Similar to other research findings, this study showed that women had a higher likelihood of treatment engagement than men (Luchansky et al. 2000
; Shah et al., 2000
; Schutz et al., 1994
). Shah et al. (2000)
found that females were twice as likely as males to participate in MMT. According to Humphrey et al. (1997)
, while there may be few females enrolled in treatment overall, they may be more likely to seek treatment because they receive pressure from family or friends or there is greater social stigma for women substance abusers which pressures them into treatment.
The finding that married clients were less likely to re-enter treatment was inconsistent with other research (Carroll & Rounsaville, 1992
; Grella et al., 2003
; Hubbard et al., 1989
; Schutz et al. 1994
). However, Moos et al. (1994)
found that clients who were never married were more likely to be re-admitted to treatment and Goldstein et al. (2002)
demonstrated that unstable living arrangements and living alone was associated with MMT re-entry. It could be reasoned that those who were married or living with others were less likely to re-enroll because their partners may be using drugs making difficult for them to be motivated to re-engage in treatment. Results of the logistic regression support this since subjects who were married were more likely to be using opioids at nine months. This is also supported by research showing that women with male drug abusing partners were retained in treatment for a shorter period of time compared to women with drug-free partners (Tuten & Jones, 2003
Employment may serve as a barrier to MMT re-engagement since those who were working were less likely to re-engage. Working substance abusers often lack insurance to cover the cost of treatment which is a barrier to treatment entry (Amaro, 1999
; Booth et al., 1998
). In addition, Kleyn and Lake (1990)
found that intravenous drug users (IDUs) who were employed were less likely to enter drug treatment since treatment could interfere with time spent on the job.
Opioid addicted veterans are an important group to target for treatment re-engagement. While it is believed that veterans should have greater access to insurance and treatment services, the current study found that they were less likely to re-engage in treatment on their own and veterans were twice as likely as their community-based counterparts to have an opioid positive urine at nine months post-discharge. More research is needed to understand why veterans are being discharged from treatment, how they could be retained, and if they do leave treatment prematurely, what can be done to re-engage them quickly.
The fact that participants with more psychiatric inpatient hospitalizations were more likely to re-enter treatment was consistent with the findings of Moos et al (1994)
, but inconsistent with Hser and colleagues (1998)
who found that those who experienced more severe psychiatric distress were less likely to re-engage in treatment. It could be that the level of psychiatric distress was so severe for individuals in the current study that they required hospitalization and the admission to a hospital may have facilitated re-admission to MMT, thereby bypassing the lengthy waiting lists that were prevalent at the time the study was conducted (Coviello et al., 2006
). This is consistent with the fact that participants who were discharged due to hospitalization (most likely a psychiatric stay of greater than 30 days) were more likely to re-enter MMT compared to participants who were discharged for other reasons. Upon discharge from the hospital these individuals may have been automatically re-instated at their MMTP.
This study is similar to others that have found poor treatment outcomes including more illicit drug use and criminal behavior among discharged clients who did not re-enter MMT (Anglin et al., 1989
). Despite having more severe problems, especially more psychiatric disorders, methadone clients who are able to re-engage in treatment within three months after discharge had better nine month post-discharge treatment outcomes in terms of less opioid use, lower incidence of IV drug use, and fewer incarcerations than those who did not re-engage, suggesting that rapid treatment re-engagement is critical. Moreover, nearly two-thirds of those who had re-engaged on their own three months after discharged were still enrolled in treatment six months later compared to less than one-quarter of those who were not in treatment three months post-discharge.
4.1 Study limitations
A major limitation of the study was the lack of random assignment of subjects to the two treatment conditions. While it would have been impossible to randomly assign subjects to the Tx group since this is a naturally occurring event, the use of propensity scores should have helped to adjust for possible imbalances between the two groups. However, due to minimal overlap in the two groups, the use of propensity scores is not advised (Shadish et al., 2002
) so we are not able to adjust for potential imbalances in the two groups. Caution is needed in interpretation of the these findings since some of the difference in outcomes may be due differences in the two groups at baseline (e.g., marital status, treatment site and heroin use) in addition to the differences between the two treatment groups.
A second major limitation was that about one-third of the former methadone clients were not able to be contacted at three months post-discharge suggesting that those who were not followed-up may represent a more severe group of out of treatment drug users. However, additional analyses of discharge reasons showed that those who were not contacted were more likely to have been discharged because they completed treatment, whereas, those who were contacted were more likely to have dropped out of treatment or were hospitalized. Individuals who complete treatment are less likely to need to re-engage in treatment than those who drop out prematurely (Luchansky et al., 2000
). Therefore, it appears that the participants who were contacted may actually represent a more typical group of methadone clients who were at greater risk and more in need of an intervention.
Despite these limitations, there were several strengths of this study. These strengths included the fact that 83% of active MMT clients participated in the post-discharge study, the diverse sample that included newly enrolled and existing MMT clients as well as clients from a VA and community-based clinics, and the overall good follow-up rate.
While the findings show that those who were more receptive to treatment re-engagement were a more severe group, those who failed to re-engage on their own tended to be higher functioning in that they were more likely to be working. In order to reach these less receptive clients, the role of an intervention like outreach case management (OCM), which was originally designed to re-engage former methadone clients back into treatment (Coviello et al., 2006
), could be expanded to help retain clients in treatment to prevent them from dropping out in the first place. For example, to prevent clients from dropping out due to conflicts with employment, a case manager could help them negotiate take-home doses, deal with transportation issues, or assist the client in developing a schedule that ensures they receive their medication and make it to work on time.
In general, drug treatment programs need better interventions to help retain and prevent the premature drop out of veterans and those who are employed. Other medications that have less restrictive dosing regimens such as depot naltrexone or buprenorphine may be more appropriate and result in better compliance for opioid addicted clients who work. Polices are needed that enhance treatment access for working substance abusers who are not eligible for Medicaid and are uninsured and unable to pay for treatment, or whose insurance does not cover the cost of treatment. Moreover, interventions that support the needs of clients who have drug abusing partners such as the work of Jones and colleagues at Johns Hopkins that involve methadone/detoxification treatment, contingency management and motivational interviewing for couples may also help retain these individuals in treatment.
Drug users often leave treatment prematurely and hence do not benefit sufficiently from treatment. In this study, about one-third (34%) of the subjects were discharged because they had stopped attending treatment. Even among those who completed treatment, seven out of ten had re-engaged in treatment at three months post-discharge, and the other three were in need of treatment, but had not re-enrolled. Opioid abusers who received intermittent treatment have more severe substance abuse and legal problems than those who receive continuous treatment (Kosten et al., 1986
). Therefore, reducing drop out rates and immediate treatment re-engagement for those who drop out prematurely, are key to improving treatment outcomes. Due to the chronic nature of addition, there is a need for interventions like recovery management check-ups (Dennis et al., 2003
; Scott & Dennis, 2009
) that involve monitoring substance abusers over expended periods.
Research is needed to examine the benefit-costs of interventions in terms of both re-engaging out of treatment drug users and potentially retaining users in treatment. While interventions that improve treatment continuity and help reduce the revolving door nature of chronic drug abuse are costly, these costs could be offset by the much more expensive consequences of continued drug use as demonstrated in this study, including more incarcerations and additional health care costs resulting from greater IV drug use among out of treatment drug users.