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Sorensen J.L., Andrews S, Delucchi K.L. et al.
Drug and Alcohol Dependence: 2009, 100, p. 100–106.
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 Sorensen at James.Sorensen@ucsf.edu.
Are therapeutic communities incompatible with methadone maintenance? Not when staff have been prepared to accept and work with methadone patients and programmes adapted to accommodate them. Then patients stay as long and sustain abstinence from illegal drug use just as well as other residents.
Summary Residential therapeutic communities have demonstrated effectiveness, yet for the most part they adhere to a drug-free ideology incompatible with the use of methadone. This study used equivalency testing As explained in the source paper, equivalence testing is a statistical technique often used to show that a new medication is indistinguishable from an approved standard medication. Outcomes from the two treatments (in this case therapeutic community residence with versus without methadone maintenance) are declared equivalent if the confidence interval for the difference between them is completely within 20% plus and minus the value of outcomes from the standard treatment. An equivalence test can find that two treatments are not equivalent yet a traditional test can also find that they fail to differ to a statistically significant degree (for an illustration see http://www.mors.org/meetings/test_eval/presentations/C_Warner.pdf). In other words, a finding of equivalence is not the same as simply finding a failure to differ. to explore the consequences of admitting opioid-dependent clients currently on methadone maintenance treatment into a therapeutic community. The study compared 24-month outcomes between 125 methadone patients and 106 opioid-dependent drug-free clients with similar psychiatric histories, criminal justice pressures and expected lengths of stay, who were all newly enrolled in a therapeutic community. Statistical equivalence was expected between groups on retention in the therapeutic community and illicit opioid use. Secondary hypotheses posited statistical equivalence in the use of stimulants, benzodiazepines, and alcohol, as well as in HIV risk behaviours. As hypothesised, the average number of days in treatment was statistically equivalent for the two groups (166.5 for the methadone group and 180.2 for the comparison group). At each assessment, the proportion of the methadone group testing positive for illicit opioids was indistinguishable from the proportion in the comparison group. The equivalence found for illicit opioid use was also found for stimulant and alcohol use. The groups were statistically equivalent for benzodiazepine use at all assessments except at 24 months where 7% of the methadone group and none in the comparison group tested positive. Injection- and sex-risk behaviours were equivalent at all observation points. The authors concluded that in these therapeutic community settings, methadone patients fared as well as other opioid users, providing additional evidence that therapeutic communities can successfully be modified to accommodate methadone patients.
commentary Generally considered incompatible treatment modalities, this is one of the few studies to show that a therapeutic community environment can be combined with methadone maintenance, and the first to do so in respect of a residential community. As the authors stress, it is important to remember that these were not the usual run of communities. For decades they had embraced methadone patients and made modifications Among those mentioned in the source article are the designation of a methadone counsellor who plays a vital role in the process of helping the programme modify its services to accept and treat methadone patients. Counsellors periodically offer methadone sensitivity training sessions to staff and patients, providing education and confronting stigma about methadone maintenance. They also conduct weekly methadone therapy groups for residents on methadone. Residents who opt to attempt withdrawal from methadone have greater access to alternative therapies and medical services. to meet their particular needs and increase their acceptance by staff and residents. It's also possible that these modifications and the presence of methadone patients changed the environment for non-methadone residents too. Residents were not randomly allocated to the two regimens but entered the facilities in the normal way. All had the kind of experience of opiate use which would have made them eligible for methadone maintenance, they were matched However, the three key variables identified in the abstract were very simply matched in an either/or way rather than in terms of degrees. on some key variables and differed little on most others, yet before, during and after leaving the communities, far more of the methadone group were in methadone treatment. The implication is that the major remaining difference between the two groups of residents lay in their preferences for alternative routes to recovery – complete abstinence, or abstinence from illegal drugs supported by substitute prescribing. The outcomes seem to suggest that in welcoming and suitably modified communities, residents who favour these different routes end up abstinent from illegal drugs in roughly the same numbers and converge somewhat Two years after joining the communities 70% of the methadone group were still being prescribed methadone compared to 30% of the non-methadone group, a narrowing of the gap of 95% versus 12% recorded at entry to the programmes. in their preferences for how to attempt to maintain this. They also show that many from both camps At six months after treatment entry, when most of the residents had left the therapeutic community treatment system, about a third tested positive for opiates rising to about a half at 18 months. Stimulant use showed the same upward trajectory but at a lower level, reaching about 40% positive by 18 months. do not totally succeed. What we don't know, however, is how the residents fared in other ways such as reintegration and mental and physical well being.
Though this study seems unique, previous reports have documented the integration of non-residential day care therapeutic communities with methadone programmes, demonstrating that patients who opt for this additional support evidence Perhaps because of their greater motivation and in this study, degree of psychological distress, as well as any impact of the community. greater remission in opiate and cocaine use. Other studies have established that with staff facilitation, 12-step mutual aid groups can (but not always See for example an account of the initially low take-up and stuttering progress of such groups in a Norwegian clinic in: Espegren O. Twelve step programme and methadone maintenance treatment. In: Waal H., Haga E., eds. Maintenance treatment of heroin addiction: evidence at the crossroads. Oslo: Cappelens, 2003, p. 321–333. smoothly) be integrated with methadone treatment and that patients who choose this option seem to benefit. Such initiatives are line with the cooperation between the founders of Alcoholics Anonymous and Vincent Dole, founder of methadone maintenance, who served on AA's board.
Simultaneous integration of residential rehabilitation and methadone is by no means unknown in Britain, In particular in the form of the ROMA rehabilitation houses in London which specialised in methadone patients. Their work was documented in: Glanz A. ROMA; Talgarth road. Report of an information-gathering exercise. London: DHSS, 1983. but far more common is the serial integration of these modalities within a client's treatment journey. In Scotland's DORIS study of drug treatment services, within 33 months most clients starting residential rehabilitation had left and spent a period on methadone. In England's similar NTORS study, perhaps a third had done so within a year. In neither case do we know how many rehabilitation clients had traversed the opposite route, though its seems likely In NTORS three-quarters of the total sample (ie, not just those entering residential rehabilitation) had been prescribed methadone in the past two years. that many had.
Thanks for their comments on this entry in draft to James L. Sorensen of the UCSF at San Francisco General Hospital. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 25 December 2008
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