Prediction of long-term outcome for heroin addicts admitted to a methadone maintenance program

Long-term course of opioid addiction

Opioid addiction is associated with excess mortality, morbidities, and other adverse conditions. Guided by a life-course framework, we review the literature on the long-term course of opioid addiction in terms of use trajectories, transitions, and turning points, as well as other factors that facilitate recovery from addiction. Most long-term follow-up studies are based on heroin addicts recruited from treatment settings (mostly methadone maintenance treatment), many of whom are referred by the criminal justice system. Cumulative evidence indicates that opioid addiction is a chronic disorder with frequent relapses. Longer treatment retention is associated with a greater likelihood of abstinence, whereas incarceration is negatively related to subsequent abstinence. Over the long term, the mortality rate of opioid addicts (overdose being the most common cause) is about 6 to 20 times greater than that of the general population; among those who remain alive, the prevalence of stable abstinence from opioid use is low (less than 30% after 10-30 years of observation), and many continue to use alcohol and other drugs after ceasing to use opioids. Histories of sexual or physical abuse and comorbid mental disorders are associated with the persistence of opioid use, whereas family and social support, as well as employment, facilitates recovery. Maintaining opioid abstinence for at least five years substantially increases the likelihood of future stable abstinence. Recent advances in pharmacological treatment options (buprenorphine and naltrexone) include depot formulations offering longer duration of medication; their impact on the long-term course of opioid addiction remains to be assessed.

Heroin-assisted treatment in the Netherlands: History, findings, and international context

This monograph describes the history, findings and international context of heroin-assisted treatment (HAT) in the Netherlands. The monograph consists of (1) a short introduction and seven paragraphs describing the following aspects of HAT in the Netherlands: (2) history of HAT studies and implementation of routine HAT in the Netherlands; (3) main findings on efficacy, safety and cost-effectiveness from the two randomized controlled HAT trials in the Netherlands; (4) new findings from a large cohort study on the effectiveness of HAT in routine clinical practice in the Netherlands; (5) unique data on the patient's perspective of HAT; (6) data on the pharmacological and pharmaceutical basis for HAT in the Netherlands; (7) description of the registration process; and (8) account of the international context of HAT. Together, these data show that HAT can now be considered a safe and proven-effective intervention for the treatment of chronic, treatment-resistant heroin dependent patients.

Relationship between Tridimensional Personality Questionnaire scores and clinic attendance among cocaine abusing, buprenorphine maintained outpatients

With the recent approval of buprenorphine for the treatment of opiate dependence in the United States it has become important to develop an understanding of the factors that influence the likelihood of successful treatment outcomes when using buprenorphine. This study examined, in a convenience sample, the relationship between novelty-seeking behaviors, as determined by Cloninger's Tridimensional Personality Questionnaire (TPQ), and attendance variables during participation in a buprenorphine-based treatment program for 21 heroin-dependent cocaine users that took place in the late 1990s. Approximately two-thirds of the participants were male and primarily African-American. About half of them were employed and had at least a high school education. Approximately one-third of them were married or cohabitating and they all resided in the greater Detroit, Michigan area of the United States. The Tridimensional Personality Questionnaire (TPQ) was administered to the participants prior to entering the treatment program. Demographic variables, psychiatric distress, and substance use severity were also evaluated. Variables with significant bivariate relationships with poor attendance measures were entered into a regression analysis predicting attendance measures. Participants who scored high on the TPQ Novelty Seeking Scale attended significantly fewer regularly scheduled visits, had a greater overall number of missed visits, and shorter treatment retention times. Demographics, substance use severity, and psychiatric distress did not have significant relationships with these attendance measures.

A staging system to predict prognosis among methadone maintenance patients, based on admission characteristics

As U.S. general internists play an increasing role in providing opioid maintenance therapy in practice offices, they are having to face the challenge of identifying patients who need specialized services especially at the outset of treatment. In methadone maintenance treatment, prognostic studies have failed to find robust predictors on the basis of single predictive variables. We hypothesize that a multivariable staging system will predict treatment outcome more accurately than single variables. We reviewed baseline and treatment data regarding 226 consecutive patients admitted to a methadone maintenance program in New Haven, Connecticut, from January 1, 1993 to March 28, 1994, and followed until December 1, 1996. The staging system was developed from the data on the first 112 patients, confirmed in the remaining 114 patients, and then applied to the entire cohort of 226 patients. Retention was the main outcome measure used in developing the staging system. The staging system was also validated as a predictor of illicit drug use during treatment and adverse discharge. In the staging system one point is scored for each of the following: use of more than two bags of heroin daily, previous prison term, previous period in reform school, and a history of diseases related to substance use, e.g., endocarditis, hepatitis, abscesses, and overdose. The total score classifies patients as Stage I (0 and 1 points), Stage II (2 points), or Stage III (3 and 4 points). This staging system was significantly associated with retention in a proportional-hazards model, and no other variable added any additional predictive influence. The specific stage was also found to be a significant predictor of adverse discharge. Although additional validation is necessary in other populations, we found the staging system to be a useful and simple way of identifying patients at risk for early attrition and adverse discharge.

Novelty seeking as a predictor of treatment retention for heroin dependent cocaine users

This study examined the relationship between novelty seeking between treatment retention and among heroin dependent cocaine users. Participants were treated with buprenorphine maintenance and contingency management. The Tridimensional Personality Questionnaire's (TPQ) Novelty Seeking scale was administered to 68 participants prior to buprenorphine induction. Demographics, mood and anxiety disorders, antisocial personality disorder, and substance use were also assessed. Variables with significant relationships with overall retention were entered into a logistic regression analysis. In addition, using a survival analysis, all variables with significant relationships with time to drop-out were entered into a multivariate proportional hazards regression with time dependent covariates. Results demonstrated that although high novelty seekers, in comparison to low novelty seekers, were more likely to drop-out by the end of treatment, they had higher retention rates during the early phases of treatment. It is suggested that buprenorphine and contingency management were viewed by participants as novel treatment components and thus facilitated high novelty seekers' success early in treatment. If replicated, results suggest that inclusion of novel treatment components might facilitate retention among this at-risk group.

Self-efficacy and substance abuse: assessment using a brief phone interview

Considerable research has shown that one's self-efficacy to avoid cigarette smoking and alcohol use increases during treatment and that high self-efficacy ratings at follow-up are associated with positive outcome. The present study extends existing research in two ways. First, self-efficacy was assessed among a predominantly crack-cocaine-using population during treatment and 1 month following treatment. Second, the viability of a brief self-efficacy measure (4 item) was assessed using a phone interview. Results from 186 patients (61% reporting crack-cocaine) interviewed following treatment showed that self-efficacy increased during treatment and was higher for patients reporting abstinence I month after treatment. The results from the brief self-efficacy assessment were comparable to an established version of the self-efficacy measure. These findings suggest that (a) self-efficacy may be related to the maintenance of abstinence from cocaine and other substances of abuse, and (b) self-efficacy can be measured quickly and reliably through a phone interview.

Patterns of service use and treatment involvement of methadone maintenance patients

Although methadone maintenance is an effective treatment for opiate addiction, variations in treatment outcome are evident. These variations may be explained in part by the rehabilitative experiences of patients as reflected in their use of collateral services. This study examined service involvement of 409 methadone maintenance patients at four clinics in order to identify the types of services used and the extent to which potentially rehabilitative services were used. Aside from welfare, there was a strikingly low level of service utilization. Even when services were used, the levels of this use were so low as to be virtually ineffective. These findings regarding treatment and social service utilization suggest that there may not be any attempt to match service provision with patient needs for services. A more rational approach to matching patient needs and available services is thus called for.

Methadone maintenance treatment: an update

Available data (this review includes old major articles and recent articles) show that, although results are heterogeneous, methadone maintenance treatments (MMTs) have a real efficiency not only to reduce illicit opiate abuse (50-80% of patients under MMT did not use heroin in the preceding month) but also to reduce criminality, HIV risks and mortality, and to improve social rehabilitation, without inducing other alternative substance abuse. A minority of patients (perhaps 5-20%) stay on MMT on a very long-term basis (more than 10 years). Efficiency of MMTs are rather poorly related to patients' variables, with the exception of a moderately deleterious effect of a low age at onset of opiate dependence, a precocious or high involvement in criminality and an abuse of non-opiate drugs. On the other hand, variables related to treatment play a more important role in explaining heterogeneity of results. Optimal daily dose, high quality of medical and psycho-social services, clear orientation towards social rehabilitation and treatment retention (to allow a sufficient duration of treatment) and slow detoxification regimen of well-stabilized patients are all factors contributing to better results.

Life activities and life quality of heroin addicts in and out of methadone treatment

The focus of the present study was the daily life activities and self-perceived health and life quality of heroin addicts both in and out of methadone treatment, based on 219 addicts followed for 8 months after treatment entry. The majority of outcome evaluations of methadone treatment have focused on the "hard" outcome criteria of drug use levels, criminal activities, and employment. The present study, in contrast, addressed how heroin addicts live on a daily basis, and whether being chemically supported on methadone was associated with changes in daily life activities and perceived quality of life. A six-dimensional measurement model of daily life activities, perceived health, and life quality was established. Substantial changes on the dimensions in a positive direction were found in the 2 months just following treatment entry. Changes in daily life activities (e.g., spending more time with the family, attending to the home) may be early indicators of the impact of methadone treatment that precede changes on the usual "hard" criteria (e.g., obtaining legal employment).

Towards a rehabilitation of methadone maintenance: integration of relapse prevention and aftercare

Methadone maintenance was originally proposed as a long-term treatment modality for opiate addiction. However, most clients leave methadone maintenance rather than take methadone indefinitely and subsequently relapse to opiate use. In this article, the author examines relapse to opiate use by clients during and after methadone maintenance treatment in the United States. He reviews models of relapse prevention and aftercare which may be applicable to clients in methadone treatment. There now exist structured and psychotherapeutic relapse prevention methods which may be integrated into methadone maintenance treatment and could serve, in addition, to revitalize methadone maintenance treatment.

Drug policy: striking the right balance

Drug policy should strike the right balance between reducing the harm done by psychoactive drugs and reducing the harm that results from strict legal prohibitions and their enforcement. It is concluded, from a cost-benefit analysis based on pharmacologic, toxicologic, sociologic, and historical facts, that radical steps to repeal the prohibitions on presently illicit drugs would be likely, on balance, to make matters worse rather than better. Specific recommendations are offered for ameliorating the dangers to users and to society that are posed by each addictive drug.

Ethnic differences in narcotics addiction. I. Characteristics of Chicano and Anglo methadone maintenance clients

This paper reviews the research literature comparing Chicano (Mexican American) to Anglo heroin addicts. In addition, characteristics of 546 Chicano and Anglo men and women who had been clients of southern California methadone maintenance programs in 1978 are compared. Background factors examined include nativity, family socioeconomic status (SES) and family interpersonal relationships, education, and gang membership. Lifetime characteristics and status at follow-up interview are reported with particular attention to legal status, criminality, employment, and interpersonal relationships. Drug experimentation history and circumstances surrounding narcotics initiation are also compared. Most observed differences prior to addiction are similar to ethnic differences found in the general population. Part II analyzes ethnic differences progressing through five stages of the addiction career.

Psychosocial factors in outcome in two opiate addiction treatments

Thirty naltrexone and 30 methadone patients in outpatient opiate addiction treatment were compared on pretreatment somatization, stress, and family support. Also, the relationship between these pretreatment variables and outcome in terms of drug abuse and retention was examined. In the methadone group, drug abuse was correlated significantly with somatization, stress, and family support. In the naltrexone group, retention was correlated significantly with somatization and stress. Treatment and research considerations were discussed.

Mexican-American heroin addicts

Next to Blacks, Mexican-Americans are the largest ethnic minority group among the visible opioid addict population in the United States. Although commonly grouped together with Puerto Ricans and other Spanish-speaking peoples under the rubric "Hispanic," Mexican-Americans have a unique culture and ethnohistory. In this report we review the clinical and research literature and present new data from studies of Mexican-American opioid users in San Antonio. Mexican-American addicts tend to use fewer classes of illicit drugs and are less likely to use stimulants and psychedelics than Whites or Blacks. Onset of daily opioid use occurs at an early age, typically around 20, yet first voluntary admission to treatment usually occurs later than it does for other ethnic groups. Mexican-American addicts tend to be arrested more frequently and spend significantly more years in correctional institutions, but there is also evidence that they spend more time voluntarily abstinent and employed during their careers. The duration of the career is prolonged, however, and typically exceeds 20 years. Mexican-Americans prefer individual to group treatment, and are especially unlikely to participate in traditional therapeutic communities and group psychotherapies. The Mexican-American client is the least likely to complete treatment without adverse termination. The literature seems unanimous in calling for more treatment of Mexican-American addicts by Mexican-American therapists, but we found little empirical outcome data which demonstrated that ethnic matching of therapist and client brings better results.