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National Study Finds Many Programs Provide Ineffective Treatment

Many outpatients are receiving methadone treatment that is not effective, according to a recent national study of 172 methadone treatment units. The study found substantial variation in treatment practices among a nationally representative sample of methadone maintenance units across the Nation.

A major finding was that a large proportion of these units are using treatment practices—such as inadequate dose levels and little patient influence on dosage decisions—that put patients at increased risk for failure. This study also found that units providing higher dose levels are retaining their patients in treatment for longer average periods of time, which corroborates earlier research.

Research methodology

The study is based on a random sample telephone survey in 1988 of directors and clinical supervisors from a variety of treatment settings, including public, private for-profit and not-for-profit units, and facilities that are based in hospitals, mental health centers, or are free standing. Of a stratified national random sample of 210 facilities, 172 (82 percent) responded, with 51 of these facilities treating methadone patients only and 121 treating a mix of methadone and nonmethadone patients. Analysis indicated that the two types of facilities are very similar in their treatment practices.

The study looked at whether treatment units are following principles that current research indicates to be important for patient success; namely:

• The longer patients remain in treatment, the less likely they are to return to illicit drug use and injections

• Patients remain in treatment longer when they receive relatively high-dose treatment and when they are allowed to participate in dosage decisions

Study findings

Data from this study show that, by these measures, many units engage in counterproductive, restrictive practices regarding both dosage practices and patient participation in dosage decisions. The study found:

• 1 of 3 units (34 percent) report that patients are aware of their dose levels only to some, little, or no extent (18,245 patients)
• 1 of 4 units (25 percent) acknowledge having an upper dose limit of 60 mg per day
• 2 of 3 units (67 percent) have an average dose level of 50 mg per day or less; 1 of 3 units (34 percent) have an average daily dose of 40 mg or less—a level most researchers consider too low to be effective
• More than 1/2 of the units (54 percent) have an average length of patient treatment of 20 months or less
• 1/2 of the units (50 percent) encourage patients to detoxify in less than 6 months
• 1 of 4 units (25 percent) have a majority of patients who are decreasing their dose levels

Units that measure high on one effective treatment practice tend to follow other effective practices as well. For example, units that have higher upper limits on dose level or higher average dose levels are also more likely to allow take-home dosages and to have patients who are aware of their dose level and able to influence it. In contrast, units with more patients who receive decreasing dose levels are less likely to have patients who are aware of their dose level; these units also have lower limits on dose level and lower average dose levels, encourage patients to detoxify sooner, and have shorter average patient time in treatment.

Some significant correlations found include:

• The more rural the environment, the less aware the patient is likely to be about dose level and the lower the average dose
• Units in the Mid-Atlantic region have higher limits on dose levels and encourage patients to detoxify later in the course of treatment
• Units in the South Atlantic region are less likely to allow patients to influence dose levels
• Units that treat a higher percent of black patients are likely to have lower limits on dose levels, lower average dose levels, and are less likely to permit take-home dosages

Unanswered questions

The authors call for detailed studies to learn more about how physicians and other staff members make their methadone treatment decisions. More study would also answer some intriguing questions, such as: what is the role of Federal regulation in promoting successful practices? This study found that those units with higher dose limits and higher average dose levels were more likely to report that their dose practices are influenced by government regulation.

Further study might also explain how public and free-standing units are able to retain their patients for a longer than average time in treatment. This success in retention occurs despite their somewhat restrictive practices, such as lower average dose levels and less patient participation in setting dosage levels.

Last Updated May 17, 2001