1 Training

The way in which team members deliver methadone maintenance treatment -including their attitudes to methadone maintenance treatment and to the people receiving it - are important factors in treatment outcomes (Ball & Ross, as cited in Bell, 1998b, 362). For example, Caplehorn, Lumley and Irwig (1998, 60) found that the strength of team members' commitment to abstinence-oriented treatment is associated with decreased retention in treatment. They note that the results of their study "highlight the need for more attention to be paid to the attitudes, beliefs and working practices of methadone program staff." They argue that team members need to be "better selected, trained and directed" (Caplehorn et al., as cited in Caplehorn et al., 1998, 60) and point out that a related study found that staff attitudes can be changed by "a clear statement of official policy and an associated educational campaign" (Caplehorn et al., as cited in Caplehorn et al. 1998, 60).

The fact that team members and "treatment philosophy, attitudes and beliefs" influence treatment outcomes, means that training - for staff providing medical, dispensing or counselling services - may be a key step in improving treatment outcomes (Ball & Ross; Szapocznik & Ladner; Bell et al., as cited in Bell, 1998b, 362). In addition, education provides not just knowledge and skills, but motivation and involvement of physicians (Bell, 1998b, 362-63).

Bell (1998b, 362-363) describes the training initiatives in Australia which have sought to expand methadone maintenance treatment in primary care settings by training primary care physicians and pharmacists. He also summarizes the work of a national committee which reviewed the components of treatment, the needed skills, and identified the following areas (including specific learning objectives and competencies for each area):

• assessment - determining suitability for treatment, followed by a comprehensive assessment of health, welfare and psychological issues
• safe and effective prescribing
• delivery of appropriately structured treatment
• addressing the individual health care needs of people receiving treatment; and
• maintaining professional conduct in delivering treatment.

Bell (1998b, 375) argues that the Australian experience demonstrates the value of initial and ongoing training that includes "values clarification" alongside empirical evidence about substance abuse treatment. Bell suggests that training helps in the recruitment of professionals, and is valued by staff in existing programs. At the same time, Bell adds a note of caution by pointing out that training "cannot compensate for a lack of resources devoted to treatment."

6.2 Program Environment

According to Bell (1998a, 166), the way in which treatment programs are organized is "almost certainly an important component of effectiveness," but one which has not been well researched. A structured approach to treatment offers a number of advantages. It ensures safety for clients/patients and staff, including freedom from harassment from staff and other clients/patients; fairness, and consistency/reliability. It requires enforcement of safe limits: clarification and consistent application of clear rules and expectations. A structured approach also requires daily attendance because this is valuable in early phases of treatment. At the same time, however, daily attendance should not be allowed to become an "obstacle to social reintegration." In addition, a structured approach provides an alternative to crime and drug seeking activities; facilitates establishing a relationship with clients/patients; and makes treatment safer by minimizing risk of diversion, injection and erratic quantities of medication. A structured approach is also an opportunity to provide relevant information at appropriate points (Bell, 1998a, 167). It allows program staff to establish a therapeutic relationship (Bell, 1998a, 168). A structured approach should be coherent, ie. its policies should be clear and non-contradictory (Bell, 1998a, 169).

Some of the obstacles to providing an effective treatment program environment include: attitudinal obstacles, including assumptions about abstinence, negative attitudes about symptom relief (Bell, 1998a, 170); imposing barriers to treatment to test motivation; low doses of methadone; time-limited treatment; abstinence orientation; control-oriented regulations and policies that lead to an "adversarial relationship between patients and staff" (Bell, 1998a, 171); low staff morale due to stressful working environments, conflict about treatment goals, and lack of team approach, poor funding, poor facility maintenance.

Bell makes a number of suggestions about how a program environment could be improved through, for example:

• utilizing a "treatment" ethos in which all interactions with clients/patients are part of their care: "Thus issues of anger, conflict and acting out become part of the materials being worked with, rather than an irritation or obstacle to the smooth running of the clinic" (Bell, 1998a, 173)
• locating methadone treatment in primary care settings. Advantages include increased anonymity, less stigma, increased accessibility, reduced loitering, etc. (Bell, 1998a, 173)
• provide adequate doses, and address clients'/patients' ambivalence about methadone
• provide structured, well-organized treatment programs with clear rationale and objectives, clear job descriptions, clear lines of communication, and regular team meetings.
• prompt intake
• clarification of policies and expectations at outset of treatment
• conducting detailed assessments and developing treatment plans, and
• maintaining clear records, including documentation of key issues for clients/patients.