Identifying methadone maintenance clients at risk for poor treatment response: pretreatment and early progress indicators.

Exhaustive searches have uncovered few demographic or other pretreatment factors that reliably predict performance in substance abuse treatments. In this study we evaluate whether early treatment response offers improved prediction of treatment response 6 and 9 months later. New admissions to methadone maintenance treatment (n = 59) were dichotomized into outcome groups based on treatment retention and ongoing drug use as revealed by urinalysis results 6 and 9 months after admission. Regression analyses revealed two early (week 2) performance measures, counseling attendance and opiate abstinence, could be used to correctly classify, the outcomes of more than 80% of the sample. Strikingly, of the 20 participants who neither submitted an opiate-negative urine sample in week 2 nor attended at least two scheduled counseling sessions by that time, not one achieved a superior 6-month outcome. The odds of having a superior outcome increased considerably for those who submitted two opiate negative urine samples and attended two counseling sessions by week 2. Thus, 6-month outcomes were well predicted by treatment performance in week 2. Similar results are reported for month 9 outcomes.

Characterizing "nonresponsive" methadone patients.

A review of records at a large urban methadone clinic revealed a substantial group of patients with treatment tenures of at least 6 months whose urinalysis results indicated continued regular use of opiates. In an attempt to characterize these "nonresponsive" patients and to identify their specific treatment needs, we compared them to a group of patients with comparable treatment tenures but whose urinalysis results indicated little or no recent illicit opiate use. Contrary to expectations, opiate use itself was virtually the only feature that clearly distinguished the two groups. "Responders" and "nonresponders" did not differ significantly on measures of psychosocial problem severity in any other area, nor did they differ in their treatment service utilization. Moreover, examination of admission data indicated that the two groups showed similar rates of improvement in the severity of their psychosocial problems in all seven measured areas. The implications of these results for treatment and clinic administration are discussed.

MMPI profiles of opiate addicts: predicting response to treatment.

Although many studies document the use of the MMPI to classify opiate users, the predictive validity of the resulting subgroups is rarely reported. In this study, we used cluster analysis to identify MMPI profile types that predicted differential response to methadone maintenance treatment. Participants (N = 151) completed MMPIs shortly after entry into treatment. Cluster analysis of MMPI scores produced four distinct subgroups that differed significantly in severity of psychosocial problems measured at admission and on the mean number of drug-free urine specimens submitted during the 24-week study period. Cluster 1 participants evidenced low levels of psychological disturbance, improved their urinalysis results over time, and submitted the most posttest drug-free urine specimens. Cluster 2 was the only other group that improved significantly over time, even though these patients were the most psychologically disturbed. The results suggest the relation between psychological problems and outcome may be more complex than is commonly assumed.

Assessing the helping alliance and its impact in the treatment of opiate dependence.

This study assesses the relationship between the patient-counselor helping alliance (HA) and progress in methadone maintenance treatment. Questionnaire measures of HA were administered to 57 patients 1 and 3 months after admission. Three-month HA measures (especially counselors' ratings) predicted reductions in drug use as measured by weekly urinalysis results and 6-month self-report data. HA was unrelated to treatment retention or improvement in psychiatric symptomatology. Moreover, controlling for urinalysis results in the previous month rendered insignificant the correlations between 3-month HA and subsequent drug use. Thus, this evaluation of the HA's unique contribution to the prediction of outcome suggests that the development of a positive HA may be more a marker of treatment progress than a necessary precursor of positive outcomes in the methadone maintenance treatment setting.

Natural classes of treatment response.

This study examines an approach to identifying patterns of treatment response over time. Treatment response profiles are identified by cluster analyzing a repeated measure of patient performance collected at intervals during treatment. The procedure is demonstrated in Study 1 using monthly urinalysis results of 103 patients entering methadone maintenance treatment. The internal, external, and face validities of derived treatment response profiles are evaluated. A logistic regression model predicting treatment response is then constructed from intake variables found to correspond with the treatment response profiles. Study 2 replicates the procedures on an independent sample. Treatment response profiles facilitate the analysis of treatment response offering advantages over common measures of treatment outcome, such as performance at follow-up, change in performance from treatment entry to follow-up, or performance summed across treatment.

Reinforcing operants other than abstinence in drug abuse treatment: an effective alternative for reducing drug use.

This study examines the effectiveness of using vouchers to reinforce either the provision of urine samples testing negative for illicit drugs (UA group) or the completion of objective, individually defined, treatment-plan-related tasks (TP group). A third group was assigned to the clinic's standard treatment (STD group). Participants were randomly assigned to groups after a 6-week baseline-stabilization period. Urine specimens were collected thrice weekly throughout the study. In the UA condition, participants earned $5 (U.S. dollars) in vouchers for each drug-free urine submitted. In the TP condition, participants earned up to $15 in vouchers per week for demonstrating completion of treatment plan tasks assigned by their counselors. Contingencies were in effect for 12 weeks, after which all participants received the clinic's standard treatment. Urinalysis results indicate that the TP intervention was significantly more effective in reducing illicit drug use than either the UA or STD interventions. These effects were maintained with a trend toward continuing improvement for the TP groups even after contingencies were discontinued.

Stages and processes of change as predictors of drug use among methadone maintenance patients.

In this study the authors evaluated the predictive validity of stages-of-change and processes-of- change measures among methadone maintenance patients. One month after treatment entry, participants completed questionnaires providing stage and process scale scores regarding readiness to discontinue polydrug use. Participants also completed an algorithm assigning them to a stage category on the basis of their stated intentions regarding quitting. The algorithm predicted urinalysis results during a 12-week posttest period; however, only 1 stage scale (contemplation) and no process scales correlated significantly with outcome. In a hierarchical regression, stage and process scale scores significantly improved prediction of posttest abstinence beyond that afforded by baseline drug-free urine rates, but this effect was attributable to the contemplation scale alone. Despite their widespread use, stage and process scales have yet to demonstrate clearly predictive validity.

A comparison of three methods of measuring the type and quantity of services provided during substance abuse treatment.

This study examined three data collection methods of quantifying and categorizing treatment services provided in a publicly funded methadone program. All three approaches were research technician implemented: (1) bi-weekly patient interview with the Treatment Services Review (TSR); (2) weekly counselor interview by the Counselor Services Interview (CSI); and (3) data abstraction from clinical patient records (REC). Fifty patients were followed over 28 days using each method to assess the services received/provided within the program. Five service domains were assessed: medical, employment, alcohol/drug, family, and psychiatric. Correlations were calculated among the three methods of data collection across each of the five service domains. Overall, low to moderate correlations were found with the highest rates of agreement detected between the TSR and the REC in the employment domain (0.48) and the REC and CSI in the family domain (0.48). Post hoc focus groups with the counselors and patients found that: (1) counseling sessions rarely focused on specific problem domains; (2) counselors and patients disagreed about the quality of treatment services; and (3) counselors 'rounded-up' time spent counseling. These findings suggest that measuring treatment service delivery varies markedly based on who provides the information (e.g. patient or treatment staff) and what procedures are used for data collection (e.g. chart abstraction or self-report).

Coping strategies and continued drug use among methadone maintenance patients.

Drug addiction has been conceived as a maladaptive means of coping utilized by individuals unable or unwilling to deal with stresses in more adaptive ways. Although a growing body of evidence supports the link between alcohol abuse and maladaptive coping styles, there is relatively little empirical support for the connection between maladaptive coping and other kinds of drug use. The present study employed a cross-sectional design to assess coping and drug use in a sample of 276 methadone maintenance patients. Structural equation modeling was used to assess the factor structure of the coping measure and the relationship between coping and unauthorized drug use. The results suggest that coping and drug use are related in this population and that this relationship is different for Black patients than for White patients.

Stages and processes of change among polydrug users in methadone maintenance treatment.

We applied the stages-of-change model of Prochaska and DiClemente to the problem of drug use among methadone maintenance patients to examine correlates of different stages of treatment readiness. The 276 subjects were divided into stage categories based on self-reported drug use and questionnaire responses regarding plans to discontinue unauthorized drug use in the future. Confirmatory factor analytic procedures validated four process scales derived from a 60-item questionnaire. Each stage was characterized by a profile of change-process scores largely consistent with predictions, though these scores did not distinguish stages as clearly as has been reported in previous research. Analysis of subject characteristics revealed that those in the Precontemplation stage reported significantly longer treatment tenures than subjects in any other stage besides Maintenance.