increased caseloads in methadone treatment programs: implications for the delivery of services and...
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Journal of Substance Abuse Tre
Regular article
Increased caseloads in methadone treatment programs:
Implications for the delivery of services and retention in treatment
Duncan Stewart, (Ph.D.)a,*, Michael Gossop, (Ph.D.)b, John Marsden, (Ph.D.)b
aHome Office, London, UKbNational Addiction Centre, Institute of Psychiatry, London, UK
Received 5 February 2004; received in revised form 29 July 2004; accepted 12 August 2004
Abstract
Changes in caseload and in the provision of counseling and comprehensive services were examined among 27 outpatient methadone
programs across England between 1995 and 1999. The number of patients treated at the programs doubled during this time and average
waiting times increased. More patients presented for treatment with alcohol and stimulant problems, dual diagnosis, and involvement in the
Criminal Justice System. Provision of individual counseling and comprehensive services was high at both points, although services for
family/relationship problems were reduced at followup. Changes were reported in disciplinary procedures. Drug positive urine tests were
more likely to result in loss of patient privileges, and there was a significant increase in discharges for breaking program rules, missing
appointments, and consuming alcohol. The study allows only tentative conclusions to be drawn, but these changes may be indicative of
increased pressures placed on the programs and their staff. D 2004 Elsevier Inc. All rights reserved.
Keywords: Methadone; Comprehensive services; Counseling; Discharge
1. Introduction
Drug misusers approach methadone treatment programs
with a range of substance use, health, and social problems.
These problems require methadone programs to do more than
prescribe a substitute opiate drug; they must also be sensitive
to the individual needs of patients and provide a range of
counseling and comprehensive services to tackle their mul-
tiple problems. Outcome studies have demonstrated that
methadone treatment can reduce patientsT use of heroin and
other drugs, and can also reduce injecting and risk behaviors,
improve health and social functioning, and reduce criminal
activity (Ball & Ross, 1991; Gossop, Marsden, Stewart, &
Kidd, 2003; Hubbard et al., 1989; Hubbard, Craddock, Flynn,
Anderson, & Etheridge, 1997; Marsch, 1998). Variations in
patient outcomes can, in part, be attributed to the frequency
and range of treatment services delivered by methadone
0740-5472/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.jsat.2004.08.006
* Corresponding address. Research Development and Statistics, Home
Office, Room 411, Horseferry House, Dean Ryle Street, London SW1P
2AW. Tel.: +020 7217 8635.
E-mail address: [email protected] (D. Stewart).
programs (Ball & Ross, 1991; Gossop, Stewart, & Marsden,
2003; Joe, Simpson, & Sells, 1994; McLellan et al., 1994;
Simpson, Joe, & Rowan-Szal, 1997). Outcomes can be
improved if treatment services are sensitive to the specific
needs of individual patients (Hser, Polinsky, Maglione, &
Anglin, 1999; Hubbard et al., 1989; McLellan, Arndt,
Metzger, Woody, & O’Brien, 1993).
Little is known about the structure and day-to-day
operating practices of methadone programs. Most detailed
descriptions of methadone programs have come from large
studies conducted in the United States (Ball & Ross, 1991;
DTAunno & Vaughn, 1992; Etheridge, Hubbard, Anderson,
Craddock, & Flynn, 1997; Hubbard et al., 1989). However,
efforts have also been made to describe the types of treatment
services provided in Europe and elsewhere (Farrell et al.,
1995; Gossop & Grant, 1991; Stewart, Gossop, Marsden, &
Strang, 2000). Even fewer studies have examined changes in
the delivery of methadone treatment. DTAunno, Folz-
Murphy, & Lin, (1999) described methadone treatment
practices from surveys of 172 U.S. programs in 1988, 1990
and 1995. During this time, average doses of methadone
had increased, and the prescription of reducing doses of
atment 27 (2004) 301–306
D. Stewart et al. / Journal of Substance Abuse Treatment 27 (2004) 301–306302
methadone had become less common. A comparison of data
from two large U.S. treatment outcome studies, the Treatment
Outcome Prospective Study (TOPS; 1979–81) and the Drug
Abuse Treatment Outcome Study (DATOS; 1991–1993), re-
vealed changes in the provision of comprehensive services
by methadone programs (Etheridge, Craddock, Dunteman,
& Hubbard, 1995). About half of the TOPS patients reported
receiving services for medical, psychological, family, legal,
educational, or financial problems during the first 3 months
of treatment. In DATOS, this had fallen to 34% and the
percentage of patients who received each of these services
(already low in TOPS) was reduced. The proportion of
patients reporting unmet needs increased substantially.
Programs may change their treatment practices because
of structural changes in the organization and funding of
health care systems (local or national), specific government
policy initiatives, or in direct response to the nature of the
problems with which patients present to treatment. In the
U.S., group counseling provision has increased in metha-
done and other treatment modalities, partly on the grounds
of the cost effectiveness of group treatments (Etheridge &
Hubbard, 2000; Gerstein & Harwood, 1990). This type of
change has been explained by reduced financial resources at
treatment programs (DTAunno & Vaughn, 1995; Etheridge
et al., 1995, 1997), but changes in the characteristics of pa-
tients have also been associated with levels of service
provision. For example, DTAunno and Vaughn (1995) found
that programs with a reported increase in patients with
cocaine problems were less likely to have reduced treatment
services across a range of domains.
The emergence of HIV infection among drug injectors
during the 1980s offers another example of the way changes
in patient characteristics can influence treatment provision.
In the United Kingdom (UK), the recognition among
practitioners and policy makers that the spread of HIV
posed a greater public health risk than drug misuse per se
(Advisory Council on the Misuse of Drugs, 1988) led to a
reappraisal of the orientation and purpose of methadone
prescribing services. Methadone programs were encouraged
to attract as many clients as possible in order to limit the
spread of the virus. Keeping clients in treatment was viewed
as an important treatment goal and a flexible and individ-
ualized prescribing policy was promoted. The principle of
harm minimization was firmly established as an additional
treatment aim, as well as abstinence from drugs, and was
endorsed by UK government drug policy.
Government strategies at the time of the present study
provided extra resources for the expansion of treatment
provision in the UK (Department of Health, 1996). This
paper describes changes in the number of patients treated
at 27 outpatient methadone programs located throughout
England during this period and addresses the relationship
between patient numbers and the delivery of counseling
and comprehensive services. The possible consequences for
treatment retention are examined in terms of changes to
program rules and regulations.
2. Materials and methods
The sample of 27 methadone programs had participated in
the National Treatment Outcome Research Study (NTORS).
Programs were purposely (not randomly) chosen for partici-
pation in the study. They were selected as being repre-
sentative of the main types of national treatment response in
the UK and were located in areas in which drug problems
and drug treatment services were prevalent. Programs were
also chosen on the grounds of their capacity to recruit suffi-
cient numbers to the study. In total, 16 methadone main-
tenance and 15 methadone reduction programs took part in
NTORS. This represented 19% of specialist prescribing
services in England and Wales (MacGregor, Smith, & Flory,
1994). Large variations in treatment practices were found
among programs within both the maintenance and reduction
modalities (Stewart et al., 2000). For this reason, and because
of the limited sample size, the results in the present paper are
for the methadone programs as a whole.
Questionnaires were completed by senior program
representatives (n = 31) in 1995 (typically by program
directors or managers), and followup questionnaires were
obtained from 27 programs in 1999. The mean followup
period was 3.7 years (SD = 0.13). Eleven of the respon-
dents had also completed the 1995 questionnaire. The
followup questionnaire included many of the same items
as the original version, allowing a direct assessment of
change over time. Detailed data were collected using a
self-completed structured instrument. This paper presents
data on program capacity; waiting lists; individual and
group counseling; services for alcohol, psychological
health, medical and family/relationship problems; and
discharge procedures. Variables were measured by five-
point ordinal scales (scored 0 to 4). In addition to the use
of repeated measures, the followup questionnaire included
items to assess the degree and direction of change (if any)
in funding and staffing levels and specific characteristics of
patients presenting to treatment. These items were mea-
sured on a five-point scale ranging from dconsiderabledecreaseT to dconsiderable increaseT.
The questionnaires were analysed as paired data sets. For
items measured by ordinal codes, changes were assessed by
Wilcoxon signed rank tests (Z), although the text summa-
rizes these data in terms of what programs might have
provided to most patients. Paired sample t-tests were
conducted for continuous variables.
3. Results
3.1. Patients at the programs
The total number of treatment places at the 27 programs
in 1995 was 4,518, but this total increased to 9,236 by 1999.
The mean capacity increased significantly from 167.3
(SD = 206.9) to 342.1 (SD = 336.9; t26 = 3.09, p = .005). This
D. Stewart et al. / Journal of Substance Abuse Treatment 27 (2004) 301–306 303
increase did not occur, or did not occur equally, at all
programs. The number of places remained the same at 4
(15%) programs, reduced at 3 (11%) and increased at 20
(74%). At one program, the number of places increased from
55 to 1200. This program had merged with another service,
and represented an outlier in the sample. When this program
was excluded from analysis, there remained a statistically
significant increase in the mean caseload, from 171.7
(SD = 209.7) to 309.1 (SD = 295.7, t25 = 3.11, p = .005).
There was an increase in the number of patients
presenting to treatment with alcohol problems at 70%
(n = 19) of the programs, although in most cases (n = 14)
the increase was indicated as dslightT. Over half (n = 15) ofthe programs reported treating more patients with problems
with stimulant drugs, and at six of these the increase was
dconsiderableT. An increase in the number of patients with a
dual diagnosis of substance use and psychiatric problems
was reported at 70% (n = 19) of programs; at 11 (41%) this
increase was dconsiderableT. No programs reported a
decrease in the number of dual diagnosis patients.
Similarly, no reductions in the number of patients with
Criminal Justice System (CJS) involvement were reported.
At 17 (63%) programs, there was an increase in patients
with CJS involvement, and at 12 (44%) programs this
increase was dconsiderableT.
3.2. Funding and staff
Respondents at over half the programs reported an
increase in levels of funding (56%; n = 15) with 30%
(n = 8) reporting a dconsiderableT increase. A decrease in
funding was reported at a third of programs (33%; n = 9).
The number of clinical staff employed was reported to
have increased at 59% (n = 16) of programs, but for most
(n = 12) this increase was dslightT. The number of clinical
staff had been reduced at 26% (n = 7) of the programs, and
at five programs these reductions were dconsiderableT.
3.3. Waiting lists
The proportion of programs with a waiting list for treat-
ment increased from 52% (n = 14) in 1995 to 63% (n = 17)
in 1999. Almost half (44%; n = 12) had a waiting list at
both measurement points, 7% (n = 2) at 1995 only, and 19%
(n = 5) at followup only. For the whole sample, there was
a near significant increase in mean waiting times from
3.6 weeks (SD = 5.0) to 8.4 weeks (SD = 12.0, t26 = 1.93,
p = .065). Among the 17 programs with a waiting list in
1999, the average number of weeks to wait for treatment
was 13.3 (SD = 12.9), compared to 7.0 (SD = 4.9) weeks at
the 14 programs with a waiting list in 1995. However, a
paired comparison for the 12 programs with a waiting list
at both measurement points showed no statistically signifi-
cant increase in waiting times (6.9 weeks (SD = 4.9) vs
9.3 weeks (SD = 5.6); t11 = 1.20, p = .259). The overall
increase in waiting times for the sample could have been
due to particularly long waiting times reported at the five
programs with a waiting list in 1999 only. The average
waiting time for these programs was 22.8 weeks (SD = 20.4),
compared to 9.0 weeks (SD = 5.8) for others with a waiting
list at followup.
3.4. Counseling and comprehensive services
All programs provided individual counseling to patients.
There was a reduction in the proportion of programs pro-
viding dmostT or dall or nearly allT patients with individual
counseling on at least a weekly basis from 30% (n = 8) to
11% (n = 3). There was no statistically significant change
in the average duration of individual counseling sessions.
The mean duration in 1995 was 45.3 min (SD = 12.0) and
48.1 min (SD = 10.1) in 1999 (t26 = 0.94, p = .355).
A third of programs (n = 9) in 1995 and 30% (n = 8) in
1999 provided group counseling to patients. The proportion
of programs providing group counseling at least once per
week for dmostT or dall or nearly allT patients increased from
two (7%) programs in 1995 to four (15%) in 1999. Among
programs providing group counseling in 1995, the mean
duration of sessions was 76.7 min (SD = 26.5). For
programs providing group counseling in 1999, the mean
duration of sessions was 66.3 min (SD = 15.1). Since group
counseling was provided by a minority of programs, no
statistical tests were conducted.
There were no statistically significant changes in the
degree to which programs provided services for alcohol,
medical and psychological health problems. The proportion
of programs providing alcohol services routinely (dquite a
lotT or da great dealT) was 68% (n = 17) in 1995 and 64%
(n = 16) in 1999; 48% (n = 13) provided alcohol services
routinely at both points. Routine provision of medical
services was reported at 63% (n = 17) of programs in 1995
and 56% (n = 15) at followup, and 41% (n = 11) did so at
both points. Services for psychological problems were the
most extensively provided service. These were provided
routinely at 93% (n = 25) of programs in 1995 and 85%
(n = 23) in 1999 while 78% (n = 21) provided this level of
service at both points.
There was a significant reduction in scores for services
for family and relationship problems (Z = 2.69, p = .007).
Routine provision reduced from 74% (n = 20) to 52%
(n = 14). Routine provision of family/relationship services
at both measurement points was reported at 44% (n = 12)
of programs.
3.5. Disciplinary and discharge procedures
Twenty-six programs in 1995 and 27 in 1999 required
patients to provide urine samples for drug testing. To enable
paired comparisons, statistical tests were conducted for the
26 programs with complete data at both points. There was a
statistically significant increase in programs responding to
drug positive urine tests by reducing patient privileges
D. Stewart et al. / Journal of Substance Abuse Treatment 27 (2004) 301–306304
(Z = 2.46, p = .014), although this occurred routinely at just
one program (at followup). Routine revision of treatment
plans was reported at over half the programs in 1995 and
1999, but with a near significant trend (Z = 1.93, p = .053)
for more patients to be discharged at followup for positive
urine tests.
There was a significant increase in the degree to which
programs discharged patients for breaking program rules
(Z = 2.95, p = .003) and missing appointments (Z = 2.70,
p = .007). Routine (doftenT or dalways or nearly alwaysT)discharge for each of these reasons increased from 7% (n = 2)
to 22% (n = 6). Discharge for violent conduct was the highest
scoring item in both 1995 and 1999, but there was still a near
significant increase (Z = 1.81, p = .071). Routine discharge
for violence increased from 41% (n = 11) to 70% (n = 19).
There was a significant increase in the scale score for
discharge in relation to alcohol use (Z = 2.54, p = .011). None
of the programs routinely discharged patients for this reason
at either point, but fewer programs reported that patients
were never discharged for alcohol use in 1999 (15%; n = 4)
compared to 1995 (48%; n = 14).
4. Discussion
Before discussing these findings it is important to high-
light some limitations to the study. The number of programs
in the study was small, although collectively they provided
more than 9,000 treatment places to patients. The programs
were purposely chosen for participation on the basis of
their ability to recruit sufficient patients, and consequently
cannot be considered as representative of methadone pro-
grams nationally. Since program capacity was a selection
factor, it is possible that the sample contained a dispropor-
tionate number of large programs. The treatment practices
of smaller methadone programs may differ from those de-
scribed here.
The use of ordinal scales for many of the measures is a
further limitation. This was intended to reduce the burden on
respondents and to capture what treatments may have been
dtypicallyT provided to patients. It also offered a means of
dealing with overlapping responses to items that measured
elements of treatment provided to some patients and not
others. However, this may have limited their sensitivity as
measures of change. The quality of the data was also de-
pendent on the ability of respondents to adequately describe
their programs. It is not possible, for example, to be certain
whether the reported increased severity of patientsT problems
reflects genuine changes in patientsT characteristics or per-
ceived changes by staff. A particular difficulty with this
methodology is the inability to guarantee that what is re-
ported as going on in a program is actually being consistently
delivered to patients. In this regard, bias could have resulted
from the two questionnaires being completed by different
individuals. Less than half of the 1995 and 1999 question-
naires were completed by the same respondent, although in
most cases this was a consequence of changes in personnel
at the programs.
Nevertheless, these findings are of interest because the
impact of expanding methadone treatment programs has not
been widely evaluated, particularly in the UK. Between 1995
and 1999, the total capacity of the programs had doubled to
over nine thousand, and three quarters of the programs re-
ported an increase in the number of treatment places. National
figures published by the UK Department of Health (2001)
confirm that substantially more drug misusers gained access
to treatment during this period. The number of patients
starting new treatment episodes (of any type) in England
increased from about 23,000 for the 6-month period ending
September 1995, to more than 30,000 for the equivalent
period in 1999.
Such expansion of treatment services may entail greater
strain on funding sources and staff workloads, at least in the
short term. Although increases in funding and clinical staff
were reported at the majority of programs, these tended to
be slight. Many patients were also waiting an unacceptably
long time for treatment. The proportion of programs with a
waiting list rose from about half in 1995 to nearly two thirds
in 1999 and overall waiting times had increased (although
not significantly). Five programs had a waiting list at
followup only, with patients waiting for an average of about
five months for treatment. The present study did not record
the proportion of patients referred to the programs that
actually attended treatment, but those who wait longer have
been found to be less likely to enter treatment (Festinger,
Lamb, Kountz, Kirby, & Marlowe, 1995) and more likely to
use heroin during treatment (Bell, Caplehorn, & McNeil,
1994). Regardless of the effect on treatment outcome,
however, it is important to recognize that while patients are
waiting for treatment they continue to be exposed to health
risks, to engage in criminal behavior, and to generate costs
to health and welfare services (Best et al., 2002).
There was evidence that patients were presenting for
treatment with more complex clinical problems during the
study; more patients with alcohol and stimulant related
problems and dual diagnosis disorders were reported. These
changes were not matched by increases in counseling and
comprehensive services provided by the programs, although
provision of services for alcohol, medical, and psychological
health problems was already high in 1995. Counseling and
other services are an important ingredient of successful
methadone treatment (Ball & Ross, 1991; McLellan et al.,
1993). In terms of services targeted at problems other than
drug use, the needs of patients in methadone programs are
not always adequately met (Etheridge et al., 1997; Hser
et al., 1999). It is encouraging, therefore, that reported
provision of services for medical, psychological, and
alcohol problems was generally high. However, services
for family and relationship problems were significantly less
commonly provided at followup. The severity of family or
relationship problems among patients at the programs was
not measured, but it is possible that program resources were
D. Stewart et al. / Journal of Substance Abuse Treatment 27 (2004) 301–306 305
directed towards services perceived as a higher priority or
were in higher demand. A study of U.S. methadone pro-
grams found that services for family problems were offered
by the majority of programs, but less than 10% of patients
received them (Etheridge et al., 1997).
There was also an increase in the number of patients
attending treatment with some form of CJS involvement.
This may reflect the expansion in arrest referral schemes in
the UK during the 1990s. These schemes involve specialist
drug workers assessing and referring drug users in police
custody to treatment and have been successful in putting
substantial numbers of drug users in contact with treatment
programs, but are likely to have placed a greater strain on
existing services (Hough, 2002).
Changes were found in the disciplinary and discharge
procedures employed by the programs. Drug positive urine
tests were more likely to result in loss of patient privileges
(e.g. take-home doses of methadone) in 1999 than in 1995,
and there was a trend towards more patients being
discharged from treatment for this reason. There were also
significant increases in the degree to which programs
discharged patients for breaking program rules, missing
appointments and excessive alcohol consumption. Few
studies report reasons why patients leave treatment, but
rates of discharge for breaking program rules of between 6%
and 22% have been reported (Ball & Ross, 1991; Desmond
& Maddux, 1996; Magura, Nwakeze, & Demsky, 1998).
Outcomes have been found to be poor for patients who
leave treatment prematurely (Zanis, McLellan, Alterman, &
Cnaan, 1996). A recent review concluded that most
discharged methadone patients either soon return to treat-
ment, or alternatively, report high levels of opiate use and
criminal involvement (Magura & Rosenblum, 2001).
It is not clear why the programs in the present study
reported more stringent disciplinary procedures at followup.
Programs may have changed their policies to improve pa-
tientsT compliance to treatment or because of the increased
pressures placed upon them. Larger caseloads and continued
waiting lists may have led to a greater intolerance of pa-
tients breaking program rules. More frequent discharges
from the programs may also have occurred as a consequence
of the increased severity of problems among their patients.
Grella, Wugalter, & Anglin (1997) observed that methadone
patients discharged from treatment were younger, and were
more likely to use cocaine, to be daily drinkers and to report
depression and interpersonal problems. Whatever the reason,
discharge from methadone treatment may be regarded as a
last resort. The case for retaining patients in treatment for
longer terms has been repeatedly made on the grounds that
patient outcomes are improved (Simpson, 1997). The
possibility that the NTORS programs were increasingly
unable or unwilling to tolerate breaches of program rules
without recourse to discharging patients is a cause for concern
and deserves further research attention.
The question of what to do with patients in treatment who
continue to use drugs is an important issue for methadone
programs. Belding, McLellan, Zanis, and Incmikoski (1998)
found that patients who continually provided opiate positive
urine samples did not differ from other patients in terms of
their use of other drugs, psychological and social function-
ing, or the use of treatment services. The authors con-
cluded that increasing doses of methadone or levels of
treatment motivation may be possible ways of dealing with
dnon-respondersT. Other studies have also found an asso-
ciation between higher methadone doses and retention in
treatment (Joe, Simpson, & Hubbard, 1991; Magura et al.,
1998; Saxon, Wells, Fleming, Jackson, & Calsyn, 1996) and
improved outcomes (Strain, Bigelow, Liebson, & Stitzer,
1999). The most common response to positive urine tests
among programs in the present study was a revision of
patientsT treatment plans, but it is not known whether this
included adjusting methadone doses.
Inevitably, the generalized picture of treatment reported
here does not fully reflect the diversity or complexity of
treatment practices, but the study provides important infor-
mation about the way in which individual treatment programs
are structured that, in the UK at least, is not readily accessible
by other means. However, only tentative conclusions can be
drawn from the study. The impact of changes in the orga-
nization and practices of methadone programs on patient
outcomes has not been directly examined in the literature.
More research is required to assess whether the kinds of
increased demands placed on methadone programs reported
here are detrimental to their effectiveness.
Acknowledgments
The authors wish to thank Dwayne Simpson (Fort Worth,
Texas) for his help and advice throughout the project. We
also wish to thank the staff at the participating agencies
without whose active support NTORS would not have been
possible, and the clients for agreeing to take part in the
project. Project funding was wholly provided by the
Department of Health. The views expressed in this paper
are those of the authors and do not necessarily reflect those
of the Department of Health.
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