Abstinence and acceptance? The problematic relationship between the German abstinence paradigm, low-threshold oriented drug work, and methadone

Drug-Substitution Treatment in Germany: A Critical Overview of Its History, Legislation and Current Practice

Within a global context, Germany was relatively late in its acceptance of substitution treatment, having first introduced methadone maintenance treatment (MMT) in the late 1980s. Since the early 1990s, Germany has taken a number of legal steps which favor harm reduction, assistance and treatment, rather than the law enforcement approach that was dominant before. As a result of this new commitment, Germany now also allows the use of non-methadone substitutes, such as buprenorphine, LAAM, dihydrocodeine (DHC) and codeine. A heroin maintenance trial has been scheduled to begin in early 2002. Despite the fact that the overall number of participants in drug-substitution treatment has risen over the past decade from about 1,000 in the early 1990s to more than 55,000 in 2001 and that MMT has been comprehensively evaluated in Germany with favorable outcomes, there remains a lack of availability of and accessibility to substitution treatment, due to rigid entry and treatment criteria imposed by the social health insurers (SHI).

In-patient treatment of opiate dependence: medium-term follow-up outcomes

BACKGROUND

The outcome for opiate-dependent patients seeking abstinence is unclear in this era of improved access to methadone maintenance.

AIMS

To measure the outcome 2-3 years after in-patient treatment.

METHOD

Opiate-dependent patients admitted with a goal of abstinence were followed-up. A structured interview examined drug use and treatment in the preceding month.

RESULTS

Five patients had died and 109 (76%) of the remaining 144 were interviewed. Fifty per cent (54 patients) reported recent opiate misuse and 57% (62) were on methadone maintenance. Twenty-three per cent (25 patients) were abstinent (i.e. neither using opiates nor on methadone maintenance). Abstinence was significantly associated with completion of the 6-week in-patienttreatment programme and attendance at out-patient after-care, and negatively associated with a family history of substance misuse.

CONCLUSIONS

Abstinence remains an attainable goal. As the principal influence on outcome was treatment adherence, inpatient services should seek to enhance rates of programme completion. After-care should be provided to patients. We caution against use of pre-treatment patient characteristics as criteria for prioritising access to in-patient treatment.

Staff attitudes and retention of patients in methadone maintenance programs

A study was made of the effect of staff commitment to abstinence-oriented policies on retention of patients in methadone maintenance. Staff working in six public methadone programs in Sydney, Australia, were surveyed in 1989 and 1992 using the Abstinence Orientation Scale. The association of the clinics' median Abstinence Orientation scores with the time in treatment of a random sample of their 1988-1989 admissions was summarised using Cox regression. Patients' risk of discharge increased by a factor of three with every one unit increase in the clinics' median Abstinence Orientation scores, (RR 3.4, 95% CI 2.3-5.0). Abstinence-oriented policies were shown to disadvantage ex-prisoners.

Changing attitudes and beliefs of staff working in methadone maintenance programs

Starting in 1989, an attempt was made to change the aim of methadone treatment in NSW from abstinence to harm-minimisation. A study was undertaken to measure change in attitudes among staff working in public methadone programs in Sydney. Using scales developed in a 1989 survey, we found a statistically significant and meaningful reduction in support for abstinence-oriented policies had occurred by 1992. There was no change in staff's support for the punishment of illicit drug use or their knowledge of the risks and benefits of methadone maintenance. This suggests problems with staff attitudes and, indirectly, the effectiveness of public health interventions, can be addressed using educational campaigns.

Measuring and comparing the attitudes and beliefs of staff working in New York methadone maintenance clinics

Scales measuring commitment to abstinence-oriented policies, attitudes to drug addiction, and knowledge of methadone maintenance were refined and tested in a survey of staff working in 14 New York maintenance programs. Confirmatory factor analysis established the validity of a 9-item Abstinence Orientation Scale and a 6-item Disapproval of Drug Use Scale. Scores on the two scales and Knowledge scores were highly correlated. There were highly significant differences in the mean Abstinence Orientation scores of the administrative and better qualified clinical staff on the one hand and the less qualified staff on the other. Senior staff generally rejected abstinence-oriented policies while nurses and counselors tended to support them.

Attitudes and beliefs of staff working in methadone maintenance clinics

Two attitudinal scales measuring commitment to abstinence-oriented treatment policies and disapproval of illicit drug use were derived from a survey of 90 staff working in 10 public methadone maintenance clinics in Sydney, Australia. The two scales were shown to be valid constructs by confirmatory factor analysis and to be internally reliable and to have high test-retest reliability. The factors underlying the two scales were highly correlated (r = .77), indicating support for policies that enforce abstinence and limit the duration of maintenance is highly associated with personal disapproval of drug use. There was no significant correlation between staff's knowledge of the benefits of methadone maintenance and their support for abstinence-oriented policies.