International Journal of the Addictions
ISSN: 0020-773X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/isum19
A Client-Developed Methadone Maintenance Program Richard J. Levine & Hugh F. Kabat To cite this article: Richard J. Levine & Hugh F. Kabat (1975) A Client-Developed Methadone Maintenance Program, International Journal of the Addictions, 10:5, 825-842, DOI: 10.3109/10826087509027341 To link to this article: http://dx.doi.org/10.3109/10826087509027341
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The International Journal of the Addictions, 10(5), 825-842, 1975
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A Client-Developed Methadone Maintenance Program" Richard J. Levine, M.S. Abboti Hospital and College of Pharmacy University of Minnesota Minneapolis, Minnesota
Hugh F. Kabat, Ph.D. Department of Clinical Pharmacy University of Minnesota Minneapolis, Minnesota
Abstract
A realistic methadone maintenance program is a continuum of four related areas: intake, rehabilitation with on-going evaluation, detoxification, and postdetoxification followup, each jointly administered by client volunteers and professional staff. In the early stages of client treatment, pharmacists have more frequent contact with program participants than do other staff
* Abstracted in part from a paper submitted to the Graduate School, University of Minnesota, in partial fulfillment of the requirements for the M.S. degree in hospital pharmacy. 825 Copyright 0 1975 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.
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professionals. At the Minneapolis Pilot City Health Center, 31 of 69 participants in the methadone maintenance program were interviewed by their pharmacist to determine client understanding of program objectives, interpretation of program effectiveness, and suggestions for program improvement. Client understanding of the objectives or program elements ranged from 30 to 97%. Client evaluation of the effectiveness of program elements ranged from 0 to 65%. The client-developed program included intake procedures to establish for each client the program objectives, rules, evaluation, guidelines, client goals, dismissal guidelines, and a review of supportive services. Rehabilitation would be continuous with consistent on-going evaluation to measure goal attainment, a decline in disruptive behavior, and freedom from illicit drug use. Detoxification should be undertaken after the client’s behavior has stabilized and he has developed a marketable skill. Monitoring of the client to assure a drug-free state would be an important element of the postdetoxification follow-up. The Pilot City Health Center, a federally funded neighborhood health center located in the inner-city area of North Minneapolis, initiated a rehabilitation program for opiate addicts in 1968. The program’s objectives were to reduce the addict’s use of illict opiates and to aid him to rehabilitate himself into a constructive member of society. The purposes of this study were threefold : 1. To determine the degree to which the clients understood the program. 2. To determine the effectiveness of the program from the client’s point of view. 3. To develop recommendations for program reorganization based upon client ideas.
The Proceedings of the Fourth National Conference on Methadone Treatment (1972) document several rehabilitation programs with disparate organizational structures and objectives. The Proceedings also highlight many of the problems that have arisen in attempts to rehabilitate opiate addicts. Critics of these programs have alleged that many program directors and supportive personnel are not equipped professionally or emotionally to undertake the responsibility of working with opiate addicts (Einstein and Garitano, 1972; Ford Foundation Report, 1972; Hess, 1972).
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At the time (Spring 1972) this study was done, the Pilot City Health Center Methadone program director and assistant director were the only paid program personnel. The program director was both a college graduate and a minister, The assistant director had 1 year of college and little or no formal counseling experience but claimed to have been a frequent drug user. The director supervised all program activities while serving as intake screener, counselor, methadone dose evaluator, and program administrator. The assistant director served as a secondary counselor when the director was not available, supervised the collection of urine specimens for laboratory analysis, and arranged medical appointments for new admissions. Volunteer seminary students organized small group sessions to confront the client with his problems and to assist him in facing reality (Kleber, 1970), but were unable to gain the confidence and cooperation of the program participants and the groups were eventually disbanded. The methadone maintenance program utilized the services of other departments in the health center-mental health, social service, pharmacy, laboratory, dentistry, and medicine. The mental health department employed a psychologist, sociologist, and a part-time psychiatrist. All in-coming addicts received a Minnesota Multiphasic Personality Inventory and met with the psychologist. In addition, they received a routine physical examination and a urine analysis for opiates. The program director established the initial methadone dosage level. The pharmacist prepared and administered daily doses of flavored methadone liquid in a concentration of 2 mg/ml. Pharmacy personnel were actively involved in the program’s organizational planning processes. The opiate addict’s initial knowledge concerning the program was usually through his street friends. Addicts wishing to be accepted as program participants generally were aware of the program regulations and the degree to which these regulations could be violated. However, his initial formal contact with the program was when he met with the program director and completed an application for admittance. The application information included age, address, education, employment, personal background, and a brief history of his addiction. Emphasis was placed on where and how he acquired opiates and approximate amounts used. Since applicants had street knowledge of the criteria for acceptance, their responses to the questionnaire assured admission because it was difficult, if not impossible, to ascertain the validity of an addict’s assertions. After the initial review of the applicant, he appeared before a screening committee consisting of program participants. In theory, the screening committee had the responsibility to accept or reject the addict’s petition
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828 PILOT C I T Y HEALTH CENTER METHADONE MAINTENANCE
PROGRAM PARTICIPANT
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SURVEY INSTRUMENT
Spring 1972
1. Do you know what t h e s c r e e n i n g committee does? Could you t e l l me what they do? How w e l l do you f e e l they a r e doing t h e i r job? 2.
A r e t h e a d d i c t s ' responses t r u e , f a l s e , o r exaggerated?
3.
When t h e a d d i c t s are interviewed should they s e t goals f o r themselves ?
a. b. c.
4.
d e t o x i f i c a t i o n of methadone. employment. enrollment i n school.
Who do you f e e l is b e s t q u a l i f i e d t o interview you?
a. b. c. d. c.
fellow a d d i c t s . psychiatrist. d i r e c t o r of t h e program. s o c i a l workers. combination of above.
5.
Were you adequately t o l d t h e r u l e s of t h e program during the i n i t i a l interview? Could you t e l l me some of t h e s e r u l e s ?
6.
Could you t e l l m e what the counselors and group l e a d e r s do? Are they h e l p f u l ?
7.
Do you know how group l e a d e r s a r e s e l e c t e d and how t h e groups a r e arranged?
8.
Do you p a r t i c i p a t e i n group meetings? Why o r why n o t ?
9.
I f you were p r o j e c t d i r e c t o r
a. b. C.
-
what q u a l i f i c a t i o n s would you look f o r i n h i r i n g counselors, how would you i n s u r e attendance and p a r t i c i p a t i o n by a l l , what t y p e s of people would you h i r e on the program?
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Would you h i r e t h e program p a r t i c i p a n t s ? What would t h e y do?
11. A f t e r a six-month p e r i o d , how s h o u l d a p e r s o n b e e v a l u a t e d ? a. b.
c.
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d.
e.
decrease abusing street drugs. decrease of i l l e g a l a c t i v i t i e s . c o n s i s t e n t employment. enrollment i n school. d e c r e a s e o f methadone dose.
12.
What d i f f e r e n t programs b e s i d e s t h e d r u g program are a v a i l a b l e a t t h e h e a l t h c e n t e r t o h e l p you and g i v e you a s s i s t a n c e ?
13.
Do you f e e l you would want t o b e d e t o x i f i e d from methadone by next year?
14.
Do you h a v e any s p e c i f i c s k i l l ?
15.
Has t h e program h e l p e d you e n r o l l i n s c h o o l o r a c q u i r e a j o b o r have you h e l p e d y o u r s e l f ?
16.
Is t h e program h e l p i n g you u n d e r s t a n d t h e r e a s o n s why you became a d d i c t e d and t h e e v e n t s which l e d up t o a d d i c t i o n ?
17.
A r e you t r y i n g t o s o l v e your OWTI problems and are you r e c e i v i n g a s s i s t a n c e from t h e drug program? Do you r e a l i z e what some of your problems are?
18.
Is t h e program h e l p i n g you resist t h e t e m p t a t i o n o f a g a i n becoming an o p i a t e a d d i c t ?
19.
How is t h e program h e l p i n g you? Is t h e program meeting y o u r n e e d s ? What would you l i k e t h e program t o do f o r you?
20
Should methadone d o s e s b e unknown? Why?
0
21.
Do you f a v o r p l a c e b o d o s e s ? Would t h i s h e l p w i t h p s y c h o l o g i c a l r e a d j u s t m e n t ?
22.
Do you f a v o r t h e p r e s e n t pick-up s c h e d u l e ?
23.
What are y o u r r e s p o n s i b i l i t i e s t o t h e program?
24.
Should p e o p l e b e d i s m i s s e d ?
a. b
.
repeated drug use. r e p e a t e d i l l e g a l a c t i v i t i e s , c o n v i c t i o n s and disruptive behavior.
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for inclusion in the program. There were times when members of the screening committee declined to admit some addicts into the program but were overridden by the director. At other times, since it was difficult for the program director to convene a meeting of the screening committee, the program director unilaterally admitted addicts into the program. After acceptance, the incoming addict was told about the methadone pick-up schedule. He was instructed not to abuse other drugs and to observe the program regulations. The FDA guidelines suggest that after a person has been maintained on methadone for 1 to 2 years and his behavioral and emotional patterns have been altered, he is ready to be detoxified, but none of the Pilot City program participants had reached that stage. If a client wished to receive assistance from the mental health department, or the program director, he had to make an appointment several days in advance. In general, an addict’s life style lacks organization or planning. He finds it difficult to keep appointments since he has no regular schedule. Until this life style pattern is changed, the client exists from day-to-day and his problems are a reflection of this existence. The absence of adequate staff personnel precluded the client from meeting with the director or assistant director on a drop-in basis. The pharmacists had more personal contact with the clients than anyone because of the daily methadone administration schedule and frequently became involved !n personal discussions with the clients in the informal pharmacy dispensing area. The pharmacist was in a unique position to observe daily changes in the clients’ physical and psychological behavioral patterns. Clients were often less reluctant to discuss problems frankly in this informal atmosphere then they were in the formal counseling meetings One coauthor (R.J.L.) was a pharmacist at the Pilot City Health Center. Although some clients had methadone take-home privileges for up to 3 days, most were required to drink their methadone daily at the Health Center in the presence of the pharmacist. The program operated within the minimal FDA regulations contained in the Federal Register. There were no standards for on-going evaluations, adjustment of methadone dosage, or dismissal from the program for violations of program rules. At the time (Spring 1972) this study was done, 69 clients were enrolled in the program.
METHODOLOGY Each program participant was asked to participate in an interview when he came to the pharmacy for his methadone. In a secluded area he
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Table 1
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Ethnic Background of Pilot City Methadone Program Participants and Those Interviewed (Spring 1972)
Client population
Number in program
Number interviewed
Black Caucasian Indian
29 39 1
9 21 1
Table 2 Sex of Pilot City Methadone Program Participants and Those Interviewed
Sex
Program participants
Participants interviewed
Male Female
56 13
26 5
Table 3 Occupational Status of Pilot City Methadone Program Participants Interviewed (N=31)
Participants Enrolled in school College, 2 Vocational training, 3 Has specific vocation Employed, 15 Unemployed, 6 Unemployed, no vocation
5
21
5
was asked to respond verbally to 24 questions. The responses were reduced to writing immediately. Interview time varied from 20 to 30 minutes. Thirty-one persons or 45% of the total program participants enrolled in the Pilot City Health Center Methadone Maintenance Program were interviewed. Demographic information for those interviewed is summarized in Tables 1, 2, and 3. The age range for those interviewed was 17 to 60 years, with the mode being 23.
UNDERSTANDING THE PROGRAM Thirty of the 31 clients interviewed were aware of the existence of the screening committee; however, 10 clients thought that the purpose of the screening committee was to determine whether the program could help the
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Interpretation of the Purpose of the Screening Committee (N =31)
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Determine if addict is legitimate Help addict Committee needs reorganization No response
10 10 8 3
Table 5 Determination of the Truthfulness of the Addict’s Response during the Screening Committee Interview (N =31)
Distorted, false, or exaggerated True Did not know
19 8 4
incoming addict and 10 that the purpose was to determine whether or not the interviewed person was a “real or legitimate” opiate addict (Table 4). Nineteen of the 31 clients interviewed stated that addicts tend to distort the truth, exaggerate, and lie, suggesting that it is difficult to determine whether the addict is telling the truth (Table 5). Only eight clients stated that they believed the responses of the interviewed addicts were true, noting that since the members of the screening committee were program participants and former addicts, they did not believe that prospective clients would lie to them or that they would know if the prospective client was untruthful. No one interviewed mentioned social and psychological rehabilitation as a goal; instead, 33 of the 49 responses to the question on program goals related to drugs (e.g., do not take street drugs, do not sell or buy methadone, observe the pharmacy pick-up schedule, and be drug free). Table 6 shows a similar pattern of responses when program participants were asked about their responsibilities to the program. Fifteen of 43 responses were in relation to obeying program rules and keeping appointTable 6 Client Interpretation of Their Responsibility to the Program (N =43)“
Drug-related response
19
Obey program rules
15
Participate in program activities Rehabilitate oneself Clients provided multiple responses.
7 2
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Table 7 Client's Knowledge of Other Services (N =45)" ~~
Mental health and social service Medical Did not know
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a
24 14 7
Clients provided multiple responses.
ment schedules, and 19 were related to drugs. Only two clients cited rehabilitation. Fourteen clients were aware that they might use the Center's medical and dental facilities. Twenty-four were aware of the availability of the Center's mental health and social services, but seven clients were unaware of any supportive services (Table 7). Twenty-one of the 31 clients interviewed stated that the purpose of the counseling groups and group leaders was to help one solve problems, but 10 clients did not know the purpose of the counseling groups. In addition, 25 out of 31 clients did not know the reasons for which the group leaders were selected.
PROGRAM EFFECTIVENESS Twenty-one of the 31 clients surveyed thought they were adequately interviewed during intake, but six clients stated that the screening committee was not doing a good job (Table 8). Fifteen clients had participated fully in group counseling sessions ; nine attended only the first few meetings but seven had never participated (Table 9). While 13 clients thought the counselors were always helpful, seven clients thought that only the initial meetings were helpful. Seven stated that the counselors were not helpful. Four had never met with counselors-two of them because they worked during the times when counselors were available (Table 10). Fifteen of the 31 clients interviewed indicated the methadone program Table 8 Client Interpretation of the Performance of the Screening Committee (N =31)
Average job Good job Not doing a good job Did not know
13 8 6 4
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Table 9 Client Attendance at Group Counseling Meetings
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Attend and participate Attended only first few meetings Never attended
(N =31)
15
9 7
Table 10 Client Evaluation of Helpfulness of Group Counselors ( N =31)
Helpful Helpful only during first few meetings Hot helpful Never attended
13 7 7
4
was either helping them enroll or remain in school, or to acquire or maintain a job. Others stated the program was not helpful. Seventeen clients thought the program was helpful in understanding why they personally became addicted ; six stated they realized the reasons by themselves but eight indicated the program was not helpful in this regard. Eleven clients indicated that the program was helping them solve some of their problems, and 17 others stated they were trying to solve their own problems. Twenty-six of the clients interviewed indicated the program was helping them resist the temptation to again become an opiate addict. Seventeen of the participants favored the existent methadone pick-up schedule.
CLIENT IDEAS Thirty clients indicated that the in-coming addicts should set goals for themselves either during the initial screening process or shortly afterwards. Twenty-six clients believed that they should be evaluated periodically for discontinuation of illegal activities, enrollment in school, maintaining a job, and decreases in the methadone dosage. Seventeen clients indicated that all these standards should be used as a criteria for evaluation, and others indicated that all of the standards should be used to measure progress except a decrease in methadone dosage. Four clients stated that there should be no standards for evaluation, and program participants should be rehabilitated only if they desire. Fourteen clients thought trained or knowledgeable addicts should be
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employed in the program. Seven thought specially trained personnel should be employed (the term professional was not used) and two thought trained addicts in conjunction with professionals should be employed. Sixteen clients thought counselors should be specially trained professionals, 12 thought only knowledgeable or trained clients should serve as counselors, and three stated clients should be able to select counselors. Twenty-six clients stated that a combination of qualified addicts and professional personnel (psychiatrist, social workers, program director, etc.) should serve on the screening committee. However, five others maintained that only program participants were qualified to serve on the screening committee by virtue of their past experience with the addict culture and life style. Every client interviewed felt that clients should be employed in the program. Twenty-four stated that ex-addicts could serve as problem solvers, and seven others that ex-addicts could serve as counselors. In order to insure attendance and participation in program activities, 21 of the clients felt that they must have a part in the decision-making process. Nine indicated that they would impose restrictions (withhold methadone take-home privileges) if clients did not participate. Twelve clients thought use of unknown doses of methadone should be explored further and could prove to be helpful, but the majority (19) observed that clients should know their dosage. Thirteen clients indicated that unknown doses of methadone could cause the client to have additional psychological problems. Twenty clients favored use of placebo doses, feeling that they would help those with additional psychological problems. Those clients who were opposed to placebo doses were opposed to deception of program participants. Fifteen clients suggested that program participants should be dismissed for repeated drug abuse or disruptive behavior, but the other 16 disagreed, citing the need for more professional assistance for clients who do not observe program guidelines.
DISCUSSION The program participants did not understand the significance of the program nor did they understand the program’s intrinsic operations. They lacked a clear understanding of their responsibilities due to the absence of a suitable orientation program for incoming addicts. Too much focus was placed on methadone and other drug rules instead of on program objectives. The incoming addict was told to be drug free,
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to observe the methadone pick-up schedule, not to sell or buy methadone, not to use unknown doses of methadone, and not to abuse street drugs. Most clients were aware of the existence of the screening committee and counseling groups, but only a third of those interviewed (10/3 1) knew the purpose of the screening committee and no one was able to outline the types of problems to be solved by the counseling groups. Most (25/31) were not even aware of how the group leaders were selected. Program participants were capable of determining the degree to which the program helps them meet their needs. Job maintenance and school enrollment represents one set of standards by which program effectiveness can be evaluated (Searcy, 1972). The Pilot City Methadone program was helping 26 of the 31 interviewed clients resist the temptation to again become an opiate addict. Thirteen of the clients interviewed found the program to be generally helpful but only seven stated that the program is helping them realize their problems. These findings suggest that the program is meeting the physical needs of the clients, but not their emotional or psychological needs. Although almost three-fourths of the clients interviewed initially thought the counselors and group meetings were helpful, as time went on the meetings did not maintain the clients’ interest or motivate them. The incoming addict finds the program both new and challenging. The usual addicts’ life style and culture requires constant change and instant gratification (Warren, 1972). Almost two-thirds of the clients interviewed (22/31) thought the clients should participate and share in the decisionmaking process in order to maintain their continued interest and to increase client motivation. Program participants were able to analyze the effectiveness of the program. They were able to make realistic suggestions for program improvements which included methods for evaluation, standards for dismissal, types of personnel to be employed, and elements of meaningful client participation. They also recognized the need for improved clientcounselor relations. Several authors have stated that staff-participant relationships in methadone maintenance programs have not been productive or meaningful (Jones, 1972; Knowles et al., 1970). They note further that due to these meaningless relationships and distrust for the professional staff, clients have frequently sought the assistance and guidance of their peers which has not always proven to be helpful (Ross, 1972). Since the origin of staff-client problems has frequently been inadequately trained professional staff who are unsympathetic to the plight and complications of the clients’
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or addicts’ life, one can understand why the program participants favor both rehabilitated addicts and knowledgeable program participants to be employed as staff personnel. This study confirms that clients feel that any person employed on the program should be knowledgeable and sympathetic concerning the addict’s life style and be specially trained. Eight of the clients interviewed felt that peer review of the addicts’ responses during the screening committee interview would guarantee truthfulness. They noted that peers can sufficiently intimidate the addicts being interviewed so that they will tell the truth. Other authors have noted that it is difficult, if not impossible, to establish the validity of the interviewed addicts’ statements. The physical signs of addiction as indicated in the Federal Register (Department of Health, Education and Welfare, 1970, 1971, 1972a, 1972b) can be established, but the years of addiction, the approximate amounts of opiates used, the level of illegal activities, and the past history of psychiatric treatment cannot be established (Trigg, 1972). It should be evident, however, that addicts wishing to be accepted as program participants already possess a street knowledge of the program standards for acceptance. They know that some of their statements may preclude them from becoming program participants, so they must lie and distort the truth if they wish to be accepted into the program (Trigg, 1972). Consistent on-going evaluations should be an integral part of any program. Rehabilitation implies that there will be change in a person’s character and life style. There must be standards to measure this change. Twenty-six of the clients interviewed stated the participants should be evaluated, and 30 of 31 stated they should establish personal goals. Client dismissal is a controversial subject. In this study 15/31 clients interviewed favored dismissal for either repeated drug use or repeated disruptive behavior, but 12 thought that these activities only indicate that the client requires more professional guidance and that he should be referred to another agency. Only if he is incorrigible do they believe that he should be dismissed.
CONCLUSIONS In this study of 31 methadone maintenance program participants, many clients did not have an understanding of the program nor did they know its purpose. Many clients did not know what was expected of them upon becoming program participants. Further, the clients indicated that the program was not assisting them in becoming rehabilitated. They made several recommendations for program improvement and reorganization.
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Every program participant must have a suitable orientation process to determine whether or not he can be helped by the program and what his role in the program will be. Trained personnel are needed but not all the personnel need be professionals. Many lay people, rehabilitated addicts, and some program participants who are motivated and doing well could be employed. Client participation in the decision-making process is also critical if the program is to motivate the participant toward rehabilitation. Realistically, the program should be divided into different stages according to the progress of the client: (1) intake, (2) rehabilitation and on-going evaluation, (3) detoxification, and (4) postdetoxification followup. For the program to best serve the needs of the clients, each stage must be related and represent a continuum from the preceding one. Program intake should serve as the addict’s initial contact with the program. After the addict is told exactly what is expected of him, he should be asked to decide whether he wishes to become a member of the program. During the intake procedure, the following items should be stressed: (1) purpose of the program, (2) program’s rules, (3) guidelines for client evaluation, (4)goal setting by the client, (5) guidelines for dismissal, and (6) availability of supportive services. A client-volunteer together with a staff counselor should interview and review the addict’s application. Then the addict should be referred to a psychologist for a routine behavioral analysis before being referred back to his client-counselor team. There should be positive feedback to indicate that the addict understands the program rules and his responsibilities. He should also be assisted in preparing goals for rehabilitation. At this stage the psychologist, counselor, and client-volunteer should bring the results of their analyses to the screening committee for a decision on acceptance of the addict into the program. The screening committee should consist of an equal number of professionals and nonprofessionals (program participants) and include the counselor, client-volunteer, and the psychologist who performed the initial addict interview. The addict should meet with the committee. When the addict is accepted, he should be assigned another client-volunteer to elaborate on the program guidelines and explain the various supportive services available. During the intake process the addict should receive a daily dose of methadone to avoid withdrawal symptoms. The new client should then be transferred to the next program stage where counselors attempt to help him rehabilitate himself. In this stage the program can best utilize the services of those motivated program
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participants and rehabilitated addicts who serve as counselor-assistants. These counselor-assistants are essential since the professional staff usually have not yet gained the confidence and cooperation of the clients because the addict has a general distrust for people, including professionals, who state that they wish to offer assistance. A trust relationship with the client can be established provided the program meets his needs and treats him with respect (Knowles et al., 1970; Muskaley, 1972). With the development of a trust relationship, the program will acquire the cooperation of the clients. During the rehabilitation stage the client should be expected to set goals for himself with the cooperation of both the professional and nonprofessional staff. These goals should be realistic and attainable by the client (Dupont, 1972; Richman, 1972). Clients should participate in all program elements. They should be active in the program’s decision-making process; their opinions should be sought out because client participation produces a sense of loyalty to the program and increases their motivation (Kleber, 1970). Clients can participate during the initial screening as counselor-assistants for program participants with personal problems, with appointment scheduling, with appointment keeping, and on a 24-hour call basis to assist clients with urgent problems. An Advisory Board consisting of an equal number of professionals and nonprofessionals should serve as the program’s final decision-making body to select appropriate courses of action for those clients that consistently disregard the program rules. Clients can serve effectively on this Advisory Board. The program should be intolerant of consistent client disruptive behavior and continual drug abuse, and the clients should be well aware of this. However, once a client is dismissed, if he wishes to return and obey the program rules, he should be readmitted. Counselors should be knowledgeable concerning the client supportive services offered by other agencies which can be utilized on a referral basis (Wilson, 1972). It is important that a line of communication be established between the agencies and the program, however, so that the client is consistently and continually evaluated. An important rehabilitation standard by which the client may be evaluated is employment or enrollment in school. Each client should be classified accordingly-employed at a job that requires a vocation, employed at a job that does not require a vocation, is a student, has a vocation but does not have a job, or has neither a vocation nor a job. Clients who are employed with marketable skills or unemployed but possessing these
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skills are apt to perform much better than their counterparts without a job or skill (Ross, 1972). The counselor should assist the client to acquire marketable skills-a difficult but obtainable objective. The rehabilitation stage should consist of on-going and consistent evaluations. The progress of the client should be continually monitored (e.g., Is he still enrolled in school? Is he still employed?) Routine urine analysis, even though it emphasizes the drug focus, is one effective way to determine whether the client is abusing drugs. Urine analysis can, however, be thought of as a guideline to determine whether or not the client requires more guidance rather than more disciplinary measures (Einstein and Garitano, 1972: Hess, 1972). If consistent drug abuse does not cease, then the problem should be referred to the Advisory Board. Group and individual counseling should be sufficiently helpful to motivate the client to attend group meetings but flexible enough to meet the client’s changing needs. Because the client can only be concerned with one goal at a time (drug abstinence or social and psychological rehabilitation), rehabilitation should be the program’s first priority for the client (Mayer, 1970; Muskaley, 1972). After the client has been maintained on methadone for a period of time (few months to a number of years), has stabilized his behavioral pattern, and acquired a specific skill which is marketable, he is ready to be detoxified from methadone. The detoxification schedule should jointly be determined by the professional counselor, the counselorassistant, and the client himself. Monitoring the client’s progress after he has been detoxified is an important responsibility of the program, so the client should be told he can still utilize the supportive services of the program whenever he feels the need. Since methadone dosage per se, abuse of other drugs, detoxification, and being drug free represent secondary priorities, necessary corrective measures should be employed if one does not follow the program guidelines regarding methadone dosage. Unknown doses and placebo doses for clients should be further evaluated. In summary, a program must meet the clients’ changing needs or it will merely perpetuate the addicts’ life-style. This can only be accomplished by adequate professional staff in collaboration with client volunteers who are capable of consistently evaluating the program, who are flexible enough to initiate and institute change, and who gain the trust, confidence, and cooperation of the clients they are to serve.
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ACKNOWLEDGMENTS
The authors are indebted to the Pilot City Health Center staff, program staff, and program participants whose cooperation made this study possible.
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REFERENCES DUPONT, R.L. Trying to treat all heroin addicts in a community. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 77-80. EINSTEIN, S., and GARITANO, W. Treating the drug abuser: Problems, factors and alternatives. Intern. J . Addictions 7 : 321-331, 1972. DEPARTMENT OF HEALTH, EDUCATION AND WELFARE, FOOD AND DRUG ADMINISTRATION. Conditions for investigational use of methadone for maintenance programs for narcotic addicts. Fed. Regist. 35(113): 9014-9015, June 1 I , 1970. DEPARTMENT OF HEALTH, EDUCATION AND WELFARE, FOOD AND DRUG ADMINISTRATION. Conditions for investigational use of methadone for maintenance programs for narcotic addicts. Fed. Regist. 35(64) : 6075-6077, April 2, 1971. DEPARTMENT OF HEALTH, EDUCATION AND WELFARE, FOOD AND DRUG ADMINISTRATION. Methadone, proposed special requirements for use. Fed. Regist. 37(67): 6940-6946, April 6, 1972a. DEPARTMENT OF HEALTH, EDUCATION AND WELFARE, FOOD AND DRUG ADMINISTRATION. Approved new drugs requiring continuation of long term studies, records, and reports. Listing of methadone with special requirements for use. Fed. Regist. 37(242): 2679Cb26806, December 15, 1972b. FORD FOUNDATION, Dealing with Drug Abuse. A Report to rhe Ford Foundation. New York: Praeger, 1972, p. 175. HESS, C.B. Mechanisms of control of methadone programs at the state level. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 253-255. JONES, S.W. Job counseling for the unskilled methadone maintenance patients. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 297298. KLEBER, H.D. The New Haven methadone maintenance program. Intern. J . Addictions 5 : 449463, 1970. KNOWLES, R., LAHIRI, S . , and ANDERSON, G. Methadone maintenance in St. Louis. Intern. J . Addictions 5 : 4 0 7 4 2 0 , 1970. MAYER, J. Treatment of drug addiction. Brit. J . Addictions. 67: 137-142, 1972. MUSKALEY, T.E. Motivation and their relationship to methadone maintenance withdrawal problems. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 177-179. RICHMAN, A. Assessing treatment success in individual patients: Chairman’s remarks. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 2 13-2 14.
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ROSS, S. The function of job rehabilitation in a methadone maintenance program-An examination of the interaction of treatment and job rehabilitation. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 289-292. SEARCY, P., JR. A suggested method of economic development for methadone maintenance treatment program patients. In Fourth National Conference on Methadone Treatment Proceedings. 1972, p. 295. TRIGG, H.L. Clinical problems of selection, prediction and patient failure. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 133-1 34. WARREN, N.J. Nursing therapeutics in methadone maintenance programs. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 281-283. WILSON, T.G.G. The Detroit experience. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 307-310.
ISSN: 0020-773X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/isum19
A Client-Developed Methadone Maintenance Program Richard J. Levine & Hugh F. Kabat To cite this article: Richard J. Levine & Hugh F. Kabat (1975) A Client-Developed Methadone Maintenance Program, International Journal of the Addictions, 10:5, 825-842, DOI: 10.3109/10826087509027341 To link to this article: http://dx.doi.org/10.3109/10826087509027341
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The International Journal of the Addictions, 10(5), 825-842, 1975
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A Client-Developed Methadone Maintenance Program" Richard J. Levine, M.S. Abboti Hospital and College of Pharmacy University of Minnesota Minneapolis, Minnesota
Hugh F. Kabat, Ph.D. Department of Clinical Pharmacy University of Minnesota Minneapolis, Minnesota
Abstract
A realistic methadone maintenance program is a continuum of four related areas: intake, rehabilitation with on-going evaluation, detoxification, and postdetoxification followup, each jointly administered by client volunteers and professional staff. In the early stages of client treatment, pharmacists have more frequent contact with program participants than do other staff
* Abstracted in part from a paper submitted to the Graduate School, University of Minnesota, in partial fulfillment of the requirements for the M.S. degree in hospital pharmacy. 825 Copyright 0 1975 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.
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professionals. At the Minneapolis Pilot City Health Center, 31 of 69 participants in the methadone maintenance program were interviewed by their pharmacist to determine client understanding of program objectives, interpretation of program effectiveness, and suggestions for program improvement. Client understanding of the objectives or program elements ranged from 30 to 97%. Client evaluation of the effectiveness of program elements ranged from 0 to 65%. The client-developed program included intake procedures to establish for each client the program objectives, rules, evaluation, guidelines, client goals, dismissal guidelines, and a review of supportive services. Rehabilitation would be continuous with consistent on-going evaluation to measure goal attainment, a decline in disruptive behavior, and freedom from illicit drug use. Detoxification should be undertaken after the client’s behavior has stabilized and he has developed a marketable skill. Monitoring of the client to assure a drug-free state would be an important element of the postdetoxification follow-up. The Pilot City Health Center, a federally funded neighborhood health center located in the inner-city area of North Minneapolis, initiated a rehabilitation program for opiate addicts in 1968. The program’s objectives were to reduce the addict’s use of illict opiates and to aid him to rehabilitate himself into a constructive member of society. The purposes of this study were threefold : 1. To determine the degree to which the clients understood the program. 2. To determine the effectiveness of the program from the client’s point of view. 3. To develop recommendations for program reorganization based upon client ideas.
The Proceedings of the Fourth National Conference on Methadone Treatment (1972) document several rehabilitation programs with disparate organizational structures and objectives. The Proceedings also highlight many of the problems that have arisen in attempts to rehabilitate opiate addicts. Critics of these programs have alleged that many program directors and supportive personnel are not equipped professionally or emotionally to undertake the responsibility of working with opiate addicts (Einstein and Garitano, 1972; Ford Foundation Report, 1972; Hess, 1972).
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At the time (Spring 1972) this study was done, the Pilot City Health Center Methadone program director and assistant director were the only paid program personnel. The program director was both a college graduate and a minister, The assistant director had 1 year of college and little or no formal counseling experience but claimed to have been a frequent drug user. The director supervised all program activities while serving as intake screener, counselor, methadone dose evaluator, and program administrator. The assistant director served as a secondary counselor when the director was not available, supervised the collection of urine specimens for laboratory analysis, and arranged medical appointments for new admissions. Volunteer seminary students organized small group sessions to confront the client with his problems and to assist him in facing reality (Kleber, 1970), but were unable to gain the confidence and cooperation of the program participants and the groups were eventually disbanded. The methadone maintenance program utilized the services of other departments in the health center-mental health, social service, pharmacy, laboratory, dentistry, and medicine. The mental health department employed a psychologist, sociologist, and a part-time psychiatrist. All in-coming addicts received a Minnesota Multiphasic Personality Inventory and met with the psychologist. In addition, they received a routine physical examination and a urine analysis for opiates. The program director established the initial methadone dosage level. The pharmacist prepared and administered daily doses of flavored methadone liquid in a concentration of 2 mg/ml. Pharmacy personnel were actively involved in the program’s organizational planning processes. The opiate addict’s initial knowledge concerning the program was usually through his street friends. Addicts wishing to be accepted as program participants generally were aware of the program regulations and the degree to which these regulations could be violated. However, his initial formal contact with the program was when he met with the program director and completed an application for admittance. The application information included age, address, education, employment, personal background, and a brief history of his addiction. Emphasis was placed on where and how he acquired opiates and approximate amounts used. Since applicants had street knowledge of the criteria for acceptance, their responses to the questionnaire assured admission because it was difficult, if not impossible, to ascertain the validity of an addict’s assertions. After the initial review of the applicant, he appeared before a screening committee consisting of program participants. In theory, the screening committee had the responsibility to accept or reject the addict’s petition
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PROGRAM PARTICIPANT
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SURVEY INSTRUMENT
Spring 1972
1. Do you know what t h e s c r e e n i n g committee does? Could you t e l l me what they do? How w e l l do you f e e l they a r e doing t h e i r job? 2.
A r e t h e a d d i c t s ' responses t r u e , f a l s e , o r exaggerated?
3.
When t h e a d d i c t s are interviewed should they s e t goals f o r themselves ?
a. b. c.
4.
d e t o x i f i c a t i o n of methadone. employment. enrollment i n school.
Who do you f e e l is b e s t q u a l i f i e d t o interview you?
a. b. c. d. c.
fellow a d d i c t s . psychiatrist. d i r e c t o r of t h e program. s o c i a l workers. combination of above.
5.
Were you adequately t o l d t h e r u l e s of t h e program during the i n i t i a l interview? Could you t e l l me some of t h e s e r u l e s ?
6.
Could you t e l l m e what the counselors and group l e a d e r s do? Are they h e l p f u l ?
7.
Do you know how group l e a d e r s a r e s e l e c t e d and how t h e groups a r e arranged?
8.
Do you p a r t i c i p a t e i n group meetings? Why o r why n o t ?
9.
I f you were p r o j e c t d i r e c t o r
a. b. C.
-
what q u a l i f i c a t i o n s would you look f o r i n h i r i n g counselors, how would you i n s u r e attendance and p a r t i c i p a t i o n by a l l , what t y p e s of people would you h i r e on the program?
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Would you h i r e t h e program p a r t i c i p a n t s ? What would t h e y do?
11. A f t e r a six-month p e r i o d , how s h o u l d a p e r s o n b e e v a l u a t e d ? a. b.
c.
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d.
e.
decrease abusing street drugs. decrease of i l l e g a l a c t i v i t i e s . c o n s i s t e n t employment. enrollment i n school. d e c r e a s e o f methadone dose.
12.
What d i f f e r e n t programs b e s i d e s t h e d r u g program are a v a i l a b l e a t t h e h e a l t h c e n t e r t o h e l p you and g i v e you a s s i s t a n c e ?
13.
Do you f e e l you would want t o b e d e t o x i f i e d from methadone by next year?
14.
Do you h a v e any s p e c i f i c s k i l l ?
15.
Has t h e program h e l p e d you e n r o l l i n s c h o o l o r a c q u i r e a j o b o r have you h e l p e d y o u r s e l f ?
16.
Is t h e program h e l p i n g you u n d e r s t a n d t h e r e a s o n s why you became a d d i c t e d and t h e e v e n t s which l e d up t o a d d i c t i o n ?
17.
A r e you t r y i n g t o s o l v e your OWTI problems and are you r e c e i v i n g a s s i s t a n c e from t h e drug program? Do you r e a l i z e what some of your problems are?
18.
Is t h e program h e l p i n g you resist t h e t e m p t a t i o n o f a g a i n becoming an o p i a t e a d d i c t ?
19.
How is t h e program h e l p i n g you? Is t h e program meeting y o u r n e e d s ? What would you l i k e t h e program t o do f o r you?
20
Should methadone d o s e s b e unknown? Why?
0
21.
Do you f a v o r p l a c e b o d o s e s ? Would t h i s h e l p w i t h p s y c h o l o g i c a l r e a d j u s t m e n t ?
22.
Do you f a v o r t h e p r e s e n t pick-up s c h e d u l e ?
23.
What are y o u r r e s p o n s i b i l i t i e s t o t h e program?
24.
Should p e o p l e b e d i s m i s s e d ?
a. b
.
repeated drug use. r e p e a t e d i l l e g a l a c t i v i t i e s , c o n v i c t i o n s and disruptive behavior.
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for inclusion in the program. There were times when members of the screening committee declined to admit some addicts into the program but were overridden by the director. At other times, since it was difficult for the program director to convene a meeting of the screening committee, the program director unilaterally admitted addicts into the program. After acceptance, the incoming addict was told about the methadone pick-up schedule. He was instructed not to abuse other drugs and to observe the program regulations. The FDA guidelines suggest that after a person has been maintained on methadone for 1 to 2 years and his behavioral and emotional patterns have been altered, he is ready to be detoxified, but none of the Pilot City program participants had reached that stage. If a client wished to receive assistance from the mental health department, or the program director, he had to make an appointment several days in advance. In general, an addict’s life style lacks organization or planning. He finds it difficult to keep appointments since he has no regular schedule. Until this life style pattern is changed, the client exists from day-to-day and his problems are a reflection of this existence. The absence of adequate staff personnel precluded the client from meeting with the director or assistant director on a drop-in basis. The pharmacists had more personal contact with the clients than anyone because of the daily methadone administration schedule and frequently became involved !n personal discussions with the clients in the informal pharmacy dispensing area. The pharmacist was in a unique position to observe daily changes in the clients’ physical and psychological behavioral patterns. Clients were often less reluctant to discuss problems frankly in this informal atmosphere then they were in the formal counseling meetings One coauthor (R.J.L.) was a pharmacist at the Pilot City Health Center. Although some clients had methadone take-home privileges for up to 3 days, most were required to drink their methadone daily at the Health Center in the presence of the pharmacist. The program operated within the minimal FDA regulations contained in the Federal Register. There were no standards for on-going evaluations, adjustment of methadone dosage, or dismissal from the program for violations of program rules. At the time (Spring 1972) this study was done, 69 clients were enrolled in the program.
METHODOLOGY Each program participant was asked to participate in an interview when he came to the pharmacy for his methadone. In a secluded area he
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Table 1
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Ethnic Background of Pilot City Methadone Program Participants and Those Interviewed (Spring 1972)
Client population
Number in program
Number interviewed
Black Caucasian Indian
29 39 1
9 21 1
Table 2 Sex of Pilot City Methadone Program Participants and Those Interviewed
Sex
Program participants
Participants interviewed
Male Female
56 13
26 5
Table 3 Occupational Status of Pilot City Methadone Program Participants Interviewed (N=31)
Participants Enrolled in school College, 2 Vocational training, 3 Has specific vocation Employed, 15 Unemployed, 6 Unemployed, no vocation
5
21
5
was asked to respond verbally to 24 questions. The responses were reduced to writing immediately. Interview time varied from 20 to 30 minutes. Thirty-one persons or 45% of the total program participants enrolled in the Pilot City Health Center Methadone Maintenance Program were interviewed. Demographic information for those interviewed is summarized in Tables 1, 2, and 3. The age range for those interviewed was 17 to 60 years, with the mode being 23.
UNDERSTANDING THE PROGRAM Thirty of the 31 clients interviewed were aware of the existence of the screening committee; however, 10 clients thought that the purpose of the screening committee was to determine whether the program could help the
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Interpretation of the Purpose of the Screening Committee (N =31)
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Determine if addict is legitimate Help addict Committee needs reorganization No response
10 10 8 3
Table 5 Determination of the Truthfulness of the Addict’s Response during the Screening Committee Interview (N =31)
Distorted, false, or exaggerated True Did not know
19 8 4
incoming addict and 10 that the purpose was to determine whether or not the interviewed person was a “real or legitimate” opiate addict (Table 4). Nineteen of the 31 clients interviewed stated that addicts tend to distort the truth, exaggerate, and lie, suggesting that it is difficult to determine whether the addict is telling the truth (Table 5). Only eight clients stated that they believed the responses of the interviewed addicts were true, noting that since the members of the screening committee were program participants and former addicts, they did not believe that prospective clients would lie to them or that they would know if the prospective client was untruthful. No one interviewed mentioned social and psychological rehabilitation as a goal; instead, 33 of the 49 responses to the question on program goals related to drugs (e.g., do not take street drugs, do not sell or buy methadone, observe the pharmacy pick-up schedule, and be drug free). Table 6 shows a similar pattern of responses when program participants were asked about their responsibilities to the program. Fifteen of 43 responses were in relation to obeying program rules and keeping appointTable 6 Client Interpretation of Their Responsibility to the Program (N =43)“
Drug-related response
19
Obey program rules
15
Participate in program activities Rehabilitate oneself Clients provided multiple responses.
7 2
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Table 7 Client's Knowledge of Other Services (N =45)" ~~
Mental health and social service Medical Did not know
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a
24 14 7
Clients provided multiple responses.
ment schedules, and 19 were related to drugs. Only two clients cited rehabilitation. Fourteen clients were aware that they might use the Center's medical and dental facilities. Twenty-four were aware of the availability of the Center's mental health and social services, but seven clients were unaware of any supportive services (Table 7). Twenty-one of the 31 clients interviewed stated that the purpose of the counseling groups and group leaders was to help one solve problems, but 10 clients did not know the purpose of the counseling groups. In addition, 25 out of 31 clients did not know the reasons for which the group leaders were selected.
PROGRAM EFFECTIVENESS Twenty-one of the 31 clients surveyed thought they were adequately interviewed during intake, but six clients stated that the screening committee was not doing a good job (Table 8). Fifteen clients had participated fully in group counseling sessions ; nine attended only the first few meetings but seven had never participated (Table 9). While 13 clients thought the counselors were always helpful, seven clients thought that only the initial meetings were helpful. Seven stated that the counselors were not helpful. Four had never met with counselors-two of them because they worked during the times when counselors were available (Table 10). Fifteen of the 31 clients interviewed indicated the methadone program Table 8 Client Interpretation of the Performance of the Screening Committee (N =31)
Average job Good job Not doing a good job Did not know
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Table 9 Client Attendance at Group Counseling Meetings
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Attend and participate Attended only first few meetings Never attended
(N =31)
15
9 7
Table 10 Client Evaluation of Helpfulness of Group Counselors ( N =31)
Helpful Helpful only during first few meetings Hot helpful Never attended
13 7 7
4
was either helping them enroll or remain in school, or to acquire or maintain a job. Others stated the program was not helpful. Seventeen clients thought the program was helpful in understanding why they personally became addicted ; six stated they realized the reasons by themselves but eight indicated the program was not helpful in this regard. Eleven clients indicated that the program was helping them solve some of their problems, and 17 others stated they were trying to solve their own problems. Twenty-six of the clients interviewed indicated the program was helping them resist the temptation to again become an opiate addict. Seventeen of the participants favored the existent methadone pick-up schedule.
CLIENT IDEAS Thirty clients indicated that the in-coming addicts should set goals for themselves either during the initial screening process or shortly afterwards. Twenty-six clients believed that they should be evaluated periodically for discontinuation of illegal activities, enrollment in school, maintaining a job, and decreases in the methadone dosage. Seventeen clients indicated that all these standards should be used as a criteria for evaluation, and others indicated that all of the standards should be used to measure progress except a decrease in methadone dosage. Four clients stated that there should be no standards for evaluation, and program participants should be rehabilitated only if they desire. Fourteen clients thought trained or knowledgeable addicts should be
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employed in the program. Seven thought specially trained personnel should be employed (the term professional was not used) and two thought trained addicts in conjunction with professionals should be employed. Sixteen clients thought counselors should be specially trained professionals, 12 thought only knowledgeable or trained clients should serve as counselors, and three stated clients should be able to select counselors. Twenty-six clients stated that a combination of qualified addicts and professional personnel (psychiatrist, social workers, program director, etc.) should serve on the screening committee. However, five others maintained that only program participants were qualified to serve on the screening committee by virtue of their past experience with the addict culture and life style. Every client interviewed felt that clients should be employed in the program. Twenty-four stated that ex-addicts could serve as problem solvers, and seven others that ex-addicts could serve as counselors. In order to insure attendance and participation in program activities, 21 of the clients felt that they must have a part in the decision-making process. Nine indicated that they would impose restrictions (withhold methadone take-home privileges) if clients did not participate. Twelve clients thought use of unknown doses of methadone should be explored further and could prove to be helpful, but the majority (19) observed that clients should know their dosage. Thirteen clients indicated that unknown doses of methadone could cause the client to have additional psychological problems. Twenty clients favored use of placebo doses, feeling that they would help those with additional psychological problems. Those clients who were opposed to placebo doses were opposed to deception of program participants. Fifteen clients suggested that program participants should be dismissed for repeated drug abuse or disruptive behavior, but the other 16 disagreed, citing the need for more professional assistance for clients who do not observe program guidelines.
DISCUSSION The program participants did not understand the significance of the program nor did they understand the program’s intrinsic operations. They lacked a clear understanding of their responsibilities due to the absence of a suitable orientation program for incoming addicts. Too much focus was placed on methadone and other drug rules instead of on program objectives. The incoming addict was told to be drug free,
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to observe the methadone pick-up schedule, not to sell or buy methadone, not to use unknown doses of methadone, and not to abuse street drugs. Most clients were aware of the existence of the screening committee and counseling groups, but only a third of those interviewed (10/3 1) knew the purpose of the screening committee and no one was able to outline the types of problems to be solved by the counseling groups. Most (25/31) were not even aware of how the group leaders were selected. Program participants were capable of determining the degree to which the program helps them meet their needs. Job maintenance and school enrollment represents one set of standards by which program effectiveness can be evaluated (Searcy, 1972). The Pilot City Methadone program was helping 26 of the 31 interviewed clients resist the temptation to again become an opiate addict. Thirteen of the clients interviewed found the program to be generally helpful but only seven stated that the program is helping them realize their problems. These findings suggest that the program is meeting the physical needs of the clients, but not their emotional or psychological needs. Although almost three-fourths of the clients interviewed initially thought the counselors and group meetings were helpful, as time went on the meetings did not maintain the clients’ interest or motivate them. The incoming addict finds the program both new and challenging. The usual addicts’ life style and culture requires constant change and instant gratification (Warren, 1972). Almost two-thirds of the clients interviewed (22/31) thought the clients should participate and share in the decisionmaking process in order to maintain their continued interest and to increase client motivation. Program participants were able to analyze the effectiveness of the program. They were able to make realistic suggestions for program improvements which included methods for evaluation, standards for dismissal, types of personnel to be employed, and elements of meaningful client participation. They also recognized the need for improved clientcounselor relations. Several authors have stated that staff-participant relationships in methadone maintenance programs have not been productive or meaningful (Jones, 1972; Knowles et al., 1970). They note further that due to these meaningless relationships and distrust for the professional staff, clients have frequently sought the assistance and guidance of their peers which has not always proven to be helpful (Ross, 1972). Since the origin of staff-client problems has frequently been inadequately trained professional staff who are unsympathetic to the plight and complications of the clients’
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or addicts’ life, one can understand why the program participants favor both rehabilitated addicts and knowledgeable program participants to be employed as staff personnel. This study confirms that clients feel that any person employed on the program should be knowledgeable and sympathetic concerning the addict’s life style and be specially trained. Eight of the clients interviewed felt that peer review of the addicts’ responses during the screening committee interview would guarantee truthfulness. They noted that peers can sufficiently intimidate the addicts being interviewed so that they will tell the truth. Other authors have noted that it is difficult, if not impossible, to establish the validity of the interviewed addicts’ statements. The physical signs of addiction as indicated in the Federal Register (Department of Health, Education and Welfare, 1970, 1971, 1972a, 1972b) can be established, but the years of addiction, the approximate amounts of opiates used, the level of illegal activities, and the past history of psychiatric treatment cannot be established (Trigg, 1972). It should be evident, however, that addicts wishing to be accepted as program participants already possess a street knowledge of the program standards for acceptance. They know that some of their statements may preclude them from becoming program participants, so they must lie and distort the truth if they wish to be accepted into the program (Trigg, 1972). Consistent on-going evaluations should be an integral part of any program. Rehabilitation implies that there will be change in a person’s character and life style. There must be standards to measure this change. Twenty-six of the clients interviewed stated the participants should be evaluated, and 30 of 31 stated they should establish personal goals. Client dismissal is a controversial subject. In this study 15/31 clients interviewed favored dismissal for either repeated drug use or repeated disruptive behavior, but 12 thought that these activities only indicate that the client requires more professional guidance and that he should be referred to another agency. Only if he is incorrigible do they believe that he should be dismissed.
CONCLUSIONS In this study of 31 methadone maintenance program participants, many clients did not have an understanding of the program nor did they know its purpose. Many clients did not know what was expected of them upon becoming program participants. Further, the clients indicated that the program was not assisting them in becoming rehabilitated. They made several recommendations for program improvement and reorganization.
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Every program participant must have a suitable orientation process to determine whether or not he can be helped by the program and what his role in the program will be. Trained personnel are needed but not all the personnel need be professionals. Many lay people, rehabilitated addicts, and some program participants who are motivated and doing well could be employed. Client participation in the decision-making process is also critical if the program is to motivate the participant toward rehabilitation. Realistically, the program should be divided into different stages according to the progress of the client: (1) intake, (2) rehabilitation and on-going evaluation, (3) detoxification, and (4) postdetoxification followup. For the program to best serve the needs of the clients, each stage must be related and represent a continuum from the preceding one. Program intake should serve as the addict’s initial contact with the program. After the addict is told exactly what is expected of him, he should be asked to decide whether he wishes to become a member of the program. During the intake procedure, the following items should be stressed: (1) purpose of the program, (2) program’s rules, (3) guidelines for client evaluation, (4)goal setting by the client, (5) guidelines for dismissal, and (6) availability of supportive services. A client-volunteer together with a staff counselor should interview and review the addict’s application. Then the addict should be referred to a psychologist for a routine behavioral analysis before being referred back to his client-counselor team. There should be positive feedback to indicate that the addict understands the program rules and his responsibilities. He should also be assisted in preparing goals for rehabilitation. At this stage the psychologist, counselor, and client-volunteer should bring the results of their analyses to the screening committee for a decision on acceptance of the addict into the program. The screening committee should consist of an equal number of professionals and nonprofessionals (program participants) and include the counselor, client-volunteer, and the psychologist who performed the initial addict interview. The addict should meet with the committee. When the addict is accepted, he should be assigned another client-volunteer to elaborate on the program guidelines and explain the various supportive services available. During the intake process the addict should receive a daily dose of methadone to avoid withdrawal symptoms. The new client should then be transferred to the next program stage where counselors attempt to help him rehabilitate himself. In this stage the program can best utilize the services of those motivated program
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participants and rehabilitated addicts who serve as counselor-assistants. These counselor-assistants are essential since the professional staff usually have not yet gained the confidence and cooperation of the clients because the addict has a general distrust for people, including professionals, who state that they wish to offer assistance. A trust relationship with the client can be established provided the program meets his needs and treats him with respect (Knowles et al., 1970; Muskaley, 1972). With the development of a trust relationship, the program will acquire the cooperation of the clients. During the rehabilitation stage the client should be expected to set goals for himself with the cooperation of both the professional and nonprofessional staff. These goals should be realistic and attainable by the client (Dupont, 1972; Richman, 1972). Clients should participate in all program elements. They should be active in the program’s decision-making process; their opinions should be sought out because client participation produces a sense of loyalty to the program and increases their motivation (Kleber, 1970). Clients can participate during the initial screening as counselor-assistants for program participants with personal problems, with appointment scheduling, with appointment keeping, and on a 24-hour call basis to assist clients with urgent problems. An Advisory Board consisting of an equal number of professionals and nonprofessionals should serve as the program’s final decision-making body to select appropriate courses of action for those clients that consistently disregard the program rules. Clients can serve effectively on this Advisory Board. The program should be intolerant of consistent client disruptive behavior and continual drug abuse, and the clients should be well aware of this. However, once a client is dismissed, if he wishes to return and obey the program rules, he should be readmitted. Counselors should be knowledgeable concerning the client supportive services offered by other agencies which can be utilized on a referral basis (Wilson, 1972). It is important that a line of communication be established between the agencies and the program, however, so that the client is consistently and continually evaluated. An important rehabilitation standard by which the client may be evaluated is employment or enrollment in school. Each client should be classified accordingly-employed at a job that requires a vocation, employed at a job that does not require a vocation, is a student, has a vocation but does not have a job, or has neither a vocation nor a job. Clients who are employed with marketable skills or unemployed but possessing these
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skills are apt to perform much better than their counterparts without a job or skill (Ross, 1972). The counselor should assist the client to acquire marketable skills-a difficult but obtainable objective. The rehabilitation stage should consist of on-going and consistent evaluations. The progress of the client should be continually monitored (e.g., Is he still enrolled in school? Is he still employed?) Routine urine analysis, even though it emphasizes the drug focus, is one effective way to determine whether the client is abusing drugs. Urine analysis can, however, be thought of as a guideline to determine whether or not the client requires more guidance rather than more disciplinary measures (Einstein and Garitano, 1972: Hess, 1972). If consistent drug abuse does not cease, then the problem should be referred to the Advisory Board. Group and individual counseling should be sufficiently helpful to motivate the client to attend group meetings but flexible enough to meet the client’s changing needs. Because the client can only be concerned with one goal at a time (drug abstinence or social and psychological rehabilitation), rehabilitation should be the program’s first priority for the client (Mayer, 1970; Muskaley, 1972). After the client has been maintained on methadone for a period of time (few months to a number of years), has stabilized his behavioral pattern, and acquired a specific skill which is marketable, he is ready to be detoxified from methadone. The detoxification schedule should jointly be determined by the professional counselor, the counselorassistant, and the client himself. Monitoring the client’s progress after he has been detoxified is an important responsibility of the program, so the client should be told he can still utilize the supportive services of the program whenever he feels the need. Since methadone dosage per se, abuse of other drugs, detoxification, and being drug free represent secondary priorities, necessary corrective measures should be employed if one does not follow the program guidelines regarding methadone dosage. Unknown doses and placebo doses for clients should be further evaluated. In summary, a program must meet the clients’ changing needs or it will merely perpetuate the addicts’ life-style. This can only be accomplished by adequate professional staff in collaboration with client volunteers who are capable of consistently evaluating the program, who are flexible enough to initiate and institute change, and who gain the trust, confidence, and cooperation of the clients they are to serve.
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ACKNOWLEDGMENTS
The authors are indebted to the Pilot City Health Center staff, program staff, and program participants whose cooperation made this study possible.
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REFERENCES DUPONT, R.L. Trying to treat all heroin addicts in a community. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 77-80. EINSTEIN, S., and GARITANO, W. Treating the drug abuser: Problems, factors and alternatives. Intern. J . Addictions 7 : 321-331, 1972. DEPARTMENT OF HEALTH, EDUCATION AND WELFARE, FOOD AND DRUG ADMINISTRATION. Conditions for investigational use of methadone for maintenance programs for narcotic addicts. Fed. Regist. 35(113): 9014-9015, June 1 I , 1970. DEPARTMENT OF HEALTH, EDUCATION AND WELFARE, FOOD AND DRUG ADMINISTRATION. Conditions for investigational use of methadone for maintenance programs for narcotic addicts. Fed. Regist. 35(64) : 6075-6077, April 2, 1971. DEPARTMENT OF HEALTH, EDUCATION AND WELFARE, FOOD AND DRUG ADMINISTRATION. Methadone, proposed special requirements for use. Fed. Regist. 37(67): 6940-6946, April 6, 1972a. DEPARTMENT OF HEALTH, EDUCATION AND WELFARE, FOOD AND DRUG ADMINISTRATION. Approved new drugs requiring continuation of long term studies, records, and reports. Listing of methadone with special requirements for use. Fed. Regist. 37(242): 2679Cb26806, December 15, 1972b. FORD FOUNDATION, Dealing with Drug Abuse. A Report to rhe Ford Foundation. New York: Praeger, 1972, p. 175. HESS, C.B. Mechanisms of control of methadone programs at the state level. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 253-255. JONES, S.W. Job counseling for the unskilled methadone maintenance patients. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 297298. KLEBER, H.D. The New Haven methadone maintenance program. Intern. J . Addictions 5 : 449463, 1970. KNOWLES, R., LAHIRI, S . , and ANDERSON, G. Methadone maintenance in St. Louis. Intern. J . Addictions 5 : 4 0 7 4 2 0 , 1970. MAYER, J. Treatment of drug addiction. Brit. J . Addictions. 67: 137-142, 1972. MUSKALEY, T.E. Motivation and their relationship to methadone maintenance withdrawal problems. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 177-179. RICHMAN, A. Assessing treatment success in individual patients: Chairman’s remarks. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 2 13-2 14.
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ROSS, S. The function of job rehabilitation in a methadone maintenance program-An examination of the interaction of treatment and job rehabilitation. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 289-292. SEARCY, P., JR. A suggested method of economic development for methadone maintenance treatment program patients. In Fourth National Conference on Methadone Treatment Proceedings. 1972, p. 295. TRIGG, H.L. Clinical problems of selection, prediction and patient failure. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 133-1 34. WARREN, N.J. Nursing therapeutics in methadone maintenance programs. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 281-283. WILSON, T.G.G. The Detroit experience. In Fourth National Conference on Methadone Treatment Proceedings. 1972, pp. 307-310.
