Methadone patients in the therapeutic community: A test of equivalency

Abstract

Background

Residential therapeutic communities (TCs) have demonstrated effectiveness, yet for the most part they adhere to a drug-free ideology that is incompatible with the use of methadone. This study used equivalency testing to explore the consequences of admitting opioid-dependent clients currently on methadone maintenance treatment (MMT) into a TC.

Methods

The study compared 24-month outcomes between 125 MMT patients and 106 opioid-dependent drug-free clients with similar psychiatric history, criminal justice pressure and expected length of stay who were all enrolled in a TC. Statistical equivalence was expected between groups on retention in the TC and illicit opioid use. Secondary hypotheses posited statistical equivalence in the use of stimulants, benzodiazepines, and alcohol, as well as in HIV risk behaviors.

Results

Mean number of days in treatment was statistically equivalent for the two groups (166.5 for the MMT group and 180.2 for the comparison group). At each assessment, the proportion of the MMT 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 MMT group and none in the comparison group tested positive. Regarding injection- and sex-risk behaviors the groups were equivalent at all observation points.

Conclusions

Methadone patients fared as well as other opioid users in TC treatment. These findings provide additional evidence that TCs can be successfully modified to accommodate MMT patients.

Introduction

Research has demonstrated that therapeutic communities (TCs) have beneficial effects in decreasing drug use (Simpson and Curry, 1997), and decreasing sexual HIV risk behaviors (Cooperman et al., 2005). An extensive literature on TC treatments for opioid dependence has found that retention in a treatment program is the main marker of a variety of successful outcomes (Carroll and McGinley, 2000, De Leon and Schwartz, 1984, McCaul et al., 2001, Simpson and Curry, 1997). In general the longer a resident remains in treatment, the more likely positive outcomes will occur. Several studies have indentified factors that predict longer retention, including less severe psychiatric illness (Condelli and De Leon, 1993, Eland-Goossensen et al., 1998), involvement with and pressure from the criminal justice system (Eland-Goossensen et al., 1998, Harrison et al., 2007, Sacks et al., 2004), and client expectations about a longer length of treatment (Condelli and De Leon, 1993, Kressel et al., 2000).

In the last decade TCs have modified their approaches to accommodate a variety of special populations, including prisoners (Sacks et al., 2004), women and their children, adolescents (De Leon, 1997), people with HIV/AIDS (Sargent et al., 1999), homeless persons (De Leon et al., 2000, Skinner, 2005) and those with co-occurring mental illness requiring psychiatric medication (Sacks et al., 1997). A small number of TCs have also made modifications to allow clients on methadone maintenance treatment (MMT) into the TC. The primary application of TC methods to MMT patients was led by George De Leon (De Leon et al., 1995). The “Passages” project was a day treatment program based on TC methods that were adapted for patients in methadone clinics. The most comprehensive evaluation of Passages indicated that its clients improved significantly more than comparison subjects on measures of cocaine and heroin use, and those who remained in Passages for at least 6 months exhibited further positive outcomes.

The use of medically prescribed drugs for substance abuse has been inconsistent with the TC perspective, however (De Leon, 2000). In the TC view, medications that alter emotional or mental states could reinforce the substance abuse and impede recovery. For example, TC staff may view methadone as a threat to the individual and the system as a whole. MMT clients tend to be marginalized and perceived as using a crutch to progress through the treatment process (Greenberg et al., 2007). These beliefs may undermine treatment success among methadone patients, and influence treatment policies. Due to philosophical differences between TCs and methadone programs, TCs often do not admit to treatment patients who are receiving methadone, and very few actually provide MMT services. For example, the National Survey of Substance Abuse Treatment Services (Office of Applied Studies, 2007) found that for residential treatment settings (including halfway houses and TCs) only 3.6% had opioid treatment programs. Similarly, a recent national survey of 380 TCs indicated that less than 10% use methadone (Institute for Behavioral Research, 2005).

Yet methadone is one of the most widely used and extensively evaluated treatments for opioid dependence. Research indicates that opioid-dependent clients treated with methadone tend to fare better than those who are not treated with methadone (Gossop et al., 2000; National Institutes of Health-Center for Disease Control, 1997; Farrell et al., 1994). In addition, the National Consensus Panel on Effective Medical Treatment of Opioid Addiction (1998) calls attention to the need for opioid-dependent persons to have access to MMT and recommends expanding the availability of MMT.

The current study explored the effectiveness of admitting opioid-dependent clients currently on MMT into TC treatment. If more TCs are to treat MMT patients, it is vital to document whether MMT patients do as well as opioid users who are not enrolled in MMT, which TCs are accustomed to treating. To examine this question we used equivalence testing (Rogers et al., 1993) to contrast a group of MMT patients to a comparison group of similar non-MMT opioid users. Equivalence testing is a statistical technique often used to show that a new medication is indistinguishable from an approved medication that is the standard of care. In this study, TC treatment for drug-free opioid users represents the usual mode of care. The aim of the study was to learn whether MMT patients would benefit as well from enrollment in a TC. In the context of a TC setting we tested whether outcomes for MMT patients would be indistinguishable from those of opioid-dependent patients not enrolled in MMT. Specifically, using a comparison group of opioid-dependent clients with similar psychiatric history, criminal justice pressure and expected length of stay in the TC, we tested the hypotheses that: (1) Retention in the TC would be statistically equivalent between patients receiving or not receiving MMT, and (2) use of illegal opioids would be statistically equivalent in the MMT and comparison groups at assessments up to 24 months from baseline. Secondary hypotheses posited statistical equivalence between the two groups in the use of stimulants, benzodiazepines, and alcohol, as well as in HIV risk behaviors and criminal behaviors. Although medical issues, employment, family issues, alcohol use, and many other factors are also important outcomes, primary hypotheses focused on retention and illegal use of opioids to preserve experiment-wise power.