Patients who stay in methadone treatment for 12 months or longer have better therapeutic outcomes — yet most drop out within the critical first year. According to a recent study funded by the National Institute on Drug Abuse (NIDA), a major factor is a clinic’s views of its patients.
Clinics perceiving methadone patients as „consumers“ who spend time and often money on treatment for opioid addiction generally try to attract patients by providing services such as child care, flexible hours, and help with housing and transportation. Clinics with the classic view of patients as „beneficiaries,“ for whom treatment is considered a privilege, may offer patients fewer options and focus on the needs of the program rather than those of the patient. The authors suggest that by viewing patients as consumers of services, rather than beneficiaries, methadone clinics can retain patients in treatment longer and improve therapeutic outcomes.
Participants in the study were 42 patients prematurely discharged from six methadone programs in metropolitan Baltimore, Maryland. The study spanned 18 months, ending in June 2006, and was based on in-depth, semi-structured interviews. About 64 percent of participants were black, the remainder white. Average age of participants was 40 years. About 60 percent were men. Approximately 74 percent of participants reported injecting heroin. The average length of treatment was 124 days, and the group had an average of three prior drug-treatment episodes.
Reasons for Premature Discharge
Of the 42 patients, 17 left early for program-related reasons, 16 because of incarceration, 5 in order to become free of all addictions, and 4 because of life events or logistics. As discussed below, the somewhat rigid „beneficiary“ thread ran through patients‘ dissatisfaction and departure.
Conflicting Views of Reasons for Discharge
Counselors had to select a reason for discharge from eight categories. „Left before completing treatment“ was the counselors‘ most common reason, even for incarcerated patients. According to the authors, this suggested unawareness of the true reasons, but an alternate explanation could be that staff do not necessarily consider paperwork to be related to treatment. Yet the discharge summary report can be important, because ideally it accompanies the patient to any subsequent programs, possibly influencing the patient’s later attempts at recovery.
Specific Program-Related Factors
- Disagreement with program rules. Some participants were frustrated with program policies and procedures that they believed were applied inconsistently or continuously changed, hindering their ability to improve their lives. For example, a homeless patient had a specific plan for regaining a construction job, but his counselor put other projects in his way, then complained he lacked stable housing. „So I was really bummed.“ He left the program.
- Conflicts with staff. Some conflicts with counselors led to confrontations and discharge from the program. Program directors sometimes refused patients‘ requests for a different counselor. Some patients saw counselors as disrespecting patients‘ „street“ education. A patient complained that he didn’t need anyone, because he was „a grown man.“
- „Feetox.“ Rapid detoxification and discharge because of late payment or nonpayment of fees evoked strong reactions. „It’s all about money,“ said an exasperated patient who was feetoxed after falling less than a week behind during the first month of treatment.
- Scheduling conflicts. Many patients tried to cope with schedules, public transportation problems, family obligations, and job-seeking. A „beneficiary“ working a 12-hour shift couldn’t get to the clinic while it was open. Another found a good job, but the commute was an hour and a half. Both chose work over treatment. The authors did not comment on the possibility that without treatment, relapse and possible job loss might occur
Desire to be Free of Addiction
Despite a generally positive view of methadone, more than 10 percent of discharged patients left treatment primarily to be free of all medication. Some were „scared of becoming dependent“ on methadone. A patient said that trying to work and get to the clinic during the time the clinic was open „became like a schedule,“ letting yet another drug — methadone — control his life.
The authors note that while studies indicate that the clinic director sets clinic policies, the counselor usually has to interpret and enforce the rules, which can create a conflict with their role as therapists. The authors believe that rules regarding take-home doses, missed doses, hours of operation, and children’s presence at the clinic may be critical factors in patient satisfaction and retention.
The authors identify several current problems:
- A short supply of methadone treatment in the Baltimore area, limiting patients‘ choices and putting some in a dependent relationship with a program.
- Inability of some patients to negotiate clinic rules.
- Decreased funding for methadone programs for the past several decades, increasing counselors‘ case loads, making individualized attention difficult, and decreasing the variety of patient services.
- Financial pressures may lead to „feetoxing“ patients. The authors note that data appear to refute the idea that contributing fees is „therapeutic,“ even for indigent patients. Heroin-addicted individuals given free treatment are more likely to enter and remain in therapy than those required to pay.
Suggestions for Staff to Increase Retention
- Clearly explain program rules to patients
- Have an appeal system offering a patient advocate
- Allow patients to switch counselors if conflicts cannot be resolved
- Consider having clinical experts review each patient’s case before discharge
- Instruct counselors to document patients‘ reasons for leaving treatment
- Separate counselors‘ rule-enforcement and counseling functions
Because of social desirability, or lack of insight, reasons patients gave may not be accurate. Moreover, elapsed time may have altered patients‘ memory of events. Nevertheless, the data may help programs improve their approaches and their outcomes.
Reisinger HS, Schwartz RP, Mitchell SG, et al. Premature discharge from methadone treatment: Patient perspectives. J Psychoactive Drugs. 2009; 41(3):285-296