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Prediction of long-term outcome for heroin addicts admitted to a methadone maintenance program
Drug and Alcohol
Dependence,
10 (1982)
383
383 - 391
PREDICTION OF LONG-TERM OUTCOME FOR HEROIN ADDICTS ADMITTED TO A METHADONE MAINTENANCE PROGRAM
BARBARA
A. JUDSON
Addiction
Research
(Received
October
and AVRAM
Foundation,
GOLDSTEIN
Palo Alto,
California
94304
(U.S.A.)
5, 1982)
Summary Ten pre-treatment and nine during-treatment variables were correlated to outcome 5 years after admission to a methadone program for 171 subjects who were in treatment for at least 6 months. The pre-treatment variables were employment, education, criminal involvement, opiate and non-opiate drug abuse, periods of abstinence, age, sex, and ethnic group. During-treatment variables were employment, arrests or incarcerations, opiate and nonopiate drug abuse, living with an addict, marital status, and months of methadone treatment. Three measures of ‘successful’ outcome were defined. In general, subjects with more involvement with criminal justice before treatment, heavy alcohol use before or during treatment, continued daily heroin use or living with an addict during treatment, or minority ethnicity were more likely to have a poor outcome. However, the correlation coefficients for even the most significant correlations were weak; the highest was r = 0.26. We conclude that none of these 19 variables provide a basis for a priori judgment about whether or not a patient applying for admission to a methadone program is likely to have a favorable long-term outcome.
Introduction When a heroin addict presents himself or herself for methadone treatment, it is of interest to know if there are predictors of outcome. Some patients will drop out quickly, others will remain in treatment for years. Some will rapidly relapse to a pattern of frequent heroin use, others will abstain for prolonged periods. Is there any way to tell, at admission, which type of patient will succeed and which will fail? Years later, we all know, some have done extraordinarily well, indeed have put the addict life-style and heroin use behind them. For others, methadone treatment is merely a passing phase, without much influence on their life-styles or drug abuse patterns. If one could tell from admission history or from progress during treatment if a 0376.8716/82/0000-0000/$02.75
@ Elsevier
Sequoia/Printed
in The Netherlands
384
patient was likely to have a good or bad outcome, perhaps treatment intervention could be tailored more specifically to that patient. In the present study we examine the correlation between various possible predictors of success and several outcome measures 5 years after admission to treatment. We found no very useful predictors of treatment success.
Method The data used here are from 171 subjects interviewed 5 years after starting treatment in the Santa Clara County (California) methadone maintenance treatment program. This group was from a random sample of 188 of the first 799 patients admitted when the program began in 1970, 17 having been excluded because they were in methadone treatment less than 6 months. Results of the 5-year follow-up study and descriptive data on the random sample have been presented [ 11. During the 5-year follow-up interview, information was obtained on drug use, employment, living situation, marital status, arrests and imprisonments, education, treatments for drug abuse, age, sex, and ethnicity. The information was gathered retrospectively, as a life history, from age 12 (or first drug use) to the time of interview. Data were recorded on a calendar year basis, unless the subject could remember specific months when events and activities occurred or changed. A ‘most-of-the-year’ rule was generally applied. Thus, if a status or activity occurred during six months or more of a calendar year, it was entered for that year, otherwise not. However, a more conservative criterion was applied to arrests or incarcerations and to heroin use. Even a single arrest or incarceration was entered; and daily heroin use for a month or more was entered as daily use for the entire calendar year. In general, subjects could remember activities or events on a monthly basis only during the year or so prior to the follow-up interview. Information that referred to the pre-treatment or treatment period was checked against treatment files, and was corrected if the discrepancy from the subject’s recollection was well documented. The data gathered in these interviews were divided into two distinct periods: the first, or variable duration, from age 12 (or first drug use) to the time of admission to treatment; and the second, of approximately 5 years, from admission to the time of the follow-up interview. The mean elapsed time after the 5-year anniversary date of entering the program at which interviews were done was 2.7 months (median 1 month, range 1 to 28 months). For the first period, we considered 10 pre-treatment variables: months of heroin use since first daily use; months abstinent from heroin while at risk in the community (since first daily use); months employed; months in school; months of heavy alcohol use’; number of arrests; months in jail or prison; age at admission; sex; and ethnicity. ’ Defined as five or more drinks daily, or 12 or more drinks daily 3 One drink
is considered
to be 12 oz. beer,
4 oz. wine,
or 1.5 oz. distilled
4 times spirits.
a week.
385
The 5-year period between admission to methadone treatment and the follow-up interview was divided into periods in treatment and periods not in treatment. For the years during which the subject was in treatment 6 months or more, nine during-treatment variables were considered. Seven of these were based on percent of time for the following activities: employment; living with an addict; incarceration; daily heroin use; heroin use less than daily (‘chipping’); heavy alcohol use’; and heavy use of non-opiate drugs2. The other two during-treatment variables were months of methadone treatment and whether or not married (including common-law marriage). When recalling past events, people tend to organize their memories by calendar year, according to the conventional time markers such as seasons, months, and holidays. The follow-up life-history interview was therefore structured by calendar year. For data analysis, however, we wished to compare subjects over comparable periods of time with respect to treatment, such as the year prior to admission, or the year prior to interview (i.e., the 5th year after admission). The transformation was carried out according to the same ‘most of the year’ rule as in the original data collection, and with the same exceptions, i.e., a month or more of daily heroin use was coded as daily use for the entire calendar year, and each arrest or incarceration was recorded. Three definitions of ‘success’ were used as dependent variables, and were correlated with the pre-treatment and during-treatment variables: (a) Abstinent Since Treatment (AST). Seventeen subjects who had no heroin use, arrests, or incarceration time, or admissions to any treatment program for drug abuse since leaving methadone treatment (mean If:SEM = 2.2 + 0.3 yr, range 1 - 5 yr) were compared to the 123 subjects who had used heroin or had an arrest or incarceration during the year prior to interview. The remaining 31 subjects (of the 171 in the sample) were abstinent from opiates at follow-up, but had not been abstinent for the whole time since leaving treatment. (b) Heroin Score (HS). Heroin use during the year prior to the followup interview was scored as follows: 0 = no use most of the year; 1 = some use, less than daily for 6 months or more; 2 = daily use for one month or more. Of the 171 subjects, 24 who were incarcerated 6 months or more of this year (and therefore not ‘at risk’) were excluded. (c) Global Outcome Score (GOS). This is a total score for the year prior to the follow-up interview, based on the following arbitrary partial scores:
‘See footnote 1, page 384. 2 Defined as follows: barbiturates and tranquilizers, 20 or more pills 3 - 4 times or more per week; amphetamines, $40 or more spent daily 3 - 4 times or more per week; marijuana, 20 or more ‘joints’ 3 - 4 times or more per week.
386 Daily heroin use for one month or more (Alternatively): Less than daily heroin use, most of year Living with an addict, most of year Arrest (no incarceration) during year Incarceration, number of months x 3 (minimum score 10) Unemployed, most of year In treatment for drug abuse, ever during year Heavy alcohol use, most of year (see footnote 1, p. 384) Heavy use of non-opioid drugs, most of year (See footnote 2, p. 385) Possible
range of scores
20 10 10 10 10 5 5 5 5
- 36
0 -96
Data analysis was carried out as follows. Since the number of patients belonging to ethnic groups other than Caucasian or Spanish-surname was very small (4% Black, 3% other), they were eliminated from the analysis of ethnicity and outcome. Subjects abstinent since leaving treatment (AST) were compared to those with heroin use or arrest or incarceration in the year prior to interview by means of Wilcoxon two-sample rank tests for all continuous variables, chi-square analysis for discrete variables (marital status, sex, ethnicity). The relationship between heroin scores (HS) or global outcome scores (GOS) on the one hand, and pre-treatment or during-treatment continuous variables on the other, was estimated by Spearman rank correlations. For discrete variables (marital status, sex, ethnicity), Wilcoxon twosample rank tests were done. ‘Statistical significance’ was defined asp < 0.05.
Results Analysis
1
This analysis compared the best outcomes with the worst: subjects abstinent and without arrests or incarceration since leaving treatment (AST group, N = 17) versus subjects who used heroin or were arrested or incarcerated during the previous year (N = 123). In the pre-treatment period, the AST group had differed significantly in the following respects but in no other: (a) Less criminal activity, as measured by the number of times arrested or incarcerated or by the total time incarcerated (p < 0.05); (b) Less heavy alcohol use (p < 0.05); (c) More likely to be of Caucasian ethnicity (p < 0.01). During treatment, the AST group had significantly less daily heroin use 0, < 0.05). Analysis 2
This analysis examined the within-subjects correlation for 147 subjects between heroin scores (HS) during the year prior to interview and all the pretreatment and during-treatment variables. This analysis excluded 24 subjects who were incarcerated for 6 months or more during that year. No significant correlations were found with pre-treatment variables, and the only during-
387
treatment variable significantly correlated with HS was daily heroin use (r = 0.22, p < 0.01). A separate analysis for 65 subjects who had not been incarcerated and also had no treatment for drug abuse during the year prior to interview revealed no significant correlations at all. Analysis 3 Finally, this analysis examined the within-subjects correlation of global outcome score (GOS) with the pre-treatment and during-treatment variables. For the total sample of 171, total time incarcerated during the pre-treatment period was significantly and positively correlated with GOS (r = 0.18, p < 0.05), i.e., the more time incarcerated before treatment, the worse the eventual outcome. Subjects of Caucasian ethnicity were more likely 0) < 0.01) to have lower GOS. Of the during-treatment variables, the significant correlations were living with an addict (r = 0.26, p < 0.01); daily heroin use (r = 0.19, p < 0.02); arrests or incarcerations (r = 0.19, p < 0.02); and heavy alcohol use (r = 0.17, p < 0.05). For the special subset of 65 subjects (see analysis 2 above), heavy alcohol use in the pretreatment period correlated significantly (r = 0.24, p = 0.05) with GOS. As in the analysis of the total group, subjects of Caucasian ethnicity were significantly more likely to have a better outcome (p < 0.05) than those with Spanish surnames. No significant correlations were found with the during-treatment variables. Comparison of pre-treatment variables of the 17 subjects who dropped out of methadone treatment in less than 6 months and the 171 who had 6 months or more of treatment showed that the 17 differed only in having significantly fewer months of employment (p = 0.01).
Discussion The results of this investigation indicate that for a heroin addict who remained in methadone treatment at least 6 months, there were three predictors of a poor outcome 5 years later. These were heavy alcohol use and criminal activity (as measured by the number or durations of incarcerations) in the pretreatment period, and minority ethnicity (Spanish surname). During the treatment period, continued daily heroin use, heavy alcohol use, and living with an addict were the only predictors of a poor outcome. Previous follow-up studies of methadone patients have produced various, and often contradictory, predictors of successful outcome. In a study of 38 successfully detoxified patients, Riordan et al. [ 21 found that the group who were opiate-abstinent at follow-up were more likely to have been unemployed, and to have had a shorter course of addiction, more involvement with criminal justice, and less education in the pre-treatment period than the group of patients who relapsed. The opiate-abstinent patients were also more likely to be Black and had been maintained on methadone longer than those who relapsed.
388
Pugliese et al. [ 31 compared patients who detoxified from methadone maintenance with staff consent (group 1) and without staff consent (group 2). Of the group 1 patients, 80% were opiate-abstinent at follow-up, compared to only 10% in group 2. Group 1 patients had a shorter history of incarceration prior to admission to the program than did group 2 patients, and had a higher rate of employment and fewer heroin-positive urine tests while in treatment. Patients in group 1 were in treatment nearly twice as long as those in group 2. Stimmel et al. [4] did a multivariate analysis of return to narcotic use after detoxification, using the following admission variables: age, sex, family composition, education, employment status, and years of drug use. Reason for detoxification (with or without staff approval, jail, violation of rules), and time in treatment were also used in the analysis. The results showed that the most important variable in estimating risk of relapse was reason for detoxification, with patients not completing treatment running a 5fold higher risk of relapse than patients who completed treatment. Lower age at admission and shorter duration of treatment were significantly but less importantly related to relapse. Smart et al. [ 5 ] found employment at admission to be positively correlated with a favorable outcome at follow-up, and Simpson [6] reported that employment in the post-treatment period was associated with lower opioid drug use and less criminal involvement. Employment during treatment, absence of behavioral problems during treatment, and time in treatment were positively correlated with opiate abstinence in the three-month period prior to follow-up in Dole and Joseph’s study [ 71, while duration of heroin use and criminality in the pre-treatment period were positively and significantly correlated with relapse. In a follow-up evaluation of patients admitted to methadone programs which were part of DARP (Drug Abuse Reporting Program), Simpson et al. [ 81 reported that favorable outcome after treatment was significantly related to older age at admission, less pre-treatment criminality, less during-treatment social deviance, and longer time in treatment. Cushman [9], on the other hand, found no relationship of outcome to time in treatment in a group of therapeutically detoxified patients (supportive detoxification with staff approval). As in the study of Stimmel et al. [4], a considerable time in treatment was prerequisite to staff approval Nor was outcome related to duration of addiction before treatment, manifest alcoholism before or during treatment, or marital status at the completion of detoxification. Patients who were employed during detoxification were more likely to have a favorable outcome. In a second follow-up study of several New York methadone programs, Cushman [lo] did find an effect of treatment duration on outcome at followup, with methadone treatment of at least 3 years duration being more often associated with successful outcome than were shorter durations of treatment. Again, steady employment during treatment was strongly associated with favorable outcome.
389
Des Jarlais and Joseph [ 111 found a strong positive correiation between alcohol use at admission and alcohol use during treatment, and also between alcohol use during treatment and after discharge. However, they found no relationship between alcohol use and opiate use for any of the time periods. In 1962 Winick [12] advanced a theory based on arrest records of known addicts, that a ‘maturing-out’ process occurred, i.e., that heroin addicts tended to give up heroin as they got older. Several other studies provided evidence that supported this view [ 13 - 161, but few follow-up studies of methadone patients have found a relationship between cessation of heroin use and age. Whitman et al. [17], in a 5-year prospective follow-up study of nonprisoner admissions to the Clinical Research Center at Lexington, Kentucky, found no pre-treatment or ‘current-state’ (at follow-up) variables that were related to relapse or opiate abstinence after leaving treatment. Pre-treatment variables examined were education; criminal history; psychiatric family history; ‘dependence process’ variables (e.g., job problems, overdoses, family problems, hospitalizations, legal problems, length of addiction); age; sex; and ethnicity. ‘Current-state’ variables included employment; marital status; children; craving for opiates; recent losses of family or friends; and loss of control. Duration of treatment was also included in the analysis. In the present study various pre-treatment variables often considered to be predictive of treatment success or failure were found to have no predictive value. Among these were employment status, total previous amount of heroin use, and age. Among the during-treatment variables it is interesting that employment status, marital status, arrests or incarcerations, use of nonopioid drugs, and even occasional heroin use were without value in predicting outcome. Duration of methadone maintenance treatment had no relationship to outcome. However, this should not be misinterpreted. Some patients who leave treatment early are responding poorly (e.g., are continuing to use heroin, or are terminated for disciplinary reasons), but others are doing well and detoxify deliberately in order to attempt abstinence. Moreover, in this methadone program, patients were encouraged to detoxify when they felt the time was ripe, and they were guaranteed immediate readmission if relapse to heroin use occurred. The resulting mixed pattern of motivation for early termination may account for the lack of a relationship between treatment duration and ultimate outcome. We draw the following conclusions from this study: (a) No a priori judgments should influence the decision to admit an applicant for methadone maintenance treatment, since there are so few predictors of outcome. Even the few predictors that are statistically significant are weak. Thus, even for the highest correlation coefficient found here (r = 0.26), only 7% of the variance would be accounted for by the correlation; consequently, the prediction would be wrong nearly as often as by chance. (b) A history of heavy alcohol use, or heavy drinking during treatment, are warnings of poor global outcome as well as of poor outcome from the
390
standpoint of abstinence from heroin. This suggests that the alcohol problem should be dealt with at the same time as the heroin problem, perhaps by giving disulfiram (Antabuse), when indicated, together with the daily methadone. (c) Since criminal activity, as measured by number and duration of incarcerations, was a predictor of poor outcome, one could argue that with facilities and budgets limited, effort should be concentrated on those without a criminal background, who are most likely to benefit. The contrary argument could be made that rehabilitative efforts should be concentrated on those with the worst criminal records; but there is no evidence as to whether or not such efforts would be effective. From the standpoint of maximum benefit to society, attempts should certainly be made to retain the worst criminals in methadone treatment, since the evidence is strong that their total crimes and the dollar value of their crimes decrease when their use of heroin decreases [18 - 211. (d) That living with an addict during treatment was predictive of poor outcome confirms common sense clinical judgment, which holds that both members of an addicted couple should be treated simultaneously.
Acknowledgement
This investigation was supported Institute on Drug Abuse.
by grant DA-973 from the National
References 1 B. A. Judson, S. Ortiz, L. Crouse, T. M. Carney and A. Goldstein, A follow-up study of heroin addicts five years after first admission to a methadone treatment program. Drug Alcohol Depend., 6 (1980) 295. 2 C. E. Riordan, M. Mezritz, F. Slobetz and H. D. Kleber, Successful detoxification from methadone maintenance. J. Am. Med. ASSOC., 235 (1976) 2604. 3 A. C. Pugliese, A. Maselli, D. J. Hess and A. Leone, Detoxification of methadone maintenance patients: A follow-up study. Drug Forum, 5 (1977) 359. 4 B. Stimmel, J. Goldberg, M. Cohen and E. Rotkopf, Detoxification from methadone maintenance: Risk factors associated with relapse to narcotic use. Ann. N. Y. Acod. Sci., 311 (1978) 173. 5 R. Smart, A. Everson, R. Segal, J. Finley and B. Ballah, A four-year follow-up study of narcotic-dependent persons receiving methadone maintenance substitution therapy. Can. J. Public Health, 68 (1977) 55. 6 D. D. Simpson, Employment among opioid addicts during a four year follow-up after drug abuse treatment. J. Drug Issues, 11 (1981) 435. 7 V. P. Dole and H. Joseph, Long-term outcome of patients treated with methadone maintenance. Ann. N. Y. Acad. Sci., 311 (1978) 181. 8 D. D. Simpson, L. J. Savage and M. R. Lloyd, Follow-up evaluation of treatment of drug abuse during 1969 to 1972. Arch. Gen. Psychiatry, 36 (1979) 772. 9 P. Cushman, Methadone maintenance: Long-term follow-up of detoxified patients. Ann. N.Y. Acad. Sci., 311 (1978) 165.
391
Jr., Detoxification after methadone maintenance treatment. Ann. IV. Y. 362 (1981) 217. 11 D. C. Des Jarlais and H. Joseph, Long-term outcomes after termination from methadone maintenance treatment. Ann. N.Y. Acad. Sci., 362 (1981) 231. 12 C. Winick, Maturing out of narcotic addiction. Bull. Narcotics, 14 (1962) 1. 13 G. H. Hunt and M. E. Odoroff, Follow-up study of narcotic drug addicts after hospitalization. Public Health Rep., 77 (1962) 41. 14 R. Stephens and E. Cottrell, A follow-up study of 200 narcotic addicts committed for treatment under the Narcotic Addict Rehabilitation Act (NARA). Br. J. Addicf., 6 7
10 P. Cushman, Acad.
(1972) 15
16 17
18
19 20 21
Sci.,
45.
M. Snow, Maturing out of narcotic addiction in New York City. Int. J. Addict.. 8 (1973) 921. J. F. Maddux and D. P. Desmond, New light on the maturing-out hypothesis in opioid dependence. Bull. Narcotics, 32 (1980) 15. B. Y. Whitman, J. L. Croughan, J. P. Miller and J. McKay, Nonpsychiatric predictors of narcotic dependence: A prospective study with a 5-year follow-up. Int. J. Addicf., 17 (1982) 473. J. F. Maddux and D. P. Desmond, Crime and treatment of heroin users. Int. J. Addicf.. 14 (1979) 891. D. K. Sechrest, Methadone programs and crime reduction: A comparison of New York and California addicts. ht. J. Addict., 14 (1979) 377. W. H. McGlothlin, M. D. Anglin and B. D. Wilson, Narcotic addiction and crime. Criminology, 16 (1978) 293. J. C. Ball, L. Rosen, J. A. Flueck and D. N. Nurco, The criminality of heroin addicts when addicted and when off opiates. In J. A. Inciardi (ed.), The Drugs-Crime Connection, Sage Publications, Beverly Hills, 1981, ch. 2.
Dependence,
10 (1982)
383
383 - 391
PREDICTION OF LONG-TERM OUTCOME FOR HEROIN ADDICTS ADMITTED TO A METHADONE MAINTENANCE PROGRAM
BARBARA
A. JUDSON
Addiction
Research
(Received
October
and AVRAM
Foundation,
GOLDSTEIN
Palo Alto,
California
94304
(U.S.A.)
5, 1982)
Summary Ten pre-treatment and nine during-treatment variables were correlated to outcome 5 years after admission to a methadone program for 171 subjects who were in treatment for at least 6 months. The pre-treatment variables were employment, education, criminal involvement, opiate and non-opiate drug abuse, periods of abstinence, age, sex, and ethnic group. During-treatment variables were employment, arrests or incarcerations, opiate and nonopiate drug abuse, living with an addict, marital status, and months of methadone treatment. Three measures of ‘successful’ outcome were defined. In general, subjects with more involvement with criminal justice before treatment, heavy alcohol use before or during treatment, continued daily heroin use or living with an addict during treatment, or minority ethnicity were more likely to have a poor outcome. However, the correlation coefficients for even the most significant correlations were weak; the highest was r = 0.26. We conclude that none of these 19 variables provide a basis for a priori judgment about whether or not a patient applying for admission to a methadone program is likely to have a favorable long-term outcome.
Introduction When a heroin addict presents himself or herself for methadone treatment, it is of interest to know if there are predictors of outcome. Some patients will drop out quickly, others will remain in treatment for years. Some will rapidly relapse to a pattern of frequent heroin use, others will abstain for prolonged periods. Is there any way to tell, at admission, which type of patient will succeed and which will fail? Years later, we all know, some have done extraordinarily well, indeed have put the addict life-style and heroin use behind them. For others, methadone treatment is merely a passing phase, without much influence on their life-styles or drug abuse patterns. If one could tell from admission history or from progress during treatment if a 0376.8716/82/0000-0000/$02.75
@ Elsevier
Sequoia/Printed
in The Netherlands
384
patient was likely to have a good or bad outcome, perhaps treatment intervention could be tailored more specifically to that patient. In the present study we examine the correlation between various possible predictors of success and several outcome measures 5 years after admission to treatment. We found no very useful predictors of treatment success.
Method The data used here are from 171 subjects interviewed 5 years after starting treatment in the Santa Clara County (California) methadone maintenance treatment program. This group was from a random sample of 188 of the first 799 patients admitted when the program began in 1970, 17 having been excluded because they were in methadone treatment less than 6 months. Results of the 5-year follow-up study and descriptive data on the random sample have been presented [ 11. During the 5-year follow-up interview, information was obtained on drug use, employment, living situation, marital status, arrests and imprisonments, education, treatments for drug abuse, age, sex, and ethnicity. The information was gathered retrospectively, as a life history, from age 12 (or first drug use) to the time of interview. Data were recorded on a calendar year basis, unless the subject could remember specific months when events and activities occurred or changed. A ‘most-of-the-year’ rule was generally applied. Thus, if a status or activity occurred during six months or more of a calendar year, it was entered for that year, otherwise not. However, a more conservative criterion was applied to arrests or incarcerations and to heroin use. Even a single arrest or incarceration was entered; and daily heroin use for a month or more was entered as daily use for the entire calendar year. In general, subjects could remember activities or events on a monthly basis only during the year or so prior to the follow-up interview. Information that referred to the pre-treatment or treatment period was checked against treatment files, and was corrected if the discrepancy from the subject’s recollection was well documented. The data gathered in these interviews were divided into two distinct periods: the first, or variable duration, from age 12 (or first drug use) to the time of admission to treatment; and the second, of approximately 5 years, from admission to the time of the follow-up interview. The mean elapsed time after the 5-year anniversary date of entering the program at which interviews were done was 2.7 months (median 1 month, range 1 to 28 months). For the first period, we considered 10 pre-treatment variables: months of heroin use since first daily use; months abstinent from heroin while at risk in the community (since first daily use); months employed; months in school; months of heavy alcohol use’; number of arrests; months in jail or prison; age at admission; sex; and ethnicity. ’ Defined as five or more drinks daily, or 12 or more drinks daily 3 One drink
is considered
to be 12 oz. beer,
4 oz. wine,
or 1.5 oz. distilled
4 times spirits.
a week.
385
The 5-year period between admission to methadone treatment and the follow-up interview was divided into periods in treatment and periods not in treatment. For the years during which the subject was in treatment 6 months or more, nine during-treatment variables were considered. Seven of these were based on percent of time for the following activities: employment; living with an addict; incarceration; daily heroin use; heroin use less than daily (‘chipping’); heavy alcohol use’; and heavy use of non-opiate drugs2. The other two during-treatment variables were months of methadone treatment and whether or not married (including common-law marriage). When recalling past events, people tend to organize their memories by calendar year, according to the conventional time markers such as seasons, months, and holidays. The follow-up life-history interview was therefore structured by calendar year. For data analysis, however, we wished to compare subjects over comparable periods of time with respect to treatment, such as the year prior to admission, or the year prior to interview (i.e., the 5th year after admission). The transformation was carried out according to the same ‘most of the year’ rule as in the original data collection, and with the same exceptions, i.e., a month or more of daily heroin use was coded as daily use for the entire calendar year, and each arrest or incarceration was recorded. Three definitions of ‘success’ were used as dependent variables, and were correlated with the pre-treatment and during-treatment variables: (a) Abstinent Since Treatment (AST). Seventeen subjects who had no heroin use, arrests, or incarceration time, or admissions to any treatment program for drug abuse since leaving methadone treatment (mean If:SEM = 2.2 + 0.3 yr, range 1 - 5 yr) were compared to the 123 subjects who had used heroin or had an arrest or incarceration during the year prior to interview. The remaining 31 subjects (of the 171 in the sample) were abstinent from opiates at follow-up, but had not been abstinent for the whole time since leaving treatment. (b) Heroin Score (HS). Heroin use during the year prior to the followup interview was scored as follows: 0 = no use most of the year; 1 = some use, less than daily for 6 months or more; 2 = daily use for one month or more. Of the 171 subjects, 24 who were incarcerated 6 months or more of this year (and therefore not ‘at risk’) were excluded. (c) Global Outcome Score (GOS). This is a total score for the year prior to the follow-up interview, based on the following arbitrary partial scores:
‘See footnote 1, page 384. 2 Defined as follows: barbiturates and tranquilizers, 20 or more pills 3 - 4 times or more per week; amphetamines, $40 or more spent daily 3 - 4 times or more per week; marijuana, 20 or more ‘joints’ 3 - 4 times or more per week.
386 Daily heroin use for one month or more (Alternatively): Less than daily heroin use, most of year Living with an addict, most of year Arrest (no incarceration) during year Incarceration, number of months x 3 (minimum score 10) Unemployed, most of year In treatment for drug abuse, ever during year Heavy alcohol use, most of year (see footnote 1, p. 384) Heavy use of non-opioid drugs, most of year (See footnote 2, p. 385) Possible
range of scores
20 10 10 10 10 5 5 5 5
- 36
0 -96
Data analysis was carried out as follows. Since the number of patients belonging to ethnic groups other than Caucasian or Spanish-surname was very small (4% Black, 3% other), they were eliminated from the analysis of ethnicity and outcome. Subjects abstinent since leaving treatment (AST) were compared to those with heroin use or arrest or incarceration in the year prior to interview by means of Wilcoxon two-sample rank tests for all continuous variables, chi-square analysis for discrete variables (marital status, sex, ethnicity). The relationship between heroin scores (HS) or global outcome scores (GOS) on the one hand, and pre-treatment or during-treatment continuous variables on the other, was estimated by Spearman rank correlations. For discrete variables (marital status, sex, ethnicity), Wilcoxon twosample rank tests were done. ‘Statistical significance’ was defined asp < 0.05.
Results Analysis
1
This analysis compared the best outcomes with the worst: subjects abstinent and without arrests or incarceration since leaving treatment (AST group, N = 17) versus subjects who used heroin or were arrested or incarcerated during the previous year (N = 123). In the pre-treatment period, the AST group had differed significantly in the following respects but in no other: (a) Less criminal activity, as measured by the number of times arrested or incarcerated or by the total time incarcerated (p < 0.05); (b) Less heavy alcohol use (p < 0.05); (c) More likely to be of Caucasian ethnicity (p < 0.01). During treatment, the AST group had significantly less daily heroin use 0, < 0.05). Analysis 2
This analysis examined the within-subjects correlation for 147 subjects between heroin scores (HS) during the year prior to interview and all the pretreatment and during-treatment variables. This analysis excluded 24 subjects who were incarcerated for 6 months or more during that year. No significant correlations were found with pre-treatment variables, and the only during-
387
treatment variable significantly correlated with HS was daily heroin use (r = 0.22, p < 0.01). A separate analysis for 65 subjects who had not been incarcerated and also had no treatment for drug abuse during the year prior to interview revealed no significant correlations at all. Analysis 3 Finally, this analysis examined the within-subjects correlation of global outcome score (GOS) with the pre-treatment and during-treatment variables. For the total sample of 171, total time incarcerated during the pre-treatment period was significantly and positively correlated with GOS (r = 0.18, p < 0.05), i.e., the more time incarcerated before treatment, the worse the eventual outcome. Subjects of Caucasian ethnicity were more likely 0) < 0.01) to have lower GOS. Of the during-treatment variables, the significant correlations were living with an addict (r = 0.26, p < 0.01); daily heroin use (r = 0.19, p < 0.02); arrests or incarcerations (r = 0.19, p < 0.02); and heavy alcohol use (r = 0.17, p < 0.05). For the special subset of 65 subjects (see analysis 2 above), heavy alcohol use in the pretreatment period correlated significantly (r = 0.24, p = 0.05) with GOS. As in the analysis of the total group, subjects of Caucasian ethnicity were significantly more likely to have a better outcome (p < 0.05) than those with Spanish surnames. No significant correlations were found with the during-treatment variables. Comparison of pre-treatment variables of the 17 subjects who dropped out of methadone treatment in less than 6 months and the 171 who had 6 months or more of treatment showed that the 17 differed only in having significantly fewer months of employment (p = 0.01).
Discussion The results of this investigation indicate that for a heroin addict who remained in methadone treatment at least 6 months, there were three predictors of a poor outcome 5 years later. These were heavy alcohol use and criminal activity (as measured by the number or durations of incarcerations) in the pretreatment period, and minority ethnicity (Spanish surname). During the treatment period, continued daily heroin use, heavy alcohol use, and living with an addict were the only predictors of a poor outcome. Previous follow-up studies of methadone patients have produced various, and often contradictory, predictors of successful outcome. In a study of 38 successfully detoxified patients, Riordan et al. [ 21 found that the group who were opiate-abstinent at follow-up were more likely to have been unemployed, and to have had a shorter course of addiction, more involvement with criminal justice, and less education in the pre-treatment period than the group of patients who relapsed. The opiate-abstinent patients were also more likely to be Black and had been maintained on methadone longer than those who relapsed.
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Pugliese et al. [ 31 compared patients who detoxified from methadone maintenance with staff consent (group 1) and without staff consent (group 2). Of the group 1 patients, 80% were opiate-abstinent at follow-up, compared to only 10% in group 2. Group 1 patients had a shorter history of incarceration prior to admission to the program than did group 2 patients, and had a higher rate of employment and fewer heroin-positive urine tests while in treatment. Patients in group 1 were in treatment nearly twice as long as those in group 2. Stimmel et al. [4] did a multivariate analysis of return to narcotic use after detoxification, using the following admission variables: age, sex, family composition, education, employment status, and years of drug use. Reason for detoxification (with or without staff approval, jail, violation of rules), and time in treatment were also used in the analysis. The results showed that the most important variable in estimating risk of relapse was reason for detoxification, with patients not completing treatment running a 5fold higher risk of relapse than patients who completed treatment. Lower age at admission and shorter duration of treatment were significantly but less importantly related to relapse. Smart et al. [ 5 ] found employment at admission to be positively correlated with a favorable outcome at follow-up, and Simpson [6] reported that employment in the post-treatment period was associated with lower opioid drug use and less criminal involvement. Employment during treatment, absence of behavioral problems during treatment, and time in treatment were positively correlated with opiate abstinence in the three-month period prior to follow-up in Dole and Joseph’s study [ 71, while duration of heroin use and criminality in the pre-treatment period were positively and significantly correlated with relapse. In a follow-up evaluation of patients admitted to methadone programs which were part of DARP (Drug Abuse Reporting Program), Simpson et al. [ 81 reported that favorable outcome after treatment was significantly related to older age at admission, less pre-treatment criminality, less during-treatment social deviance, and longer time in treatment. Cushman [9], on the other hand, found no relationship of outcome to time in treatment in a group of therapeutically detoxified patients (supportive detoxification with staff approval). As in the study of Stimmel et al. [4], a considerable time in treatment was prerequisite to staff approval Nor was outcome related to duration of addiction before treatment, manifest alcoholism before or during treatment, or marital status at the completion of detoxification. Patients who were employed during detoxification were more likely to have a favorable outcome. In a second follow-up study of several New York methadone programs, Cushman [lo] did find an effect of treatment duration on outcome at followup, with methadone treatment of at least 3 years duration being more often associated with successful outcome than were shorter durations of treatment. Again, steady employment during treatment was strongly associated with favorable outcome.
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Des Jarlais and Joseph [ 111 found a strong positive correiation between alcohol use at admission and alcohol use during treatment, and also between alcohol use during treatment and after discharge. However, they found no relationship between alcohol use and opiate use for any of the time periods. In 1962 Winick [12] advanced a theory based on arrest records of known addicts, that a ‘maturing-out’ process occurred, i.e., that heroin addicts tended to give up heroin as they got older. Several other studies provided evidence that supported this view [ 13 - 161, but few follow-up studies of methadone patients have found a relationship between cessation of heroin use and age. Whitman et al. [17], in a 5-year prospective follow-up study of nonprisoner admissions to the Clinical Research Center at Lexington, Kentucky, found no pre-treatment or ‘current-state’ (at follow-up) variables that were related to relapse or opiate abstinence after leaving treatment. Pre-treatment variables examined were education; criminal history; psychiatric family history; ‘dependence process’ variables (e.g., job problems, overdoses, family problems, hospitalizations, legal problems, length of addiction); age; sex; and ethnicity. ‘Current-state’ variables included employment; marital status; children; craving for opiates; recent losses of family or friends; and loss of control. Duration of treatment was also included in the analysis. In the present study various pre-treatment variables often considered to be predictive of treatment success or failure were found to have no predictive value. Among these were employment status, total previous amount of heroin use, and age. Among the during-treatment variables it is interesting that employment status, marital status, arrests or incarcerations, use of nonopioid drugs, and even occasional heroin use were without value in predicting outcome. Duration of methadone maintenance treatment had no relationship to outcome. However, this should not be misinterpreted. Some patients who leave treatment early are responding poorly (e.g., are continuing to use heroin, or are terminated for disciplinary reasons), but others are doing well and detoxify deliberately in order to attempt abstinence. Moreover, in this methadone program, patients were encouraged to detoxify when they felt the time was ripe, and they were guaranteed immediate readmission if relapse to heroin use occurred. The resulting mixed pattern of motivation for early termination may account for the lack of a relationship between treatment duration and ultimate outcome. We draw the following conclusions from this study: (a) No a priori judgments should influence the decision to admit an applicant for methadone maintenance treatment, since there are so few predictors of outcome. Even the few predictors that are statistically significant are weak. Thus, even for the highest correlation coefficient found here (r = 0.26), only 7% of the variance would be accounted for by the correlation; consequently, the prediction would be wrong nearly as often as by chance. (b) A history of heavy alcohol use, or heavy drinking during treatment, are warnings of poor global outcome as well as of poor outcome from the
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standpoint of abstinence from heroin. This suggests that the alcohol problem should be dealt with at the same time as the heroin problem, perhaps by giving disulfiram (Antabuse), when indicated, together with the daily methadone. (c) Since criminal activity, as measured by number and duration of incarcerations, was a predictor of poor outcome, one could argue that with facilities and budgets limited, effort should be concentrated on those without a criminal background, who are most likely to benefit. The contrary argument could be made that rehabilitative efforts should be concentrated on those with the worst criminal records; but there is no evidence as to whether or not such efforts would be effective. From the standpoint of maximum benefit to society, attempts should certainly be made to retain the worst criminals in methadone treatment, since the evidence is strong that their total crimes and the dollar value of their crimes decrease when their use of heroin decreases [18 - 211. (d) That living with an addict during treatment was predictive of poor outcome confirms common sense clinical judgment, which holds that both members of an addicted couple should be treated simultaneously.
Acknowledgement
This investigation was supported Institute on Drug Abuse.
by grant DA-973 from the National
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