Br.J. Addict., 1974, Vol. 69, pp. 173-179. Longman. Printed in Great Britain.

Correlates and Extent of Orug Abuse on aMethadone Maintenance Program

Susan Price and Kay Jamison*LImversitji of California, Los Angeles

Since its inception by Dole and Nyswander in 1963, methadone maintenance hasrapidly become the treatment of choice for chronic heroin addiction. The wide-spread acceptance of methadone maintenance is based on its ability to producecross tolerance to heroin, to eliminate the psychological craving for heroin, and tofacilitate the social rehabilitation of narcotic addicts, as measured by increasedemployment and reduced criminal activity. Although the efficacy of methadonemaintenance in facilitating social rehabilitation is well documented in the litera-ture,^' '̂ -̂ * the extent to which it is able to reduce and eliminate drug abuse is notas well established and is becoming an issue of increasing concern. ̂ ^ This studyfocuses on the extent of continued drug abuse, the types of drugs used, and thedemographic, biographic, and personality correlates of patients who continue toabuse drugs while on methadone maintenance.

The Treatment ProgramThe methadone maintenance treatment program at the Veterans AdministrationHospital, Sepulveda, California, opened on H January, 1971. The subject popu-lation used in the study outlined here was comprised of those patients who wereaccepted on the program between January 1971 and January 1972 (jV=163).

Eligibility RequirementsIn accord with the Federal Drug Administration guidelines for 1971, the applicantswere required to be veterans, over 24 years of age, with a documented history ofphysiological dependence on one or more opiate drugs, a confirmed history of oneor more previous treatment failures, and current evidence of physiological depend-ence (such as a dirty luine or fresh tracks or withdrawal symptoms). Infrequently,an exception was made to the last requirement in order to begin methadone main-tenance immediately after a patient was released from another institution. Patientswith major medical problems were not eligible. Initially, patients under age 24 wereencouraged to seek an alternate form of treatment, such as a therapeutic conmiunity,but the minimum age was finally set at 18 years by the Federal Drug Administration.In the early months of the program, patients with evidence of thought disorder

* The authors would like to express their appreciation to Dr. Elaine Holmes andR. Patterson, C. Dardcn and M. Zamora of the V.A. Hospital, Sepulveda, and Dr.William McGlothlin of the Psychology Department at U.CX.A., for their assistance.

f The research was conducted while the first author vfa& a clinical psychology traineeon the Methadone Ward at the V.A. Hospital, Sepulveda, and while the second authorwas supported by U.S.P.H.S. prcdoctoral fellowship #2 FOl MH 4559-03DA.

173

174 Susan Price and Kay Jamison

and/or a history of psychiatric hospitalization were not eligible, but this requirementwas relaxed by the end of the first year.

Staff, Program, and FacilitiesPatients who were eligible for maintenance spent approximately 21 days as in-patients. During this period they were stabilized on a methadone dosage level notexceeding 120 milligrams. As soon as adequate staff was available, the inpatientswere required to attend daily one-hour group therapy sessions led by a team ofpsychologists, social workers, and ex-addict counselors. Rehabilitative servicesincluded individual and conjoint psychotherapy, crisis intervention and vocationalguidance, as well as job and education placement. These services continued to beoffered when the patients were discharged to outpatient status.

As outpatients, the men were required to come in daily for their supervised doseof methadone. In addition, they were required to attend a one-hour group therapysession once a week. Mandatory group therapy was dropped at the end of the firstyear in favor of individual case contact with the treatment team.

Urine Surveillance. Supervised urine samples were collected at least once a weekand analyzed for methadone, morphine, quinine, cocaine, barbiturates, amphet-amines, and unidentified compounds. After 90 days without a single urine positivefor morphine a patient could qualify for three-day-weekend take-home doses ofmethadone. As a disciplinary measure, if a patient slipped back into abuse ofmorphine, barbiturates, or amphetamines the weekend pri\'ileges were revoked untilthe urinaiyses showed no further evidence of drug abuse. For some chronic drugabusers, daily urines were collected to monitor their progress and to put pressure onthem to stop using drugs. If the drug abuse continued the patient was detoxified andsuspended from the program until he seemed motivated to stop using drugs. Nopatients were permanently discharged from the maintenance program for drugabuse during the first year. Patients who were arrested and jailed were temporarilysuspended from the program to serve their sentence and then readmitted, unless thesentence required long-term incarceration.

During the first year of the methadone maintenance program a total of 163patients were treated; 101 of these patients were on the program for six months ormore. Ofthe 163 addicts treated, two were sent to jail (one for a pre-methadonearrest, the other for a post-methadone charge); four were detoxified; four weretransferred to other programs; and three died (two from homicide, one from anaccidental head injury).

Analysis MetkodGroup SelectionFor purposes of analysis, three groups of addict outpatients were distinguished. Thefirst, the total sample, comprised all addicts who were on the methadone main-tenance program for any period of time between 11 January, 1971 and 11 January,1972 (JV=163). The average number of months as an outpatient for this groupwas 7 1. The second group, designated as No Drug Abuse, was made up of all thoseaddicts who had been on the program for at least six months and who had neverhad a urine pcaitive for morphine, barbiturates, amphetamines, or cocaine (jV=37);

Correlates and Extent of Drug Abuse on a Methadme Maintenance Program 175

for this group the average number of months as an outpatient was 9-2. The thirdand final group, Drug Abusers, comprised all those patients who had been on theprogram at least six months and who had more than 10 per cent of their urinesamples positive for morphine and/or barbiturates, amphetamines, and cocaine(jV=27). The average number of months as an outpatient for this group was 8*1;the average percentage of dirty urines was 19-8 with a range of 10-9'-40-0 per cent.Although the No Drug Use subjects were on the program an average of one monthlonger than the Drug Abusers, the average number of urine samples taken for bothgroups was virtually the same (37-6 and 36-5 respectively); this is a result ofincreased surveillance for patients reporting positive for drug use.

Analysis of Urine Reports

Urine samples, as explained earlier, were taken from the patients on a randombasis, roughly once a week. Our analysis includes only those urine reports takenfrom January 1971 through March 1972. The patients in the total sample were onoutpatient basis for an average of 7-1 months and had an average of 30-3 urinestaken, thus giving an average of 4 3 urines per patient per month. The generalprocedure in analyzing the urine reports was to disregard antibiotics, tranquilizers,unidentified substances, and heroin cutting agents such as quinine, unless there wasa positive morphine association. This latter decision was based on the ward doctor'sassumption that quinine might be a result of gin and tonic, although the probabiiityof this is admittedly low. No tests for alcohol use were done. Given these proceduresof analysis, coupled with weekly urine samples, the estimate of dirty urines may bespuriously low. For example, ignoring quinine may also result in ignoring thepossibility that low-grade heroin, not picked up by the urinalysis, was used; likewise,ignoring unidentified compounds might result in ignoring some other types of drugabuse. However, the assumption was made here that it is desirable to be certain ofthe specific drug involved, while keeping in mind that this could conceivably affectthe results.

Sources of DataBasic demographic data were obtained from the patients' medical and personaldrug use histories, and the data on drug usage were obtained from the urinalysesdescribed above. Additionally, most of the addicts (147 of the 163, or, all of theaddicts who were still on the program at the end of the first year) were given a briefself-administered questionnaire which tapped information about arrest and employ-ment records prior to coming on the methadone program, how successful they feltthe methadone program had been for them, history of other drug treatments, reasonsfor coming on the program, and how much longer they expected to be on methadone.Eighty-eight per cent of the questionnaires were returned; this incomplete returnrate, along with incomplete biographical data on the patients, resulted in varyingJV's for some of the variables. Graphs 1 and 2 were based on data fi-om the total

sample.In addition to these sources of data, ex-addict counselors were asked to evaluate

each of the patient's success on methadone maintenance as measured by the

176 Susan Price and Kay Jamison

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Correlates and Extent of Drug Abuse on a Methadone Maintenance Program 111

foUowing two criteria: (1) overall success on the program {personal happiness,employment, family relations, making new friends, health, etc.), and (2) continueddrug use. For the first criterion a seven-point rating scale was used, ranging fromDramatic Worsening to Dramatic Improvement. For the second criterion, a five-point response scale was used, with responses ranging from Strongly committed tocontinued drug abuse to Strongly committed to staying clean.

One final source of data were scores on Rotter's Internal-External (I-E) scale.The I-E scale is designed to measure generalized expectations that the individualcan exercise control over his outcomes versus expectations that control overoutcomes is a function of chance or other external forces. This inventory has beenfound to be correlated with success in a treatment program with alcohoHcs. TheI-E scales were given to 118 subjects, or 72-4 per cent of the addicts on themethadone program.

ResultsDemographic, Biographic, and Personality VariablesBasic demographic and biographic data can be summarized in the following way.There were virtually no differences between the non-drug using sample and thedrug abusers on the following variables: age, number of years using heroin, age ofinitial heroin use, strength of former heroin habit, I.Q,., years of education, numberof arrests in the year immediately prior to starting on the methadone program,I-E score, and the amount of time the addicts expected to remain on the program.Interestingly, the majority of all ofthe addicts stated they expected to remain onmethadone maintenance less than two years. There was no significant differencebetween the two groups on the average methadone dosage level; however, 7-4 percent ofthe drug abusers were on maintenance dosages of 50 mg. or less, as comparedwith 2-7 per cent in the non-drug using group.

On those variables where there were significant differences between the groups,the results can best be summarized by stating that those addicts who were on theprogram six months or longer and who did not use drugs were more likely thanthose in tbe drug using group to: (1) be married {p < 0-05), (2) to have had moreoverdoses from heroin prior to coming on the program (p < 0-05); and (3) to havebeen employed more months of the year just prior to starting methadone main-tenance (p < O-OI) and, after starting the program, they were more likely to beemployed (p < 0-05).

There were no significant differences between the groups on either of thecounselor ratings or on the addicts' own evaluations of their gains from the program.

Drug Abuse on the ProgramFor the total sample there was an average of 7-4 per cent urines positive for drugabuse, including amphetamines, barbiturates, and cocaine, as well as morphine.Two-thirds of the addicts never showed a urine positive for morphine and, of theremaining one-third, roughly one-half (46-2 per cent) of them showed positive formorphine only once. Graph 1 shows the number of patients with positive morphinesas a function of number of weeks on the program. It can be seen that initial morphineabuse peaked at weeks 1-4 (22-2 per cent) with another slight peak at weeks 9-12

178 Susati Price and Kay Jamison

(16-7 per cent); altogether, almost one-half (48-2 per cent) ofthe initial morphineabuse (i.e. the first time the patient was positive for morphine) occurred in weeksi-12, or roughly the first three months on the program. There was virtually noabuse after week 28, or six to seven months after starting on methadone. Graph 2shows the percentage of patients positive for morphine as a function of programmonth, starting with January 1971. With the exception of March of 1972, whichshowed at 16-4 per cent morphine abuse rate—probably due to the fact that duringthis month the methadone program moved its facilities from one part of the hospitalto the other—the morphine abuse rate stabilized at under 10 per cent. The urinereports were also analyzed by checking days ofthe week on which positive morphineswere found; the results indicated that there were slightly more dirty urines onTuesdays and Thursdays but that these frequencies were not significantly different.

Approximately one-fourth ofthe total sample (26-6 per cent) had used amphet-amines and one-fourth (25-9 per cent) had used barbiturates after having started onthe program. There was some degree of overlap between these two groups, as36-5 per cent of those who had used either of the drugs had used both of them.Cocaine had been used by 15 per cent ofthe addicts. Almost one-half of the totalsample of 161 patients (46-0 per cent) had never had a dirty urine for any drug,and of those on the program for at least six months (JV*=101), 37 per cent hadremained totally clean.

DiscussionThe results of this study give some indication of the ability of methadonc main-tenance to reduce and, in most cases, eliminate heroin use. With the exception ofthe month of March, 1972, the morphine abuse rate stabilized at considerably lessthan 10 per cent during the first year ofthe program, with two-thirds ofthe patientsnever turning in a urine positive for morphine. Nearly one-half of the heroin useoccurred during the first three months of treatment, and then was virtually absentafter a patient remained on the program for at least six months.

As for abstinence from drugs other than methadone, the results of this studyshow that the urinaiyses for nearly one-half (46-0 per cent) ofthe patients did notdetect any use of heroin, barbiturates, amphetamines or cocaine; of the totalsample, the urinaiyses indicated that 33 per cent used morphine at one time oranother, although only ll-l per cent had used it three times or more. Roughlyone-fourth ofthe sample had used barbiturates after having started on the program.Cocaine was used by 15 per cent of the addicts. As with morphine, only a smallpercentage ofthe subjects had used these drugs more than once, indicating that themajor bulk ofthe reported abuse was probably experimental in nature, rather thanbeing a persistent pattern of abuse.

A Drug Abuser in this study was defined as a patient who had at least 10 per centofhis urine reports positive for drugs other than methadone. Approximately 25 percent of the addicts on the program for six months or longer fell into this category.Non-Drug Users, those addicts with no positive urines, comprised 37 per cent ofthesample on the program for at least six months. In contrasting the two groups, wefound that the Non-Drug Users were significantly more likely than their drug-takingcounterparts to be married, to have had more heroin overdoses, and to have had a

Correlates and Extent of Drug Abuse on a Methadone Maintenance Program 179

more promising employment history. These findings are similar to those reportedby Wilson who found that success on the California civil addict program wascorrelated with marital status and previous employment record.^

Our study revealed no significant difference in the average methadone dosagelevel between the two addict groups, although there was a higher percentage ofDrug Abusers on dosages of 50 mgs. or less. This is consistent with the findings ofWeiland and Moffett (1970) who found that low maintenance dosages are associatedwith higher rates of drug abuse. ̂

The results of this study seem to have some implications for future studies whichattempt to evaluate the ability of methadone maintenance to reduce drug abuse.During the month of March, 1972, the heroin abuse rate on this program nearlydoubled. At this time the ward was moved to a new location in the hospital, andmandatory group therapy was dropped in favor of individual case contact with thetreatment team. It is possible that the patients may have thought that urinesurveillance would not be as strict and thus felt freer to experiment with drugs.Previous evaluation studies have not examined the effects of program variables, andthus results such as these may have been overlooked. Since changes in location,policy, or staff members may affect the amount of drug abuse, it seems importantthat programs keep a history of any significant changes which occur over time. Ingeneral, the few existing studies that have looked specifically at the problem ofcontinued drug abuse have been conducted in quite different treatment settings,with different staff and patient populations, over varying periods of urine sur-veillance, with varying criteria for what constitutes "drug abuse", and at differentpoints in the history of a given program. Variations along these dimensions makecomparisons across studies difficuU, and impede arriving at a clear understandingof how much drug abuse typically occurs on a methadone maintenance program.

References1. Doi-E, V. P., NYSWANDER, M . E . and WARNER, A. W. Successful Treatment of

750 Criminal Addicts. J.A.M.A., 206, 2708-2711, {Dec. 16) 1968.2 DOLE, V. P. and NYSWANDER, M . Rehabilitation of Heroin Addicts after Blockade

with Methadone. Xew Tork State J. of Medicine, 66. 20U-2017, 1966.3. GEARING, F . R . Success and Failures in Methadone Maintenance Treatment of

Heroin Addiction in New York City. Proceedings of the Third National Conference onMethadone Treatment, Nov. 1970, pp. 2-16.

4. WEILAND, W . F . and CHAMBERS, C . D . Methadone Maintenance: A Comparison ofTwo Subilization Techniques. Intemational J. Addictions, 5{4), 645-649 {Dec, 1970).

5. CHAMBERS, C . D . and TAYLOR, W . J. R. Patterns of "Cheating" among MethadoneMaintenance Patients, for presentation at the Eastern Psychiatric Association Inc.Fourteenth Annual Meeting, 1970, New York City.

6. DoBBS, W. H. Methadone Treatment of Heroin Addiction, J.A.M.A., 218, 1536-1540, {Dec. 6) 1971. , . ^ ^

7. HOLMES, E . A Comparison of Three Aversive Condiuoning Paradigms m the ireat-ment of Alcoholism. Unpublished Doctoral Dissertation, 1971.

8. WILSON, B. D . A Pilot Study Investigating Three Groups of Cahfornia s Civil Addicts.Mimeographed paper, August, 1969. , , , , ^

9. WEILAND, W . F . and MOFFETI, A. D. Results of Low Dosage Methadone Ireatment.Proceedings ofthe Third National Conference on Methadone Treatment, Nov. 1970, pp. 48-49.