Objectives This study determined the cost-effectiveness of expanding methadone maintenance treatment for heroin addiction, particularly its effect on the HIV epidemic. Methods We developed a dynamic epidemic model to study the effects of increased methadone maintenance capacity on health care costs and survival, measured as quality-adjusted life-years (QALYs). We considered communities with HIV prevalence among injection drug users of 5% and 40%. Results Additional methadone maintenance capacity costs $8200 per QALY gained in the high-prevalence community and $10,900 per QALY gained in the low-prevalence community. More than half of the benefits are gained by individuals who do not inject drugs. Even if the benefits realized by treated and untreated injection drug users are ignored, methadone maintenance expansion costs between $14,100 and $15,200 per QALY gained. Additional capacity remains cost-effective even if it is twice as expensive and half as effective as current methadone maintenance slots. Conclusions Expansion of methadone maintenance is cost-effective on the basis of commonly accepted criteria for medical interventions. Barriers to methadone maintenance deny injection drug users access to a cost-effective intervention that generates significant health benefits for the general population.

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HIV Transmission and the Cost-Effectiveness of Methadone Maintenance

Context Effective alternatives to long waiting lists for entry into methadone hydrochloride maintenance treatment are needed to reduce the complications of continuing heroin dependence and to increase methadone treatment entry. Objective To compare the effectiveness of interim methadone maintenance with that of the usual waiting list condition in facilitating methadone treatment entry and reducing heroin and cocaine use and criminal behavior. Design Randomized, controlled, clinical trial using 2 conditions, with treatment assignment on a 3:2 basis to interim maintenance–waiting list control. Setting A methadone treatment program in Baltimore. Participants A total of 319 individuals meeting the criteria for current heroin dependence and methadone maintenance treatment. Interventions Participants were randomly assigned to either interim methadone maintenance, consisting of an individually determined methadone dose and emergency counseling only for up to 120 days, or referral to community-based methadone treatment programs. Main Outcome Measures Entry into comprehensive methadone maintenance therapy at 4 months from baseline; self-reported days of heroin use, cocaine use, and criminal behavior; and number of urine drug test results positive for heroin and cocaine at the follow-up interview conducted at time of entry into comprehensive methadone treatment (or at 4 months from baseline for participants who did not enter regular treatment). Results Significantly more participants assigned to the interim methadone maintenance condition entered comprehensive methadone maintenance treatment by the 120th day from baseline (75.9%) than those assigned to the waiting list control condition (20.8%) ( P P P P P Conclusion Interim methadone maintenance results in a substantial increase in the likelihood of entry into comprehensive treatment, and is an effective means of reducing heroin use and criminal behavior among opioid-dependent individuals awaiting entry into a comprehensive methadone treatment program.

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A Randomized Controlled Trial of Interim Methadone Maintenance

Objective: The objective of this study was to examine the prevalence of psychiatric disorders in a group of patients who had recently entered a methadone maintenance programmeMethod: A total of 62 patients were interviewed using the Composite International Diagnostic Interview (CIDI) within 6 months of commencing methadone maintenance The CIDI was used to establish symptoms of psychiatric illness at interview and in the 12 months priorResults: In the 12 months prior to interview, 76% of the sample fulfilled ICD-10 criteria for a psychiatric disorder other than substance-use disorder Over half of the group interviewed fulfilled ICD-10 criteria for an affective disorder, two-thirds fulfilled criteria for an anxiety disorder and just under half fulfilled diagnostic criteria for both an affective disorder and an anxiety disorder in the 12 months prior to interview At the time of interview, 19% fulfilled ICD-10 diagnostic criteria for a moderate or severe affective disorder Seventy per cent of males and 

Prevalence of Psychiatric Disorder in a Methadone Maintenance Population

Factors associated with methadone maintenance treatment retention among street-recruited injection drug users.

OBJECTIVE: High risk injection practices are common among injecting drug users (IDUs), even following intervention efforts. Moreover, relapse to risk behaviors has been reported among those who initiate risk reduction. Substance abuse treatment offers the potential to reduce or eliminate injecting risk behaviors through drug cessation. We report on the effectiveness of two intervention strategies in facilitating treatment entry among out-of-treatment IDUs: motivational interviewing (MI), and intervention developed to help individuals resolve their ambivalence about behavior change, and free treatment for 90 days. These conditions were compared with an intervention focusing on a hierarchy of safer injecting practice, referred to here as risk reduction (RR), and no free treatment. METHODS: Nearly 200 out-of-treatment IDUs were randomly assigned to one of four experimental conditions: MI/free treatment, MI/no free treatment, RR/free treatment, and RR/no free treatment. Regardless of assignment, we assisted anyone desiring treatment by calling to schedule the appointment, providing transportation, and waiving the intake fee. RESULTS: Overall, 42% of study participants entered treatment. No significant differences were found between MI and RR; however, 52% of those assigned free treatment entered compare with 32% for those who had to pay. Other predictors of treatment entry included prior treatment experiences, perceived chance of contracting acquired immunodeficiency syndrome (AIDS) greater than 50%, "determination" stage of change, greater frequency of heroin injecting, and fewer drug-using friends. CONCLUSIONS: These findings support the importance of removing barriers to treatment entry.

Facilitating Treatment Entry among Out-of-Treatment Injection Drug Users

The Millon Clinical Multiaxial Inventory (MCMI) was administered to 144 men and 86 women within 1 month of admission to methadone maintenance treatment and was readministered 18 months following admission. Based on prior research, we hypothesized there would be significant decreases on scales measuring affective disturbance, anxiety, and social isolation and little change in scales measuring antisocial and narcissistic traits. In addition, it was hypothesized that changes on the MCMI would be related to retention in treatment and illicit drug use during the interim between initial assessment and follow-up. Data were analyzed using a multivariate analysis of variance (MANOVA) for repeated measures. There was an overall decrease in MCMI scores, indicating less psychopathology between initial assessment and follow-up. MCMI scales did not change as a function of retention status, but decreases in MCMI scale scores were greater for subjects who were light drug users in the 6 months prior to the follow-up compared to heavy users. Inspection of individual MCMI scales supported our hypothesis; there were decreases on scales measuring affective disturbance, anxiety, and social isolation, but not on scales measuring antisocial and narcissistic traits.

Changes in Millon Clinical Multiaxial Inventory scores among opiate addicts as a function of retention in methadone maintenance treatment and recent drug use.

Charles Fleming

Papers

Changes in Millon Clinical Multiaxial Inventory scores among opiate addicts as a function of retention in methadone maintenance treatment and recent drug use.

Users of free treatment slots at a community-based methadone maintenance clinic