Drug abuse treatment programs have substantially improved their methadone treatment practices and increased their HIV prevention efforts since the late 1980s, according to recent NIDA-funded research. These improvements appear to be partly the result of NIDA's efforts to improve drug abuse treatment and HIV/AIDS outreach.
Clinical studies conducted in the late 1980s and early 1990s indicated that methadone treatment is more likely to reduce heroin use if the dose level is at least 60 milligrams per day (mg/day), if patients are given a voice in determining their dose levels, and if no restriction is placed on treatment duration. Subsequent research, however, indicated that the majority of the Nation's methadone treatment facilities were dispensing methadone doses less than 60 mg/day, were not giving patients a voice in dosage decisions, and were encouraging patients to stop taking methadone in 6 months or less.
The treatment facilities most likely to conduct HIV prevention activities were those that had more patients at high risk of HIV infection, more resources, and lower patient-to-staff ratios.
In response to this situation, NIDA and other Federal agencies took steps to improve methadone treatment. NIDA funded an Institute of Medicine report that recommended changes in heroin addiction treatment practices and their regulation. NIDA also funded the development of a quality assurance program that evaluates methadone treatment facilities in terms of patient outcomes. In addition, the Center for Substance Abuse Treatment (CSAT) developed a set of methadone treatment guidelines and distributed them to State substance abuse agencies and treatment providers around the country.
To determine whether these efforts were in fact improving methadone treatment practices, in 1995 Dr. Thomas D'Aunno of the University of Chicago and his colleagues at the University of Michigan in Ann Arbor collected data from 116 methadone treatment facilities located throughout the country and compared them with data collected on these same facilities in 1988 and 1990. Results showed improvement during the 7-year period, particularly regarding methadone dosage. The average dose was 45 mg/day in 1988 and 46 mg/day in 1990. By 1995, however, the average dose had increased to 59 mg/day. Also, more programs were allowing patients to participate in dosage decisions, and more programs were waiting at least a year before encouraging patients to stop taking methadone.
"Although these results show that methadone treatment facilities have made substantial improvements, we still need to make more progress," says Dr. D'Aunno. "We found an average dose of 59 mg/day in our sample of treatment facilities, but recent research indicates that doses between 80 and 100 mg/day may be the most effective in reducing heroin use." (See "High-Dose Methadone Improves Treatment Outcomes,")
The study found differences in treatment practices in different areas of the country and for different population groups. Dr. D'Aunno suggests that efforts targeted at particular groups of programs may be a further step to improve treatment.
Dr. Bennett Fletcher of NIDA's Division of Epidemiology, Services, and Prevention Research agrees that efforts to improve methadone treatment practices should continue but adds that misunderstandings some patients have about methadone may also contribute to the problem. For example, he says, some patients attribute adverse effects to methadone that it actually does not cause. "These patients may develop medical or dental problems while taking heroin, but they don't notice them either because of heroin's analgesic effect or because they are distracted by withdrawal symptoms during abstinence," he says. "Once they're in methadone treatment and physiologically stabilized, the medical or dental problems are unmasked. It is easy to blame methadone for these problems, when in fact they were pre-existing." These misunderstandings may cause some patients to request lower methadone doses or to stop methadone prematurely, says Dr. Fletcher.
The Bandwagon Effect
Dr. D'Aunno, along with colleagues at the University of Iowa in Iowa City and the Centers for Disease Control and Prevention in Atlanta, also evaluated treatment facilities' HIV prevention efforts, including HIV testing, counseling, and outreach. For this project, they used data collected from the sample of methadone treatment facilities plus other substance abuse treatment facilities for a total of 618 facilities.
As with the methadone treatment practices, the investigators found that the facilities had made substantial improvements in their HIV prevention efforts over the period from 1988 to 1995. In both 1988 and 1990, only 39 percent of the facilities provided HIV testing and counseling, but by 1995, 61 percent were providing these services. Also, 51 percent of the facilities in 1988 and 65 percent in 1990 were engaging in HIV outreach, but by 1995 this had increased to 75 percent.
The investigators found that the treatment facilities most likely to conduct HIV prevention activities were those that had more patients at high risk of HIV infection, more resources, and lower patient-to-staff ratios. Also, these facilities generally were publicly rather than privately funded and had clinical supervisors who supported HIV prevention practices.
Perhaps the most important factor in promoting HIV prevention practices, however, seemed to be pressure from people in the drug abuse treatment field. "When the HIV epidemic first started, many treatment facilities were uncertain how to react," says Dr. D'Aunno. "As some facilities began conducting HIV testing, counseling, and outreach, pressure began to mount for other facilities to do the same. This eventually created a bandwagon effect."
NIDA helped get the bandwagon going by supporting research programs in which scientists worked together with practitioners to develop effective HIV/AIDS outreach techniques, according to Dr. D'Aunno. "These programs set a good example for treatment providers," he says. "The providers saw local researchers and other providers working together on HIV prevention, and they decided to follow their lead."
D'Aunno, T.; Folz-Murphy, N.; and Lin, X. Changes in methadone treatment practices: Results from a panel study, 1988-1995. American Journal of Drug and Alcohol Abuse 25(4):681- 699, 1999 [Full Text].
D'Aunno, T.; Vaughn, T.E.; and McElroy, P. An institutional analysis of HIV prevention efforts by the Nation's outpatient drug abuse treatment units. Journal of Health and Social Behavior 40(2):175-192, 1999. [Abstract]