Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 25 February 2013

The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors. If displayed, click prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.


Contents

Seminal and thought-provoking studies from the training research archive

These additions to the Effectiveness Bank were part of a project identify seminal and key workforce development studies for the UK Substance Misuse Skills Consortium. Still challenging and thought-provoking, they have stood the test of time and remain major landmarks in the relatively scarce substance use treatment training literature.

Getting the right people from the start is key to effective training and therapy ...

The client is walking towards a hole; do you shout 'Stop' or suggest they consider the pros and cons? ...

Methadone doctors have to learn to be patient-centred and relinquish control ...

Overcoming staff bias against maintenance and harm reduction ...


An evaluation of workshop training in motivational interviewing for addiction and mental health clinicians.

Baer J.S., Rosengren D.B., Dunn C.W. et al.
Drug and Alcohol Dependence: 2004, 73(1), p. 99–106.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Baer at jsbaer@u.washington.edu. You could also try this alternative source.

US study suggests that when it comes to choosing therapists, choosing the 'right' people who have not been trained in motivational interviewing would be better than choosing the 'wrong' people who have been trained; the former not only start at a higher level, but are more able to benefit from and retain training.

Summary A US study of a workshop on motivational interviewing whose participants were mainly addiction treatment specialists confirmed the rapid erosion of improvements in practice and added an intriguing insight into the importance of choosing the right raw material. Trainees demonstrated their motivational interviewing skills with actor-clients before the workshop, at the end, and two months later, when most indicators of how far they had absorbed the approach's principles and techniques were no longer significantly elevated. However, this was not the case for all the trainees.

Based on their last audiotapes, eight of the 19 had retained their proficiency in motivational interviewing. The interesting thing was that even before the training, these clinicians had been more proficient than the other trainees – in fact, they were already more proficient than the rest would be two months after training. Not only did they start from a higher level, they went on to absorb and retain more of what they had learnt.


Findings logo commentary On the basis of these findings, given a choice between choosing the 'right' people who have not been trained in motivational interviewing, and the 'wrong' people who have, the former would be the better choice. It seems that some people are more receptive to this approach in their everyday lives, and that the same people are more able to become yet more proficient. In contrast, within months much of the training was wasted when it fell on less fertile human ground.

Last revised 18 February 2013. First uploaded 18 February 2013

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Top 10 most closely related documents on this site. For more try a subject or free text search

STUDY 2009 The alliance in motivational enhancement therapy and counseling as usual for substance use problems

REVIEW 2005 The motivational hallo

DOCUMENT 2013 Sometimes best to break the rules

REVIEW 2011 Implementing evidence-based psychosocial treatment in specialty substance use disorder care

STUDY 2005 How does motivational interviewing work? Therapist skill predicts client involvement within motivational interviewing sessions

REVIEW 2006 My way or yours?

STUDY 2011 Therapist effectiveness: implications for accountability and patient care

STUDY 2011 An experimental demonstration of training probation officers in evidence-based community supervision

REVIEW 2013 Meta-analysis of the effects of MI training on clinicians’ behavior

REVIEW 2011 Evidence-based therapy relationships: research conclusions and clinical practices





How does motivational interviewing work? Therapist skill predicts client involvement within motivational interviewing sessions.

Moyers T.B., Miller W.R., Hendrickson S.M.L.
Journal of Consulting and Clinical Psychology: 2005, 73(4), p. 590–598.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Moyers at tmoyers@unm.edu. You could also try this alternative source.

Analysis of counselling session recordings from therapists trained in motivational interviewing suggests that the important quality of seeming 'genuine' can suffer if training mandates unnaturally withholding normal responses; however, departing from these tenets is risky unless done by a socially skilled therapist.

Summary The featured report derives from a US study which randomly allocated an unusually diverse (in terms of initial proficiency) set of addiction counsellors and clinicians who applied for training in motivational interviewing to different training regimens. An earlier report from the study had established that client responses to trainees changed in the desired direction only when workshops had been reinforced by continued expert coaching and feedback on performance.

Source study

In more detail, the most basic training option was merely being given a training video and manual and being told to train yourself; these trainees altered their practice little. In comparison, those allocated to a workshop but no follow-up evidenced immediate improvements in counselling proficiency with a client-actor. During the workshop it had been stressed that this was not a complete training regimen, but a platform from which trainees could learn by paying attention to and responding to their clients in their everyday work: signs of commitment to change would indicate the counsellor was on the right track; resistance would call for a change of direction.

Nevertheless, as in previous studies, even after this workshop practice improvements were found to have dissipated four months later when the trainees submitted tapes of their work with real clients. The three forms of continuing support trialled in the study largely prevented this deterioration. One took the form of mailed feedback on the trainee's counselling samples, comparing their detailed proficiency profile with that of expert practitioners. The second instead took the form of six 'coaching' phone calls initiated by the trainer to ask about any problems and help solve them, each incorporating role play exercises. The third consisted of both forms of continuing input, meaning that counsellors could not only gain expert guidance on their problems with clients, but also on the feedback from their sample sessions.

Only the third, enriched form of continuing support made enough or the right kind of difference to what the trainees did for this to be reflected in increased 'change talk' (thought the main way the therapy promotes real change) and diminished resistance on the part of their clients. It seemed that the workshop's attempt at self-generated learning was insufficient without an external guide to help trainees recognise when clients were or were not responding well and to offer guidance on how best to respond.

Featured report

For the featured report, the same post-training, real-client audiotapes from the study were used to relate therapist behaviour to the degree to which their clients cooperated with therapy and opened up emotionally and by disclosing personal information – responses which overlap with therapeutic alliance and signify active engagement in therapy.

Overall, client engagement was unrelated to the frequency with which the therapist made statements compatible (such as open questions) or incompatible (such as warning) with the specific techniques recommended in motivational interviewing, a surprise result. But engagement was strongly related to embodying the overall spirit of motivational interviewing and to more general social skills not confined to motivational therapists, including empathy, warmth, supporting the client's autonomy, and coming across as 'genuine', an amalgam of seeming open, honest and trustworthy.

This last quality, being genuine, was difficult for raters to agree on from the audiotapes (videos might have helped), but still about as strongly related to engagement as the other qualities. It also seemed to account for a twist in the findings with potentially far-reaching implications.

As mentioned above, doing the things a diligent motivational interviewer should avoid surprisingly made no overall impact on client engagement with therapy. In theory, confronting clients, warning or directing them, and imposing advice or expressing concern without their permission, should have provoked clients to resist therapy.

But when socially skilled counsellors 'broke the rules' in these ways, they actually enhanced the effect their skills had on client engagement. Moreover, it seemed that within (and only within) the kind of empathic, caring context these counsellors were able to create, doing things such as warning and expressing uncalled for advice and concern deepened the client's engagement with therapy. Socially skilled counsellors tended to avoid these risky manoeuvres, but also had the wherewithal to carry them off without alienating their clients – in fact, the reverse.

Genuineness seemed one explanation for this conundrum. Therapists who honestly and openly expressed the concerns they were feeling and gave advice they felt the client needed without holding their tongues, or trying to manipulate the client into doing the expressing for them, would have rated higher on being genuine, and perhaps also come across this way to the clients. This quality has long been recognised as one of the keys to effective therapy.


Findings logo commentary The findings of this study can better be understood in the light of an evaluation of a two-day motivational interviewing workshop for probation staff in Oregon, who gave glowing accounts of the improvements in their understanding of and proficiency in motivational interviewing, a view they sustained over the subsequent four months. Their views were corroborated at the end of the workshop by a paper-and-pen evaluation of how they would respond to sample client statements.

The disappointment came when these in-theory assessments were checked against ratings of audiotapes of how the therapists actually behaved at three stages: before the workshop with a client; at the end with someone acting as a client; and with a real client four months later. Especially when the raters were assessing overall adherence to motivational principles rather than specific techniques, the improvements were quite small and left the trainees falling far short of expert practice, largely because they were unable to suppress their previous interactional styles. On one dimension which attempted to reflect how 'genuine' the therapists were, things had even got worse, seemingly because for them this new approach felt unnatural, making them feel uncomfortable.

By four months later even the post-workshop boost in use of specific techniques had eroded. Clinching this negative picture was the fact that, compared to pre-workshop tapes, their clients too did not 'improve' in the balance of commitment versus resistance to change. It seems likely that the natural way a parole officer relates to real 'clients' is quite far removed from motivational interviewing, and reversion to type was the dominant trend. Being trained to go against the grain simply meant that raters felt the parole officers were less genuine in their interactions with clients after than before the workshops. Told about this finding, the trainees explained that this new approach felt unnatural. It does not take much imagination to realise that within the undeniably unequal and coercive context of the criminal justice system, adopting an 'It's up to you' stance might feel like a false position, and also feel false to outsiders and clients.

In a way, this should not be a surprise. Everyone knows the difference between warning, advice and concern which conveys and comes from loving care and respect for one as an equal, and that which comes from and conveys accusation, denigration, and an attempt to exert control. We also know that the former is likely to be listened to and deepen our relationship with the carer, while the latter signifies an alternative agenda rather than common purpose in the pursuit of the recipient's welfare.

Despite intuitively 'making sense', the featured report's results came from a single study and should not be taken to give the green light to extreme negative responses contraindicated in motivational interviewing like shaming and sarcasm, indicative less of good social skills and a caring attitude than of the lack of them. And though we might expect it, we do not know if deepened client engagement in this study translated in to stronger commitment to curbing substance use and then in actual change. For example, one component of engagement was expressing emotion, yet this is not always related to better post-therapy outcomes.

If we take it at face value, overall this work confirms that learning technical skills and abstract principles is not enough to securely transfer the wisdom experts have gained over many years of practice, reflection, and discussion with colleagues, though some willing trainees with a head start in their existing social skills and attitudes to their clients can benefit from training and do even better.

As the analysts (including Bill Miller, co-originator of motivational interviewing) who found following manuals diminishes the effectiveness of motivational interviewing put it, "counselors sometimes attend such training in the hope of learning a few tricks to make clients do what they want them to do. MI is nothing of the sort. Rather, it is a complex clinical style for eliciting the client's own values and motivations for change. It is far more about listening than telling, about evoking rather than instilling."

Had they had the featured report's findings to hand, they might have added that the quality of being genuine can suffer from drilling in 'tricks' and in unnaturally withholding normal caring responses, but also that contravening motivational interviewing's tenets is risky unless done by a socially skilled therapist who by doing so conveys rather than contravenes the empathic concern at the heart of good therapy.

For more on these and similar studies see these background notes to an earlier Findings review.

Last revised 21 February 2013. First uploaded 21 February 2013

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Top 10 most closely related documents on this site. For more try a subject or free text search

DOCUMENT 2013 Sometimes best to break the rules

STUDY 2009 The alliance in motivational enhancement therapy and counseling as usual for substance use problems

REVIEW 2011 Evidence-based therapy relationships: research conclusions and clinical practices

STUDY 2011 Therapist effectiveness: implications for accountability and patient care

STUDY 2012 A preliminary study of the effects of individual patient-level feedback in outpatient substance abuse treatment programs

REVIEW 2005 The motivational hallo

STUDY 2010 A randomized controlled study of a web-based performance improvement system for substance abuse treatment providers

STUDY 2010 Gender differences in client-provider relationship as active ingredient in substance abuse treatment

REVIEW 2011 Integration of treatment innovation planning and implementation: strategic process models and organizational challenges

REVIEW 2006 My way or yours?





Alternatives to non-clinical regulation: training doctors to deliver methadone maintenance treatment.

Bell J.
Addiction Research: 1996, 3(4), p. 315–322.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Bell at james.bell@kcl.ac.uk. You could also try this alternative source.

Seminal study of how to train out socially derived attitudes to methadone maintenance as a policy solution to a social problem and train in attitudes which place it within mainstream medical practice as a treatment of individuals which does not 'fix' their problems but offers the opportunity for positive change.

Summary This account is based on the description of the study in the chapter by the same author 'Training health professionals to deliver methadone treatment' in the book Methadone maintenance treatment and other opioid replacement therapies.

In the Australian state of New South Wales training for medical practitioners in the delivery of methadone maintenance treatment has comprised a written manual, an interactive workshop, and a supervised clinical placement. The training has been evaluated and progressively modified in the light of feedback from participants and observers.

Main findings

Participants liked the training and particularly valued the use of clinical vignettes and case studies. Six to 18 months after undertaking training most trainees indicated that they were prescribing methadone, and expressed a strong interest in continuing education and peer support. However, a one-day interactive workshop was commonly felt too short to cover all the material.

The most valuable feedback on the training process came from observers who attended the first four workshops. Observers and facilitators met after each workshop to identify difficulties. It quickly became apparent that the key challenge did not relate to lack of knowledge, but to the assumptions and attitudes of medical practitioners.

Attitudes to addicts and addiction which were most problematic were those which polarised at two extremes. At one were practitioners who expressed negative views of drug users, and who saw the goal of treatment as being to achieve abstinence from all drugs. For these doctors, the justification for methadone treatment was that it helps control deviant behaviour. Their understanding was that methadone is offered to patients in return for compliance with the expectations of the prescriber. This contractual understanding essentially sees methadone as a system of rewards and punishments to encourage patients to become abstinent and be less antisocial.

At the other extreme were trainees who expressed more positive views of addicts, seeing them not as individuals with problems, but people making lifestyle choices discriminated against by social policy. For these 'progressives', there is little inherently problematic about dependence on heroin; rather, the problems associated with heroin addiction arise because the drug is illegal, and supplies are therefore expensive and impure.

Both perspectives conceptualise methadone maintenance as a system of controlled drug distribution to reduce the harmful consequences of heroin addiction. For both, and for many politicians and administrators, methadone maintenance is a pragmatic solution to a social problem, rather than a treatment of individuals. In this frame of reference, regulations about how methadone should be prescribed and dispensed are more relevant than principles of treatment.

To the committee organising the training, this frame of reference was problematic. It identified methadone treatment as different from 'mainstream' medical practice, not part of the duty of care owed to individual patients seeking treatment. Within the regulatory framework, usual assumptions about patient care are often not seen as applying; rather, any practices which fit within the regulations are acceptable. In contrast, 'treatment' involves assumptions about individual patient care and professionalism which are a better defence against poor practice than regulations.

A related problem identified in the workshops was that many practitioners had difficulties coming to terms with the motivational and interactive nature of the treatment of dependence. They expected clear guidelines on how to respond to clinical problems, for example, on how to respond to benzodiazepine abuse among patients on methadone. Instead of clear directions, it was suggested that responses depended on what the patient was willing or able to do, and that even when a plan was negotiated, they should not be surprised if it was not adhered to. They found difficulty with the suggestion that sometimes the most helpful response is to advise, wait and observe, and avoid being provoked into fruitless attempts to control patients' behaviour. Treatment as something passive which at best permits change to occur is unfamiliar and challenging to those trained in a biomedical framework. The frustration of working in this way is another obstacle to seeing methadone maintenance as a 'real' form of treatment.

Addressing the problems identified in training

Manual and workshop were progressively modified in the light of these problems. The first session of the workshop became devoted to exercises exploring trainees' attitudes to addicts and addiction. Most doctors share community antipathy towards heroin users, for many exacerbated by occasional experience of treating difficult, hostile, drug-seeking patients. Such experiences often give rise to an adversarial approach to treating heroin users. An exercise to address these difficulties was adopted to place methadone treatment in the context of medical practice, identifying the types of patients doctors find difficult. Heroin users presented as examples of patients embodying many of the traits which doctors find difficult. The skills needed to respond appropriately were emphasised as generic skills of value in all areas of medical practice.

A similar approach was adopted to deal with beliefs about heroin addiction. Here too, practitioners tend to reflect community assumptions about addiction to heroin, and a crucial aspect of training was to avoid either exaggerating or trivialising the problems. This was addressed by considering problems of dependence on a variety of drugs – benzodiazepines, alcohol, tobacco – and to the biopsychosocial factors promoting vulnerability to dependence.

Frustration provoked by patients who continue to abuse drugs while in treatment was addressed by modifying both manual and workshop to clarify that treatment of dependence is permissive – not causing people to change but allowing them to do so. The goal is to allow patients more control over their lives. Treatment with methadone can reduce the level of behavioural dependence on opioids, allowing patients the opportunity – depending on their circumstances – to lead more normal and productive lives. The fact that some are unable to take advantage of this respite is something clinicians and policymakers must acknowledge.

The final and perhaps most important lesson from the training programme was to recognise the limitations of a single training session, particularly in dealing with attitudinal issues. A system of continuing education, based around case discussions and clinical problems, has now been developed.

Last revised 16 February 2013. First uploaded 16 February 2013

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Top 10 most closely related documents on this site. For more try a subject or free text search

STUDY 1995 Lessons from a training programme for methadone prescribers

STUDY 1998 Changing attitudes and beliefs of staff working in methadone maintenance programs

DOCUMENT 2013 Delivering recovery. Independent expert review of opioid replacement therapies in Scotland

STUDY 2004 Methadone programme loosens up, increases capacity, patients do just as well

DOCUMENT 2012 Medications in recovery: re-orientating drug dependence treatment

DOCUMENT 2014 Time limiting opioid substitution therapy

DOCUMENT 2009 Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence

HOT TOPIC 2015 Prescribing opiate-type drugs to opiate addicts: good sense or nonsense?

MATRIX CELL 2014 Drug Matrix cell A2: Interventions; Generic and cross-cutting issues

STUDY 2011 How does cognitive behaviour therapy work with opioid-dependent clients? Results of the UKCBTMM study





Changing attitudes and beliefs of staff working in methadone maintenance programs.

Caplehorn J.R.M., Lumley T.S., Irwig L. et al.
Australian and New Zealand Journal of Public Health: 1998, 22(4), p. 505–508.
Unable to obtain a copy by clicking title? Try this alternative source.

In Sydney in Australia an official campaign and educational efforts had the desired effect of shifting staff attitudes in methadone maintenance clinics away from achieving abstinence and withdrawal and towards long-term treatment aimed at reducing harm.

Summary The featured study sought to establish whether staff attitudes in methadone maintenance clinics in New South Wales in Australia changed as a result of an official campaign to reorient these programmes from aiming primarily for abstinence to aiming primarily to reduce harm. The data sources were two staff surveys either side of the campaign.

At the time of the first survey in 1989 health service policy on methadone maintenance was strongly abstinence-oriented: "The methadone program will have a drug-free outcome as its basic objective. Doctors and counsellors will be asked to actively pursue the withdrawal from methadone of patients whenever this can be achieved." In the second half of 1989, around the time the first survey was completed, a new policy was circulated stating that: "The principal aim of methadone treatment programs is to assist opioid-dependent persons to improve their health and social functioning and alleviate the adverse social consequences of their drug use by reducing and eliminating their illicit drug use ... Methadone treatment is also intended to complement strategies to minimise the risks of transmission of [HIV] amongst intravenous opioid users and from them to other members of the community."

To herald the change in policy, in mid-1989 a special HIV-focused issue of the health department's educational magazine for alcohol and drug treatment staff was produced. The first Australian National Methadone Conference was held in Sydney in New South Wales in 1991 and staff at public methadone units were paid to attend. Several hundred heard presentations on harm minimisation and the importance of methadone dose for retention of patients in maintenance. Staff training seminars conducted by the health department featured speakers from the conference.

The Abstinence Orientation Scale

Answers are scored as positive or negative in such a way that higher total scores reflect greater orientation to abstinence.

1 Methadone maintenance patients who continue to use illicit opiates should have their dose of methadone reduced.
2 Maintenance patients who ignore repeated warnings to stop using illicit opiates should be gradually withdrawn off methadone.
3 No limits should be set on the duration of methadone maintenance.
4 Methadone should be gradually withdrawn once a maintenance patient has ceased using illicit opiates.
5 Methadone services should be expanded so that all narcotic addicts who want methadone maintenance can receive it.
6 Methadone maintenance patients who continue to abuse non-opioid drugs (eg, benzodiazepines) should have their dose of methadone reduced.
7 Abstinence from all opioids (including methadone) should be the principal goal of methadone maintenance.
8 Left to themselves, most methadone patients would stay on methadone for life.
9 Maintenance patients should only be given enough methadone to prevent the onset of withdrawals.
10 It is unethical to maintain addicts on methadone indefinitely.
11 The clinician's principal role is to prepare methadone maintenance patients for drug-free living.
12 It is unethical to deny a narcotic addict methadone maintenance.
13 Confrontation is necessary in the treatment of drug addicts.
14 The clinician should encourage patients to remain in methadone maintenance for at least three to four years.

To assess the results 90 staff were surveyed at the 10 public methadone units in Sydney in 1989 and 92 at 11 of the 12 clinics operating in 1992. The surveys assessed their orientation to abstinence/withdrawal versus maintenance as goals of methadone treatment ( panel), their disapproval of drug use, and their knowledge of the risks and benefits of maintenance treatment.

Main findings

There was a highly significant fall between 1989 and 1992 in average abstinence orientation scores. After adjusting for other factors, the 1989 score can be interpreted as respondents agreeing with seven of the 14 items on the scale and disagreeing with the other seven. The 1992 score can be interpreted as respondents agreeing with three, being uncertain about another three, and disagreeing with the remaining eight items. Similar results were obtained from the 33 staff who answered both surveys.

However, this turning away from abstinence as an overriding goal varied across clinics. At one the score actually increased; between surveys this clinic had moved premises and seven of its nine staff left, including its doctor and its manager, a strong supporter of harm minimisation.

After allowance was made for other factors, there was no significant difference in respondents' average knowledge scores in 1989 and 1992 or in the degree to which they disapproved of drug use. In 1989 disapproval was closely related to abstinence orientation but much less closely The correlation fell from 0.65 to 0.33. in 1992.

The authors' conclusions

The study shows staff attitudes change with time and the process of change can probably be facilitated by education campaigns. There was a shift in the attitudes and beliefs of staff working in public methadone units in Sydney in 1989–92 away from abstinence-oriented policies. Somewhat surprisingly, this was not associated with any change in their support for the punishment of illicit drug users or their knowledge of the benefits and risks of maintenance treatment. Staff changed their views on methadone treatment without changing their views on drug addiction or improving their fairly poor scores on a test of basic knowledge of methadone maintenance.

That the results were similar when restricted to people who had completed both surveys indicates that the change was not simply due to staff who supported abstinence being replaced by those more wedded to harm reduction. Neither did it seem to reflect a broader shift in public opinion, which remained strongly in favour of abstinence-oriented policies. The divergence of public and staff attitudes suggests the change in official policy and the accompanying educational campaign may have successfully influenced staff attitudes.

Increased support for abstinence-oriented policies at one clinic indicates that local factors – particularly influential individuals – can have a significant effect on a methadone programme's organisational culture. Policy-driven change is likely to be less successful in situations where there is opposition from those in leadership roles. To facilitate or consolidate change and improve the quality of care, more attention needs to be paid to attitudes and beliefs when selecting staff for employment and promotion in maintenance programmes.

Last revised 19 February 2013. First uploaded 19 February 2013

Comment/query to editor
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Give us your feedback on the site (two-minute survey)
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Top 10 most closely related documents on this site. For more try a subject or free text search

STUDY 1996 Alternatives to non-clinical regulation: training doctors to deliver methadone maintenance treatment

STUDY 1995 Lessons from a training programme for methadone prescribers

STUDY 2004 Methadone programme loosens up, increases capacity, patients do just as well

DOCUMENT 2012 Medications in recovery: re-orientating drug dependence treatment

DOCUMENT 2013 Delivering recovery. Independent expert review of opioid replacement therapies in Scotland

DOCUMENT 2014 Time limiting opioid substitution therapy

STUDY 1995 An evaluation of private methadone clinics

DOCUMENT 2009 Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence

MATRIX CELL 2014 Drug Matrix cell A2: Interventions; Generic and cross-cutting issues

HOT TOPIC 2015 Prescribing opiate-type drugs to opiate addicts: good sense or nonsense?





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