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

Effects of sleep deprivation on sleep homeostasis and restoration during methadone-maintenance: a [31]P MRS brain imaging study

Insomnia afflicts many individuals, but particularly those in chronic methadone treatment. Studies examining sleep deprivation (SD) have begun to identify sleep restoration processes involving brain bioenergetics. The technique ([31])P magnetic resonance spectroscopy (MRS) can measure brain changes in the high-energy phosphates: alpha-, beta-, and gamma-nucleoside triphosphate (NTP). In the present study, 21 methadone-maintained (MM) and 16 control participants underwent baseline (BL), SD (40 wakeful hours), recovery1 (RE1), and recovery2 (RE2) study nights. Polysomnographic sleep was recorded each night and ([31])P MRS brain scanning conducted each morning using a 4T MR scanner (dual-tuned proton/phosphorus head-coil). Interestingly, increases in total sleep time (TST) and sleep efficiency index (SEI) commonly associated with RE sleep were not apparent in MM participants. Analysis of methadone treatment duration revealed that the lack of RE sleep increases in TST and SEI was primarily exhibited by short-term MM participants (methadone <12 months), while RE sleep in long-term MM (methadone >12 months) participants was more comparable to control participants. Slow wave sleep increased during RE1, but there was no difference between MM and control participants. Spectral power analysis revealed that compared to control participants; MM participants had greater delta, theta, and alpha spectral power during BL and RE sleep. ([31])P MRS revealed that elevations in brain beta-NTP (a direct measure of ATP) following RE sleep were greater in MM compared to control participants. Results suggest that differences in sleep and brain chemistry during RE in MM participants may be reflective of a disruption in homeostatic sleep function.

Prediction of relapse among heroin users treated in Spanish therapeutic communities. A comparison of different models

The roles of selected heroin use "relapse" theoretical models were studied by analyzing the composition of each predictive model, comparing their predictive capacity on relapse and abstinence, and integrating them into an overall model. This study is based on two groups of heroin misusers (one "relapsed," n = 130; one "abstinent," n = 130) treated in 15 Spanish therapeutic communities. Data were collected by using a structured interview and urine analysis. A logistic regression model was used to build up and cross-validate six different predictive models. This study resulted in several partial models with a predictive capability ranging between 47 and 78% of abstinence and relapses, while the overall model reached 85 and 89%, respectively. The authors conclude that it is advisable to integrate several models in order to prevent relapse more effectively: motivational-conditioned, situational, cognitive-affective, and coping skills models.

Psychological and behavioural factors associated with relapse among heroin abusers treated in therapeutic communities

The authors carried out a comparative study on two groups of heroin abusers treated in several therapeutic communities: One group consumed heroin on at least three occasions between the fifth and sixth months of treatment (n = 130), and the other continued without consuming heroin after 7 months of treatment (n = 130). The instruments used for data collection were a structured interview and urine analysis. The relapsed group includes older patients with more medical problems, lower educational and occupational level, and major chronicity in heroin consumption. The collection of retrospective data referring to the treatment period shows that relapsed patients more frequently consumed alcohol, hashish, cocaine, and amphetamines; suffered more heroin cravings; used fewer coping strategies to overcome the craving; and justified the craving or the heroin consumption in more situations than those who abstained. The last heroin craving during the treatment period arose in different temporal, social, and physical contexts in the two groups, and it was accompanied more frequently by inadequate responses in the relapsed group: psychophysiological alterations, depressed feelings, negative thoughts, and coping behaviours. The two groups are different in their attitudes toward heroin abstinence. The authors discuss the findings from a cognitive-behavioural perspective and come to the conclusion that various models need to be integrated.

Follow-up of inpatient cocaine withdrawal for cocaine-using methadone patients

Significant proportions of opiate-dependent persons entering methadone treatment are also addicted to cocaine and continue to use cocaine during treatment. One standard response to cocaine use has been inpatient detoxification. This study examined the effectiveness of this procedure by comparing pre- and posttreatment urine toxicologies for methadone patients who had been hospitalized for cocaine withdrawal. The results showed a negligible effect on cocaine abstinence (less than 1 out of 10 patients abstinent 12 weeks after detox) and a modest reduction in the frequency of cocaine use (one-quarter decline in urine tests positive after 12 weeks). These findings raise serious doubts about the cost-effectiveness of inpatient cocaine detoxification. Better strategies need to be implemented to enhance the chances of remaining abstinent once detoxified.

Improving detoxification outcomes from methadone maintenance treatment: the interrelationship of affective states and protracted withdrawal

Changing paradigms of health care and increasing knowledge of opioid addiction continue to influence the attitudes of the health profession toward methadone maintenance treatment (MMT). This approach has again reached the forefront of attention because of its significant role in reducing HIV transmission associated with intravenous drug use. In spite of the well-documented benefits of MMT, patients continue to detoxify from methadone for a variety of reasons both overt and covert. Variable outcomes and generally poor long-term abstinence rates results. At present uncertainty still exists surrounding who should attempt detoxification, when or how this should be done, or whether in fact detoxification should be attempted at all. This article describes and examines factors that are positively and negatively associated with detoxification outcome. Evidence for the interrelationship of two notably significant determinants, affective states and protracted withdrawal, are presented and discussed as they relate to theories of relapse and outcome.

A self-help group for drug-addicted clients. Assisted implementation in outpatient treatment

Although self-help groups are a popular referral target of drug abuse treatment programs, they are not usually viewed as a viable way to extend support and services to clients as part of a structured treatment program. This article describes a client-led support group that was established by clients and a psychological consultant to meet increasing demands for service in an out-patient opiate treatment program. The group is also an alternative to more structured 12-step groups. This describes the history of the group as the first client-led support group in the clinic, the group-psychological consultant model and materials used, the evolution of the group, and how several obstacles were dealt with, including attendance, domineering members, HIV issues, crises, privacy, and leadership. The article describes step-by-step how counselors could implement such a group in a drug treatment setting.

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.

Modifying the process of treatment to meet the threat of AIDS

Treatment for drug users is unlikely to receive sufficient resources to expand to the level of treatment need. Moreover, there is indication that a substantial minority of injection drug users have never initiated needed treatment in spite of long histories of injecting drugs. Given the potential for that population to contract and spread AIDS, it is important that we explore street-based treatment alternatives derived from findings regarding the efficacy of outreach/intervention programs. Those programs were found both to reduce drug-taking behaviors of injecting drug users and to prepare those users for clienthood. Additional strategies that need to be explored include: aftercare, behavioral counseling for sex partners of drug treatment clients, and partial (i.e., survival) treatment services for clients who cannot be accommodated within existing treatment capacity.

Cocaine abuse in methadone maintenance programs: integrating pharmacotherapy with psychosocial interventions

Cocaine abuse by methadone-maintained patients threatens to undermine the success of methadone programs by sustaining a drug-abusing lifestyle as well as contributing to the spread of HIV. The search for a pharmacotherapeutic agent for the treatment of cocaine has met with limited success. The most promising results emerge when specific agents, such as desipramine, are matched appropriately to specific patient characteristics, such as depression or antisocial personality disorder. For some patients, abstinence from cocaine may also require the addition of intensive psychosocial treatments that target the considerable problems faced by inner-city opioid-addicted individuals. This article discusses ways in which future research could be directed toward investigating the interaction between psychosocial services and pharmacologic treatments, while at the same time developing and testing hypotheses concerning appropriate patient-treatment matching variables.

Correlates of alcohol use among methadone patients

This study examines the predictors of alcoholism among 201 patients from three methadone maintenance treatment programs (MMTPs) in New York City. Using the Michigan Alcohol Screening Test, one-fifth of the sample met criteria for alcohol dependence. Few subjects were currently enrolled in any form of chemical dependency treatment other than MMTP. Alcoholics started to use alcohol at an early age, and almost every alcoholic subject admitted to alcohol abuse before entering MMTPs. More alcoholics than nonalcoholics reported symptoms of somatization, obsessive-compulsive behavior, depression, phobic anxiety, and psychosis. Logistic regression indicated that alcoholism among MMTP patients was associated with years drinking, years of sharing needles, utilization of drug abuse detoxification but not alcohol detoxification, smaller increases in methadone dosage over time, and psychiatric symptomatology. Findings are discussed in terms of their implications for designing more efficacious treatment approaches for dually addicted patients in MMTPs.