While it is certainly possible to incorporate more adaptive treatment models with or without integrated treatments for psychiatric or other comorbid problems in opioid agonist treatment programs, this is not the only way to improve the treatment network and the patients it manages. This report provides descriptive information on the goals and outcomes of one alternative. CAST operates within the publicly-supported opioid agonist treatment network in Baltimore and accepts referrals of chronic drug using patients from other network programs for a brief duration of intensified services that includes comprehensive psychiatric and pain evaluations and care. The good utilization of treatment slots over the study evaluation is compelling evidence of both the need for, and acceptance of, this approach across most of the publicly-supported opioid agonist treatment providers in Baltimore.
The strong and sustained support for the CAST initiative may also be interwoven with the finding that a substantial number of treatment referrals benefited appreciably from their relatively brief exposure to the CAST treatment approach. Many of these patients were at high risk of discharge from the referring program. These findings provide good support for the use of adaptive treatments with behavioral contingencies to reduce substance use (Brooner & Kidorf, 2002
). The CAST service delivery approach can potentially decrease treatment drop-out and discharge rates in Baltimore and reduce the unproductive cycling of patients from one substance abuse treatment program to another, although this hypothesis was not tested in the present study.
The excellent adherence to highly intensive schedules of counseling over significant durations of time also illustrates the benefits of using reinforcement to improve service utilization (Brooner et al., 2004
; Carroll & Onken, 2005
; Petry, Martin, & Simcic Jr., 2005
; Rawson et al., 2002
). Higher rates of adherence to group-based counseling, including the community support group, was associated with successful completion, demonstrating the critical role of adherence in achieving good treatment outcomes (Brooner et al., 2004
; World Health Organization, 2003
). That even highly adherent patients received care for many weeks before meeting completion criteria is consistent with other studies showing that the beneficial effects of counseling are often delayed in drug-using populations (Carroll, Rounsaville, Nich, Gordon, Wirtz, & Gawin, 1994
; Carroll & Onken, 2005
). Taken together, the good outcomes provide preliminary support for the use of CAST service delivery models in other publicly-funded methadone maintenance treatment networks, with a possible further application for the increasing number of opioid-dependent individuals receiving buprenorphine in physician office-based settings that experience episodes of drug use within usual care practices.
Despite the overall success of this clinical initiative, about half of the sample failed to achieve enough improvement to return to the referring program in the time period covered by this report, many of whom chose to go to other treatment centers. While this was a group of patients selected for unremitting drug use despite months of routine care in the referring program, we nonetheless are exploring ways to increase the percentage of these patients meeting reasonable criteria for success. Most of the patients who continued to use drugs in the CAST service left the program against medical advice, though ten of them were accepted back by the referring program despite the lack of significant improvement. This fact may have inadvertently weakened the CAST intervention by reducing the motivation to reduce drug use as a condition of return to the parent program. This has become a topic of concern to us and the referring programs, and new approaches are being developed to address the issue.
The high rates of psychiatric disorder identified in the sample sharply contrasts with low rates of reported chronic pain problems. Across varying definitions of chronic pain, studies have reported prevalence rates for chronic pain that range from about 30% to 60% of patients in substance abuse programs (e.g., Peles, Schreiber, Gordon, & Adelson, 2005
; Rosenblum, Joseph, Fong, Kipnis, Cleland, & Portenoy, 2003
), with very few of these patients reporting any specific treatment for the problem (Clark, Stoller & Brooner, 2008
). It is possible that some of these patients simply stopped reporting chronic pain to staff based on the belief that it will be dismissed in an attempt to seek additional medication or rationalize continuing drug use. We are working on methods to raise awareness of the issue and increase the detection of this problem in patients with persistent drug use.
The major limitation of this report is its naturalistic and descriptive design. While the overall results are encouraging, a randomized controlled trial would provide a more rigorous evaluation of the merits of this approach. The report evaluated a selected sample of drug using patients, of uncertain representativeness, referred by their substance abuse counselors from community-based programs in one northeastern city. It is not known how this sample of patients compared with others attending privately funded methadone treatment programs, the individuals who failed to attend the CAST program upon initial referral, or with other poorly functioning patients never referred to the CAST initiative. The absence of available baseline data on individual patients, including the length of time in prior methadone treatment and severity of co-occurring drug use, also limits the generalizability of this report and the extent to which these patients represent the most severely affected subset in the treatment system. The present report would also have been strengthened by the collection and inclusion of some outcome data on patients returned to the referring program (e.g., urinalysis results, retention for at least a month or longer). Nevertheless, the good utilization of CAST treatment slots over the first 14–15 months of the service, the high rates of program completion and participation, and the favorable anecdotal reports from referring programs, suggest that this approach is a viable alternative to substantially changing the infrastructure of each of the individual network programs to offer more intensive and integrated substance abuse and psychiatric services.