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CORK Bibliography: Methadone Maintenance

74 citations. 2007 to present

Prepared: September 2008

Anglin MD; Conner BT; Annon J; Longshore D. Levo-alpha-acetylmethadol (LAAM) versus methadone maintenance: 1-year treatment retention, outcomes and status. Addiction 102(9): 1432-1442, 2007. (44 refs.)

Aims: To compare levo-alpha-acetylmethadol (LAAM) and methadone maintenance (MM) on treatment retention, drug use during treatment and at follow-up, and abstinence. Design A two-group experimental design with patients assigned randomly (2 : 1) to receive fully subsidized LAAM or MM for 52 weeks. Settings: A community clinic providing maintenance treatment in Los Angeles, California. Participants: A total of 315 treatment-seeking patients willing to be assigned randomly to treatment condition; 289 (91.7%) were interviewed at 52 weeks. Intervension LAAM or MM, plus ancillary services available to all patients. Medication dose varied according to clinical judgement. Findings Treatment retention and status at 52-week follow-up, weekly clinical urinalysis, self-reported drug use and research urinalysis on samples collected at follow-up. Measurements LAAM participants were more likely to complete the planned 52 weeks (57.4%) than MM participants (46.2%) and were less likely to be discharged for arrest/incarceration. LAAM produced fewer during treatment clinic opiate-positive samples (M = 48.8) than MM (M = 62.3). Further, 24.4% on LAAM compared to 11.8% on MM were able to sustain at least 12 weeks of abstinence during the last 24 weeks of treatment. Opiate use at follow-up was lowest (50.9%) among LAAM participants in maintenance treatment. No adverse events, cardiological or otherwise, were observed with LAAM administration. Conclusions LAAM is an effective medication for the treatment of opiate dependence in community clinics with numerous behavioral and clinical advantages. LAAM is more effective than MM in promoting retention and extended reduction in and abstinence from opiate use while in treatment.

Ball SA. Comparing individual therapies for personality disordered opioid dependent patients. Journal of Personality Disorders 21(3): 305-321, 2007. (53 refs.)

Within a psychotherapy development research project, thirty male (50%) and female (50%) personality disordered outpatients receiving methadone maintenance were randomly assigned to receive one of two 6-month manual-guided individual psychotherapies, Dual Focus Schema Therapy (DFST) or 12 Step Facilitation Therapy (12FT). All participants met diagnostic criteria for at least one personality disorder with antisocial, borderline, avoidant, and dependent being the most common. There were no significant differences between the two therapies for retention, utilization, or reductions in psychiatric symptoms or psychosocial impairment. Both therapy conditions demonstrated significant reductions in various severity indicators. Participants demonstrated more rapid decreases in the frequency of their substance use over six months of DFST in comparison to 12FT. DFST also was associated with a stronger therapeutic alliance between therapists and participants. Contrary to predictions, 12FT demonstrated better reduction of dysphoric affect than did DFST. DFST shows initial promise as the first time-limited manual-guided psychotherapeutic approach for the full range of personality disorders encountered in substance abuse patients.

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.

Berkman ND; Wechsberg WM. Access to treatment-related and support services in methadone treatment programs. Journal of Substance Abuse Treatment 32(1): 97-104, 2007. (19 refs.)

This study examines whether the mechanism through which a methadone maintenance treatment site offers seven treatment-related and support services is related to whether a patient receives such services. Mechanisms include the provision of services on-site, at another program site, or through formal or informal linkage arrangements. Analysis was conducted on a nationally representative sample of methadone treatment sites. Providing services on-site was found to be positively related to patient access to a majority of services, whereas, in general, offering services at another program site or through formal or informal linkages was not found to be effective. Not-for-profit or public ownership of treatment sites was also found to be positively related to patient access.

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.

Burns, L.; Mattick, RP; Lim, K.; Wallace, C. Methadone in pregnancy: Treatment retention and neonatal outcomes. Addiction 102(2): 264-270, 2007. (41 refs.)

Aim: To examine the association between retention in methadone treatment during pregnancy and key neonatal outcomes. Design: Client data from the New South Wales Pharmaceutical Drugs of Addiction System was linked to birth information from the NSW Midwives Data Collection and the NSW Inpatient Statistics Collection from 1992 to 2002. Measurements Obstetric and perinatal characteristics of women who were retained continuously on methadone maintenance throughout their pregnancy were compared to those who entered late in their pregnancies (less than 6 months prior to birth) and those whose last treatment episode ended at least I year prior to birth. Findings There were 2993 births to women recorded as being on methadone at delivery, increasing from 62 in 1992 to 459 births in 2002. Compared to mothers who were maintained continuously on methadone throughout their pregnancy, those who entered treatment late also presented later to antenatal services, were more likely to arrive at hospital for delivery unbooked, were more often unmarried, indigenous and smoked more heavily. A higher proportion of neonates born to late entrants Were born at less than 3 7 weeks gestation and were admitted to special care nursery more often. Conclusion: Continuous methadone treatment during pregnancy is associated with earlier antenatal care and improved neonatal outcomes. Innovative techniques for early engagement in methadone treatment by pregnant heroin using women or those planning to become pregnant should be identified and implemented.

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.

Daiter J; Teplin D; Varenbut M; Worster A; Raz B. Diagnostic value of self-report of alcohol use in patients enrolled in a methadone maintenance treatment program (MMTP). Journal of Addictive Diseases 26(3): 87-92, 2007. (25 refs.)

Screening for ethanol use amongst the methadone maintained population has been the subject of some debate over recent years. Of particular concern is the diagnostic value of self report of alcohol use in patients enrolled in a methadone maintenance program (MMTP). This study demonstrates unequivocally that denial of alcohol use by methadone maintenance program patients is completely unreliable when compared to urine testing. Conversely, admission of alcohol use by this same population has some value. This study concludes that routine ethanol screening is justified at baseline and at frequent intervals thereafter for all patients enrolled in a methadone maintenance program.

Dawe S; Harnett P. Reducing potential for child abuse among methadone-maintained parents: Results from a randomized controlled trial. Journal of Substance Abuse Treatment 32(4): 381-390, 2007. (55 refs.)

High rates of child abuse and neglect occur in many families in which either or both parents abuse illicit drugs. This study reports on the results of a randomized controlled trial with families having a parent on methadone maintenance (N = 64), in which an intensive, home-based intervention, the Parents Under Pressure (PUP) program, was compared to standard care. A second brief intervention control group of families received a two-session parenting education intervention. The PUP intervention draws from the ecological model of child development by targeting multiple domains of family functioning including the psychological functioning of individuals in the family, parent-child relationships, and social contextual factors. Mindfulness skills were included to address parental affect regulation, a significant problem for this group of parents. At 3- and 6-rnonth follow-up, PUP families showed significant reductions in problems across multiple domains of family functioning, including a reduction in child abuse potential, rigid parenting attitudes, and child behavior problems. Families in the brief intervention group showed a modest reduction in child abuse potential but no other changes in family function. There were no improvements found in the standard care group and some significant worsening was observed. Results are discussed in terms of their implications for improved treatment.

de los Cobos JP; Sinol N; Trujols J; del Rio E; Banuls E; Luquero E et al. Association of CYP2D6 ultrarapid metabolizer genotype with deficient patient satisfaction regarding methadone maintenance treatment. Drug and Alcohol Dependence 89(2/3): 190-194, 2007. (27 refs.)

Objective: The activity of cytochrome P-450 enzyme 2D6 (CYP2D6) could be related to heroin-dependent patient satisfaction with methadone maintenance treatment. We sought to compare satisfaction with the usual methadone treatment in patients who are ultrarapid, extensive or poor metabolizers, according to CYP2D6 genotyping. Methods: Two hundred and five heroin-dependent patients filled out the Verona Service Satisfaction Scale for methadone maintenance treatment (VSSS-MT), before CYP2D6 genotyping. Results: VSSS-MT overall scores were comparable in the poor metabolizer (N = 9) and extensive metabolizer (N = 185) groups, although they were higher in poor metabolizers and extensive metabolizers taken together than in the ultrarapid metabolizers (N = 11) (p < 0.003). Likewise, ultrarapid metabolizers scored higher than the rest of the sample on the VSSS-MT Basic Interventions subscale (p < 00 1). Regarding this subscale, no poor metabolizers felt dissatisfied, and ultrarapid metabolizer males (N = 7) reported lower satisfaction than ultrarapid metabolizer females (N = 4) (p < 0.022). Ultrarapid metabolizer genotype accounted for 4.2% of the variance on the VSSS-MT total scores, and 5.0% on the Basic Intervention scores. Conclusion: Heroin-dependent patients who are CYP2D6 ultrarapid metabolizers according to genotyping present deficient satisfaction with methadone maintenance treatment.

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.

Dysart K; Hsieh HC; Kaltenbach K; Greenspan JS. Sequela of preterm versus term infants born to mothers on a methadone maintenance program: Differential course of neonatal abstinence syndrome. Journal of Perinatal Medicine 35(4): 344-346, 2007. (7 refs.)

Objective: We determined the effect of preterm delivery on the course of neonatal abstinence syndrome (NAS) in infants born to mothers participating in a methadone maintenance program. Study design: A retrospective cohort study was conducted in which infant and maternal data were collected from the medical records of 53 preterm and 66 term infants. Infants were selected from all infants admitted to Thomas Jefferson University hospital born between 1998 and 2002 whose mothers were enrolled in the methadone maintenance program. All infants were managed by a standard protocol utilizing the Neonatal Abstinence Scoring System (NASS) and neonatal opiate solution (NOS). Preterm and term infants were compared. Results: Preterm infants had shorter lengths of stay, treatment courses and required less medication than did term infants during the same time period. Conclusion: These data indicate that following exposure to maternal methadone, preterm infants have a different neonatal course than do infants born at term.

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.

Federman AD; Arnsten JH. Primary care affiliations of adults in a methadone program with onsite care. Journal of Addictive Diseases 26(1): 27-34, 2007. (39 refs.)

Methadone maintenance treatment programs (MMTP) often provide onsite primary care. It is unclear whether patients in these settings consider the MMTP their usual source of care. We conducted cross-sectional interviews of 62 adults in an inner-city MMTP with onsite primary care to determine their usual source of care. Program enrollment ranged from 1 to 27 years (median, 4) and 63% attended >= 5 days per week. Seventy-six percent had >= 1 chronic disease. Only 53% reported having a usual source of care, which included hospital-based clinics (45%), the MMTP (23%), private physicians (19%), and other sites (13%). Patients were more likely to identify the MMTP as their usual source of care if they had cardiovascular disease (RR 6.9, 95% CI 2.2 to 21.9) or HIV (RR 5.6, 95% CI 1.7 to 18.5). Successfully promoting appropriate utilization of onsite primary care may require a better understanding of MMTP patients' perceptions of primary care.

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.

Fucci N; De Giovanni N. Methadone in hair and sweat from patients in long-term maintenance therapy. Therapeutic Drug Monitoring 29(4): 452-454, 2007. (11 refs.)

The authors refer to their experience with alternative matrices to supervise the methadone therapy of heroin abusers. For this purpose, hair, sweat, and urine samples were collected from 10 heroin addicts and from a control group and were submitted to gas chromatographic/mass spectroscopic analysis for methadone and its main metabolite, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), determination. The advantages of alternative matrices to urine samples in the supervision of methadone maintenance therapy are discussed. In particular, the detection of methadone in sweat could be a preferable option to the urine matrix as a result of the feasibility of sampling that allows noninvasive collection, which is not susceptible to adulteration. The ratio between EDDP and methadone in sweat and hair was also calculated to provide information about program agreement.

Gainey RR; Haggerty KP; Fleming CB; Catalano RF. Teaching parenting skills in a methadone treatment setting. Social Work Research 31(3): 185-190, 2007. (30 refs.)

This article discusses the effects of substance abuse, delinquency, and other problem behaviors on parenting and family. Children of substance abusers represent a high risk population. Prenatal exposure to addictive substances and the medical complications that may arise are important factors in placing this population at high risk of drug abuse and other behavior problems. As children of drug abusers grow older, their lives are often characterized by exposure to continued drug use by family members, chronic illnesses, financial troubles, legal conflicts and family disorganization.

Gilbert L; El-Bassel N; Wu E; Chang M. Intimate partner violence and HIV risks: A longitudinal study of men on methadone. Journal of Urban Health 84(5): 667-680, 2007. (69 refs.)

Whereas research has suggested that drug-involved men are at disproportionately high risk of engaging in transmission risk behaviors for HIV and of perpetrating intimate partner violence (IPV) against women, only a few cross-sectional studies have examined the relationship between IPV and HIV/sexually transmitted infection (STI) transmission risks among heterosexual, drug-involved men. This study builds on previous cross-sectional research by using a longitudinal design to examine the temporal relationships between perpetration of IPV and different HIV/STI transmission risks among a random sample of 356 men on methadone assessed at baseline (wave 1), 6 months (wave 2), and 12 months (wave 3). The findings indicate that (1) perpetration of IPV in the past 6 months at wave 1 was associated with having more than one intimate partner, buying sex, and sexual coercion at subsequent waves and that (2) noncondom use, injecting drugs, and sexual coercion at wave 1 were associated with subsequent IPV. The temporal relationships between perpetration of IPV and HIV risks found in this study underscore the need for HIV prevention interventions targeting men on methadone to consider IPV and HIV risks as cooccurring problems.

Gjersing LR; Butler T; Caplehorn JRM; Belcher JM; Matthews R. Attitudes and beliefs towards methadone maintenance treatment among Australian prison health staff. Drug and Alcohol Review 26(5): 501-508, 2007. (23 refs.)

Introduction and Aims. Justice Health NSW has one of the most extensive prison-based methadone programmes in the world. We examine prison health staff attitudes towards methadone treatment and compare these with community methadone staff. Design and Methods. A cross-sectional survey of 202 staff employed by Justice Health New South Wales was undertaken in 2003. Results. The mean scores on the various sub-scales were: abstinence-orientation (AO) 2.9 (95% CI 2.8- 3. 0); disapproval of drug use (DDU) 3.3 (95% CI 3.2 - 3.4); knowledge (1, now) 2.7 (95% CI 2.4 - 2.9); and toxicity 4.6 (95 % CI 4.2 - 5. 0). Both the A 0 and DD U score were correlated negatively with the 1, now score (r = - 0. 3 7 and r = - 0. 13, respectively). Prison health staff had higher A 0 (2.9 vs. 2.6, p < 0. 00 1) and DDU (3.3 vs. 2.6, p < 0. 00 1) scores, and lower 1; now (2.7 vs. 7. 0, p < 0. 001) scores than methadone staff working in the Australian community. They were more knowledgeable than US community methadone staff about the toxicity of methadone (4.6 vs. 0. 0, p < 0.001). Discussion and Conclusions. This is the first survey to examine prison health staff attitudes to methadone treatment. Correctional health staff tend to be more abstinence-orientated, more likely to disapprove of drug use, and less knowledgeable about the risks and benefits of methadone than Australian community methadone staff. The findings have important implications for training health staff working in the prison environment with regard to client retention on methadone treatment.

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.

Gourevitch MN; Chatterji P; Deb N; Schoenbaum EE; Turner BJ. On-site medical care in methadone maintenance: Associations with health care use and expenditures. Journal of Substance Abuse Treatment 32(2): 143-151, 2007. (34 refs.)

To evaluate whether long-term drug treatment with on-site medical care is associated with diminished inpatient and outpatient service use and expenditures, we linked prospective interview data to concurrent Medicaid claims of drug users in a methadone program with comprehensive medical services. Patient care was classified as follows: long-term (. 6 months) drug treatment with on-site usual source of medical care (linked care), long-term drug treatment only, or neither. Multivariate analyses adjusted for visit clustering within patients (n 423, with 1,161 person-years of observation). After adjustment, linked care participants had more Outpatient visits (p < .001), fewer emergency department (ED) visits (24% vs. 33%, p -.02) and fewer hospitalizations (27% vs. 40%, p =.002) than the "neither" group. Ambulatory care expenditures in the linked group were increased, whereas expenditures for other services were similar or reduced. Longterm drug treatment with on-site medical care was associated with increased ambulatory care, less ED and inpatient care, and no net increase in expenditures.

Greenberg B; Hall DH; Sorensen JL. Methadone maintenance therapy in residential therapeutic community settings: Challenges and promise. Journal of Psychoactive Drugs 39(3): 203-210, 2007. (43 refs.)

The therapeutic community (TC) and methadone maintenance treatment (MMT) have individually demonstrated consistent positive outcomes yet rarely have been combined. This article describes how a well-established residential therapeutic community integrated methadone maintenance treatment into its activities. Practical recommendations regarding how to incorporate MMT in a residential program are provided including topics for staff (training, coordination with the methadone service provider agency), patients (education, confronting stigma about methadone maintenance), and potential therapeutic activities (methadone group therapy). The implementation of these staff, patient, and therapeutic adaptations can assist residential substance abuse treatment programs in integrating these two addiction treatment modalities.

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.

Hancock MM; Prosser CC; Ransibrahmanakul K; Lester L; Craemer E; Bourgeois JA et al. Liver transplant and hepatitis C in methadone maintenance therapy: A case report. Substance Abuse Treatment, Prevention, and Policy 2(e-article 5), 2007. (12 refs.)

Methadone maintenance therapy for the treatment of opioid dependence continues to carry a social stigma. Until recently, patients on methadone were not considered for liver transplantation. We describe the first case of a patient on methadone who received a liver transplant for end stage liver disease and was successfully treated for recurrent hepatitis C. More than five years post transplant and three years post viral clearance, the patient continues to do well and is stable on low-dose methadone. This case emphasizes the need to reconsider the non-evidence based policy adopted by transplant centers that require methadone maintenance therapy patients to stop methadone prior to consideration for transplant evaluation.

Johansson BA; Berglund M; Lindgren A. Efficacy of maintenance treatment with methadone for opioid dependence: A meta-analytical study. Nordic Journal of Psychiatry 61(4): 288-295, 2007. (25 refs.)

The two aims of this study were to analyse the impact of methadone on outcome, and to confirm the results from previous meta-analyses by using a different methodology. The literature on randomized controlled trials (RCT) of methadone as maintenance treatment for opioid dependence was systematically reviewed. Eight studies involving 1511 patients were included. Both dichotomous and continuous variables were transformed into the standardized effect size (d). Homogeneity was analysed. A random effect model was used in all calculations. The combined analyses for retention, abuse and criminality were all significant: d = 0.90, d = 0.61, and d = 0.35, respectively. A test of heterogeneity was significant for all three outcomes: P<0.01 for all comparisons. The type of study design was a significant moderator in five of nine comparisons: for retention in all three comparisons, concerning abuse in gradual detoxification vs. untreated controls and concerning criminality in placebo vs. untreated controls. In these subgroups, three of six studies were homogeneous. In one study, methadone maintenance treatment reduced abuse of illegal opioids in prisoners. We conclude that methadone maintenance treatment in opioid dependence shows positive effects on retention, opioid abuse and criminality compared with non-active controlled conditions. Type of study design could explain some of the heterogeneity found. A different meta-analytical approach made it possible to confirm effects of methadone on retention and opioid abuse from previous studies and document effect on criminality.

Kinlock TW; Gordon MS; Schwartz RP; O'Grady K; Fitzgerald TT; Wilson M. A randomized clinical trial of methadone maintenance for prisoners: Results at 1-month post-release. Drug and Alcohol Dependence 91(2/3): 220-227, 2007. (56 refs.)

Background: Despite its effectiveness, methadone maintenance is rarely provided in American correctional facilities. This study is the first randomized clinical trial in the US to examine the effectiveness of methadone maintenance treatment provided to prisoners with pre-incarceration heroin addiction. Methods: A three-group randomized controlled trial was conducted between September 2003 and June 2005. Two hundred eleven Baltimore pre-release inmates who were heroin dependent during the year prior to incarceration were enrolled in this study. Participants were randomly assigned 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). Results: Two hundred participants were located for follow-up interviews and included in the current analysis. The percentages of participants in each condition that entered community-based treatment were, respectively, counseling only 7.8%, counseling+transfer 50.0%, and counseling + methadone 68.6%, p <.05. All pairwise comparisons were statistically significant (all ps <.05). The percentage of participants in each condition that tested positive for opioids at 1-month post-release were, respectively, counseling only 62.9%, counseling + transfer 41.0%, and counseling + methadone 27.6%, p <.05, with the counseling only group significantly more likely to test positive than the counseling + methadone group. Conclusions: Methadone maintenance initiated prior to or immediately after release from prison appears to have beneficial short-term impact on community treatment entry and heroin use. This intervention may be able to fill an urgent treatment need for prisoners with heroin addiction histories.

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.

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.

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.

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.)

Lubman DI; Allen NB; Peters LA; Deakin JFW. Electrophysiological evidence of the motivational salience of drug cues in opiate addiction. Psychological Medicine 37(8): 1203-1209, 2007. (37 refs.)

Background. Drug-related stimuli reliably induce craving in experimental paradigms, yet are rarely cited by drug users as major precipitants of relapse. We examined the motivational significance of drug cues in opiate dependence, by exploring their impact on central attentional processes. Method. Fourteen methadone-maintained subjects and 14 matched controls were studied. Subjects performed a novel active visual oddball task, consisting of opiate-related and matched neutral pictures, some of which (the oddballs) included a white cup. Subjects were fitted with a 32-channel electrode cap. The P300 for each stimulus category was identified using temporal principal components analysis. Results. The P300 elicited by opiate stimuli was significantly larger than that elicited by neutral stimuli in the methadone-maintained group but not in the controls. There was also a non-significant trend for the opiate stimuli to elicit larger P300s than the oddball stimuli in the addicted group. Conclusions. These results suggest that drug cues acquire motivational salience and automatically capture attentional resources in opiate addicts, even when engaged in a non-drug-related task. Enhanced P300s to drug cues may provide an important biological marker of crucial psychological mechanisms relevant to addiction.

Lundgren LM; Sullivan LM; Maina AW; Schilling RF. Client factors associated with length of stay in methadone treatment among heroin users who inject drugs: Quantitative analysis of state-level substance abuse treatment utilization data. Journal of Addiction Medicine 1(1): 26-32, 2007. (34 refs.)

The objective of this study was to examine, for a population of 8,258 adult injection drug users (IDUs) who all had entered a Massachusetts licensed methadone maintenance treatment program (MMT) between 1996 and 2002, client factors associated with remaining in MMT for a minimum of 1 year after program entry. Two binomial logistic regression models were developed. The first model examined the association between age, sex, race/ethnicity, parental status, employment status, educational status, health insurance status, homelessness status, having injected drugs in the past month, residential treatment use, number of overall treatment admissions, and whether a client's longest consecutive stay in MMT had lasted for 1 year or more. Second, to examine the stability of the statistical relationships identified in the first logistic regression model, a second logistic regression model examined whether there were significant differences in client level characteristics between those who used MMT for 6 months or less compared with their counterparts. Those who were older, women, those who were not homeless, those who resided with their children, those who had public health insurance, and those who had not used residential treatment were significantly more likely to have stayed in MMT for at least 1 year or more. In contrast, those who were younger, males, homeless, did not live with children, had no insurance, and had used residential treatment were significantly more likely to have stayed in MMT for 6 months or less compared with their counterparts. Those who stayed in MMT for 1 year or more were more likely to have stable lives compared with those who dropped out of MMT before a year. Providing services to improve MMT clients' employment, housing, and family stability may help improve MMT retention rates. Second, clients with a history of having used residential substance abuse treatment were more likely to stay in MMT for a shorter time period compared with their counterparts. The extent to which treatment bifurcation is a matter of choice or related to other factors needs to be further explored.

Magura S; Blankertz L; Madison EM; Friedman E; Gomez A. An innovative job placement model for unemployed methadone patients: A randomized clinical trial. Substance Use & Misuse 42(5): 811-828, 2007. (27 refs.)

This article presents the outcomes of an innovative vocational rehabilitation model designed for methadone-maintained patients-the Customized Employment Supports (CES) model. CES counselors work intensively with a small caseload of patients to overcome the vocational as well as non-vocational barriers that hinder employment, with the goal of attaining rapid job placement. A randomized clinical trial was implemented at two methadone treatment programs in New York City and was funded by the National Institute on Drug Abuse The study tested the hypothesis that patients assigned to the experimental (CES) condition would have better employment outcomes than those assigned to a control condition who received standard vocational counseling at the programs. The data were collected from May 2001 through April 2005. The efficacy sample for the analysis consisted of 168 patients who completed follow-up interviews. The sample was 58% male, 75% minority group, average age 45 years, and in methadone treatment for an average of five years. The results supported the hypothesis for two measures of employment; i.e., the CES group was significantly more likely than the control group to obtain both any paid employment and informal paid employment. However, there were no significant differences for competitive employment or total earnings. Implications of the findings for the improvement of vocational rehabilitation for addiction patients are discussed.

Meyer M; Wagner K; Benvenuto A; Plante D; Howard D. Intrapartum and postpartum analgesia for women maintained on methadone during pregnancy. Obstetrics and Gynecology 110(2, Part 1): 261-266, 2007. (8 refs.)

OBJECTIVE: To determine whether methadone maintenance alters intrapartum or postpartum pain or medication requirements. METHODS: Sixty-eight patients treated with methadone for opiate dependence during pregnancy (vaginal n=35; cesarean n=33) were matched retrospectively to control women. Analgesic medication and pain scores (0-10) were extracted from the medical record. The primary endpoint was opiate use postpartum (oxycodone equivalents). The secondary endpoints were pain scores and intrapartum analgesia. RESULTS: There were no differences in intrapartum pain or analgesia. After vaginal birth, methadone-maintained women experienced increased pain (methadone, 2.7 [1.9-5.0]; control, 1.4 [0.5-3.0], P=.001) but no increase in opiate use ([mean +/- standard deviation] methadone 12.7 +/- 32.1; control 6.8 +/- 12.7 mg/24 h, P=.33); after cesarean delivery both pain (methadone, 5.3 [4.1-6.0]; control, 3.0 [2.2-3.9], P=.001) and opiate use (methadone, 91.6 +/- 51.8; control, 54.0 +/- 18.6 mg/24 h, P=.001) increased. CONCLUSION: Methadone-maintained women have similar analgesic needs and response during labor, but require 70% more opiate analgesic after cesarean delivery.

Millson P; Challacombe L; Villeneuve PJ; Strike CJ; Fischer B; Myers T et al. Reduction in injection-related HIV risk after 6 months in a low threshold methadone treatment program. AIDS Education and Prevention 19(2): 124-136, 2007. (41 refs.)

This study assessed injection-related HIV risk behavioral changes among opioid users 6 months after enrollment in low-threshold (harm reduction based) methadone maintenance treatment (MMT) programs within needle exchange services in Kingston and Toronto, Ontario, Canada. Changes were assessed for all participants (whole cohort), participants who continued to use illicit drugs by any route (drug-using subcohort); and those who continued to inject drugs (injecting subcohort). In this prospective observational cohort study, an interviewer-administered questionnaire examining injection-related HIV risk behaviors was administered to 183 study participants at entry to treatment and 6 months later. Changes in risk behaviors were analyzed using conditional logistic regression which took into account the paired nature of the data. We found that the proportion of participants injecting drugs, sharing needles, sharing drug equipment, indirectly sharing and using shooting galleries declined with follow-up for the whole cohort. Within the drug-using subcohort, there was a decrease in the proportion of individuals who injected drugs, while within the injecting subcohort the sharing of injection equipment and the use of shooting galleries declined. Our findings suggest that low-threshold MMT programs can reduce the risk of HIV without the enforcement of abstinence-based policies.

Mitcheson L; McCambridge J; Byrne S. Pilot cluster-randomised trial of adjunctive motivational interviewing to reduce crack cocaine use in clients on methadone maintenance. European Addiction Research 13(4): 6-10, 2007. (28 refs.)

This pilot trial explored the effectiveness of an adjunctive single session of motivational interviewing (MI) to reduce crack cocaine use in a methadone maintenance treatment population. Twenty-nine participants were cluster randomised by clinician to MI or a crack information control condition as part of treatment as usual. The intervention had a modest impact on one crack cocaine measure but was not statistically significant in this small sample. A large and statistically significant reduction in heroin use amongst those in the MI condition was observed. This pilot study demonstrated that it was feasible to incorporate a psychosocial intervention within a busy outpatient methadone maintenance programme and the findings support the value of undertaking a larger trial.

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.

Padaiga Z; Subata E; Vanagas G. Outpatient methadone maintenance treatment program - Quality of life and health of opioid-dependent persons in Lithuania. Medicinia - Lithuania 43(3): 235-241, 2007. (39 refs.)

Background. The evaluation of quality of life and self-perceived health represents an assessment of the impact of treatment on patient functioning and well-being. Objective. Our aim was to explore the impact of methadone maintenance treatment on quality of life and self-perceived health of opioid-dependent persons in Lithuania. Methods. A total of 102 opioid-dependent patients were recruited in the study. A prospective follow-up study design was used. To assess quality of life, the WHOQOL-BREF 26-item version was used. The impact of methadone maintenance treatment on self-perceived health was assessed by Opiate Treatment Index (OTI). Results. Following 6 months of methadone maintenance treatment, significant improvements in physical (P=0.004), psychological (P=0.004), and environmental (P=0.048) components of quality of life were observed; no statistically significant improvements were found in social component of quality of life. Study participants reported lower rates of medical morbidity associated with injection (P<0.001), cardiorespiratory (P=0.034), musculoskeletal (P<0.001), neurological (P=0.013), gastrointestinal (P<0.001), and general health (P<0.001). Conclusions. Methadone maintenance treatment substantially reduces morbidity associated with opioid dependence and improves the quality of life of patients.

Pang L; Hao Y; Mi GD; Wang CH; Luo W; Rou KM et al. Effectiveness of first eight methadone maintenance treatment clinics in China. AIDS 21(Supplement 8): S103-S107, 2007. (15 refs.)

Objective: To evaluate the effectiveness of the first phase of eight methadone maintenance treatment (MMT) clinics in China. Design: Repeated cross-sectional surveys. Methods: Three surveys of clients attending the first phase of eight MMT clinics were carried out at entry, and 6 and 12 months after enrolment. Drug using behaviours, drug- related criminal activity, and relationships with families were compared for the three periods. Blood specimen were collected and tested for HIV for each client at entry, and HIV-negative clients were re-tested after 12 months. Results: A total of 585, 609 and 468 clients participated in the first, second and third surveys, respectively. The proportion of clients who injected drugs reduced from 69.1 to 8.9 and 8.8%, and the frequency of injection in the past month had reduced from 90 times per month to twice per month, employment increased from 22.9 to 43.2 and 40.6%, and self-reported criminal behaviours reduced from 20.7 to 3.6 and 3.8% in the three surveys. By the third survey, 65.8% of clients reported a harmonious relationship with families, an increase from 46.8% at entry, and 95.9% of clients were satisfied with MMT services. Eight HIV seroconversions were found among 1153 clients during 12 months. Conclusion: The study demonstrated that the first phase MMT contributed to a reduction in drug use, drug injecting behaviours, drug-related criminal behaviours, HIV infections, and improved relationships within families among heroin users who participated in the MMT programme. MMT needs to be scaled up nationwide rapidly with improved services.

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; Rados V; Adelson M. Characterization of former heroin addict patients with hepatitis C virus antibodies in a methadone maintenance treatment (MMT) clinic in Israel. Substance Use & Misuse 42(9): 1477-1484, 2007. (13 refs.)

Aims: To compare characteristics, retention in treatment and cessation of drug abuse of 249 positive hepatitis C (HCV+) with 188 negative hepatitis C (HCV-) antibody patients. Methods: Data on Hepatitis C, Hepatitis B and HIV results, urine-proven drug use, and modified ASI of all patients admitted to the Adelson MMT clinic between June/1993-Dec/2002 were prospectively collected. Results: HCV+ patients manifested more ever injecting drug use, immigrants, positive HIV antibody, hepatitis B antigen, years of opiate addiction pre-MMT and benzodiazepines misuse after one year in MMT than HCV-patients, with similar 1-year retention and proportion of opiate use cessation. Conclusions: Although characteristics of HCV+ and HCV-differed, they manifested similar outcomes: treatment retention and proportion of opiate use cessation.

Peles E; Schreiber S; Naumovsky Y; Adelson M. Depression in methadone maintenance treatment patients: Rate and risk factors. Journal of Affective Disorders 99(1-3): 213-220, 2007. (39 refs.)

Background: Depression is widely prevalent among former heroin addicts in methadone maintenance treatment (MMT). The risk factors for depression among MMT patients that have not been well characterized, was studied. Methods: In a cross-sectional study (January, 2004-August, 2005), 90 MMT patients were evaluated for depression by the 21-item Hamilton Rating Scale for Depression (21-HAM-D) and the Brief Psychiatric Rating scale (BPRS). To study possible induction of depression by drug abuse, urine samples tested for, opiates, cocaine metabolite (benzoylecgonine), benzodiazepines (BDZ), cannabis (THC), amphetamines and methadone metabolite during I month preceding study entry: a drug was defined as being positive if at least one sample was positive. Results: The 21-HAM-D and BPRS scores were significantly correlated (Pearson R=0.76, p < 0.0005). Fifty percent were found to be suffering from depression (21-HAM-D, scored 18). Fifteen new patients in MMT had better scores (5.1 +/- 5.7) than continuous patients (17.7 +/- 6.2, p < 0.0005), independent of treatment duration. Higher scores were in 5 1 patients with any Axis I psychiatric diagnosis (18.9 +/- 5.7 vs. 11.4 +/- 7.9, p < 0.0005), 74 abusing and or using prescribed BDZ (16.3 +/- 7.4 vs. 11.7 +/- 8, p=0.03), and 3 6 prescribed more than one type of medication (17.5 +/- 7.3 vs. 14.2 +/- 7.7, p=0.05). Females (N=40) bad poorer scores than males (17.6 +/- 7 vs. 14.1 +/- 7.9, p=0.03), especially 12 admitted into treatment while pregnant (20.2 +/- 4.1). Limitation: Patient drug abuse and withdrawal could distort evaluation and lead to misclassification of depression. Conclusion: The major risk factors for depression were already being in MMT, female gender, any DSM-IV Axis I psychiatric diagnosis, taking any psychotropic medication, abuse or using prescribed BDZ, and methadone dose > 120 mg/day.

Pelet A; Doll S; Huissoud T; Resplendino J; Besson J; Favrat B. Methadone maintenance treatment (MMT) in general practice or in specialized centers: Profile of patients in the Swiss Canton of Vaud. American Journal of Drug and Alcohol Abuse 33(5): 665-674, 2007. (24 refs.)

We studied profile of patients (n 1782) treated in specialized centers and general practice (GP) enrolled in methadone maintenance treatment (MMT) programs during 2001 in the Swiss Canton of Vaud. We found that GPs treated the majority of patients (76%). Specialized centers treated a higher proportion of patients with uncontrolled intravenous use of cocaine and heroin, and prescribed neuroleptics as concomitant medication three times more frequently than GPs. Patients treated in specialized centers were more likely to undergo screening for HIV, HBV, HCV, and receive complete HBV immunization. In conclusion, specialized centers are more likely to treat severely addicted patients and patients with a poor global assessment (physical, psychiatric, and social).

Ponizovsky AM; Grinshpoon A. Quality of life among heroin users on buprenorphine versus methadone maintenance. American Journal of Drug and Alcohol Abuse 33(5): 631-642, 2007. (23 refs.)

Objectives: To assess the quality of life (QoL) of heroin users starting and following 4 and 8 months of maintenance treatment program using buprenorphine vs. methadone. Methods: Participants received maintenance treatment with oral methadone or sublingual buprenorphine for the treatment of heroin dependence. Participants' QoL was measured using the Quality of Life Enjoyment and Satisfaction Questionnaire completed before treatment and at 1-, 4-, and 8-month follow-up. Baseline data from 304 heroin-dependent participants starting maintenance treatment, and 4- month and 8-month follow-up data for the 180 and 129 participants, respectively, retained in trial treatment are presented. Results: For the participants retained in treatment, statistically significant improvements in QoL and all specific life domains were observed in 4 and 8 months. However, for users who were maintained on methadone, this improvement was observed during the first month of treatment. Conclusions: The results show the beneficial effects of the maintenance treatment programs using both buprenorphine and methadone with regard to satisfaction with QoL and all specific life domains among heroin-dependent outpatients, with methadone having an earlier onset than buprenorphine. Further studies are needed to identify the factors linked to these benefits and their time course.

Potik D; Adelson M; Schreiber S. Drug addiction from a psychodynamic perspective: Methadone maintenance treatment (MMT) as transitional phenomena. Psychology and Psychotherapy. Theory, Research and Practice 80(Part 2): 311-325, 2007. (47 refs.)

Purpose. To present a psychodynamic (specifically object-relations) approach to the understanding of drug addiction and recovery among patients in Methadone Maintenance Treatment (MMT), and to discuss the role of psychodynamic psychotherapy among drug addicts, focusing on the processes which patients undergo during counselling. Methods. We review some psychodynamic explanations of the drug addiction phenomenon, and illustrate the psychodynamic comprehension framework of the issue according to Winnicott's theory, by describing a few psychotherapeutic interventions with our MMT patients. Results. The main premise is that treatment in a MMT program is accompanied by changes in-patients' life-styles and behaviour, which are parallel to transitional phenomena. As such, methadone and counselling serve as transitional objects during these processes. Conclusions. Drug addiction is a widespread phenomenon that affects many areas in the addicts' life; therefore, some eclecticism from therapists has a beneficial effect on the outcome.

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.

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.

Rosenblum A; Parrino M; Schnoll SH; Fong C; Maxwell C; Cleland CM et al. Prescription opioid abuse among enrollees into methadone maintenance treatment. Drug and Alcohol Dependence 90(1): 64-71, 2007. (36 refs.)

A multi-state survey of 5663 opioid dependent persons enrolling in 72 methadone maintenance treatment programs (MMTPs) was conducted to determine the prevalence of prescription opioid (PO) abuse, factors associated with PO abuse and sources for POs. Regions where PO abuse was believed to be prevalent were oversampled; primary opioid was defined as the drug used the most before coming to the MMTP. Among primary heroin abusers, 69% reported abusing POs. Opioid abuse frequencies among primary PO abusers were oxycodone (79%), hydrocodone (67%), methadone (40%), morphine (29%), heroin (13%), hydromorphone (16%), fentanyl (9%) and buprenorphine (1 %). Correlates (p <= .01) of PO abuse, using general estimating equations, were: low urbanicity (MMTPs located in comparatively low population density counties), white ethnicity, no history of injecting primary drug, no previous methadone treatment, younger age, chronic pain, and pain as a reason for enrollment. The most frequent sources of POs were dealer, friend or relative, and doctor's prescription; least frequent were Internet and forged prescription. One-third of PO abusers reported a history of injecting their primary drug. PO abuse is highly prevalent among MMTP patients. Future studies should describe HIV/HCV needle injection practices, characteristics that predict treatment outcomes, and factors that contribute to higher prevalence of persistent pain among PO abusers. reserved.

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.

Schiff M; Levit S; Moreno RC. Retention and illicit drug use among methadone patients in Israel: A gender comparison. Addictive Behaviors 32(10): 2108-2119, 2007. (45 refs.)

Objectives: To examine gender differences or similarities regarding the retention rate in the course of a 13-month treatment and in long-term retention up to 14 years among 2683 patients treated in eight (of 10) methadone maintenance clinics located in communities in Israel. Methods: The study is based on a computerized set of data on 2683 (331 female and 2352 male) patients older than 18 years of age (mean age=43.30 SD=8.53) who underwent treatment in one of eight methadone maintenance programs in Israel sometimes (or all the time) between January 1, 1991 and October 30, 2005. Results: 79.6% of the patients had a 100% retention rate in the 13-month time slot examined. The survival curves for the long-term retention show that retention in treatment was similar for both female and male patients. However, long-term retention is higher among female patients aged 31-40. Conclusion: It is premature to conclude that there are no gender differences in retention since there seem to be different profiles of female patients, characterized by different retention rates, as implied by the great variability in the females' retention behavior found in the regression analysis.

Schwartz RP; Jaffe JH; Highfield DA; Callaman JM; O'Grady KE. A randomized controlled trial of interim methadone maintenance: 10-Month follow-up. Drug and Alcohol Dependence 86(1): 30-36, 2007. (27 refs.)

This study compares interim maintenance (IM) to a waiting list condition at an opioid treatment program (OTP). As defined by US federal regulations, IM provides observed methadone dosing and emergency counseling only for a maximum of 120 days. Three hundred and nineteen individuals enrolled on an OTP waiting list were randomly assigned on a 3:2 basis to either IM or waiting list control. Outcomes were measured at OTP entry (or at 4 months from baseline for those who did not enter treatment), and 6 months thereafter. At the second follow-up, 129 (64.8%) of the IM participants reported being enrolled in an OTP, versus 33 (27.5%) of the controls, p <.001. Significant treatment condition x time interaction effects occurred for heroin and cocaine use (both p's <.001) and the ASI Legal composite score (p <.001). Moreover, a significant difference occurred between conditions at the second follow-up for heroin-positive drug tests (interim 48.1% versus control 72.3%, p=.001) but not for cocaine-positive drug tests. At 10 months after study enrollment, there are sustained benefits of IM as compared to waiting list in terms of increased treatment entry and reduced heroin use and criminal behavior.

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.

Senbanjo R; Wolff K; Marshall J. Excessive alcohol consumption is associated with reduced quality of life among methadone patients. Addiction 102(2): 257-263, 2007. (33 refs.)

Aim: To evaluate the impact of excessive alcohol consumption on the health-related quality of life of patients receiving methadone treatment for opioid dependence. Design A cross-sectional survey. Participants: One hundred and ninety-two patients attending out-patient methadone clinics in the south-cast of England, United Kingdom. Measurements Quality of life (QoL) was assessed using the Medical Outcomes Study: General Health Survey, Short Form (SF-12). Alcohol consumption was assessed using the Alcohol Use Disorders Identification Test (AUDIT). Findings Approximately one-third of the sample (57/192) were AUDIT-positive (score : 8) and 20 of the 135 AUDIT negative patients reported past history of alcohol problems. AUDIT-positive patients were less satisfied with their methadone dose than AUDIT-negative patients (P = 0.002), despite having a higher dose. AUDIT-positive patients reported more physical (P = 0.020) and psychological (P = 0.034) health problems and poorer QoL (P = 0.008) with an estimated effect size of 0.46. Lower QoL scores for AUDIT positive patients affected both 'physical' (P = 0.009) and 'psychological' (P = 0.012) health domains with poor role functioning ('role limitation' due to physical health. P < 0.001. and to emotional health, P = 0.009), social functioning (P = 0.015) and self-perceived general health (P = 0.029). Conclusion: Excessive alcohol consumption may be associated with a distinctive pattern of QoL impairment in methadone patients. In addition to advising methadone patients regarding their alcohol consumption, comprehensive care plans should seek to restore normal personal, family and social role functioning through the provision of appropriate health and social care.

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.

Shi J; Zhao L-Y; Epstein DH; Zhao C; Shuai Y; Yan B et al. The effect of methadone maintenance on illicit opioid use, human immunodeficiency virus and hepatitis C virus infection, health status, employment, and criminal activity among heroin abusers during 6 months of treatment in China. Journal of Addiction Medicine 1(4): 186-190, 2007. (39 refs.)

Purpose: This study was designed to evaluate the effects of methadone maintenance treatment (MMT) on severity of dependence, depression, human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection, health status, employment, and criminal activity among heroin abusers after 3 and 6 months of treatment, compared with baseline, in China. Methods: A total of 102 methadone maintenance treatment (MMT) patients (87 men and 15 women; mean age, 36.1 years; standard deviation = 6.9) without major medical or psychiatric comorbidity participated in the experimental procedure. They were given oral methadone (maximum daily dose 80 mg, minimum daily dose 30 mg). Opioid use was assessed by twice-weekly urinalysis; HIV and HCV status were assessed by standard blood tests. Questionnaires were administered to assess blood-borne-virus risk behavior, severity of dependence, depression, health status, employment, and criminal activity. Changes over time were evaluated by 1-way analysis of variance (ANOVA) followed by post hoc t tests. Results: Opioid use was reduced from 26.7 days per month at baseline to 0.7 and 0.0 days at 3 and 6 months, respectively. No participant seroconverted to HIV and HCV positivity during the 6 months of MMT. Health status significantly improved, as did severity of dependence, depression, and criminal activity, after 3 and 6 months MMT. Conclusions: The results support the broad beneficial effects of MMT in China.

Sindelar JL; Olmstead TA; Peirce JM. Cost-effectiveness of prize-based contingency management in methadone maintenance treatment programs. Addiction 102(9): 1463-1471, 2007. (26 refs.)

Aim: To determine if prize-based contingency management (CM), which has been shown to improve treatment outcomes over usual care (UC) alone, is cost-effective. Design: A cost-effectiveness study of a multi-site clinical trial. Data on the outcome measures came from the original effectiveness trial. Cost data were gathered by clinic survey specifically for this cost-effectiveness analysis. Setting: Six methadone maintenance community clinics participating in the National Drug Abuse Treatment Clinical Trials Network. Participants: Participants were recruited from six methadone maintenance community treatment programs. The study sample consisted of 388 participants: 190 in the UC condition and 198 in the CM condition. Participants were randomized at each site to either the UC or the CM condition based on the presence of stimulants (cocaine, amphetamine or methamphetamine) and opioids in their baseline urine sample. Intervention Prize-based contingency management added to usual care. Measurements Longest duration of abstinence (LDA), number of stimulant-negative urine samples and costs of treatment. Findings: Compared to usual care, the incremental cost of using prize-based CM to lengthen the LDA by 1 week was $141 [95% confidence interval (CI), $105-$193]. The incremental cost to obtain an additional stimulant-negative urine sample was $70 (95% CI, $53-$117). Conclusions: By comparing this study to a companion study, we found that adding prize-based CM to usual care may be more cost-effective in methadone maintenance clinics than in counseling-based drug-free clinics.

Sorensen JL; Haug NA; Delucchi KL; Gruber V; Kletter E; Batki SL et al. Voucher reinforcement improves medication adherence in HIV-positive methadone patients: A randomized trial. Drug and Alcohol Dependence 88(1): 54-63, 2007. (43 refs.)

This clinical trial evaluated a contingency management intervention designed to improve medication adherence among HIV-positive methadone maintenance patients. After a 4-week baseline observation phase, eligible participants (N=66) were randomly assigned to: (a) medication coaching sessions every other week to assist with adherence strategies (comparison group) or (b) medication coaching plus voucher reinforcement for opening electronic medication caps on time (voucher group). Baseline adherence (percent doses taken/percent total possible doses) was 51% using electronic measurement, 75% using self-report and 75% using pill count. The intervention was provided for 12 weeks, with a 4-week follow-up. The primary outcome results of the clinical trial indicated effectiveness during the intervention, with significant mean adherence differences between voucher and comparison groups using electronic measurement (78% versus 56%), pill count (86% versus 75%), and self-report (87% versus 69%). Differences between groups faded after vouchers were discontinued. Contingency management shows promise as a strategy to promote antiretroviral medication adherence in this population.

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.

Stallwitz A; Stover H. The impact of substitution treatment in prisons - A literature review. (review). International Journal of Drug Policy 18(6): 464-474, 2007. (88 refs.)

Substitution treatment (ST) has established itself as a generally recognised type of treatment for opioid dependence worldwide. Although the number of countries providing ST in prison has slowly started to grow over the last years, its application in the custody setting remains controversial. ST in prison is mainly employed in form of detoxification. Maintenance treatment is provided in only a limited number of international prisons. This literature review is centred around the question: "What is known about the effectiveness of prison based ST?" Furthermore, it investigates how this knowledge can be applied to improve treatment scope and quality. Effectiveness, as defined by the examined studies, refers to short- and lon.-term reduction of drug use and relapse, reduction in drug use related risk behaviours, reduction in criminal conduct and recidivism, facilitating the manageability of drug using prisoners and improving their physical stabilisation. In this context, substitute dosage, treatment duration, patient retention rates, complementary psycho-social care and the effects of disrupting maintenance treatment when entering the institution are scrutinised. Results show that prison-based ST and especially prison-based methadone maintenance treatment (PMMT) can reduce drug use and injection in penal institutions. Moreover, PMMT provision can reduce injecting risk behaviours as well as drugs charges and re-admission rates. However, for PMMT to retain patients in treatment and reduce illegal drug use and criminal behaviour a sufficiently high dose of methadone (e.g.. >60 mg) and the treatment duration lasting the entire period of imprisonment appear crucial. On the basis of the analysed results the authors recommend the provision of PMMT for individuals with long-standing opioid dependence and suggest major expansions of prison based ST in many countries.

Stein MD; Anderson BJ; Niaura R. Smoking cessation patterns in methadone-maintained smokers. Nicotine & Tobacco Research 9(3): 421-428, 2007. (48 refs.)

To determine predictors of smoking cessation duration in a randomized clinical trial, we assigned participants to nicotine patch (8-12 weeks) plus either (a) a baseline tailored brief motivational intervention, a quit date behavioral skills counseling session, and a relapse prevention follow-up session, or (b) brief advice using the National Cancerer Institute's 4A's model. A total of 383 smokers from five methadone maintenance treatment centers in Rhode Island were enrolled, of whom 312 (82%) completed 6-month follow-up assessments. The primary outcome was longest period of self-reported abstinence during follow-up. Participants were on average 40.5 years of age; 51.9% were male, and 77.6% were White. In multivariate analysis controlling for demographics, nicotine dependence, depressive symptoms, and smoking-related symptoms, we found longer periods of abstinence in persons reporting at least one 24-hr quit attempt in the year prior to baseline (OR=1.97, p=.003), in those anticipating success in cessation (OR=1.33, p=.024), and in those with a greater percentage of nicotine patch use days (OR=2.78, p,. 001). Past quit attempts, self-efficacy, and constant nicotine replacement were associated with duration of abstinence among methadone-maintained smokers. Attention to these domains in future intervention studies may improve treatment success.

Stitzer ML; Peirce J; Petry NM; Kirby K; Roll J; Krasnansky J et al. Abstinence-based incentives in methadone maintenance: Interaction with intake stimulant test results. Experimental and Clinical Psychopharmacology 15(4): 344-350, 2007. (22 refs.)

Baseline drug use detected in urine toxicology has been shown to predict drug abuse treatment outcome, including response to contingency management interventions with drug abstinence as their target. This study examined the association between baseline urine test result and treatment outcome in stabilized methadone maintenance patients with ongoing stimulant use to determine whether abstinence incentives were differentially effective in those testing stimulant negative versus positive at study entry. Participants were 386 methadone-maintained patients who took part in a National Drug Abuse Treatment Clinical Trials Network multisite study aimed at reducing stimulant abuse during treatment (J. M. Peirce et al., 2006). At study intake, 24% of participants tested stimulant negative and 76% tested positive. Those testing negative at entry submitted 82% negative urines during the study versus 36% for those testing positive at entry (odds ratio [OR] = 8.67; confidence interval [CI] = 5.81-12.94). Compared with those receiving usual care, the addition of abstinence incentives resulted in a significant increase in stimulant-negative urine samples submitted during the study both for those testing negative at study entry (OR = 2.27; CI = 1.13-4.75) and for those testing positive (OR = 1.84; CI = 1.25-2.71). These findings suggest that abstinence incentives have significant clinical benefits independent of initial drug use severity among methadone maintenance patients with ongoing stimulant drug use.

Sylvestre DL; Clements BJ. Adherence to hepatitis C treatment in recovering heroin users maintained on methadone. European Journal of Gastroenterology and Hepatology 19(9): 741-747, 2007. (27 refs.)

Objectives Injection drug users are often denied hepatitis C (HCV) treatment due to concerns about adherence, despite limited data about the impact of such common issues as psychiatric illness and intercurrent drug use. We sought to define the impact of these and other potential adherence barriers in a real-world sample of recovering drug users. Methods We conducted a prospective observational study of 71 methadone-maintained patients who received interferon and ribavirin combination therapy in a community-based clinic with expertise in treating addictive disorders. Adherence measures were conducted with monthly interview, medication counts, and urine toxicology testing. Results Overall, 48 (68%) were adherent, and adherent patients were significantly more likely to achieve a sustained virologic response (42 vs. 4% in nonadherent patients). Patients with and without a prior psychiatric history were similarly adherent (64 vs. 72%, respectively, P>0.5), and the initiation of new psychiatric medications during HCV treatment was associated with improved adherence overall (P=0.02) and in patients that did not report a preexisting psychiatric diagnosis (P=0.04). Trend towards reduced adherence in patients without a period of abstinence was seen before initiating HCV treatment, 46 vs. 72% of those who had been abstinent for at least 1 month (P=0.10). Although occasional drug users were similarly adherent to those who were completely abstinent, patients who relapsed to regular drug use showed a significantly lower level of adherence (P=0.03). Conclusions We conclude that the majority of methadone-maintained drug users can adhere to HCV treatment, even those with psychiatric illness and relatively limited pretreatment drug abstinence. Lack of pre-HCV treatment drug abstinence and regular drug use during HCV treatment may be relative barriers to medication adherence, but the initiation of psychiatric medications during HCV treatment may be a helpful intervention. This report provides further evidence for an individualized approach to HCV treatment that does not categorically exclude patients with potential barriers such as mental illness and limited drug abstinence.

Tuchman E. Exploring the prevalence of menopause. symptoms in midlife women in methadone maintenance treatment. Social Work in Health Care 45(4): 43-62, 2007. (40 refs.)

Menopause is a natural process that occurs in women's lives as part of normal aging. Many women go through the menopausal transition with few or no symptoms, while some have significant or even disabling symptoms. The purpose of this paper is to describe the menopausal symptom experience of 135 urban methadone-maintained midlife women between the ages of 40 and 55 years. A cross-sectional survey comprising sample characteristic questions and a 14-item menopause symptom checklist was administered. Ninety-six percent reported one or more symptoms with a mean of 6.2 symptoms. Symptom reporting was found to be relatively high, with more, than half of the sample reporting hot flashes, night sweats, sleep disturbances, joint pains, and fatigue in the two weeks preceding the survey. However, the psychological symptoms.(irritability and depression) were the two most common symptoms in this sample. This study documents a relatively heavy burden of symptoms in an aging cohort of methadone-maintained women. The physical and psychological impact of aging and, in particular, the experience of menopause in these women is rarely studied and poorly understood. This gap in critical knowledge is further complicated by the remarkable similarity of many symptoms associated with menopause and opiate withdrawal. Aging, drug-related health problems, and poor access to health care further complicate the picture and underscore the importance of better integration of health care with social work intervention.

Valentine K. Methadone maintenance treatment and making up people. Sociology 41(3): 497-514, 2007. (29 refs.)

This article considers the operations of methadone maintenance treatment through the use of concepts proposed by actor-network theory and historical ontology. The former provokes a concern with the co-constitution of treatment regimes by various actors, including non-human actants. The latter provokes a concern with the creation of new identities. Analysis of methadone often examines treatment as a nether world, and clients as neither addicted nor autonomous. The analysis undertaken here instead emphasizes what is produced in methadone maintenance treatment, rather than the inexactness of existing categories. It considers four identities produced through methadone treatment the dissatisfied customer; the stable user; the individual in need of guidance; and the lay carer. This analysis enables a study of what and who is produced through treatment in terms that problematize simple distinctions between good and bad and independent, stable and chaotic.

van der Zanden BP; Dijkgraaf MGW; Blanken P; van Ree JM; van den Brink W. Patterns of acquisitive crime during methadone maintenance treatment among patients eligible for heroin assisted treatment. Drug and Alcohol Dependence 86(1): 84-90, 2007. (23 refs.)

Objective: To determine the patterns of acquisitive crime during methadone maintenance treatment among chronic, treatment-resistant heroin users eligible for heroin assisted treatment in the Netherlands. Methods: We retrospectively assessed the type and number of illegal activities during 1 month of standard methadone maintenance treatment in 51 patients prior to the start of heroin assisted treatment. Data were collected using a semi-structured interview focussed on crime with special emphasis on property crime. Volume analyses consisted of frequencies and descriptives of mean numbers of offences per day and per type. Results: In a Dutch population of problematic drug users eligible for and prior to commencing heroin assisted treatment, 70% reported criminal activities and 50% reported acquisitive crimes. Offending took place on 20.5 days per month with on average 3.1 offences a day. Acquisitive crime consisted mainly of shoplifting (mean 12.8 days, 2.2 times/day) and theft of bicycles (mean 5.8 days, 2.4 times/day); theft from a vehicle and burglaries were committed less frequently. The majority of these patients (63%) reported to have started offending in order to acquire illicit drugs and alcohol. Conclusion: During methadone maintenance treatment, 50% of criminally active, problematic heroin users eligible for heroin assisted treatment reported acquisitive crime. Shoplifting, thefts and/or other property crimes were committed on average two to three times on a crime day. This study discusses that the detail provided by self-reported crime data can improve cost estimates in economic evaluations of heroin assisted treatment.

Waal H. Merits and problems in high-threshold methadone maintenance treatment: Evaluation of medication-assisted rehabilitation in Norway 1998-2004. European Addiction Research 13(2): 66-73, 2007. (36 refs.)

Background: Methadone maintenance treatment (MMT) in Norway emphasizes rehabilitation and control with strict intake criteria and rules for involuntary termination. Consequently, the programme should be characterized as high threshold and restrictive, which is somewhat out of tune with the general European trend towards harm reduction and diversity. Methods: The programme has undergone an extensive evaluation with quantitative and qualitative methods. Findings: MMT is at present integrated into the general health and social security system. The restrictive traits have not prevented rapid development in the capacity and coverage. Results on retention and drug use are above average for MMT programmes, but results on vocational rehabilitation are not impressive. The system is costly and some inherent structural problems cause concern. Conclusion: On this basis, central authorities have decided to keep the core structure of the programme, but to implement several changes. Medical diagnosis and evaluation should replace formal regulating criteria.

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.

Whitley SD; Kunins HV; Amsten JH; Gourevitch MN. Colocating buprenorphine with methadone maintenance and outpatient chemical dependency services. Journal of Substance Abuse Treatment 33(1): 85-90, 2007. (21 refs.)

Buprenorphine may be used to treat opioid dependence in office-based settings, but treatment models are needed to ensure access to psychosocial services needed by many patients. We describe a novel buprenorphine treatment program colocated with methadone maintenance and outpatient chemical dependency services. We conducted a retrospective chart review of the first 40 consecutive patients initiating buprenorphine treatment in this program to determine characteristics associated with treatment retention. Exclusion criteria were current alcohol or benzodiazepme dependence. Secondary drug users and patients who were psychiatrically or medically ill were included. At 6 months, 60% (n = 24) were retained, 13% (n = 5) tested positive for opiates, and 25% (n = 10) tested positive for secondary substances. Patients who were older (odds ratio [OR] per year of age = 1.1, confidence interval [CI] = 1.0-1.2) and those who were employed (OR= 9.8, Cl = 1.8-53.1) were more likely to remain in treatment, but other variables were not associated with retention. Our experience demonstrates that buprenorphine can be successfully integrated into outpatient substance abuse treatment.

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.

Woody GE; Kane V; Lewis K; Thompson R. Premature deaths after discharge from methadone maintenance: A replication. Journal of Addiction Medicine 1(4): 180-185, 2007. (41 refs.)

Objective: Examine rate and causes of death among patients discharged from methadone maintenance, relate them to reasons for discharge, and discuss treatment implications. Method: Naturalistic study of deaths and causes of death among 636 opioid-dependent veterans treated with methadone maintenance between January 1, 2000 and August 31, 2002. Results: Among 456 patients who remained on methadone, 31 (6.8%) died (1 overdose, 1 accident, 13 liver problems, 16 other medical). Among 180 discharged patients, 34 (18.8%) died. Reasons for discharge and causes of death were: continuing drug use (N = 52), 11 deaths (4 overdoses, 4 liver problems, 3 other medical); other disciplinary problems (N = 31), 8 deaths (2 suicides, 2 overdoses, 3 other medical, 1 unknown); other reasons (N = 97), 15 deaths (2 suicides, 1 overdose, 1 accident, 7 liver problems, 3 other medical, 1 unknown). Deaths were significantly less (P < 0.05) among patients who remained on methadone than in each category of those discharged. Follow-up interviews of 99 of 146 discharged patients showed problems in drug use, medical, employment, and psychiatric areas, and that only 21% were in treatment. Conclusions: These findings are consistent with a previous study from the same program, and also from other studies, showing that participating in methadone maintenance reduces mortality. Considered in light of the increased mortality among patients discharged for continuing drug use or behavioral problems, these data suggest that premature mortality can be reduced by keeping patients in treatment and/or taking steps to ensure that discharged patients are promptly enrolled in another program.

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.