Staffing patterns of American methadone maintenance programs

Journal of Subsfance Abuse Treatment, Printed in the USA. All rights reserved.

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Vol. I, pp. 255-259,

0740-5472190

1990

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Copyright 0 1990Pergamon

REPOR T

Staffing Patterns of American Methadone Maintenance Programs DONALD A. CALSYN, PhD,*yt ANDREW J. SAXON, MD,*‘? PAUL BLAES, MA* AND SHANNON LEE-MEYER, BA*‘$ *Veterans Affairs Medical Center, Seattle, TDepartment of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and *Department of Psychology, State University of New York, Stony Brook

Abstract-Methadone maintenance is the most frequently utilized treatment for heroin addiction and also represents one of the best AIDS-prevention tools for the IV drug using population. Despite these important roles, very little has been reported about how methadone maintenance clinics are staffed. Surveys covering various aspects of program operations, including staffing, were sent to all clinics (N = 557) listed in the 1984 National Directory of Drug Abuse and Alcohol Treatment Programs. Using ANOVA, staffing patterns were compared across programs as a function of clinic size, city size, region of the country, and funding resources. While few differences were found based on city or clinic size, staffing patterns varied as a function of regional location as well as the sources of a clinic’s funding. Keywords-Methadone maintenance, staffing, drug abuse treatment, clinic administration.

(Aiken, LoScuito, Ausetts, & Brown, 1984), client retention (Brown & Breuster, 1973; Brown, Gfroerer, Thompson, & Bardine, 1985), and overall client adjustment following treatment (Ottomanelli, 1978; LoScuito et al., 1984; McLellan, Woody, Luborsky, & Goehl, 1988). Studies on counselor effectiveness have demonstrated that counselors are differently effective (McLellan et al., 1988) and counseling is superior to no counseling (Longwell, Miller, & Nichols, 1978). However, counselor effectiveness was not shown to be related to counselor training or background. Given methadone’s role as a major treatment modality, it seems instructive to extend the current line of inquiry to include an examination of the methadone maintenance staff as a constellation, in addition to the current analyses of its individual parts. With this goal in mind, questionnaires were sent to all methadone maintenance clinics listed in the 1984 National Directory of Drug Abuse and Alcohol Treatment Programs (ADAMHA, 1985). Clinics were surveyed about various aspects of operations, including staffing patterns. Differences in staffing as a function of geographic region, sources of funding, city size and clinic size were examined.

INTRODUCTION Methadone maintenance is the most commonly utilized treatment strategy for opioid addiction and represents one of the best AIDS-prevention tools for the IV drug using population (Cooper, 1989). Despite these important roles, there are few existing reports regarding the staffing patterns of methadone maintenance clinics (Ball et al., 1986; Jackman, 1973). Instead, the literature focuses primarily on professional compared with paraprofessional issues, or the role of the recovering addicted individual as a counselor. These groups have been compared numerous times across a variety of measures. These include counselors’ attitudes and expectations for their clients, as well as clients’ attitudes towards counselors (LoScuito, Aiken, Ausetts, & Brown, 1984), drug use during and after treatment Preparation of this article was supported in part by National Institute of Drug Abuse Grant #ROlDA05281 and the Medical Research Service of the Department of Veterans Affairs. This paper was presented in part at the annual meetings of Western Psychological Association, Reno, Nevada, April 1989. Requests for reprints should be sent to Donald Calsyn (116DDTP), VA Medical Center, 1660 South Columbian Way, Seattle, WA 98108.

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D.A. Calsyn et al.

256

practitioners/physician assistants, nurses, psychologists, pharmacists, social workers (MSW), master’s degree counselors, bachelor’s degree counselors, associate arts degree counselors, and paraprofessional counselors. Respondents were then asked to list the number of staff who were recovering substance abusers. Differences in clinic staffing as a function of clinic demographics were analyzed using either contingency table analysis or analysis of variance using the Statistical Package for the Social Sciences (Nie, Hull, Jenkins, Steinbrenner, & Bent, 1975). Clinic demographics used in the analyses were region, clinic size, city size, and program types. Region was defined by first digit in clinic’s zip code: East (0,1,2), South (3,7), Midwest (4,5,6), West (8,9). Clinic size was broken down based on number of patients as small (less than loo), medium (loo-199), or large (greater than 200). City size was defined by population as small (less than lOO,OOO),medium (lOO,OOO-999,999),or large (greater than l,OOO,OOO). Program types identified were Veterans Administration, other government supported, nonprofit community-based, and proprietary.

METHOD

Procedure

A questionnaire concerning various aspects of clinic operations was sent to five methadone maintenance clinics in the Pacific Northwest. Clinic directors were asked to complete the questionnaire and make comments on pertinence, ease in completing, and clarity of the questions. This pilot testing prompted modifications to the questionnaire. The final version of the questionnaire with cover letter requesting participation was then sent to all methadone maintenance clinics (N = 557) listed in the 1984 Program Directory published by ADAMHA (1985). If the questionnaire was not returned within six weeks, a second questionnaire was sent. If the second questionnaire was not returned within three months, it was counted as nonreturned. Sixty-three (11.3%) of the questionnaires were returned undelivered or the clinic reported no longer offering methadone maintenance. Of the remaining 494 clinics, 324 (65.6%) returned usable questionnaires. Five clinics (1 To) returned unusable questionnaires, and 165 (33.4%) questionnaires were never returned. Clinics failing to return questionnaires did not differ significantly from those returning questionnaires in city size or regional location. All usable questionnaires were completed and returned between July 1987 and February 1988. Respondents were asked to list the number of staff in each of the following categories: physicians, nurse

RESULTS

Presented in Figure 1 is the percentage of clinics employing each type of staff person. Over 90% of clinics employ nurses or physicians. Most clinics report having counselors with master’s (65.1%) or bachelor’s (72.5%) degrees on staff. Fewer clinics have on staff paraprofessional counselors (46.9%) or social work-

TYPE OF STAFF PHYSICIANS NURSES ARNP/PA’S PHARMACISTS PSYCHOLOGISTS SOCIAL

AA

WORKERS

MA/MS

COUNSELORS

BA/BS

COUNSELORS

DEGREE

COUNSELORS

PARAPROFESSIONALS RECOVERING 0%

20%

40%

PERCENTAGE

~;~~~ ~~~

60%

80%

100%

OF CLINICS

FIGURE 1. Percentage of methadone clinics nationwide employing various types of staff.

257

Staffing of Methadone Maintenance Clinics

ers (42.9070). Psychologists (36.1 o/o), pharmacists (33.6%), nurse practitioners/physician assistants (36.1 Yo), and associate degree counselors (32.4%) were utilized by even fewer clinics. Less than half the clinics (47.2%) utilized recovering staff, despite the focus on their use in the literature. Figure 2 shows the mean percentage of each type of staff utilized by clinics. Nationwide, medical staff account for 44.4% of the staffing with nurses being the highest at 27.1%. Counseling staff (including M.S.W.s) account for 49.1 Vo of the staffing. Psychologists (3.6%) and pharmacists (2.9%) make up a small percentage of staffing in methadone clinics. The mean percentage of staff identified as being recovering substance abusers was 10.3% (SD = 13.2%). Table 1 lists the percentage of each type of staff utilized as a function of the clinics’ funding. Proprietary clinics employ proportionally more physicians, nurses, and nurse practitioners/physician assistants than other types of clinics. Nonprofit community-based clinics employ more master’s degree counselors than local government or VA clinics. VA clinics employ more psychologists and pharmacists than other clinics. Also VA clinics employ a greater percentage of paraprofessionals and recovering staff than other clinics. Presented in Table 2 are the percentages of each type of staff utilized as a function of geographic region of the country in which the clinic is located. Nurses are employed more frequently in clinics in the West. Clinics in the South and West employ more nurse practitioners/physician assistants. Clinics in the East employ MSWs more frequently than clinics in the West. Clinics in the South and East employ more bachelor’sdegree counselors than Midwestern or Western clinics. Midwest clinics employ psychologists more often than clinics in the South and’west. Clinics in the Midwest utilize more paraprofessionals and recovering staff

than other clinics. There were no significant differences in staffing as a function of city size or clinic size. DISCUSSION The bulk of the staffing for the typical methadone maintenance clinic is nearly evenly divided between medical and counseling personnel. Specialists such as psychologists and pharmacists are utilized by a minority of programs and account for a very small percentage of the staff. Despite the focus on use of formerly addicted counselors in the literature, less than half the programs utilize them, and only 10% of all staff were identified as recovering substance abusers. Based on the emphasis in the literature, we found these figures to be low. From this survey it is impossible to discern if these figures reflect recent changes in staffing or more long-standing patterns. The results indicate that proprietary clinics utilize medical staff more heavily, suggesting stronger focus on the medication dispensing and medical aspects of treatment, whereas the other types of clinics use a greater percentage of counseling staff suggesting stronger focus on counseling and case management. A similar phenomenon operates with clinics in the West, which report more staffing with medical personnel compared to clinics in other regions. VA clinics’ more frequent use of paraprofessional and recovering staff is consistent with VA hiring regulations, which allow employing these individuals in a special exempt classification. The VA’s more frequent use of pharmacists and psychologists reflects the VA multidisciplinary approach to providing substance abuse and psychiatric treatment services throughout the VA Health Care System. A precedent for providing services in this manner was already established within the VA system prior to establishing of methadone clinics.

PHYSICIANS

13% PARAPROFESSIONALS

9%

AA DEGREE COUNSELORS 5%

BA/BS COUNSELORS

PSYCHOLOGISTS SOCIAL

4%\ WORKERS

j 7%

16%

/MA,Ms COUNSELORS

13%

FIGURE 2. Mean nationwide staffing pattern of methadone maintenance

clinics.

D.A.

258

TABLE 1 Percentage of Each Type of Staff Utilized by Methadone Maintenance

Calsyn

et al.

Clinics as a Function of Clinic Funding

Clinic Funding

Type of Staff Physiciansa Nursesb Nurse Practitioners/ Physician’s Assistants= PharmacistsC PsychologistsC Social Workers (MSW)d MAIMS Counselorse BA/BS Counselors AA Degree Counselors ParaprofessionalsC Recoveringd

Local Government (n = 78)

Nonprofit Community (n = 175)

Proprietary (n=31)

(n !A23)

12.5 27.5

12.7 25.6

18.1 33.3

10.7 21.7

3.1 3.3 3.1 7.4 10.2 17.1 5.5 10.3 11.0

4.0 2.6 3.6 6.5 15.4 16.9 4.9 7.9 10.5

9.6 1.0 1.4 3.1 13.1 13.6 2.3 5.1 4.2

2.8 10.2 8.4 11.0 3.3 16.3 1.0 19.0 17.0

F 5.1** 3.8* 6.8*** 19.1 l ** 6.5*** 3.0* 7.7*** 1.5 3.1 5.9*** 3.4’

‘p < .05, l*p < .Ol , l**p < ,001. aProprietary > Local Government, Nonprofit, VA. bProprietary > VA, Nonprofit. =VA > Proprietary, Nonprofit, Local Government. dVA > Proprietary. eNonprofit > Local Government and Proprietary > VA.

& Jaffee (June, 1989) have amply demonstrated that different methadone programs have markedly different success rates based largely on the quality of the program. While the present survey does not directly address quality, it does extend to a nationwide scope the concept that programs display significant varia-

The current study provides useful information about typical staffing, but suffers in the brevity of information requested about staffing within a longer questionnaire inquiring about various aspects of clinic operations. In their examination of six different methadone programs on the Eastern seaboard, Ball, Ross,

TABLE 2 Percentage of Each Type of Staff Utilized by Methadone Maintenance

Clinics as a Function of Region

Region

Type

of Staff

Physicians Nurses= Nurse Practitioners/ Physician’s Assistantsb Pharmacists PsychologistsC Social Workers (MSW)d MAIMS Counselors BA/BS Counselors AA Degree Counselors Paraprofessionals= Recovering’ ‘p < .05, l*p < .Ol( l**p < .OOl aWest > East, South, Midwest. “South, West > East, Midwest. CMidwest > South, West. dEast > West. eMidwest > East. ‘Midwest > East, South, West.

East (n = 140)

South (n = 41)

Midwest (n = 49)

West (n = 83)

12.1 27.1

14.6 22.1

14.9 22.4

12.6 32.4

2.0 12.9***

2.8 3.2 4.3 8.3 12.7 18.1 3.7 7.6 9.0

7.0 4.1 2.2 5.2 14.0 18.0 2.9 9.9 7.7

1.1 3.3 5.2 7.7 13.1 12.6 6.1 13.6 17.3

7.3 1.7 2.2 4.1 12.6 13.3 5.6 8.1 9.8

7.3*** 2.6 4.0** 3.6* 0.1 3.4’ 2.3 2.7* 5.0”

F

Staffing of Methadone

Maintenance

Clinics

tions in their provision of basic services. This finding parallels our survey’s discovery related to urine screening practices which also vary widely (Saxon, Calsyn, Haver, & Erickson, 1990; Calsyn, Saxon, & Bardnt, in press). It seems reasonable to assume that such dramatic differences in treatment orientation would lead to differences in outcome. This hypothesis can be tested directly by future investigations in this area which might focus more on the specific duties of different clinical staff, percentage of time engaged in those duties, client caseloads, and availability of administrative support staff, as well as on treatment outcome. REFERENCES Aiken, L.S., LoScuito, L.A., Ausetts, M.A., & Brown, B.S. (1984). Paraprofessional drug counselors: Diverse route to the same role. International Journal of the Addictions, 19, 153-173. Alcohol, Drug Abuse and Mental Health Administration. (1985). National Directory of Drug Abuse and Alcoholism Treatment and Prevention Programs. U.S. Department of Health and Human Services (DHHS Publication No. ADM 85-321). Washington, DC: U.S. Government Printing Office. Ball, J.C., Ross, A., & Jaffee, J.H. (1989, June). Cocaine and heroin use by methadone maintenance patients.Paper presented at the annual scientific meeting of the Committee on Problems of Drug Dependence, Keystone, CO. Ball, J.C., Corty, S., Petroski, S.P., Bond, H., Tommasello, A., & Graff, H. (1986). Medical services provided to 2,394 patients at methadone programs in three states. Journal of Substance Abuse Treatment, 3, 203-209. Brown, B.S., & Brewster, G.W. (1973). A comparison of addictclients retained and lost to treatment. International Journal of the Addictions, 8, 421-426.

259 Brown, B.S., Gfroerer, J., Thompson, P., & Bardine, A. (1985). Setting and counselor type as related to program retention. International Journal of the Addictions, 20, 723-136. Calsyn, D.A., Saxon, A. J., & Bardnt, C.D. (in press). Urine screening practices in methadone maintenance clinics: A survey of how results are utilized. Journal of Nervous and Mental Disease. Cooper, J.R. (1989). Methadone treatment and acquired immunodeficiency syndrome. Journal of the American Medical Association, 262, 1664-1668. Jackman, J.M. (1973, March). One successful staffing pattern for a methadone maintenance clinic. Proceedings of the National Conference on Methadone Treatment (pp. 174-178). Longwell, B., Miller, J., & Nicholas, A.W. (1978). Counselor effectiveness in the methadone maintenance program. International Journal of the Addictions, 13, 307-3 15. LoScuito, L., Aiken, L.S., Ausetts, M.A., & Brown, B.S. (1984). Paraprofessional versus professional drug abuse counselors: Attitudes and expectations of the counselors and their clients. International Journal of the Addictions, 19, 233-252. McLellan, A.T., Woody, G.E., Luborsky, L., & Goehl, L. (1988). Is the counselor an “active ingredient” in substance abuse rehabilitation? An examination of treatment success among four counselors. Journal of Nervous and Mental Disease, 176, 423-430. Nie, N.H., Hull, C.H., Jenkins, J.G., Steinbrenner, K., & Bent, D.H. (1975). Manual for the Statistical Package for the Social Sciences. New York: McGraw-Hill. Ottomanelli, G.A. (1978). Patient improvement, measured by the MMPI and Pyp, related to paraprofessional and professional counselor assignment. International Journal of the Addictions, 13, 503-507. Saxon, A.J., Calsyn, D.A., Haver, V.M., &Erickson, L. (1990). A nationwide survey of urinalysis practices of methadone maintenance clinics: Utilization of laboratory services. Archives of Pathology and Laboratory Medicine, 114, 94-100.