Patient-Centered Methadone Treatment: More Evidence that Mandated Counseling Is Unnecessary

Early discontinuation of treatment is common in methadone treatment programs (MTPs), and many patients drop out or are administratively discharged because of restrictive program requirements. To determine whether less restrictive rules would improve retention and drug use outcomes, this clinical trial randomized new MTP patients in Baltimore during 2011–2014 to treatment as usual (TAU, n=151) or patient-centered methadone (PCM, n=149), in which counseling was optional, graduated consequences replaced involuntary discharge for rule infractions, and counselors were not responsible for enforcing clinic rules.

• There were no differences across groups in the proportion of patients at 12 months with opioid-positive urine tests (60%), cocaine-positive urine tests, self-reported heroin or cocaine use, meeting DSM-IV opioid or cocaine dependence criteria, treatment retention, HIV risk behaviors, or physical or mental health quality of life. PCM participants did report slightly better WHO Quality of Life scores (mean 3.7) than did those receiving TAU (mean 3.4).
• No differences were detected between groups in therapeutic alliance or patient satisfaction.
• Counseling attendance did not differ between groups. Over 12 months, PCM participants attended a mean of 8.7 individual and 3.8 group counseling sessions, compared with 7.8 and 6.4, respectively, among the TAU group.
• Although TAU counselors discussed rule violations and counseling requirements more often, involuntary discharge was rare in both groups.

Comments: A less restrictive approach to methadone treatment in which counseling was optional and responses to rule infractions were not heavy-handed did not worsen treatment outcomes. In fact, allowing patients to choose whether or not to attend counseling resulted in only a modest reduction in counseling attendance. This null study suggests that mandated counseling is unnecessary in methadone treatment programs.

Peter D. Friedmann, MD, MPH

Reference: Schwartz RP, Kelly SM, Mitchell SG, et al. Patient-centered methadone treatment: a randomized clinical trial. Addiction. 2017;112(3):454–464.