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CORK Bibliography: Methadone Maintenance

70 citations. January 2008 to present

Prepared: September 2009

Barry DT; Bernard MJ; Beitel M; Moore BA; Kerns RD; Schottenfeld RS. Counselors' experiences treating methadone-maintained patients with chronic pain: A needs assessment study. Journal of Addiction Medicine 2(2): 108-111, 2008. (24 refs.)

Purpose: This study was designed to conduct a needs assessment concerning methadone counselors' experiences working with methadone-maintained patients with chronic pain and measure counselors' interest in receiving specialized training to treat such patients. Methods: A survey, developed by the authors, was administered to 25 counselors with a combined caseload of 956 patients at 3 opioid agonist treatment programs. Results: Patients with chronic pain comprised 27% of counselors' overall caseloads. Counselors believed that, on average, 46% of these patients' pain had a psychologic component and 56% exhibited continued drug use, which patients attributed to ongoing pain. Twenty-three counselors reported an interest in receiving specialized training in treating chronic pain. A variety of management issues, including monitoring the use of pain medications and providing pain management referrals, were reported. Conclusions: Findings from this needs assessment study suggest specific targets, which may be important to consider, in prospective specialized methadone maintenance treatment (MMT) counselor training and counseling for MMT patients with chronic pain.

Anglin MD; Conner BT; Annon JJ; Longshore D. Longitudinal effects of LAAM and methadone maintenance on heroin addict behavior. Journal of Behavioral Health Services & Research 36(2): 267-282, 2009. (27 refs.)

Levo-alpha-acetylmethadol maintenance (LAAM) was compared to methadone maintenance (MM) on the behavioral performance of 315 heroin addicts before, during, and after 12 months of fully subsidized treatment. Assessments of drug use, criminal behavior, HIV risk behaviors, and employment and residential status were obtained at treatment intake and at 6, 12, and 18 months after admission. Treatment retention and in-treatment suppression of heroin use were significantly better for the LAAM group than for the MM group. Improvements were also noted during treatment in criminal behavior, criminal justice involvement, and employment status, and there were reductions in injection HIV risk and number of sexual partners. Most significant effects were primarily related to active participation in maintenance treatment. Under subsidized treatment, retention rates were two to four times that of similar clients in local community programs during the same period. LAAM was a useful and a potentially important addition to treatment options for opiate addiction, conferring greater retention and opiate suppression benefits. Its removal from application provides a historical lesson concerning the introduction of new medications into addiction health services.

Banta-Green CJ; Maynard C; Koepsell TD; Wells EA; Donovan DM. Retention in methadone maintenance drug treatment for prescription-type opioid primary users compared to heroin users. Addiction 104(5): 775-783, 2009. (28 refs.)

Aims: To assess retention in methadone maintenance treatment for prescription-type opioid primary (PTOP) users compared to heroin users. Design and participants A retrospective cohort study was carried out to examine the association between opiate types used on 12-month retention. The study population consisted of adults admitted to one of 11 not-for-profit methadone maintenance clinics in 2004 and 2005 throughout Washington State (n = 2308). Logistic regression analyses with fixed effects for treatment agencies were conducted. Measurements Opiate use type in past 30 days: any heroin use or primary prescription opioid without heroin use. Demographics, other drugs used, self-reported medical and psychiatric concerns, social, familial and legal issues, public assistance type and housing stability were documented at intake using a comprehensive biopsychosocial instrument, the Treatment and Assessment Reports Generation Tool. Findings The odds of being retained in treatment for PTOP compared to heroin users not adjusting for other factors was 1.33 (95% confidence interval [CI], 1.03, 1.71). In the final logistic regression model the odds of retention for PTOP compared to heroin users was 1.25 (95% CI, 0.93, 1.67), indicating that there was no statistically significant difference in treatment retention by opiate type after adjusting for demographics, treatment agencies, other drug use, public assistance type, medical, psychiatric, social, legal and familial factors. Conclusion: The findings of this study suggest that PTOP can be treated at methadone maintenance treatment facilities at least as effectively as heroin users in terms of treatment retention.

Barry DT; Beitel M; Joshi D; Schottenfeld RS. Pain and substance-related pain-reduction behaviors among opioid dependent individuals seeking methadone maintenance treatment. American Journal on Addictions 18(2): 117-121, 2009. (15 refs.)

We surveyed 293 opioid dependent individuals seeking methadone maintenance treatment about their pain experiences and their substance-related pain reduction behaviors. Among the 213 respondents reporting recent pain of at least moderate typical pain intensity, two-thirds had a lifetime history of chronic pain. In comparison to those without a lifetime history of chronic pain, those with a lifetime history were older, reported higher pain frequency, were more likely to endorse accident or surgery and less likely to endorse don't know as the genesis of their recent pain, and endorsed comparable levels of substance-related pain reduction behaviors. These findings may have implications for resource and program planning in MMT programs.

Batki SL; Canfield KM; Smyth E; Ploutz-Snyder R. Health-related quality of life in methadone maintenance patients with untreated hepatitis C virus infection. Drug and Alcohol Dependence 101(3): 176-182, 2009. (48 refs.)

Objective: To assess health-related quality of life (HRQOL) in methadone maintenance treatment (MMT) patients with untreated chronic HCV infection and to determine the clinical factors that predict HRQOL. Method: HRQOL was measured in 100 MMT patients entering an HCV treatment trial. Subjects were mostly male (61%) and white (81%) with a mean age of 43 (+/- 10). 57% had a current non-substance use psychiatric disorder. 55% had a current (past 12 months) substance use disorder, including 44% with current opioid or cocaine abuse/dependence. HRQOL in our sample was compared to published reports for the general population as well as for non-MMT HCV patients. To assess predictors of SF-36 HRQOL, hierarchical multiple regression techniques were used to assess model improvement with four blocks of baseline predictors: Demographics, Medical Severity, Addiction Severity, and Depression Severity. Results: HRQOL scores were significantly lower than scores for the general population and were also lower than scores reported for untreated HCV patients not in MMT. Regression analysis demonstrated a consistent pattern whereby Depression Severity increased predictive accuracy for HRQOL measures over simpler models. Beck Depression Inventory scores significantly predicted quality of life across both the mental and physical composite scores and all eight sub-scales of the SF-36. Conclusions: Untreated HCV patients in MMT had lower HRQOL than HCV patients not in MMT. Depression Severity was associated with significantly lower quality of life measures, suggesting that psychiatric evaluation and intervention prior to the start of HCV treatment may improve overall quality of life and could influence HCV treatment outcomes in MMT patients.

Bell J; Trinh L; Butler B; Randall D; Rubin G. Comparing retention in treatment and mortality in people after initial entry to methadone and buprenorphine treatment. Addiction 104(7): 1193-1200, 2009. (24 refs.)

To compare retention in treatment and mortality among people entering methadone and buprenorphine treatment for opioid dependence. The Pharmaceutical Drugs of Abuse System (PHDAS) database records start- and end-dates of all episodes of methadone and buprenorphine treatment in New South Wales, and the National Death Index (NDI) records all reported deaths. Data linkage study. First entrants to treatment between June 2002 and June 2006 were identified from the PHDAS database. Retention in treatment was compared between methadone and buprenorphine. Names were linked to the NDI database, and 'good matches' were identified. Deaths were classified as occurring during induction, maintenance and either post-methadone or post-buprenorphine, depending on the latest episode of treatment prior to death. The numbers of inductions into treatment, of total person-years spent in each treatment, and person-years post-methadone or buprenorphine, were calculated. Risk of death in different periods, and different treatments, was analysed using Poisson regression. A total of 5992 people entered their first episode of treatment-3349 (56%) on buprenorphine, 2643 on methadone. Median retention was significantly longer in methadone (271 days) than buprenorphine (40 days). During induction, the risk of death was lower for buprenorphine (relative risk = 0.114, 95% confidence interval = 0.002-0.938, P = 0.02, Fisher's exact test). Risk of death was lowest during treatment, significantly higher in the first 12 months after leaving both methadone and buprenorphine. Beyond 12 months after leaving treatment, risk of death was non-significantly higher than during treatment. Buprenorphine was safer during induction. Despite shorter retention in treatment, buprenorphine maintenance was not associated with higher risk of death.

Bloor M; McIntosh J; McKeganey N; Robertson M. 'Topping up' methadone: An analysis of patterns of heroin use among a treatment sample of Scottish drug users. Public Health 122(10): 1013-1019, 2008. (20 refs.)

Objectives: To determine: (a) whether Scottish drug users on methadone maintenance use heroin less frequently than their peers following other forms of drug treatment; and (b) to what extent those on methadone maintenance 'top up' with heroin. Design: A cohort study followed-up for 33 months from 2001 to 2004. Methods: Four hundred and ten interviewees who responded at at[ four interview sweeps, recruited as new treatment entrants from 28 drug treatment agencies across Scotland. Results: Sixty-eight of the 401 interviewees had commenced an episode of methadone-maintenance treatment at the start of the study. There was no significant difference between the methadone-maintained sample and the other interviewees in their propensity to abstain from heroin use, nor was there any difference between the two groups in the mean reduction over time in their self-reported dependence on drugs. However, if the outcome measure used is the change (between baseline and 33 months) in the number of days that the interviewee reported having used heroin in the previous 3 months, the reduction in the number of days that heroin was used was significantly greater (52 days) in the methadone-maintained group than in the rest of the sample (36.4 days). This fall in the number of days of heroin use was greater still if the comparison was restricted to those who had continued on methadone-maintenance treatment, although 67.4% of those still on methadone maintenance had 'topped up' with heroin at some point in the 3 months prior to 33-month follow-up. Those on higher maintenance doses were not significantly more likely to have reduced the number of days on which they used heroin compared with those on lower doses, and those still on methadone maintenance were not more likely to have reduced their criminality (measured by the number of days on which they committed acquisitive crimes in the previous 3 months) compared with the rest of the sample. Conclusions: Methadone-maintained drug users are not more likely to achieve abstinence than drug users receiving other forms of treatment, but they are significantly more likely to achieve a reduction in the frequency of their illicit drug use; they 'top up' on methadone, but the frequency of their illicit drug use is less than that of drug users in other treatment modalities. These data confirm the value of methadone-maintenance services as part of a 'mixed economy' of services for the treatment of drug use.

Brands B; Blake J; Marsh DC; Sproule B; Jeyapalan R; Li S. The impact of benzodiazepine use on methadone maintenance treatment outcomes. Journal of Addictive Diseases 27(3): 37-48, 2008. (31 refs.)

The purposes of this study were to examine predictors of benzodiazepine use among methadone maintenance treatment patients, to determine whether baseline benzodiazepine use influenced ongoing use during methadone maintenance treatment, and to assess the effect of ongoing benzodiazepine use on treatment outcomes (i.e., opioid and cocaine use and treatment retention). A retrospective chart review of 172 methadone maintenance treatment patients (mean age = 34.6 years; standard deviation = 8.5 years; 64% male) from January 1997 to December 1999 was conducted. At baseline, 29% were "non-users" (past year) of benzodiazepine, 36% were "occasional users," and 35% were "regular/problem users." Regular/problem users were more likely to have started opioid use with prescription opioids, experienced more overdoses, and reported psychiatric comorbidity. Being female, more years of opioid use, and a history of psychiatric treatment were significant predictors of baseline benzodiazepine use. Ongoing benzodiazepine users were more likely to have opioid-positive and cocaine-positive urine screens during methadone maintenance treatment. Only ongoing cocaine use was negatively related to retention. Benzodiazepine use by methadone maintenance treatment patients is associated with a more complex clinical picture and may negatively influence treatment outcomes.

Chugh SS; Socoteanu C; Reinier K; Waltz J; Jui J; Gunson K. A community-based evaluation of sudden death associated with therapeutic levels of methadone. American Journal of Medicine 121(1): 66-71, 2008. (33 refs.)

BACKGROUND: Published case reports have associated the therapeutic use of methadone with the occasional occurrence of sudden cardiac death. Because of the established utility of this drug and with the eventual goal of enhancing safety of use, we performed a community- based study to evaluate this association. METHODS: During a 4-year period, we prospectively evaluated all patients who consecutively had sudden cardiac death and underwent investigation by the medical examiner in the metropolitan area of Portland, Ore. Case subjects of interest were those with a therapeutic blood level of methadone (< 1 mg/L), and case comparison subjects were those with no methadone identified. Patients with recreational drug use or any drug overdose were excluded from either group. Detailed autopsies were conducted, including the detection and quantification of all substances in the blood. RESULTS: A total of 22 sudden cardiac death cases with therapeutic levels of methadone ( mean 0.48 +/- 0.22 mg/L; range 0.1-0.9 mg/L) were identified (mean age 37.0 +/- 10 years, 68% were male) and compared with 106 consecutive sudden cardiac death cases without evidence of methadone ( mean age 42 +/- 13 years, 69% were male). The most common indication for methadone use was pain control (n = 12, 55%). Among cases receiving methadone therapy, sudden death-associated cardiac abnormalities were identified in only 23% (n = 5), with no clear cause of sudden cardiac death in the remaining 77% (n = 17). Among cases with no methadone, sudden death-associated cardiac abnormalities were identified in 60% (n = 64, P = .002). CONCLUSION: The significantly lower prevalence of cardiac disease in the case group implicates methadone, even at therapeutic levels, as a likely cause of sudden death. These findings point toward an association between methadone and occurrence of sudden death in the community. Clinical safeguards and further prospective studies specifically designed to enhance safety of methadone use are warranted.

Compton PA; Ling W; Torrington MA. Lack of effect of chronic dextromethorphan on experimental pain tolerance in methadone-maintained patients. Addiction Biology 13(3/4): 393-402, 2008. (77 refs.)

Good evidence exists to suggest that individuals on opioid maintenance for the treatment of addiction (i.e. methadone) are less tolerant of experimental pain than are matched controls or ex-opioid addicts, a phenomenon theorized to reflect opioid-induced hyperalgesia (OIH). Agonist activity at the excitatory ionotropic N-methyl-D-aspartate (NMDA) receptor on dorsal horn neurons has been implicated in the development of both OIH and its putative expression at the clinical level-opioid tolerance. The aim of this study was to evaluate the potential utility of the NMDA-receptor antagonist, dextromethorphan (DEX), to reverse or treat OIH in methadone-maintenance (MM) patients. Utilizing a clinical trial design and double-blind conditions, changes in pain threshold and tolerance [cold pressor (CP) and electrical stimulation (ES)] following a 5-week trial of DEX (titrated to 480 mg/day) in comparison with placebo was evaluated in a well-characterized sample of MM patients. The sample (n = 40) was 53% male and ethnically diverse (53% Latino, 28% African American, 10% White, 9% other), with a mean age of 48.0 years (SD = 6.97). Based on t-test analyses, no difference was found between groups on CP pain threshold, CP pain tolerance, ES pain threshold or ES pain tolerance, both pre- and postmedication. Notably, DEX-related changes significantly differed by gender, with women tending to show diminished tolerance for pain with DEX therapy. These results support that chronic high-dose NMDA antagonism does not improve tolerance for pain in MM patients, although a gender effect on DEX response is suggested.

Conner KR; Ross ME; Baciewicz G; Sworts LM; Meldrum SC. Reliability of the lifetime Inventory of Drug Use Consequences(INDUC) in methadone maintenance patients. Journal of Psychoactive Drugs 41(1): 93-98, 2009. (25 refs.)

One hundred twenty one opiate-dependent individuals in methadone maintenance treatment at an urban university medical center in the U.S. were administered the Inventory of Drug Use Consequences (InDUC), and 68 subjects provided follow-up assessments at two to six weeks. The sample included 61 (50.4%) women; 86 (71.1%) of the subjects reported that they were White, 29 (24.0%) Black, and six (5.0%) other race. The mean age was 41.9 (SD = 9.7) years. Ninety-nine (81.8%) of participants had used opiates intravenously. INDUC total scores and a short form showed high internal consistency (a) and test-retest reliability (ICC) across gender, race, ethnicity, anew and education, supporting their use as global measures of drug use consequences. The interpersonal scale was also reliable across strata whereas the physical and intrapersonal scales were not reliable. The impulse control and social responsibility scales were stable but not internally consistent.

Corsi KF; Lehman WK; Booth RE. The effect of methadone maintenance on positive outcomes for opiate injection drug users. Journal of Substance Abuse Treatment 37(2): 120-126, 2009. (35 refs.)

This study examined outcome variables for 160 opiate injection drug users (IDUs) who entered methadone maintenance between baseline and 6-month follow-up. Outcome variables of interest included drug use, productivity, and HIV risk behaviors. Participants were recruited through street outreach in Denver, CO, from 2000 through 2004 using targeted sampling. The sample was primarily men, White (48%), averaged 39 years of age, and had been injecting drugs for an average of nearly 20 years. Significant improvements were found in univariate tests. Logistic regression revealed that spending more time in treatment was a significant predictor of positive outcomes on drug use and HIV risk behaviors. The results underscore the importance of retaining IDUs in methadone maintenance to maximize their treatment success. Results from this study show that time in treatment can affect many aspects of the participant's life in a positive way, including reduction of HIV risk.

Coviello DM; Zanis DA; Wesnoski SA; Domis SW. An integrated drug counseling and employment intervention for methadone. Journal of Psychoactive Drugs 41(2): 189-197, 2009. (35 refs.)

After drug use stabilization, employment has long been considered an important goal for clients enrolled in Methadone Maintenance Treatment Programs (MMTPs). The integrated counseling and employment intervention described here is a manualized treatment based on interpersonal cognitive problem solving (ICPS) theory. The six-month intervention utilized a problem-solving framework to help methadone clients obtain a job and manage employment within the context of drug treatment. In this pilot study, 23 subjects were randomly assigned to either integrated ICPS drug and employment counseling (n = 12) or to an ICPS drug counseling control condition (n = 11). While there were no differences between the integrated and control conditions, both groups showed a significant improvement in employment outcomes and reduction in HIV risk behaviors at the six-month follow-up. Although there may be concerns regarding the generalizability of the findings, overall, the problem solving framework may be an improvement over standard methadone counseling. The intervention may be beneficial when implemented with a larger group of motivated ex-offenders who are mandated to drug treatment as a condition of their parole.

Czuchry M; Newbern-McFarland D; Dansereau DF. Visual representation tools for improving addiction treatment outcomes. Journal of Psychoactive Drugs 41(2): 181-187, 2009. (32 refs.)

To examine the effectiveness of two visual representation counseling techniques for reducing illicit drug use, participants were randomly assigned to receive standard treatment "as usual" or standard treatment supplemented with free mapping or free plus guide mapping. Each counselor delivered all types of treatment to participants to control for differences in counselor characteristics (e.g., experience, empathy). Eighty-two participants who had received one year of methadone maintenance treatment and had urinalysis and self-report data for illicit drug use six months after treatment were examined. Compared to participants receiving standard treatment, participants randomly assigned to the free plus guide mapping condition had significantly lower opiate use based on urinalysis and self-report data. These results support the use of the free plus guide visual representation strategy and provide evidence for the concurrent validity of self-report measures of illicit drug use.

Davstad I; Stenbacka M; Leifman A; Romelsjo A. An 18-year follow-up of patients admitted to methadone treatment for the first time. Journal of Addictive Diseases 28(1): 39-52, 2009. (65 refs.)

An 18-year addiction career, 1985-2003, for 157 heroin dependent subjects (73% men; 49% human immunodeficiency virus seropositive) admitted for the first time to Stockholm's Methadone Maintenance Treatment program during 1989 to 1991 was analyzed with data from seven official registers and patient records. Regression analyses and incidence rates for various outcomes were calculated for subjects in first methadone maintenance treatment at the end of the observation period, discharged from first methadone maintenance treatment, in second methadone maintenance treatment, and discharged from second methadone maintenance treatment. Being human immunodeficiency virus positive (HR = 3.8), lodging (HR = 1.9) and prison sentence (HR = 1.7) predicted mortality for the 45% deceased. Approximately 70% of living subjects participated in methadone maintenance treatment at some period each year. Subjects in first or second methadone maintenance treatment had less criminality and had spent more time in methadone maintenance treatment (70% to 100%) than those discharged from first or from second methadone maintenance treatment (50%). Efforts and interventions should be intensified to increase time in treatment also for those with high problem severity.

Deck D; Wiitala W; McFarland B; Campbell K; Mullooly J; Krupski A et al. Medicaid coverage, methadone maintenance, and felony arrests: Outcomes of opiate treatment in two states. Journal of Addictive Diseases 28(2): 89-102, 2009. (52 refs.)

A modest number of clinics in Oregon and Washington provide MMT maintenance treatment (MMT) services. More than 10,000 clients in each state were followed for 3 years after an initial admission for opiate use between 1993 and 2000. Medicaid clients in both states had far greater access to MMT than their non-Medicaid counterparts, controlling for differences in client characteristics using propensity scores. Months in MMT were associated with much lower arrest rates than time not in treatment, but unexpectedly this was only true for clients participating in MMT for many months. Despite differences in the treatment systems for opiate addiction in these two states observed in previous studies, the current findings generalized across both states.

Deering DE; Sellman JD; Adamson SJ; Horn J; Frampton CMA. Development of a brief treatment instrument for routine clinical use with methadone maintenance treatment clients: The Methadone Treatment Index. Substance Use & Misuse 43(11): 1547-1561, 2008. (39 refs.)

Routine measurement of treatment outcome between clinician and client in alcohol and drug user treatment services is an important quality improvement initiative. It is particularly important for clients receiving long-term treatment such as methadone maintenance treatment, as fluctuations in substance use, functioning, and health are to be expected. Although there are a number of standardized alcohol and drug user treatment outcome instruments available for research and clinical use, a key challenge is to develop clinical instruments that will actually be used routinely in busy practice settings by a range of staff. Such instruments need to be brief, acceptable to staff and clients, easy to use, provide immediate feedback, and meet adequate psychometric requirements. This report describes development work undertaken in three studies of the Methadone Treatment Index (MTI). The MTI is a brief instrument comprising measures of recent substance use, aspects of social and behavioral functioning, and physical and psychological health. The MTI was designed in consultation with clinicians and clients for use in monitoring treatment progress with clients receiving methadone maintenance treatment. Key findings were that the MTI was acceptable to clients, produced clinically relevant information, and has satisfactory psychometric properties, although it was not used to measure change in this study. Further evaluation of the MTI on a longitudinal basis is supported.

Du WJ; Xiang YT; Wang ZM; Chi Y; Zheng Y; Luo XN et al. Socio-demographic and clinical characteristics of 3129 heroin users in the first methadone maintenance treatment clinic in China. Drug and Alcohol Dependence 94(1/3): 158-164, 2008. (34 refs.)

Background: This study aimed to determine the characteristics of heroin users in the first methadone maintenance treatment (MMT) clinic in China. Methods: In a retrospective chart review, the notes of 3127 heroin users who received both detoxification and MMT at the clinic were analyzed. Their socio-demographic and clinical data were collected, and the frequency of human immunodeficiency virus (HIV), Hepatitis C virus (HCV), and syphilis infections was investigated. Results: The main findings are as follows: (1) 66.5% of the patients were younger than 35 years; (2) 55.1% were married at admission; (3) 32% were non-local residents; (4) the majority had high school level education, a history of smoking and alcohol consumption prior to the initial heroin use, and did not have stable jobs; (5) 28.4% were self-employed; (6) 5.4% of the sample had total hearing loss coupled with loss of speech; (7) 83.4% sniffed heroin or injected it intravenously at the time of admission, but 87.2% had smoked the drug when they first began abusing it; (8) a significant proportion of the patients were infected with HIV, HCV, and syphilis. Conclusions: Some of the above findings are not consistent with the results of previous studies conducted in Western countries and China. The unique socio-cultural and clinical characteristics of heroin abusers in different regions of China should be considered when MMT services are planned.

Dunn KE; Sigmon SC; Mcgee MR; Heil SH; Higgins ST. Evaluation of ongoing oxycodone abuse among methadone-maintained patients. Journal of Substance Abuse Treatment 35(4): 451-456, 2008. (29 refs.)

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 (1300 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.

Epperson M; El-Bassel N; Gilbert L; Orellana ER; Chang M. Increased HIV risk associated with criminal justice involvement among men on methadone. AIDS and Behavior 12(1): 51-58, 2008. (38 refs.)

This paper examines the relationship between HIV risk and criminal justice involvement among a random sample of 356 men enrolled in methadone maintenance treatment programs in New York City. Bivariate and logistic regression analyses were performed to estimate the associations between measures of criminal justice involvement and participant HIV risk, controlling for socio-demographic variables. A lifetime history of incarceration was significantly associated with being HIV positive (Adjusted OR = 5.08). Recent arrest was associated with unprotected vaginal sex and having multiple female sexual partners. Sex trading was associated with both arrest and incarceration, and the strongest association was found between selling sex and recent incarceration (Adjusted OR = 5.69). Results suggest that recent criminal justice involvement among men with substance abuse histories is associated with increased HIV risk behaviors. Findings underscore the need for targeted HIV prevention efforts for men on methadone with a recent history of arrest or incarceration.

Fareed A; Casarella J; Amar R; Drexler K. Dose-dependent cognitive impairment in an elder methadone-maintained patient. Journal of Addiction Medicine 3(2): 109-110, 2009. (10 refs.)

Finkelstein J; Lapshin O; Cha E. Feasibility of promoting smoking cessation among methadone users using multimedia computer-assisted education. Journal of Medical Internet Research 10(5): article e33, 2008. (70 refs.)

Background: The prevalence of smoking is very high among methadone users. As a method of delivering health education, computers can be utilized effectively. However computer-assisted education in methadone users has not been evaluated systematically. Objective: This study was aimed at assessing feasibility and patient acceptance of an interactive educational module of a multi-component smoking cessation counseling computer program for former illicit drug users treated in an outpatient methadone clinic. Methods: The computer-mediated education for hazards of smoking utilized in this study was driven by major constructs of adult learning theories. The program interface was tailored to individuals with minimal computer experience and was implemented on a touch screen tablet PC. The number of consecutive methadone-treated current smokers enrolled in the study was 35. After providing socio-demographic and smoking profiles, the patients were asked to use the educational program for 40 minutes. The impact of the computer-mediated education was assessed by administering a pre- and post-intervention Hazards of Smoking Knowledge Survey (HSKS). An attitudinal survey and semi-structured qualitative interview were used after the educational session to assess the opinions of participants about their educational experience. Results: The computer-mediated education resulted in significant increase of HSKS scores from 60.5 +/- 16.3 to 70.4 +/- 11.7 with t value 3.69 and P <.001. The majority of the patients (78.8%) felt the tablet PC was easy to use, and most of the patients (91.4%) rated the educational experience as good or excellent. After controlling for patient baseline characteristics, the effect of computer-mediated education remained statistically significant. Conclusions: Computer-assisted education using tablet PCs was feasible, well-accepted, and an effective means of providing hazards of smoking education among methadone users.

Fischer B; Cruz MF; Patra J; Rehm J. Predictors of methadone maintenance treatment utilization in a multisite cohort of illicit opioid users (OPICAN). Journal of Substance Abuse Treatment 34(3): 340-346, 2008. (41 refs.)

Although methadone maintenance treatment (MMT) has been a primary treatment response to illicit opioid use in Canada for decades, analytical treatment data are scarce. Using data from the multisite OPICAN cohort of illicit opioid and other drug users repeatedly assessed between 2002 (baseline) and 2005 (last follow-up [FU]), we (1) longitudinally examined characteristics associated with MMT uptake between baseline and FU and (2) cross-sectionally compared drug use patterns between cohort participants in MMT (n = 133) and those not in MMT (n = 400) at the last FU through bivatiate and multivariate analyses (stepwise logistic regression). Significant baseline predictors of MMT uptake emerging in the logistic regression model included injection drug, heroin, as well as alcohol use, housing status, and Quebec City as a site. Furthermore, lower prevalence levels of opioid (e.g., morphine and OxyContin) and nonopioid (e.g., cocaine and crack) drug use as well as lower frequency of heroin use days were observed among MMT users. This study highlights potential factors relevant for improved MMT uptake and illustrates possible reductions of drug use related to MMT.

Gordon MS; Kinlock TW; Schwartz RP; O'Grady KE. A randomized clinical trial of methadone maintenance for prisoners: Findings at 6 months post-release. Addiction 103(8): 1333-1342, 2008. (57 refs.)

Aims: This study examined the effectiveness of methadone maintenance initiated prior to or just after release from prison at 6 months post-release. Design: A three-group randomized controlled trial was conducted between September 2003 and June 2005. Setting A Baltimore pre-release prison. Participants Two hundred and eleven adult pre-release inmates who were heroin-dependent during the year prior to incarceration. Intervention Participants were assigned randomly to the following: counseling only: counseling in prison, with passive referral to treatment upon release (n = 70); counseling + transfer: counseling in prison with transfer to methadone maintenance treatment upon release (n = 70); and counseling + methadone: methadone maintenance and counseling in prison, continued in a community-based methadone maintenance program upon release (n = 71). Measurements: Addiction Severity Index at study entry and follow-up. Additional assessments at 6 months post-release were treatment record review; urine drug testing for opioids, cocaine and other illicit drugs. Findings Counseling + methadone participants were significantly more likely than both counseling only and counseling + transfer participants to be retained in drug abuse treatment (P = 0.0001) and significantly less likely to have an opioid-positive urine specimen compared to counseling only (P = 0.002). Furthermore, counseling + methadone participants reported significantly fewer days of involvement in self-reported heroin use and criminal activity than counseling only participants. Conclusions: Methadone maintenance, initiated prior to or immediately after release from prison, increases treatment entry and reduces heroin use at 6 months post-release compared to counseling only. This intervention may be able to fill an urgent treatment need for prisoners with heroin addiction histories.

Gruber VA; Delucchi KL; Kielstein A; Batki SL. A randomized trial of 6-month methadone maintenance with standard or minimal counseling versus 21-day methadone detoxification. Drug and Alcohol Dependence 94(1/3): 199-206, 2008. (28 refs.)

Background: Important questions remain regarding the necessary duration and intensity for methadone treatment to be effective. Methods: As part of a clinical trial of tuberculosis chemoprophylaxis [Batki, S.L., Gruber, V.A., Bradley, J.M., Bradley, M., Delucchi, K., 2002. A controlled trial of methadone treatment combined with directly observed isoniazid for tuberculosis prevention in injection drug users. Drug Alcohol Depend. 66 283-293. doi:10.1016/SO376-8716(01)00208-3], patients with opioid dependence were recruited from an outpatient 21-day methadone detoxification program and were randomly assigned to one of three treatment conditions: (1) continuation in 21-day methadone detoxification; (2) transfer to 6-month methadone maintenance with only minimal counseling; or (3) transfer to 6-month methadone maintenance with standard twice monthly counseling and as-needed social work and psychiatric services. Both the 6-month maintenance treatments were followed by 1.5 months of detoxification. Urine drug tests and self-report measures were collected at baseline, months 1-6, and month 8.5. Results: Compared to 21-day methadone detoxification, 6-month methadone maintenance with either minimal or standard counseling resulted in fewer opiate positive urine tests and days of self-reported heroin and alcohol use. There was no change in cocaine use or other outcome measures. The increased counseling available in the standard counseling condition did not appear to reduce heroin use further than the minimal counseling condition, in contrast to the effect found for more structured counseling in long-term methadone maintenance (McLellan et al., 1993). Conclusions: Six months of methadone maintenance, even with minimal counseling, reduces heroin and alcohol use more than 21-day methadone detoxification.

Haasen C; Eiroa-Orosa FJ; Verthein U; Soyka M; Dilg C; Schafer I et al. Effects of heroin-assisted treatment on alcohol consumption: Findings of the German randomized controlled trial. Alcohol 43(4): 259-264, 2009. (34 refs.)

Alcohol has been suggested to be a risk factor for opioid-dependent patients in methadone maintenance treatment (MMT). Literature shows that MMT has limited effects on alcohol use. Nevertheless, a decrease in alcohol use was detected in the Swiss heroin-assisted treatment (HAT) study. In this article, we carry out an in-depth analysis of the German HAT trial with the aim of determining whether alcohol use was affected among patients undergoing HAT and MMT. Analysis was carried out using self-reported data on consumption units of alcohol used (CU), Addiction Severity Index composite scores (ASI CSs), and carbohydrate-deficient transferrin (CDT) measures. Results suggest significant reduction of CU and CDT in both groups, yet larger effects in the HAT group. ASI CS significantly decreased in the HAT but not in the MMT group. The greater benefit of HAT in reducing alcohol use may be due to the greater daily frequency of dispensing heroin coupled with a requirement of sobriety at each dosing occasion.

Haskew M; Wolff K; Dunn J; Beam J. Patterns of adherence to oral methadone: Implications for prescribers. Journal of Substance Abuse Treatment 35(2): 109-115, 2008. (31 refs.)

We investigated patterns of nonadherence to substitute treatment among patients attending an inner London community drug dependency unit and explored factors associated with nonadherence. We undertook 91 face-to-face confidential interviews with methadone-maintained patients attending community pharmacies. Thirty-eight patients (42%) had been either partial or poor adherers to their prescribed methadone regime in the past month. Multinomial logistic regression revealed that compared to full adherers, both poor adherers and partial adherers were more likely to be prescribed by unsupervised consumption. Poor adherers were also more likely to have less frequent pickups. There were seven types of nonadherent behavior detected, with dose splitting being the most prevalent (34%), followed by dose storage (28%) and missed pickups from the pharmacy (18%). We suggest that prescribers include an assessment of medication adherence at regular patient reviews as supervised consumption does not solve all adherence problems with methadone. New approaches to encouraging adherence, including a more systematic monitoring of adherence to improve the effectiveness of methadone programs, are needed.

Hines S; Theodorou S; Williamson A; Fong D; Curry K. Management of acute pain in methadone maintenance therapy in-patients. Drug and Alcohol Review 27(5): 519-523, 2008. (16 refs.)

Methadone maintained treatment (MMT) patients may be given less opioid analgesia for acute pain than the general patient, due to requests for analgesia being misinterpreted as craving for drugs. Pain studies have showed that MMT patients have hyperalgesic responses and that cross-tolerance to opioids may be present, suggesting that they may need more analgesia than the non-MMT patient. This study compares the pain management of MMT patients and controls during an acute hospital stay. It is a retrospective study of MMT in-patients and controls matched for medical condition, age and gender, comparing the analgesia given and pain stated in hospital notes. Patients with a chronic pain condition were excluded. MMT patients and controls did not differ in relation to median morphine dose received or average number of pain reports per day, and only a small proportion of both groups engaged in drug-seeking behaviour. Behavioural problems were significantly more common among MMT patients (39% versus 5%, p < 0.001). The fact that the opioid doses were not significantly different between subjects and controls seems to contradict the experimental evidence that patients on methadone tend to be hyperalgesic. Alternatively, MMT patients may be hyperalgesic, and statistically equal levels of opioid analgesia given to both groups may indicate an effective under-treatment of pain in the hyperalgesic MMT group. Inadequate analgesia may contribute to both behavioural problems and premature discharge. Resolving these uncertainties will require prospective studies.

Jarvinen M. Approaches to methadone treatment: Harm reduction in theory and practice. Sociology of Health & Illness 30(7): 975-991, 2008. (29 refs.)

The paper analyses methadone treatment in Copenhagen - as it is described by methadone users and staff at different outpatient centres. The starting point is a theoretical model distinguishing between two different approaches to methadone treatment: 'palliative' and 'curative'. Included in the model are three dimensions (1) treatment goals at the methadone centres (abstinence vs. stabilisation) (2) treatment focus (focus on addiction vs. focus on the consequences of addiction) and (3) conceptualisation of methadone (methadone as similar to or different from heroin). The paper shows that there is a discrepancy between the attitudes of the staff and those of the users. While the staff favour an almost clear-cut palliative approach to methadone treatment, defining curative goals as both unrealistic and as belonging to the past, the users prefer an approach that does not exclude the goal of abstinence and does not focus on the consequences of drug use alone but also on their problematic relationship to drugs (legal as well as illegal). Furthermore, the users' attitudes towards methadone are far more ambivalent than the staff's. For the users, methadone is not just medicine; it is also a dependence-producing and 'dangerous' drug.

Jones HE; O'Grady KE; Malfi D; Tuten M. Methadone maintenance vs. methadone taper during pregnancy: Maternal and neonatal outcomes. American Journal on Addictions 17(5): 372-386, 2008. (47 refs.)

This study compared five groups of participants: those receiving either three-day methadone-assisted withdrawal (MAW) alone (n = 67), three-day MAW followed by methadone maintenance (MM) (n = 8), seven-day MAW alone (n = 28), seven-day MAW followed by MM (n = 20), or a continuous MM sample (n = 52) enrolled between 1995-2001 in an urban drug treatment center. On average, patients in the three MM groups remained in treatment longer, attended more obstetrical visits, and more often delivered at the program hospital than patients in the two MAW alone groups. Given the poor maternal MAW outcomes, methadone maintenance should be considered as the primary treatment approach for opioid-dependent pregnant women.

King VL; Burke C; Stoller KB; Neufeld KJ; Peirce J; Kolodner K et al. Implementing methadone medical maintenance in community-based clinics: Disseminating evidence-based treatment. Journal of Substance Abuse Treatment 35(3): 312-321, 2008. (25 refs.)

Methadone medical maintenance (MMM) is an effective intervention that minimizes the demands of opioid agonist treatment without compromising good treatment response. Despite the benefits of MMM to both patients and treatment programs, little information is available to help community-based programs implement MMM and select patients who might benefit from this intervention. This study evaluates the impact of a seven-session seminar presentation combined with optional on-site consultation on subsequent changes in clinical programming and on the opinions of community-based treatment staff (n = 96) in five methadone maintenance treatment clinics regarding both the adoption of an MMM protocol and the use of an adaptive stepped care model to deliver it. The presentations were developed based on results from a randomized clinical trial (King, V L., Kidorf, M. S., Stoller, K. B., Schwartz, R., Kolodner, K., Brooner, R. K. (2006) A 12-month controlled trial of methadone medical maintenance integrated into an adaptive treatment model. Journal of Substance Abuse Treatment 3 1, 385-393.) together with other studies of MMM to help program staff (a) understand the risks and benefits of MMM, (b) develop criteria to choose who may benefit from MMM, and (c) implement an adaptive stepped care delivery system that includes MMM as the least restrictive level of care. A survey of clinic staff opinion about MMM and stepped care was administered at baseline and at five other points over the course of the 1-year project. Overall, the presentations were rated highly favorable for content and presentation (3.3 on a 4-point scale). At the 12-month follow-up, staff were more likely to believe that MMM facilitates patient participation in community-based rehabilitation oriented activities (p = .026) and that MMM patients receive adequate counseling services (p = .025) and were more likely to support treatment that matches patients who are stable with minimal intensities of care (p = .041). One clinic modified its routine care to an adaptive stepped care model in response to the presentations, and 3 of the 5 clinics used MMM levels of treatment intensity at the end of the project. The results suggest that seminar presentations combined with on-site consultation may be a beneficial mechanism for helping staff at community-based programs learn about and adopt effective interventions developed and tested using rigorous research designs.

King VL; Stoller KB; Kidorf M; Kindbom K; Hursh S; Brady T et al. Assessing the effectiveness of an Internet-based videoconferencing platform for delivering intensified substance abuse counseling. Journal of Substance Abuse Treatment 36(3): 331-338, 2009. (33 refs.)

Enhanced schedules of counseling can improve response to routine opioid-agonist treatment, although it is associated with increased time demands that enhance patient resistance and non-adherence. Internet-based counseling can reduce these concerns by allowing patients to participate froth home. This study assesses treatment satisfaction and response to Internet-based (CRC Health Group's e-Getgoing) group counseling for partial responders to methadone maintenance treatment. Patients testing positive for an illicit substance (n = 37) were randomly assigned to e-Getgoing or onsite group counseling and followed for 6 weeks. Patients in both conditions responded favorably to intensified treatment by achieving at least 2 consecutive weeks of abstinence and 100% attendance to return to less-intensive care (e-Getgoing: 70% vs. routine: 71%, ns). Treatment satisfaction was good and comparable across conditions. E-Getgoing patients expressed a preference for the Internet-based service, reporting convenience and increased confidentiality as major reasons. Integrating Internet-based group counseling with on-site treatment services could help expand the continuum of care in methadone maintenance clinics.

Kinlock TW; Gordon MS; Schwartz RP; O'Grady KE. A study of methadone maintenance for male prisoners. Criminal Justice and Behavior 35(1): 34-47, 2008. (54 refs.)

This study examined benefits of methadone maintenance among prerelease prison inmates. Incarcerated males with preincarceration heroin dependence (n = 197) were randomly assigned to (a) group educational counseling (counseling only); (b) counseling, with opportunity to begin methadone maintenance on release (counseling + transfer); or (c) counseling and methadone maintenance in prison, with opportunity to continue methadone maintenance on release (counseling + methadone). At 90-day follow-up, counseling + methadone participants were significantly more likely than counseling-only and counseling + transfer participants to attend drug treatment (p = .0001) and less likely to be reincarcerated (p = .019). Counseling + methadone and counseling + transfer participants were significantly less likely (all ps < .05) to report heroin use, cocaine use, and criminal involvement than counseling-only participants. Follow-up is needed to determine whether these findings hold over a longer period.

Kleber HD. Methadone maintenance 4 decades later: Thousands of lives saved but still controversial. Journal of the American Medical Association 300(19): 2303-2305, 2008. (14 refs.)

This article considers the impact of the publication of "A Medical Treatment for Diacetylmorphine (Heroin) Addiction: A Clinical Trial With Methadone Hydrochloride" by Vincent P. Dole, MD, and Marie Nyswander, MD JAMA. 1965;193(8):646-650. The effects of this article are best understood by knowing what preceded it. The current scientific consensus is that opioid dependence is a chronic and severe medical disorder, and withdrawal alone is usually followed by rapid relapse. A century ago, however, withdrawal was often considered adequate to treat narcotic addiction, with methods used often more dangerous than withdrawal. Individuals who relapsed were viewed as doing so out of choice rather than necessity. Forty years after the last maintenance clinics closed, the 1965 article by Dole and Nyswander landed with a bang.1 Dole, an internist, believed narcotic addiction was a metabolic disease, not very different from diabetes; Nyswander, a psychiatrist, had frustrating years of treating individuals with narcotic addiction with psychotherapy only to see them relapse. Their study, conducted in New York City first at the Rockefeller Institute and later moving to Manhattan General Hospital, included 22 participants with heroin addiction. One year later, Dole et al reported empirical data on the induced narcotic blockade. Long-term follow-up studies later confirmed that therapeutic success on a larger scale was possible. The author reviews the changes in attitudes and practice since the original article.

Knealing TW; Roebuck MC; Wong CJ; Silverman K. Economic cost of the therapeutic workplace intervention added to methadone maintenance. Journal of Substance Abuse Treatment 34(3): 326-332, 2008. (24 refs.)

Therapeutic workplace is a novel intervention that uses access to paid training and employment to reinforce drug abstinence within the context of standard methadone maintenance. We used the Drug Abuse Treatment Cost Analysis Program as a standard method of estimating the economic costs of this intervention. In a 1-year period, the therapeutic workplace served 122 methadone maintenance clients who had a median length of stay of 22 weeks. The workplace maintained a mean daily census of 48 clients. The combined cost of methadone maintenance and the therapeutic workplace was estimated at US$362 per week. This cost is less than that of other treatments that might be used to promote abstinence in individuals who continue to use drugs during methadone treatment. Given prior evidence of effectiveness, these cost data may be useful to policy makers, social service agencies, and researchers interested in using or further developing the therapeutic workplace intervention.

Kosten TR; Gardner TJ. New hot topics sections: 1. China's new march forward in addiction treatment: Methadone for the masses 2. Issues in formulating DSM V. American Journal of Drug and Alcohol Abuse 34(2): 123-126, 2008. (5 refs.)

This editorial commentary considers two of the major themes addressed in this issue. One is the discussion of the dimensions of introduction of opiate problems in China, the very recent introduction of methadone-maintenance, as well as the magnitude of problems attendent to needle sharing. The other major topic considered is the formulation of DSM-V and the issues that are central in the discussions: the role of tolerance in making a diagnosis, diagnostic differences that result from stages in human development, the abuse-dependence distinctions and whether these are continuous or dichotomous disorders.

Krantz MJ; Martin J; Stimmel B; Haigney MCP. Concerns about consensus guidelines for QTc interval screening in methadone treatment response. (letter, response). Annals of Internal Medicine 151(3): 218-219, 2009. (7 refs.)

Kurth ME; Sharkey KA; Millman RP; Corso RP; Stein MD. Insomnia among methadone-maintained individuals: The feasibility of collecting home polysomnographic recordings. Journal of Addictive Diseases 28(3): 219-225, 2009. (16 refs.)

Sleep disturbance among methadone-maintained patients is highly prevalent. A full understanding of sleep disturbance requires polysomnographic measures along with subjective sleep quality measures. The goal of this study was to describe the authors' experiences in performing at-home unattended polysomnography in this population. Participants had a Pittsburgh Sleep Quality Index score of six or higher, which indicates clinically significant insomnia, and 65% of eligible individuals agreed to enroll. Among 88 participants (53% female, 82% white, and a mean methadone dose of 105 mg/day), each undergoing two nights of home polysomnography, we initiated 165 of a maximum of 176 recordings. Overall, 81.7% of participants provided at least one night of "acceptable" polysomnographic data of at least 4 hours duration. Urine toxicology on polysomnographic nights demonstrated that benzodiazepine use was common. The authors conclude that unattended polysomnography is feasible in a population of individuals receiving methadone maintenance treatment. Polysomnography signal quality and overall study success rates were similar to those in non-substance using populations.

Langleben DD; Ruparel K; Elman I; Busch-Winokur S; Pratiwadi R; Loughead J et al. Acute effect of methadone maintenance dose on brain fMRI response to heroin-related cues. American Journal of Psychiatry 165(3): 390-394, 2008. (17 refs.)

Objective: Environmental drug-related cues have been implicated as a cause of illicit heroin use during methadone maintenance treatment of heroin dependence. The authors sought to identify the functional neuroanatomy of the brain response to visual heroin-related stimuli in methadone maintenance patients. Method: Event-related functional magnetic resonance imaging was used to compare brain responses to heroin-related stimuli and matched neutral stimuli in 25 patients in methadone maintenance treatment. Patients were studied before and after administration of their regular daily methadone dose. Results: The heightened responses to heroin-related stimuli in the insula, amygdala, and hippocampal complex, but not the orbitofrontal and ventral anterior cingulate cortices, were acutely reduced after administration of the daily methadone dose. Conclusions: The medial prefrontal cortex and the extended limbic system in methadone maintenance patients with a history of heroin dependence remains responsive to salient drug cues, which suggests a continued vulnerability to relapse. Vulnerability may be highest at the end of the 24-hour interdose interval.

Lobmann R; Verthein U. Explaining the effectiveness of heroin-assisted treatment on crime reductions. Law and Human Behavior 33(1): 83-95, 2009. (57 refs.)

This study examines the relationship between heroin-assisted treatment versus methadone maintenance and the criminal activity of 1,015 individuals participating in a German model project. The main objective is to investigate how these treatments contribute to a decline of criminal behavior. The analyses are based upon self-reported criminal offence and police data on alleged criminals. Logistic regression is employed to explain the variance in the 12-month prevalence 1 year after program admission. The results clearly show a decline of criminal offences among participants receiving maintenance treatment; this decline was significantly greater in the heroin group with respect to property crimes and drug offences. The multivariate analysis reveals that the effects are due to a decrease of illegal drug use and absence from the drug scene.

Lu L; Zhao D; Bao YP; Shi J. Methadone maintenance treatment of heroin abuse in China. (editorial). American Journal of Drug and Alcohol Abuse 34(2): 127-131, 2008. (27 refs.)

Maremmani I; Pacini M; Lamanna F; Pani PP; Trogu M; Perugi G. Predictors for non-relapsing status in methadone-maintained heroin addicts. A long-term perspective study. Heroin Addiction and Related Clinical Problems 10(4): 19-28, 2008. (55 refs.)

Despite the established effectiveness of Methadone Maintenance Therapy (MMT), specific evidence regarding factors influencing the prognosis of enrolled patients is quite limited. This study aims to ascertain which patient- or treatment-related features, assessed in a standardized way at the beginning of the program, do have an influence on whom is retained for long-term compliance with retention in treatment. 129 patients (94 male and 35 female) were treated in a methadone maintenance treatment program for 6 years on average. Retention in treatment was compared (survival analysis and Leu-Desu statistics) among groups of patients selected on the basis of socio-demographic and clinical variables. The variables that showed statistically significant differences (p<0.05) for an association regarding retention rate were included in separate logistic backward regression analyses comprising outcomes as dependent variables. Results show that dual diagnosis, defined by concurrent psychiatric disorders in evidence before the onset of heroin use, is the strongest negative predictor of relapse throughout a six year's average observation period, regardless of other clinical and socio demographic variables. Such a finding should be read in the context of a high-threshold setting, and accounts only for those patients, who had been retained in treatment over the first year.

Mattick RP; Breen C; Kimber J; Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. (review). Cochrane Database of Systemic Reviews 3: article CD002209, 2009. (31 refs.)

Background: Methadone maintenance was the first widely used opioid replacement therapy to treat heroin dependence, and it remains the best-researched treatment for this problem. Despite the widespread use of methadone in maintenance treatment for opioid dependence in many countries, it is a controversial treatment whose effectiveness has been disputed. Objectives: To evaluate the effects of methadone maintenance treatment (MMT) compared with treatments that did not involve opioid replacement therapy (i.e., detoxification, offer of drug-free rehabilitation, placebo medication, wait-list controls) for opioid dependence. Search strategy: We searched the following databases up to Dec 2008: the Cochrane Controlled Trials Register, EMBASE, PubMED, CINAHL, Current Contents, Psychlit, CORK [www. state. vt.su/adap/cork], Alcohol and Drug Council of Australia ( ADCA) [www.adca.org.au], Australian Drug Foundation (ADF-VIC) [www.adf.org.au], Centre for Education and Information on Drugs and Alcohol (CEIDA) [www.ceida.net.au], Australian Bibliographic Network (ABN), and Library of Congress databases, available NIDA monographs and the College on Problems of Drug Dependence Inc. proceedings, the reference lists of all identified studies and published reviews; authors of identified RCTs were asked about other published or unpublished relevant RCTs. Selection criteria: All randomised controlled clinical trials of methadone maintenance therapy compared with either placebo maintenance or other non-pharmacological therapy for the treatment of opioid dependence. Data collection and analysis Reviewers evaluated the papers separately and independently, rating methodological quality of sequence generation, concealment of allocation and bias. Data were extracted independently for meta-analysis and double-entered. Main results: Eleven studies met the criteria for inclusion in this review, all were randomised clinical trials, two were double-blind. There were a total number of 1969 participants. The sequence generation was inadequate in one study, adequate in five studies and unclear in the remaining studies. The allocation of concealment was adequate in three studies and unclear in the remaining studies. Methadone appeared statistically significantly more effective than non-pharmacological approaches in retaining patients in treatment and in the suppression of heroin use as measured by self report and urine/hair analysis (6 RCTs, RR = 0.66 95% CI 0.56-0.78), but not statistically different in criminal activity (3 RCTs, RR=0.39; 95% CI: 0.12-1.25) or mortality (4 RCTs, RR=0.48; 95% CI: 0.10-2.39). Authors' conclusions: Methadone is an effective maintenance therapy intervention for the treatment of heroin dependence as it retains patients in treatment and decreases heroin use better than treatments that do not utilise opioid replacement therapy. It does not show a statistically significant superior effect on criminal activity or mortality.

McMillan GP; Lapham S; Lackey M. The effect of a jail methadone maintenance therapy (MMT) program on inmate recidivism. Addiction 103(12): 2017-2023, 2008. (21 refs.)

To evaluate the effects of a jail-based continuation of methadone maintenance therapy (MMT) on subsequent inmate recidivism risks. Prospective, longitudinal, observational study. A large, Southwestern United States jail that continues MMT for heroin-addicted inmates on MMT at the time of booking. A total of 589 inmates booked between 22 November 2005 (the start date for the MMT program) and 31 October 2006. The outcome measure was time from release to subsequent re-booking in the jail. Predictors included binary dosing with methadone in the jail, final dose received (mg), age, gender, race/ethnicity, previous bookings and days in jail. Random effects Weibull proportional hazards models were fit to the recidivism times to estimate the impact of treatment with MMT in the jail on re-booking risks. There was no statistically significant effect of receiving methadone in the jail or dosage on subsequent recidivism risks (hazard ratio = 1.16; 95% confidence interval = 0.8-1.68). Offering jail-based MMT does not increase recidivism risks by eliminating the deterrent effect of imposed withdrawal, nor does it reduce recidivism in this high-risk population.

Michelazzi A; Vecchiet F; Leprini R; Popovic D; Deltito J; Maremmani I. GPs' office based methadone maintenance treatment in Trieste, Italy. Therapeutic efficacy and predictors of clinical response. Heroin Addiction and Related Clinical Problems 10(2): 27-38, 2008. (50 refs.)

Objective: To evaluate the effectiveness of methadone treatment carried out by General Practitioners (GPs) and to identify response treatment factors. Methods: 33 subjects with heroin addiction according to the DSM-IV-R criteria, 25 males and 9 females with an average age of 26 6 years, were placed in an observational protocol with average duration of 429 273 days. Retention rate, substance use, overall clinical improvement, social adaptation, quality of life and psychopathologic symptoms were used as outcome measures. In order to assess predictors of treatment response dropout and non-dropout subjects were compared at baseline. Results: At the end of the observational period, 6 patients (18.2%) had a positive outcome, 8 (24.2%) negative outcome, while 19 (57.6%) were still in treatment with a Cumulative retention of 60% at the end of the third year of observation. In 25 non-dropout patients baseline-endpoint improvement results were statistically significant for substance use, global clinical evaluation, psychological, social and occupational functioning, and craving. They also showed improvement in all of investigated psychopathological and quality of life dimensions. There were no significant side effects associated with their treatment. Patients with higher severity of illness, with problematic relationships with spouse/partner, difficulty with socialization and organization of leisure, with an altered mental state at beginning of treatment, subjects with dual diagnosis (especially bipolar disorder), with greater severity of obsessive-compulsive symptoms, interpersonal sensitivity, depression, violence, with greater severity of psychopathological symptoms. with the largest number of problematic areas as regarding the quality of life, patients with a low close of methadone given for treatment were considered most at risk for abandoning treatment. Conclusions: Methadone treatment carried out by General Practitioners appears safe and effective, especially in less severe patients treated with adequate doses, without severe psychopathology, without dual diagnoses (particularly bipolar disorder) and with quality of life impairment only in limited areas.

Neufeld K; King V; Peirce J; Kolodner K; Brooner R; Kidorf M. A comparison of 1-year substance abuse treatment outcomes in community syringe exchange participants versus other referrals. Drug and Alcohol Dependence 97(1-2): 122-129, 2008. (54 refs.)

This longitudinal cohort study of 324 consecutive admissions to methadone maintenance treatment between 08/1994 and 09/1997 compared 1-year outcomes of opioid-dependent patients referred from a syringe exchange program (SEP; n = 81) versus other sources (n = 243). All participants received stepped-based counseling. The Addiction Severity Index was completed upon admission. Treatment outcomes were assessed using weekly urine testing and days in treatment. GEE regression models were used to evaluate the association between baseline variables and treatment outcomes. SEP referrals were older, included more males and African Americans, reported greater unemployment and heavier heroin. cocaine, and injection drug use at admission. During treatment. SEP referrals used more opioids (OR 2.57: 95% CI 1.86-3.56) and cocaine (OR 2.77: 95% CI 1.93-3.95), and were less likely to complete 1 year (35%) compared to other referrals (56%; hazard ratio 1.88; 95% CI 1.35-2.62). Nevertheless, referral source was not significantly associated with outcome when adjusted for baseline characteristics. Greater baseline frequency of substance and injection drug use, and younger age were positively associated with ongoing opioid and cocaine use. African American race and baseline unemployment were also associated with ongoing cocaine use. Younger age and greater baseline cocaine use were associated with poorer retention at 1 year. The poorer treatment response of SEP referrals is likely clue to higher baseline problem severity. Specialized interventions may be required to reduce drug use and improve retention in this population.

Novick DM; Kreek MJ. Critical issues in the treatment of hepatitis C virus infection in methadone maintenance patients. (review). Addiction 103(6): 905-918, 2008. (152 refs.)

Aims: Hepatitis C virus (HCV) infection is a common chronic complication of injection drug use. Methadone maintenance programs contain large numbers of patients infected with HCV. This paper reviews HCV infection with emphasis on the medical care of HCV-infected, or HCV and human immunodeficiency virus co-infected, patients on methadone or buprenorphine maintenance. Methods Literature searches using PubMed, PsycINFO and SocINDEX were used to identify papers from 1990-present on antiviral therapy for HCV in methadone maintenance patients and on liver transplantation in methadone maintenance patients. Results: Injection drug use is the most significant risk factor for HCV infection in most western countries. The prevalence of HCV antibody is high in injection drug users (53-96%) and in patients enrolled in methadone maintenance programs (67-96%). Studies of antiviral therapy for HCV in methadone maintenance patients show rates of sustained virological response (SVR), defined as negative HCV-RNA 24 weeks after the end of treatment, of 28-94%. In studies with contrast groups, no significant differences in SVR between methadone and contrast groups were found. Excellent completion rates of antiviral therapy (72-100%) were found in five of six studies. There are many barriers to methadone maintenance patients' receiving antiviral therapy, and research on overcoming barriers is discussed. Liver transplantation has been successful in methadone maintenance patients but has not been utilized widely. Conclusion: High quality medical care for all aspects of HCV infection can be provided to methadone maintenance patients. The literature supports the effectiveness of such services, but the reality is that most patients do not receive them.

Nyamathi A; Cohen A; Marfisee M; Shoptaw S; Greengold B; de Castro V et al. Correlates of alcohol use among methadone-maintained adults. Drug and Alcohol Dependence 101(1/2): 124-127, 2009. (21 refs.)

This prospective study (n = 190) examined correlates of alcohol use from baseline data of a longitudinal trial conducted among moderate and heavy alcohol users receiving methadone maintenance therapy (MMT). The sample included MMT clients who were 18-55 years of age, and were receiving MMT from five large methadone maintenance clinics in the Los Angeles area. Half of the sample was heavy drinkers and nearly half (46%) reported heroin use. Using a structured questionnaire, correlates of heavy alcohol use included White and Hispanic ethnicity, and fair or poor physical health combined with older age ( 50 years). We also found that MMT clients who were younger than 50 years, regardless of health status, were more likely to be heavy drinkers. Compared with moderate alcohol consumers, a greater number of heavy alcohol users also experienced recent victimization. To optimize MMT, alcohol screening should be part of routine assessment and alcohol treatment should be made available within MMT Programs. Moreover, special consideration should be provided to the Most Vulnerable clients, such as the younger user, those with a long-term and current history of heavy drug use, and those victimized and reporting fair or poor health. In addition, promoting attention to general physical and mental health problems within MMT programs may be beneficial in enhancing health outcomes of this population.

Nyamathi A; Compton P; Cohen A; Marfisee M; Shoptaw S; Greengold B et al. Correlates of hospitalization for alcohol-using methadone-maintained persons with physical health problems. Western Journal of Nursing Research 31(4): 525-543, 2009. (48 refs.)

This cross-sectional study (n = 190) examined correlates of hospitalization for physical health problems among methadone maintenance therapy (MMT) clients with a history of alcohol abuse. The study was derived from baseline data collected for a longitudinal trial assessing the effect of motivational interviewing among alcohol-abusing adults undergoing MMT The sample included clients who were 18-55 years of age, abusing alcohol, and receiving MMT from five large methadone maintenance clinics in the Los Angeles area. A structured questionnaire was used to collect the data. Correlates of hospitalization in logistic regression analysis included lack of social support, recent victimization, age of first alcohol use, chronic severe pain in the previous 6 months, not having children, and ethnicity. Identification of hospitalization risk factors among alcohol-abusing MMT clients is a first step to developing risk-reducing interventions designed to lower hospitalization rates in this population.

Pang TTP; Lee SS. Measuring the geographic coverage of methadone maintenance programme in Hong Kong by using geographic information system (GIS). International Journal of Health Geographics 7(article 5), 2008. (32 refs.)

Objective: While access and utilization form core components in assessing the effectiveness of a health service, the concept of coverage is often neglected. In this study we propose to develop a GIS- based methodological framework for the measurement of district- based geographic coverage to examine the service effectiveness of methadone treatment programme ( MTP) in Hong Kong on a regular basis. Methods: To overcome the incompatibility of spatial units, population data and data of heroin addiction of the year 2001 are interpolated by population- weighted and area- weighted algorithms. Standard overlay and proximity analytical functions are used to delineate altogether 20 accessible zones around each methadone clinic at a fixed 1.5 km Euclidean distance. Geographic coverage here is defined as the percentage of heroin addicts covered by a methadone clinic within the accessible zone by district. Results: A total of 6413 out of 11000 reported heroin addicts are found geographically covered. The average geographic coverage in Hong Kong is 44.6%, with the figure varying from 0% to 96% by district. One district having no clinic results in 0% coverage whereas another without a clinic yields 15.3% coverage from the clinic in adjacent district. Maps illustrating district- based geographic coverage are generated. Conclusion: As continuous data collection is required for a monitoring system, the simplified approach facilitates the handling of large volume data and relevant data analysis. It is concluded that the number of methadone clinics is as important as their locations. Geographic coverage could become an important consideration for monitoring harm reduction.

Peles E; Schreiber S; Adelson M. Pathological gambling and obsessive compulsive disorder among methadone maintenance treatment patients. Journal of Addictive Diseases 28(3): 199-207, 2009. (38 refs.)

The aims of this study was to assess the prevalence of lifetime pathological gambling (pathological gambling) and current obsessive compulsive disorder among former heroin addicts currently in methadone maintenance treatment. A cross-sectional study of 154 patients from a methadone maintenance treatment clinic affiliated of a tertiary-referral medical center was conducted. The South Oaks Gambling Screen and Yale-Brown Obsessive Compulsive Scale were used for measurement purposes. Lifetime pathological gambling was found in 45 (29.2%) patients (current pathological gambling was found in 10 [6.5%] patients). Clinical obsessive compulsive disorder (defined if scored as moderate to extreme) was found in 51.1% of patients in the pathological gambling groups and 39.4% of patients in the non-pathological gambling group, with higher obsessive scores in the pathological gambling group versus the non-pathological gambling group. Logistic regression (multivariate analyses) found pathological gambling in more males (odds ratio = 3.6, 95% confidence interval = 1.5-8.8), a high obsessive score (odds ratio = 1.07, 95% confidence interval = 0.1-1.1), and older age on admission (40 years and older) (odds ratio = 2.4, 95% confidence interval = 1.1-5.0). Because only 10 (6.5%) patients were still currently gambling, more urgent intervention should be considered to the unexpected high rate of clinical obsessive-compulsive disorder (42.9%) in the sample, possibly because the clinic studied is of a higher severity than that accepted to the methadone maintenance treatment clinics in the community.

Pollack HA; D'Aunno T. Dosage patterns in methadone treatment: Results from a National Survey, 1988-2005. Health Services Research 43(6): 2143-2163, 2008. (32 refs.)

To examine the extent to which U.S. methadone maintenance facilities meet established standards for minimum dosages, 1988-2005. Data were collected from a nationally representative sample of outpatient treatment facilities in 1988 (n=172), 1990 (n=140), 1995 (n=116), 2000 (n=150), and 2005 (n=146). Random-effects multiple regression analysis was used to examine unit characteristics associated with below recommended doses. Data regarding the proportion of patients who received maintenance dosages of < 40, 60, and 80 mg/day were collected from unit directors and clinical supervisors. Forty-four percent of patients receive doses of at least 80 mg/day-the threshold identified as recommended practice in recent work. Thirty-four percent of patients receive doses below 60 mg/day, while 17 percent receive doses below 40 mg/day. Units that serve a high proportion of African American or Latino clients were more likely to report low-dose care. Units managed by individuals who strongly favor abstinence models (e.g., Narcotics Anonymous) were more likely to provide low-dose care. One-third of methadone facilities provide doses below recommended levels. Managerial attitudes about abstinence and their relationship to low doses underscore the contested role of methadone in treatment of opiate disorders.

Preston KL; Ghitza UE; Schmittner JP; Schroeder JR; Epstein DH. Randomized trial comparing two treatment strategies using prize-based reinforcement of abstinence in cocaine and opiate users. Journal of Applied Behavior Analysis 41(4): 551-563, 2008. (39 refs.)

We compared two strategies of prize-based contingency management (CM) in methadone-maintained outpatients. Urine was tested thrice weekly, for 5 weeks pre-CM, 12 weeks GM, and 8 weeks post-CM. Participants were randomly assigned to a cocaine contingency (four prize draws for each cocaine-negative urine, N = 29) or an opiate-cocaine contingency (one draw for each urine negative for opiates or cocaine, four draws if negative for both, N = 38). There were no group differences in cocaine abstinence during CM or post-CM and no differences in opiate abstinence during CM, opiate abstinence was greater in the opiate-cocaine group post-CM, and heroin craving was reduced in this group during and post-CM. Draws earned per cocaine-negative urine (four vs. one) did not affect cocaine use.

Reid MS; Fallon B; Sonne S; Flammino F; Nunes EV; Jiang H et al. Smoking cessation treatment in community-based substance abuse rehabilitation programs. Journal of Substance Abuse Treatment 35(1): 68-77, 2008. (65 refs.)

Nicotine dependence is highly prevalent among drug- and alcohol-dependent patients. A multisite clinical trial of smoking cessation (SC) treatment was performed at outpatient community-based substance abuse rehabilitation programs affiliated with the National Drug Abuse Treatment, Clinical Trials Network. Cigarette smokers (N = 225) from five methadone maintenance programs and two drug and alcohol dependence treatment programs were randomly assigned in a 2:1 ratio to receive either (1) SC treatment as an adjunct to substance abuse treatment-as-usual (TAU) or (2) substance abuse TAU. Smoking cessation treatment consisted of I week of group counseling before the target quit date and 8 weeks of group counseling plus transdermal nicotine patch treatment (21 mg/day for Weeks 1-6 and 14 mg/day for Weeks 7 and 8) after the target quit date. Smoking abstinence rates in SC, 10%-11% during treatment and 5%-6% at the 13- and 26-week follow-up visits, were significantly better than those in TAU during treatment (p <.01). In addition, SC was associated with significantly greater reductions as compared with TAU in cigarettes smoked per day (75% reduction, p <.001), exhaled carbon monoxide levels (P <.001), cigarette craving (p <.05), and nicotine withdrawal (p <.05). Smoking cessation did not differ from TAU on rates of retention in substance abuse treatment, abstinence from primary substance of abuse, and craving for primary substance of abuse. Compliance with SC treatment, moderate at best, was positively associated with smoking abstinence rates. Smoking cessation treatment resulted in significant reductions in daily smoking and modest smoking abstinence rates without having an adverse impact on substance abuse rehabilitation when given concurrently with outpatient substance abuse treatment. Substance abuse treatment programs should not hesitate to implement SC for established patients.

Rogers RE; Higgins ST; Silvertnan K; Thomas CS; Badger GJ; Bigelow G et al. Abstinence-contingent reinforcement and engagement in non-drug-related activities among illicit drug abusers. Psychology of Addictive Behaviors 22(4): 544-550, 2008. (28 refs.)

Methadone-maintained cocaine abusers (N = 78) were randomly assigned to I 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.

Rosen D; Smith ML; Reynolds CF. The prevalence of mental and physical health disorders among older methadone patients. American Journal of Geriatric Psychiatry 16(6): 488-497, 2008. (41 refs.)

Objectives: The aging opioid-addicted cohort from the 1970s has begun to alter the demographic characteristics of individuals in need of services for heroin addiction. Yet, despite clear trends that indicate the population of older methadone patients is increasing, little is known about their well-being and service needs. The goal of this study was to assess the physical and mental health status of older methadone patients. Design: Face-to-face interviews were conducted with study participants. Setting: This study was conducted at a free-standing methadone clinic in a Midwestern industrial city. Participants: A clinic sample of 140 adult methadone patients over the age of 50 was recruited for face-to-face interviews. Measures: Mental health status was assessed by the Composite International Diagnostic Interview. The SF-12v2 was administered to measure a range of physical health issues. Participants were also asked about a variety of chronic conditions. In addition, respondents provided access to their drug screen results from monthly urine tests for illegal drug use for 1 year before and 1 year after the interview. Results: Findings revealed that over half (57.1%) of respondents had at least one mental health disorder in the past year. In the year before the interview, the most prevalent mental health disorder experienced by older adult patients was major depressive episode (32.9%). The most prevalent anxiety disorders were posttraumatic stress disorder (27.8%) and generalized anxiety disorder (29.7%). Additionally, women experienced significantly higher levels of depression than males (43.8% versus 27.2%), and nearly twice the prevalence rate of agoraphobia and panic disorders. Regarding physical health, respondents reported high rates of health problems in the past year, including arthritis (54.3%) and hypertension (44.9%). The majority of respondents reported having fair to poor physical health (57.7%). When examining the entire 24-month period during which urine data were collected, three quarters (76.4%) of the respondents had at least 1 month where the urine screen detected illegal drug use. Conclusions: In the next decade, the growing and aging substance abusing population will require clinicians trained in both geriatrics and substance abuse. Health and mental health professionals have the opportunity to address the specialized needs of this population and prepare for the shifting service needs these older patients will require.

Ross D; Lo F; Mckim R; Allan GM. A primary care/multidisciplinary harm reduction clinic including opiate bridging. Substance Use & Misuse 43(11): 1631-1642, 2008. (30 refs.)

Wait times for methadone maintenance programs are associated with significant dropout rates. This puts the substance user at risk of continued illegal and high-risk behavior. We describe a unique model of daily dispensing opiates other than methadone to bridge clients awaiting methadone management. The Health and Harm Reduction Clinic is a community-based, primary care health clinic in Edmonton, Alberta, Canada, an urban city of 1 million. The team is comprised of a family physician, nurse practitioner, social/mental health worker and addictions counsellor. Descriptive data utilizing chart reviews from 2001 to 2005 are presented: one hundred four noninjection drug users and 86 injection drug users, with 43 of the latter being bridged. This team model, which includes opiate bridging to a methadone program, appears to provide a reasonable approach for community-based practices to offer quality care for substance-abusing patients. Further clarification of the impact on health outcomes and health service utilization is suggested.

Ryder N; Cullen W; Barry J; Bury G; Keenan E; Smyth BP. Prevalence of problem alcohol use among patients attending primary care for methadone treatment. BMC Family Practice 10: article 42, 2009. (35 refs.)

Background: Problem alcohol use is associated with adverse health outcomes among current or former heroin users and primary care is providing methadone treatment for increasing numbers of this population. This study aimed to determine the prevalence of problem alcohol use among current or former heroin users attending primary care for methadone treatment and to describe the socio-demographic characteristics and health service utilisation characteristics associated with problem alcohol uses. Methods: We conducted a cross sectional survey of patients sampled from a national database of patients attending general practice for methadone treatment. Participants were recruited by their general practitioner and data was collected using an interviewer-administered questionnaire, which included the Alcohol Use Disorders Identification Test ('AUDIT'), with a score of >7 considered abnormal (ie 'AUDIT positive cases') and socio-demographic, medical and substance use characteristics. Results: We interviewed 196 patients (71% of those invited, 31% of those sampled, 11% of the national database). The median age was 32 years, 55% were hepatitis C positive, 79% had used illicit drugs in the previous month and 68% were male. Sixty-eight 'AUDIT positive' cases were identified (prevalence of 35%, 95% CI = 28-41%) and these were more likely to have attended a local Emergency Department in the previous year (p < 0.05) and less likely to have attended a hospital clinic in the previous year (p < 0.05). Twenty-seven (14%) scored 20 or higher indicating possible alcohol dependence. Conclusion: Problem alcohol use has a high prevalence among current or former heroin users attending primary care for methadone treatment and interventions that address this issue should be explored as a priority. Interventions that address problem alcohol use in this population should be considered as a priority, although the complex medical and psychological needs of this population may make this challenging.

Sacerdote P; Franchi S; Gerra G; Leccese V; Panerai AE; Somaini L. Buprenorphine and methadone maintenance treatment of heroin addicts preserves immune function. Brain, Behavior and Immunity 22(4): 606-613, 2008. (69 refs.)

Opiate addiction influences many physiological functions including immune responses. The objective of this study was to investigate the immune system function in heroin addicted patients submitted to methadone or buprenorphine maintenance treatment compared to untreated heroin addicts and healthy controls. Four groups were studied: group A included nine heroin addicted subjects, who were still injecting heroin; groups B and C were composed of 12 patients previously addicted to heroin, being treated with methadone (mean dosage 58 +/- 12.7 mg/day) or buprenorphine (mean dose 9.3 +/- 2.3 mg/day) since at least 6 months; group D was composed of 15 sex and age matched healthy controls. Lymphoproliferation and peripheral mononuclear cell cultures production of the Th1 cytokines IL-2 and IFN-gamma, the Th2 cytokine IL-4, and of the pro-inflammatory cytokine TNF-alpha were evaluated in all the patients and controls. PHA-lymphoproliferation was lower in untreated heroin addicts than in controls, while it was normal in methadone and buprenorphine treated patients. An altered Th1/Th2 balance, characterized by reduced IL-4, IFN-gamma and TNF-alpha but normal IL-2 levels, was present in untreated heroin addicted subjects, while the Th1/Th2 balance was well conserved in the methadone and buprenorphine groups. These findings suggest that the immune system abnormalities in heroin addicted patients can be restored to almost normal values by controlled treatment with methadone and buprenorphine.

sBarry D; Weinstock J; Petry NM. Ethnic differences in HIV risk behaviors among methadone-maintained women receiving contingency management for cocaine use disorders. Drug and Alcohol Dependence 98(1/2): 144-153, 2008. (60 refs.)

To identify ethnic differences in HIV risk behaviors among cocaine using women receiving methadone maintenance for opioid dependence, and to evaluate the efficacy of contingency management (CM) for cocaine use disorders in reducing HIV risk behaviors. Methods: African American (N=47), Hispanic (N=47), and White women (N=29) were randomized to standard methadone treatment or standard methadone treatment plus a CM intervention. They completed the HIV Risk Behavior Scale (HRBS) indicating frequency of drug use and sexual behaviors across the lifetime, in the month before baseline, and in the 3 months following clinical trial participation. Ethnic group differences and the effect of CM on change in HIV risk behaviors between baseline and follow-up were evaluated.Results: White women reported significantly higher lifetime rates of risky drug use and sexual behaviors on the HRBS than African American women; neither group differed significantly from Hispanic women. No ethnic group differences in HIV risk behaviors were identified in the month prior to baseline. At follow-up, African American women reported fewer high-risk drug use behaviors than White or Hispanic women, and Hispanic women reported more high-risk sexual behaviors than White or African American women. CM was associated with reduction in high-risk drug use behaviors regardless of ethnicity, but did not affect high-risk sexual behaviors. Conclusions: White women receiving methadone maintenance engage in more lifetime HIV risk behaviors than African American women. CM for cocaine use reduces risky drug use behaviors, but certain ethnic groups may benefit from additional targeted HIV prevention efforts.

Schwartz RP; Kelly SM; O'Grady KE; Peterson JA; Reisinger HS; Mitchell SG et al. In-treatment vs. out-of-treatment opioid dependent adults: Drug use and criminal history. American Journal of Drug and Alcohol Abuse 34(1): 17-28, 2008. (25 refs.)

This study compared the characteristics of opioid-addicted adults seeking (n=169) and not seeking (n=74) methadone treatment in Baltimore, Maryland. Participants entering treatment were recruited from six methadone treatment programs, while out-of-treatment participants were recruited from the streets using targeted sampling methods. Measures included the Addiction Severity Index, a Supplemental Questionnaire, and urine drug test. Data were analyzed using ANOVA, chi(2), and regression, holding key background variables constant. Despite the lack of differences between the samples in demographic characteristics, the out-of-treatment sample reported significantly more days of heroin, cocaine, and alcohol use and spent significantly more money on drugs and earned more illegal income at baseline.

Schwartz RR; Jaffe JH; O'Grady KE; Kinlock TW; Gordon MS; Kelly SM et al. Interim methadone treatment: Impact on arrests. Drug and Alcohol Dependence 103(3): 148-154, 2009. (41 refs.)

Aims: This study examines the frequency and severity of arrest charges among heroin addicts randomly assigned to either interim methadone (IM) maintenance or to remain on a waiting list for methadone treatment. It was hypothesized that IM participants would have a: (I) lower number of arrests at 6 and 12 months and (2) lower mean Crime severity scores at 6 and 12 months post-baseline. Methods: Available official arrest data were obtained for all 319 study participants for a period of 2 years before and after Study enrollment. Crime severity ratings of charges were made using an established measure of crime severity. Findings: Participants randomly assigned to IM as compared to those on a waiting list had a significant reduction in number of arrests at 6 but not at 12 months from study enrollment. There were no significant differences in whether participants were arrested for a more severe crime but frequency of severe crime was relatively low in both groups. Additional post hoc analyses based on whether participants were in methadone treatment at 4 and 10 months after original random assignment to treatment condition revealed that those participants not in treatment at these follow-up assessment points were significantly More likely to be arrested and to have a higher mean crime severity rating at 12 and 24 months post-baseline assessment. Conclusions: IM as compared to the waiting list condition, had a significant reduction in number Of Officially recorded arrests from baseline to 6 months post-baseline. Those who were enrolled in methadone treatment at the 4- and 10-month follow-up assessment, regardless of initial assignment, had fewer arrests at 12 and 24 months post-baseline.

Sharkey KM; Kurth ME; Corso RP; Brower KJ; Millman RP; Stein MD. Home polysomnography in methadone maintenance: Patients with subjective sleep complaints. American Journal of Drug and Alcohol Abuse 35(3): 178-182, 2009. (26 refs.)

Objective: Most patients in methadone maintenance treatment (MMT) complain of poor sleep. Few studies have examined MMT patients' sleep using polysomnography (PSG), and none to our knowledge have employed home PSG. Standard sleep laboratory research protocols often require two consecutive PSG nights because of inter-night variability in sleep attributed to first-night adaptation to a novel sleep environment and recording procedures. The purpose of this study was to assess the stability of sleep measures across two consecutive nights of home PSG in opioid-dependent MMT patients. Methods: Home PSG was performed in 50 MMT patients with subjective sleep complaints. Participants were 54% female and 82% white with mean age = 36.8 years, median methadone dose = 100 mg/day, and median MMT duration = 286 days. Results: Thirty-six participants completed two consecutive nights of at-home PSG and 14 completed one. For the former group, no differences in sleep measures were found across recordings. The one-night group had significantly less total sleep time, Stage 2 sleep, REM sleep, and shorter REM latency than the two-night group. Conclusions: Home PSG is a viable method for recording sleep in opioid-dependent MMT patients, and was stable across consecutive nights of study. Two nights of home PSG for MMT patients, therefore, are not necessarily required and confidence in the reliability of data from one night of recording can be assumed. Excluding MMT research participants with one PSG may exclude patients with the worst sleepprecisely the group that most warrants investigation.

Sheridan J; Goodyear-Smith F; Butler R; Wheeler A; Gohns A. Barriers to, and incentives for, the transfer of opioid-dependent people on methadone maintenance treatment from secondary care to primary health care. Drug and Alcohol Review 27(2): 178-184, 2008. (16 refs.)

Aim. To explore barriers to, and incentives for, clients on methadone-maintenance treatment (MMT) in Auckland, New Zealand to transfer from secondary care to general practitioner (GP) care. Design. Surveys (with free text response sections) of MMT secondary care staff, stabilised clinic clients, authorised GPs and GP patients. Results. High response rates from secondary care staff (77%) and GPs (74%). Barriers to stable clients' transfer included financial cost and attitudes of secondary care staff and clients. Incentives for patient transfer included confidentiality, a holistic approach to their care, continuity of care, increased patient control, convenience and avoidance of contact with other opioid-dependent people. Distrust in the quality of care provided by authorised GPs was a major barrier for some secondary care staff and their clients, despite prerequisite training for authorisation. In contrast, patients rated primary better than secondary care with none stating a likelihood to return to the secondary service within 6 months. Conclusions. Progression from secondary to primary care should be incorporated in MMT planning from the outset, with secondary services staff reassured about the quality of primary care. An integrated transition period and exploration of funding options to assist transfer from largely publicly funded secondary to largely privately funded primary care are also recommended.

Soroudi N; Perez GK; Gonzalez JS; Greer JA; Otto MW; Safren SA et al. CBT for medication adherence and depression (CBT-AD) in HIV-Infected patients receiving methadone maintenance therapy. Cognitive and Behavioral Practice 15(1): 93-106, 2008. (66 refs.)

For individuals with HIV who are current or former injection drug users, depression is a common, distressing condition that can interfere with a critical self-care behavior-adherence to antiretroviral therapy. The present study describes the feasibility and outcome, in a case series approach, of cognitive behavioral therapy to improve adherence and depression (CBT-AD) among individuals with HI-V and depression undergoing methadone maintenance treatment for heroin dependence. CBT-AD integrates cognitive behavioral therapy for depression with our intervention for improving adherence to antiretroviral therapy for HIV(Life-Steps; [Safren, S. A., Otto, M. W, Worth, J., Salomon, E., Johnson, W., Mayer, K, et al. (2001). Two strategies to increase adherence to HTV antiretroviral medication: Life-Steps and medication monitoring. Behavioral Research and Therapy, 39, 1151-11621]). Specifically, in CBT-AD, patients first receive a cognitive behavioral intervention focusing on improving skills related to medication adherence. Each of the subsequent CBT modules (activity scheduling, cognitive restructuring, problem-solving training, and relaxation training/diaphragmatic breathing) is designed to address both self-care-adherence behaviors as well as depression. The process and outcome with 4 cases suggest that the treatment was feasible and acceptable and was generally associated with improvements. This case series provides an example of how cognitive behavioral therapists can integrate the treatment of depression with the enhancement of critical self-care behaviors in the context of highly complex, medical and psychiatric comorbidity.

Suh JJ; Langleben DD; Ehrman RN; Hakun JG; Wang Z; Li Y et al. Low prefrontal perfusion linked to depression symptoms in methadone-maintained opiate-dependent patients. Drug and Alcohol Dependence 99(1-3): 11-17, 2009. (65 refs.)

Background: Clinically depressed patients wsithout substance use disorders, compared to controls, exhibit significantly lower resting regional cerebral blood flow (rCBF) in the prefrontal cortex (PFC). In this study, we examined the link between resting rCBF in the PFC and current depressive symptoms in methadone-maintained opiate-dependent (MM) patients with or without major depression. Methods: Arterial spin labeled perfusion fMRI at 3 Tesla was used to measure resting rCBF in 21 MM patients. Per-fusion data were analyzed using SPM2. The relationship between Beck Depression Inventory (BDI) score and resting rCBF was examined in a single regression analysis. Results: The BDI scores ranged between 0 and 18 (m = 7.0, S.D. = 4.8), and 30% of the sample had mild to moderate depression symptoms according to BDI scores. A negative correlation was observed between BDI scores and relative rCBF in the bilateral ventrolateral prefrontal cortex, and middle frontal gyri. Conclusions: The inverse relationship between prefrontal paralimbic rCBF and depression scores suggests a link between reduced fronto-limbic activity and depressive symptoms in MM patients. A significant subgroup of opiate-dependent patients has clinical or sub-clinical depression that is often undetected; our data identify brain substrates of depression symptoms that may also be a potential marker of relapse in this population. Treatment strategies targeting these brain regions may improve outcomes in depressed substance abusers.

Tait RJ; Ngo HTT; Hulse GK. Mortality in heroin users 3 years after naltrexone implant or methadone maintenance treatment. Journal of Substance Abuse Treatment 35(2): 116-124, 2008. (39 refs.)

Concerns that treatment for heroin dependence using naltrexone may increase suicide rates during treatment and fatal overdoses posttreatment have been expressed. There is also disquiet about mortality during induction onto methadone. We assessed mortality during specific periods following treatment with naltrexone implants or methadone. Data were assembled using the Western Australian Data Linkage System. The methadone cohort comprised all those who started methadone in Western Australia during 2001-2002: The naltrexone cohort comprised all Western Australian heroin-dependent persons who received their first implant in 2001-2002. There were 15 (2.7%) deaths in the methadone cohort (n = 553) and 6 (1.8%) deaths in the naltrexone cohort (n = 341). Mortality rates for the "initial 14-day period," "stable treatment," and "overall" were 94.47, 0.0, and 5.83 deaths/1,000 person-years for the methadone group. In the naltrexone group, the rates "during first treatment (0-6 months)," "post first treatment," and overall were 0.0, 4.21, and 3.76 deaths/1,000 person-years. The age-standardized mortality rate ratio for naltrexone compared to methadone was 0.645 (95% confidence interval = 0.123-1.17). Increased mortality during induction onto methadone was confirmed. Evidence relating naltrexone to either increased suicide or overdose was not found. Overall mortality rates for naltrexone implant were similar to those for methadone, but increased mortality during methadone induction was avoided.

Werb D; Kerr T; Marsh D; Li K; Montaner J; Wood E. Effect of methadone treatment on incarceration rates among injection drug users. European Addiction Research 14(3): 143-149, 2008. (45 refs.)

Background: Methadone maintenance treatment (MMT) has been shown to dramatically reduce illicit opioid use and criminal activity among injection drug users (IDU). However, questions remain concerning the effect of MMT in reducing rates of incarceration among IDU. We therefore sought to investigate the long-term effect of MMT on rates of incarceration. Methods: We performed a generalized estimating equation longitudinal analysis of factors associated with incarceration among participants in the Vancouver Injection Drug Users Study (VIDUS). We also recorded whether participants reported having difficulty accessing drug treatment during the study period. Results: Among 1,247 active IDU, 624 (50.0%) reported being incarcerated at least once during the 6-year study period. In multivariate analysis, there was a strong negative association between methadone treatment and incarceration (adjusted odds ratio = 0.64, 95% CI: 0.54-0.76, p < 0.001) despite intensive covariate adjustment. Conclusions: Given our findings concerning the strong negative association between MMT and incarceration, and the reported high-risk injection practices of incarcerated IDU, limiting the availability of MMT has the potential to further exacerbate the high levels of HIV transmission found among IDU who are in need of treatment both in their communities and in correctional facilities.

Willner-Reid J; Belendiuk KA; Epstein DH; Schmittner J; Preston KL. Hepatitis C and human immunodeficiency virus risk behaviors in polydrug users on methadone maintenance. Journal of Substance Abuse Treatment 35(1): 78-86, 2008. (47 refs.)

We examined the impact of methadone maintenance treatment (MMT) on risk behaviors for transmission of blood-borne diseases in polydrug users who had tested positive or negative for hepatitis C virus (HCV). At intake, HCV-positive participants (n = 362) engaged in more human immunodeficiency virus (HIV) risk behaviors (as measured by the HIV Risk-Taking Behavior Scale) than HCV-negative participants (n = 297; p <.001). This difference was specific to injection-related behaviors and decreased significantly within the first few weeks of MMT (p <.0001). Where needles continued to be used, HCV-positive participants became more likely over time to engage in safer injecting practices. Furthermore, HCV-positive participants became more likely to use condoms than HCV-negative participants. These findings demonstrate that both drug- and sex-related risk behaviors decrease during MMT and emphasize the benefits of methadone programs for public health and HIV/HCV prevention.

Yang LJ; Li JH; Zhang YP; Li H; Zhang WD; Dai FQ et al. Societal perception and support for methadone maintenance treatment in a Chinese province with high HIV prevalence. American Journal of Drug and Alcohol Abuse 34(1): 5-16, 2008. (18 refs.)

Methadone maintenance treatment (MMT) was first piloted in April 2004 in Yunnan, China, to reduce HIV transmission. This study aimed to examine public support for MMT and was based on cross-sectional data collected in March-April 2006 on a random sample of 411 police staff, medical/health professionals, community members, and drug users. Multivariate logistic regressions were used to analyze the data. The support was the strongest amongst the police and medical professionals but the lowest in drug users. A considerable proportion of the respondents viewed MMT as contradictory to China's drug control policies and this factor was negatively associated with support for MMT. Dissemination of more accurate knowledge and the resolution of these conflicts are urgently needed to increase the public support for MMT.