Providing methadone maintenance to heroin addicts while they are wait-listed for a treatment program can increase the likelihood they will enroll when spaces open up, say NIDA-funded researchers. The finding corroborates several previous studies in Europe and the United States. In the new study, participants who received methadone maintenace reported reduced use and criminal activity.
Across the Nation, full-to-capacity opioid treatment programs commonly put heroin-addicted men and women who present for treatment on waiting lists. By the time a treatment slot becomes available, the deferred applicants often have lost touch with the program or no longer desire treatment. The underlying idea of interim methadone maintenance is to capitalize on individuals' possibly transient motivation by providing help when help is requested, explains Dr. Robert Schwartz, who conducted the study with colleagues from the Friends Research Institute, the University of Maryland, and The Johns Hopkins University.
Benefits Early and Late
The researchers recruited 319 heroin-addicted men and women who placed themselves on the wait list of a single community-based program for methadone maintenance. The men and women typified people on methadone wait lists in the Baltimore area, in that most were African-American and reported abusing heroin daily as well as cocaine during the past month. The investigators randomly assigned each individual to receive free interim methadone maintenance for up to 120 days—the maximum time programs can legally provide methadone to an unenrolled individual—or to remain on a wait list. Both groups received information on how to access the waiting lists of the 11 other public methadone programs in the area.
The investigators interviewed each participant at the start of the study; upon his entry into comprehensive methadone treatment or, if he or she did not go into treatment, after 120 days; and 6 months after the second interview. Participants reported their alcohol, heroin, and cocaine abuse and provided urine samples at all three time points; those in the interim treatment group also provided samples at weeks 6 and 7 post-entry.
The results showed that 76 percent of study participants receiving interim methadone entered comprehensive care within 4 months, compared with only 21 percent in the control group. At the time of the last interview, 78 percent of interim methadone patients had entered a full-service program, compared with 33 percent of controls. Of the study participants who entered comprehensive treatment programs, 80 percent of those who had received interim methadone and 64 percent of controls were still attending at their last interviews.
The men and women who received interim treatment reported abusing heroin on a mean of 4 of the last 30 days prior to the 4-month followup interview, compared with 26 days for wait-listed patients. At the end of 4 months, the interim methadone group had a 57 percent rate of heroin-positive urine samples, while the control group had a 79 percent positive rate (see chart). The substantial difference in opiate-positive drug tests remained at the last interview, with a 48 percent positive rate among interim-treated patients, compared to a 72 percent positive rate among controls. Participants who received interim methadone reported spending less money on drugs and receiving less illegal income in the past month compared with controls. On average, study participants reported spending $872 monthly on illegal drugs at the beginning of the study. By the end, the methadone-maintained participants had reduced these expenditures dramatically, to an average of $76, compared with $560 among the controls—a difference that was also maintained at the 6-month followup. "If we can corroborate this self-report data from other sources, the money saved from not spending on drugs would more than pay for the interim medication," Dr. Schwartz notes. "It costs about $20 to $30 per week per person. That is cheap, especially when you consider the cost of criminal activity foregone, and the hospitalizations and incarcerations avoided."
While more of the participants who received methadone entered full-service treatment, they took longer to do so (a mean of 117 days) compared to those in the control group (59 days). However, Dr. Schwartz says, "People in the interim group knew they were going to get full service at the clinic where they were receiving their interim medication at the end of the study. Those in the control group who accessed treatment probably represent a highermotivated subgroup—they actively sought it out using the local program information we gave them."
Participants assigned to interim methadone began receiving the medication on their second day in the study, after completing an initial one-on-one orientation and physical exam. Nursing staff administered a dose of 20 mg, which increased by 5 mg per day with a target of 80 mg. Participants could slow or stop the dose schedule by seeing a nurse; they could exceed the 80 mg target by meeting with the program's emergency counselor. The only other service provided was emergency counseling, and three interim participants requested and received emergency counseling during the 4 months of treatment. Patients who failed to show up for three consecutive doses were discharged from the interm methadone—program-wide rule that did not change for study participants. The clinic staff did not contact individuals who missed doses.
Dr. Thomas Hilton of NIDA's Division of Epidemiology, Services and Prevention Research says, "Dr. Schwartz and his team have demonstrated that interim medication is a significant recruitment tool. This might even be an appropriate way to start treatment for everyone needing methadone maintenance. It exposes patients to some degree of structure, helps them ease into a more intensive, full-service program and accommodate their lifestyle to the structure required in the full service program." Interim methadone also may be an important tool for retention, says Dr. Hilton, because patients may be ready for the medication before they're ready for counseling. After a few months on methadone alone, patients may be better able to engage with a counselor, making the relationship more productive. Six methadone programs in the Baltimore area have taken their cue from the study's findings and now offer interim maintenance. "What the interim treatment approach does is add patients to existing programs," Dr. Schwartz explains. "It is not hard for the staff to do, it's less expensive, and it's effective. We hope it becomes more widespread."
Schwartz, R.P., et al. A randomized controlled trial of interim methadone maintenance. Archives of General Psychiatry 63(1):102-109, 2006. [Abstract]
Schwartz, R.P., et al. A randomized controlled trial of interim methadone maintenance: 10-month followup. Drug and Alcohol Dependence [June 19, 2006 Epub Ahead of Print] [Abstract]