In this study, equivalence testing was used to determine whether MMT patients were indistinguishable from patients who were not receiving MMT at a TC. TCs are not accustomed to treating opioid-dependent patients on MMT. TCs traditionally emphasize abstinence rather than maintenance on opioids, and even medically prescribed methadone is viewed as a mood-altering drug that reinforces substance dependence and impedes recovery. Many staff may view MMT as a threat to the environment of the TC. Despite these potential obstacles to treatment, however, our findings suggest that the MMT clients fare as well as non-MMT clients.
MMT clients did not differ from non-MMT clients on key outcome variables, including retention in the TC, illicit opioid use, alcohol use, stimulant use, benzodiazapine use (with the exception of the 24-month follow-up), and injection- and sex-risk behaviors at all follow-up assessments. These findings suggest that the TC was modified to the point that MMT clients can be integrated successfully into an environment that is usually opposed toward patients taking methadone.
The 24-month longitudinal study design allowed for the examination of long-term treatment effects. Multiple assessments up to 24 months after admission, with excellent follow-up rates, provide a longer-term view than most previous studies of TC residents. Of the published studies that have examined TC treatment outcomes, for example, only three have followed patients up to 24 months (Condelli and De Leon, 1993
; Wexler et al., 1999
; De Leon et al., 2000
A substantial proportion of participants in both groups did not return to illicit opioid use, and of the clients in MMT, many continued to use methadone. Across the follow-up periods, however, the proportion of participants who used illicit opioids increased steadily. At 18 months, a large proportion of clients were no longer enrolled in the TC yet a subgroup used illicit opioids. This subgroup of illicit-opioid using participants may have benefited from better availability of extended treatment or aftercare services. For example, it may be useful to identify the point at which clients had returned to illicit opioid use, reassess motivation for treatment and actively link them to treatment, such as in the Recovery Management Checkup intervention developed by Scott and Dennis (Scott et al., 2005
It is noteworthy that more than two-thirds of the MMT patients were receiving MMT at each follow-up point. Since methadone use is viewed as inconsistent with TC philosophy and may possibly be seen as a threat by some treatment staff, MMT patents may have felt pressure to discontinue MMT, yet a substantial proportion of MMT participants reported using methadone during the 24 months after enrollment in the study. Additionally, from study admission to the 24-month follow-up interview a significant increase appeared in the proportion of comparison group participants receiving methadone. These findings suggest that many clients in the comparison group also perceived advantages to being on MMT.
Our MMT treatment rates are in the upper range of methadone retention rates reported in recent studies; 1-year retention rates ranged from 25% to more than 70% (Rowan-Szal et al., 2000
; Neufeld et al., 2008
; Deck and Carlson, 2005
). The relatively high MMT participation rates and new entrants into methadone treatment observed in this study suggest an acceptance of and commitment to MMT among clients receiving services in a TC setting. We caution, however, that the data are point prevalence enrollment self-reported by study participants and do not always reflect continuous retention in a single MMT program.
Regarding secondary hypotheses, stimulants (cocaine and methamphetamine) were the most frequently used illicit drugs after illicit opioids, and the MMT and non-MMT groups showed equivalent use. Other drugs and alcohol were used less frequently.
The results of this study should be considered in light of design limitations. Participants were not randomly assigned to treatment conditions. Thus, participants self-selected to receive MMT, which may reflect a higher perceived need for MMT, commitment to MMT, knowledge of methadone treatment services, and acceptance of methadone treatment as an important part of their recovery. The finding that the majority of MMT patients were in MMT treatment at follow-up interviews up to 24 months provides further evidence of their commitment to this treatment modality. This strong commitment to MMT may have protected these clients from antithetical views toward MMT by some TC clients or staff. MMT clients without this strong commitment may not have fared as well in other TC settings. In addition, the TC environment of the treatment program examined in this study may not extend to other TC programs. The TC had years of experience with incorporating methadone patients into the milieu, and the program made modifications to allow TC residents to receive MMT (see Greenberg et al., 2007
), thus findings from this study may not extend to TCs that have policies excluding or discouraging methadone maintenance treatment. In addition, our study did not gather information on short-term interruptions of TC treatment (under 14 days), which could overstate the TC retention rates and make the results less generalizable. Research shows that shorter dropout between initial dropout and first readmission is a predictor of longer retention when clients return to the TC later ( De Leon and Schwartz, 1984
). Similarly, the findings for non-MMT group may not generalize to TCs that do not allow MMT. Allowing MMT patients may have impacted non-MMT residents in unknown ways. For example, the linear increase in methadone use by the comparison group may reflect positive perceptions of MMT that they acquired during their stay in the TC. Thus, additional studies are needed to assess the impact of integration of MMT services in the TC setting, specifically the impact on patients and staff.
Although the study has limitations, results suggest that methadone patients can benefit from TC treatment and respond as well as a comparison group matched on psychiatric history, criminal justice pressure and expected length of stay. Because traditional TCs have had unfavorable views about methadone treatment and a belief that the use of methadone treatment by those in the TC would pose a threat to the entire community, it was reasonable to raise the question of whether TC residents receiving MMT would have equivalent treatment outcomes to those not receiving methadone treatment in a modified TC setting. While the TC had prior experience in treating patients on methadone, the present study created a unique opportunity to increase the population of patients on methadone maintenance therapy during the course of the study. In preparation for the influx of methadone patients, the TC developed specific strategies to educate both staff and clients about methadone treatment and to address the unique treatment needs of methadone patients (Greenberg et al., 2007
There remain significant barriers to overcome before a large number of programs will treat MMT patients in the TC setting. In addition to challenges about treatment philosophy, values, and attitudes toward methadone there is also additional cost. In this case the TC collaborated with the community’s mobile methadone program, allowing residents already on MMT to continue receiving methadone without cost to them in trade for providing parking and office space at the Walden House outpatient program. Similar opportunities may not be available in other communities. We also point out that evidence of equivalent effectiveness has not been the driving force in shaping the substance abuse treatment network. Thus, there are both scientific and practical limitations to this work, and considerably more research, policy change, and positive treatment experiences will be needed for system change to occur.
The results of the present study provide evidence that the implementation of these staff, patient, and therapeutic adaptations allowed methadone patients to be successfully integrated into the TC setting. These findings are consistent with those of De Leon et al. (1995)
demonstrating that suitably modified TCs can be employed successfully with methadone maintenance patients. Perfas and Spross (2007)
contend that the traditional drug-free orientation of TCs has been changing rapidly in response to the need to treat co-occurring disorders, and a key issue is to accept current health care realities without compromising the unique qualities of the TC approach. That said, persuading TCs to change their philosophy is only one step in incorporating MMT into the TC setting. Organizational change must also be addressed. For example, TC programs may not have the medical staff and resources to store methadone, and it may be difficult to identify MMT programs willing to work as partners with a TC to provide methadone. Despite these barriers, the results of the present study suggest that TC treatment programs may want to consider expanding their reach to accommodate patients receiving opioid replacement therapy such as methadone.