Opioid-Addiction Treatment: Maintenance or Abstinence Better?

The key to the effectiveness of maintenance therapy is treatment retention, which has been shown to significantly reduce mortality and other negative outcomes; however, “in methadone clinics, patients are often discharged from the clinic against their will,” said Robert Schwartz, M.D., the medical director and a senior research scientist at the Friends Research Institute in Baltimore.

The patient's autonomy and the methadone clinic's perspective are sometimes in conflict and become a source of tension, according to Schwartz. The methadone clinic staff may be discouraged by a patient's lack of progress or incomplete abstinence despite some degree of improvement. “They may hope to replace that patient with a ‘good’ patient,” he said.

On the question of how long the patient will stay in a methadone maintenance program, Schwartz said that about half of patients entering these programs drop out in the first year.

He and his colleagues conducted a study at six methadone clinics in the Baltimore area and found that nearly 80 percent of patients left the programs for program-related reasons. For example, clinics dropped patients who had treatment interrupted because of brief incarceration, drug use, missed medications, failure to adhere to clinic rules, failure to pay nominal fees, or interpersonal conflicts with staff or counselors. Staff frustration often leads to discharge against a patient's wishes, particularly since physicians are typically not closely involved in the program operation on a daily basis.

Since approximately 60 percent of methadone clinics in the United States are run by for-profit entities, there have been concerns about the quality of treatment provided and a lack of sufficient physician oversight at many clinics, Kleber noted.

To increase patient retention and improve outcomes at methadone clinics, Schwartz suggested several approaches: include the patient's need for autonomy and perspective in the treatment plan rather than have the clinic dictate it; review program rules and make them simple, sensible, and patient friendly; change counselors or transfer patient to another program if conflicts arise; and be more cautious in making the decision to discharge a patient.

Furthermore, clinicians should address psychiatric comorbidities while treating addiction, Schwartz recommended. “We also need to make decisions based on the patient's functioning rather than exclusively on urine test results.”

The effectiveness of contingency management, which uses a system of incentives and disincentives designed to make abstinence attractive and drug use unattractive, was supported by research on various substance use disorders, Kenzie Preston, Ph.D., a senior investigator and chief of the Clinical Pharmacology and Therapeutics Research Branch within the Intramural Research Program at NIDA, said at the workshop.

There are a variety of flexible contingency-management strategies that can be used effectively along with other treatments, she explained. For example, if a patient meets all the scheduled specimen collections and produces consecutive negative drug-screen results, he or she is given a voucher with monetary value to exchange for various prizes or merchandises. The value of the vouchers can remain the same or increase over time with more clean results. Other forms of reinforcement are assistance with child care, access to housing, vocational training, and greater flexibility with treatment (for example, take-home doses of methadone).

Targeted behaviors are not limited to abstinence from opioid use, she added, but may also include abstinence from other substance use, adherence to naltrexone treatment, and therapy retention.

“As for the question of whether [contingency management] is terminable or interminable, at this point there is no yes or no answer, and [we need to] look at it long term,” she said.