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© 2003 American Public Health Association
RESEARCH AND PRACTICE |
Donald A. Calsyn, Frank J. DeMarco, Andrew J. Saxon, and Kevin L. Sloan are with the Addictions Treatment Center, Veterans Affairs Puget Sound Health Care System (VAPSHCS) and the University of Washington School of Medicine, Seattle. Karen E. Gibbon is with the Addictions Treatment Center, VAPSHCS, and the University of Washington School of Pharmacy, Seattle.
Correspondence: Requests for reprints should be sent to Donald A. Calsyn, PhD (MS:116DDTP), VA Puget Sound HCS, 1660 South Columbian Way, Seattle, WA 98108 (e-mail: donald.calsyn{at}med.va.gov).
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INTRODUCTION |
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 TOP INTRODUCTION METHODSRESULTSDISCUSSIONReferences |
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Opioid substitution treatment (OST) is the most widely used treatment for opiate dependence.1,2 The preponderance of evidence suggests that retention in OST is associated with decreased opiate use and criminality.3–5 However, continued illicit drug use among patients in OST is common.6–8 Program responses to ongoing use vary widely,9 though discharge is a frequent response. Some patients nevertheless are unable or unwilling to cease illicit use despite the threat of treatment termination. Unfortunately, outcomes for out-of-treatment opiate addicts are very poor.3 Recently published OST guidelines recommend that programs find alternatives to treatment termination for ongoing drug use.10
For treatment programs, such a no-discharge policy poses certain dilemmas. If a program retains patients despite ongoing drug use, harm may be reduced for that subset of patients. However, the potential benefits of retention of drug-using patients in treatment could be offset if illicit use were to increase among other patients in the program who might have otherwise been motivated to cease or reduce their use by the threat of discharge. The value of a putative harmreduction strategy is determined not only by its effectiveness in reducing harm among members of the target group (i.e., microharm) but also by the extent to which it does not inadvertently increase harm among members of other groups or the larger population (macroharm).11
In April 1998, the OST program at the Veterans Affairs Puget Sound Health Care System (VAPSHCS) in Seattle, Washington, instituted a minimal services (MS) treatment track as an alternative to discharge for patients who continued to use illicit drugs. MS was designed to retain these patients in treatment. MS also was designed to introduce additional contingencies that 1) encouraged abstinence and 2) simultaneously minimized demands on clinic and staff resources and opened additional treatment slots to reduce the waiting list for new patients. The components of the MS program are listed in Table 1
. After the MS program was in place for 1 year, the new policy’s impact on both MS patients and the clinic population at large was assessed by means of a program evaluation.
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METHODS |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Subjects
Subjects were all patients enrolled in OST at the VAPSHCS between April 1, 1997, and March 31, 1999 (n = 189). The MS program was initiated April 1, 1998, and our 2-year time frame permitted comparison of clinic-wide urinalysis (UA) results for the year before the initiation of MS (hereafter referred to as "year 0") vs the year after initiation of MS ("year 1"). The patient population during this period was 75.1% non-Hispanic White, 19.0% African American, 3.2% Latino/Hispanic, 1.6% Asian/Pacific Islander, and 1.1% American Indian/Alaska Native. The panel was overwhelmingly male (98.9%). Patients on average were aged 48.6 years (standard deviation [SD] = 6.7 years). By the end of the study period, the average length of the current treatment episode was 5.3 years (SD = 4.9 years). The average methadone dose in the clinic during both years was approximately 75 mg/day. The mean length of time in MS for the 35 patients placed in the program during year 1 was 193.8 days (SD = 120.5 days; range = 34–365 days). The mean maximum weekly levomethadyl acetate hydrochloride (LAAM) dose among MS patients during year 1 was 360 mg (SD = 87.7 mg, range = 140–500 mg).
Procedure
A chart review was conducted for all subjects by means of extraction of demographic data; admission dates; discharge dates; prior patient MS, if any, with subsequent disposition; and UA results for amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, opiates, and alcohol.
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RESULTS |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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At the end of year 1, 25 (71.4%) of MS patients were still in treatment; of these patients, 9 (36%) met criteria for reentry into the regular program while 16 remained in MS at the end of year 1. Mean maximum LAAM dose during year 1 did not differentiate those patients who successfully reentered the regular program from those who did not (t31 = .529; P = .601). We examined changes in the percentage of positive drug screens submitted by MS patients during the 6 months before their placement in MS compared with the 6 months after their placement. Table 2
displays the results of these analyses for opiates, cocaine, and benzodiazepines. Results are given as z-scores for each drug category.12 The MS patients as a group demonstrated a significant decline in detectable illicit drug use.
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A within-subjects analysis collapsed across drug classes (i.e., benzodiazepines, cocaine, and opiates) also was conducted. This analysis found that 13 patients (about 38%) demonstrated significant reductions in the percentage of positive UA results for the 6 months after MS placement compared with the 6 months prior. Another 19 patients (56%) showed no statistically significant differences, and only 2 (6%) showed a significant increase. To investigate whether the MS program was associated with changes in clinic-wide harm (macroharm), the proportion of positive UA results in year 1 were compared with those in year 0 for non-MS patients. The percentage of positive UA results was not significantly different from year 0 to year 1 for alcohol, amphetamines, barbiturates, cannabis, or opiates. For cocaine, positive results declined slightly (d = -1.5%; z = -3.27; P < .05), whereas illicit benzodiazepine use showed a slight increase (d = 0.8%; z = 2.47; P < .05).
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DISCUSSION |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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This study lends support to the hypothesis that retention of drug-using patients in modified OST can benefit those patients without an associated significant increase in harm to the larger clinic population. Nearly three quarters of the patients placed in MS were retained in treatment, and more than 1 third of those retained improved sufficiently to return to the regular OST program. As a group, MS patients cut their detectable benzodiazepine, cocaine, and opiate use roughly in half, with more than 1 third showing significant reductions in positive UA results 6 months after placement in MS. These results were obtained with little evidence of an associated increase in clinicwide harm as measured by positive UA results.
The MS program differs importantly from a simple no-discharge policy because it uses contingency management principles to encourage continued efforts toward reduction or cessation of illicit drug use. These contingency management strategies include both positive and negative consequences, although within the MS program, the latter are probably more salient. Negative consequences include denial of most clinic services and privileges but not the threat of discharge for continued illicit drug use. Positive consequences consist of retention in treatment, reinforcement from staff for attendance in the required MS groups and for any periods of abstinence achieved, and the ability to return to the regular full-service program (with a clear and behaviorally specified path for doing so). Through the use of these contingency management strategies, the MS program is more than just a holding tank for noncompliant patients. Rather, it is an active component of the overall treatment program that seeks to motivate patients to stabilize, reduce, or cease their use of illicit substances.
Some limitations apply to this study, and our findings should be interpreted with these in mind. First, these data were obtained from an extant OST population composed primarily of White, male, middle-aged military veterans. The results of this study should therefore be generalized with caution and may not apply to other OST populations. Second, the within-subjects preintervention–postintervention comparison design employed in this study precludes inferences of causality, and our results should not be taken to imply that the MS program caused the observed change. Third, the sample size was small, and thus some null findings may be due to inadequate power.
With these caveats in mind, our results suggest that retention of drug-using patients in some form of limited treatment may have benefits that outweigh its costs with respect to patients and the larger society.
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Acknowledgments |
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Charles Seaman, MD, provided some of the conceptualization for the minimal services track when he described to A. J. Saxon a similar program at the Department of Veterans Affairs Outpatient Clinic in Berkeley, California, where he was a former medical director.
Human Participation Protection
The study was approved by the human subjects committee of the University of Washington and the research and development committee of the Veterans Affairs Puget Sound Health Care System.
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Footnotes |
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Contributors
D. A. Calsyn, clinical team leader for the opioid substitution program in which the minimal services track was instituted and a co-leader of all MS therapy groups, contributed to conceptualization of the MS treatment track, study implementation, and manuscript preparation. F. J. DeMarco, a co-leader of the minimal services therapy groups, contributed to study conceptualization, data collection, data analysis, and manuscript preparation. A. J. Saxon, the program’s medical director at the time the minimal services track was instituted, contributed to conceptualization of the MS treatment track, study implementation, and manuscript preparation. K. L. Sloan, an expert in health services research, and K. E. Gibbon, the clinical pharmacist for the opioid substitution program in which the MS track was instituted, contributed to MS data collection and manuscript preparation.
Accepted for publication November 28, 2001.
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References |
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TOPINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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1. Effective Medical Treatment of Opiate Addiction. Bethesda, Md: National Institutes of Health; 1997. NIH Consensus Statement 108;15:1–38.
2. Parrino MW. Overview: current treatment realities and future trends. In: Parrino MW, ed. State Methadone Treatment Guidelines: Treatment Improvement Protocol (TIP) Series. Rockville, Md: Center for Substance Abuse Treatment; 1993:1–9.
3. Ball JC, Lange RW, Myers CP, Friedman SR. Reducing the risk of AIDS through methadone maintenance treatment. J Health Soc Behav.1988;29:214–226.[Web of Science][Medline]
4. Senay EC. Methadone maintenance treatment. Int J Addict.1985;20:803–821.[Web of Science][Medline]
5. Simpson DD, Sells SB. Effectiveness of treatment for drug abuse: an overview of the DARP research program. Adv Alcohol Subst Abuse. 1982;2:7–29.
6. Kosten TR, Rounsaville BJ, Kleber HD. A 2.5-year follow-up of cocaine use among treated opiate addicts. Have our treatments helped? Arch Gen Psychiatry.1987;44:281–284.
7. Ball JC, Ross A. The Effectiveness of Methadone Maintenance Treatment: Clients, Programs, Services, and Outcome. New York, NY: Springer-Verlag; 1991.
8. Calsyn DA, Wells EA, Saxon AJ, et al. Contingency management of urinalysis results and intensity of counseling services have an interactive impact on methadone maintenance treatment outcome. J Addict Dis. 1994;13:47–63.[Medline]
9. Calsyn DA, Saxon AJ, Barndt CD. Urine screening practices in methadone maintenance clinics: a survey of how the results are used. J Nerv Ment Dis.1991;179:222–227.[Medline]
10. Barthwell A, Gastfriend DR. Treating multiple substance abuse. In: Parrino MW, ed. State Methadone Treatment Guidelines: Treatment Improvement Protocol (TIP) Series. Rockville, Md: Center for Substance Abuse Treatment; 1993:73–84.
11. MacCoun RJ. Toward a psychology of harm reduction. Am Psychol.1998;53:1199–1208.[Medline]
12. Bruning JL, Kintz BL. A Computational Handbook of Statistics. Glenview, Ill: HarperCollins; 1987.
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