Methadone dose increase, and abstinence reinforcement, for treatment of continued use during methadone maintenance

Although methadone maintenance is an effective therapy for heroin dependence, some patients continue to use heroin and may benefit from therapeutic modifications. This study evaluated a behavioural intervention, a pharmacological intervention, and a combination of both interventions.

Methods
Throughout the study all patients received daily methadone hydrochloride maintenance (initially 50 mg/d orally) and weekly counselling.
Following baseline treatment patients who continued to use heroin were randomly assigned to 1 of 4 interventions:
(1) contingent vouchers for opiate-negative urine specimens (n29 patients);
(2) methadone hydrochloride dose increase to 70 mg/d (n=31 patients);
(3) combined contingent vouchers and methadone dose increase (n=32 patients); and
(4) neither intervention (comparison standard; n=28 patients). Methadone dose increases were double blind.

Vouchers had monetary value and were exchangeable for goods and services.
Groups not receiving contingent vouchers received matching vouchers independent of urine test results.
Primary outcome measure was opiate-negative urine specimens (thrice weekly urinalysis).

Results
Contingent vouchers and a methadone dose increase each significantly increased the percentage of opiate-negative urine specimens during intervention.
Contingent vouchers, with or without a methadone dose increase, increased the duration of sustained abstinence as assessed by urine screenings.
Methadone dose increase, with or without contingent vouchers, reduced frequency of use and self-reported craving.

Conclusions
In patients enrolled in a methadone-maintenance program who continued to use heroin, abstinence reinforcement and a methadone dose increase were each effective in reducing use.  When combined, they did not dramatically enhance each other’s effects on any one outcome measure, but they did seem to have complementary benefits.
Source: Author Kenzie et al published in Arch Gen Psychiatry. 2000;57:395-404

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