SUPPLEMENTARY METHADONE SELF ADMINISTRATION AMONG METHADONE MAINTENANCE CLIENTS* MAXINESTITZER,GEORGE
BIGELOWand IRA
LIEBSON
Department of Psychiatry. Baltimore City Hospitals and Department of Psychiatry and Behavioral Sciences. The Johns Hopkins University School of Medicine
Abstract-The presentstudy
derives from two related questions: (I) Can methadone dose alterations act as reinforcers‘! (2) Do methadone dose alterations affect symptomatology of methadone maintained clients’? Twenty three clients were offered six opportunities to alter their own methadone dose on a single day by as much as f20mg. Dose increases were selected on the vast majority of occasions (94.3%). Thus. supplemental methadone did function as a reinforcer for these clients. There was little evidence that dose increases which clients chose had any appreciable subjective effects. Neither symptomatology self reports nor judgements of dosage adcq.lacy were significantly altered following acute methadone dose increases. The amount of supplemental methadone which clients self administered could not be predicted by demographic characteristics. by length of time enrolled in maintenance treatment. by type or amount of illicit supplementary drug use. or by adequacy judgements of stable methadone dose. However. dosage self regulation may have predictive potential as a measure of dcgrec of behavioral dependence on narcotic drugs.
The subject of methadone dosage occupies considerable time and attention in methadone maintenance clinics. Numerous dose alterations, the majority of which are dose increases, may be given to individual clients during the course of “maintenance” treatment, presumably in response to symptomatic complaints (Stitzer & Bigelow, 1976). The factors which maintain dosage adjustment, however, are not clear. Dosage alterations may influence how clients feel either as a result of their pharmacological effects or their status as a placebo procedure. Several studies have compared groups of clients maintained on different dosages of methadone and found no difference in overall level of reported comfort, drug craving or opiate use as a function of methadone doses above 50 mg (Berry & Kuhn, 1973; Garbutt & Goldstein, 1972; Goldstein & Judson, 1973) but some studies suggest that doses of 30-50 mg may be inferior to higher dosages in terms of client comfort and continued opiate use (Garbutt & Goldstein, 1972; Goldstein & Judson, 1973; Ling et al., 1976). On the other hand, client comfort may not be the real issue in dosage adjustment. Rather, higher doses of methadone may be acting as reinforcers and may thereby maintain the behavior of dosage bargaining so long as client efforts are occasionally rewarded with increased dosages. The present study derives from two related questions: (1) Can methadone dose changes act as reinforcers? (2) Do methadone dose alterations affect symptomatology of methadone maintained clients? To explore these questions, clients were offered the opportunity to regulate their own methadone dose for single days on several occasions. In one previous study (Goldstein et al., 1975) outpatient methadone maintenance clients were given the chance to alter their methadone dose by 5 mg each week. Most clients raised their dose at some point during the study, but median dosage increased by only 10 mg during 25 study weeks. However, doses above 50 mg resulted in loss of take-home privileges; thus, many clients were essentially faced with a choice between higher methadone doses or continuing take-home privileges. In addition, the size of each dose increase allowed was quite small. The present study asks whether methadone maintenance clients will alter their dose on a single day basis when no choice or loss of privileges is involved and when acute dose changes as large as 20mg can be obtained. If clients reliably *This research was supported by USPHS grant No. DA-01472 and Research Scientist Development Award NO. DA-00050 from the National Institute on Drug Abuse. Send reprint requests to Dr M. Stitzer. Baltimore City Hospitals, D-S-West 4940 Eastern Ave.. Baltimore. MD 21224. 61
MAXINESTITZER.GEORGEBIGELKIW and IRA LIEINN
62
take advantage of this opportunity, then methadone dose alteration can be considered a reinforcing event. In addition, if clients choose to alter their doses, the detectibility of these dosage alterations can be assessed on symptom self report measures. METHODS
Participants
Participants were 23 male methadone maintenance clients. Demographic and addiction history characteristics are summarized in Tables 1 and 3. Most participants showed at least occasional urinalysis positives for one or more drug class; clients whose samples were consistently negative for drugs other than methadone were typically channeled into other studies. However, four clients participated who had clean urines throughout their participation (see Table 3); two of these (JBA, RSN) had previously participated in experimental dose alteration studies which had exposed them to dose alterations as large or larger than those available in this study. Procedure
Clients reported to the clinic seven days per week, and drank their daily methadone dose mixed in cherry syrup vehicle (Methadose@) under nurses’ observation. Clients were told that occasionally they could alter their dose up or down for a single day at a time, and that the point of the study was to see what clients choose to do when given an opportunity to alter their methadone dose. Dose self regulation opportunities generally occurred twice a week on Tuesdays and Fridays for 3 consecutive weeks., On self regulation days clients could alter their dose up or down by as much as 20 mg or 50% of their stable dose, whichever was smaller. Only two clients, with stable doses of 20 mg (FLW) and 30 mg (MRJ). were limited to maximum dose changes smaller than 20 mg. Clients selected their dose by completing a brief questionnaire. No more than 3 clients ever participated simultaneously in this study, which was conducted over a period of 14 months; data from each client are therefore relatively independent. Urine samples were collected under observation at the clinic on Mondays and Fridays and occasionally on Wednesdays, and were analyzed for evidence of supplementary drug use. Table 1. Characteristics
of study participants (N = 23) Median
Range
Age (yr)
28
Years of education Years of addiction Months of previous methadone treatment Methadone dose (mg) Weeks enrolled at this clinic prior to study
I2 8
19-39 8-14 2-15
10 50
G-95 2&80
3.5
2-64.5
Table 2. Distribution of patient choices on methadone dosage self regulation opportunities Percent of opportunities (N = 141) Dow
94.3
increases
Largest available increase chosen 507; or more of largest available increase chosen Less than 50% of largest available increase chosen Dose decwaws No dose change
Total
16.6 12.1 5.1 2.8 2.8 99.9
Supplementary Table
methadone
3. Individual
Client
Methadone dose (mg)
Weeks at stable methadone dose
CIM CHW cos WAA BUJ WIG JAM KEM MAV WID TRR SNR BAJ TGP NLD BDW YAA TUW FLW WLR ROR MRJ SMR
80 55 50 60 60 50 50 50 80 50 60 45 50 50 50 60 50 50 20 50 50 30 40
TRS TR 1.5 1.0 TR TR 2.5 TR TR 1.5 2.0 34.5 63.5 1.5 2.0 I.0 19.5 7.0 2.5 2.5 2.5 2.5 3.0
self administration
dose self regulation
Percent of total allowabic supplemental methadone taken 100 100 100 100 100 100 too 100 100 100 100 100 100 91.7 91.7 87.5 87.5 83.3 83.3 50.0 50.0 38.9 12.5
63
data
Dose adequacy judgcmcnt* 3.8 3.6 4.0 3.9 5.0 4.0 4.0 5.0$ 3.0 4.2 3.8 3.w 3.0 4.0 3.8 4.2 4.5s 4.0 3.0 4.0 3.7$ 3.0 3.2
Drug classes positive during studyt MBTO BTO TO MT BT TO MT TO T T
0 M MT T M T MT M M
*Shown are average scores obtained on 47 dose self regulation days for each client. These represent adequacy judgements of the client’s regular methadone dose. Dose adequacy judgements are as follows: I = much too high. 2 = a little too high. 3 = just right. 4 = a little too low. 5 = much too low. t Drug classes are identified as follows: M = opiates. B = barbiturates. T = benzodiazepine tranquilizers. 0 = other drugs. $ For clients who transferred to this clinic from another program. weeks at stable methadone dose arc indeterminate. 3 These clients did not complete daily reports. Shown arc average scores on twice weekly reports completed during the study period.
Prior to receiving the daily methadone dose, each client completed a 59-item symptom checklist describing the extent to which they had experienced various symptoms during the previous 24 hr on a scale of 0 (not at all) to 3 (severe). These were scored by summing responses on items grouped into 5 symptom clusters. The five symptom clusters were narcotics withdrawal, narcotics overdose, psychological complaints, sleep and sexual disturbances, and miscellaneous complaints. Items in these symptom clusters were chosen on the basis of known side effects of chronic narcotics use, as well as common symptoms of intoxication and narcotics withdrawal. In addition, clients were asked to judge the adequacy of the dose they received the previous day on a Spoint scale from “much too high” to “much too low.” The scores on each of 5 symptom clusters as well as the dose adequacy item were averaged for each client on days prior to dose self regulation opportunities, on days when dose self regulation opportunities occurred and on days after dose self regulation. It is on the latter day that clients report the effects of altered doses which they received on the previous dose self regulation day. These three average scores were rank-ordered for each client and a Freidman 3-way analysis of variance for rank scores used to determine whether scores tended to be consistently altered as a result of dose alterations. The analysis examined only those occasions when clients increased their dose. RESULTS
Table 2 shows clients’ choices on 141 dose self regulation opportunities. Dose increases were chosen on the vast majority of opportunities (94.3%) with maximum allowable dose increases being chosen on 76.6% of opportunities. Dose decreases were selected on only 4 occasions (2.8%) and no dose change was selected on 2.8% of opportunities.
MAXINE STITZER, GEORGE BIGELOW and IRA LIEB~ON
64
+20-
0 Y
-2o-
--
---L%-a-C
WLI Successive
~___._
PLW
~___
MI,
Dose Self-Regulation
5MI .
Roe
Opportunities
Each square shows dose alterations chosen by an individual methadone maintenance client on six consecutive occasions. Data shown are from the IO study participants who chose something other than the maximum available supplementary methadone on at least one occasion. The horizontal lines at zero represent each client’s stable methadone dose. Points above this line represent dose increase choices, points below the line represent dose decrease choices. and points falling on the line represent choices of no dose alteration. For clients FLW and MRJ maximum allowable dose alterations were + IO and + I5 mg. respectively. All other clients could alter their dose by f20mg on each occasion when self regulation was offered.
Thirteen of the 23 clients (56.5%) self administered the maximum available supplemental methadone on every occasion that dose self regulation was permitted. Six other clients self administered 83-92x of the total available supplemental methadone. Only 4 clients took as little as 50% or less of the total supplemental methadone available to them. Sequence of dose choices over consecutive self regulation opportunities is shown in Fig. 1 for the 10 clients (43.4%) who did not always choose the maximum allowable dose increase. Five clients (TGP, NLD, BDW, WLR, FLW) tended to choose progressively larger dosage increments dver successive occasions. The other 5 clients exhibited no systematic pattern in their choices over successive occasions. The dose decreases observed in two clients (TUW, ROR) most likely represent errors made by clients in filling out their request sheets. Client ROR, for example, switched from 20 mg decreases to 20mg increases after one of the clinic nurses pointed out to him that he had been choosing dose decreases. There is little evidence that the dose increases which clients chose for themselves had any appreciable subjective effects, or produced any significant side effects. No significant differences were found for any cluster of symptomatology self reports on the day before, the day of, or the day after self administered methadone dose increases (Freidman 3-way analysis of variance for rank scores). Also, methadone dose increases did not reliably alter clients’ judgement of the adequacy of their medication dosage. Of the 13 clients who routinely judged their stabilization dose to be “too low” and who filled out forms daily during the experiment, 10 continued to judge their dose as “too low” even when they requested and received dose increases; only three clients (WAA, JAM, WID) consistently altered their dose adequacy judgements to indicate that their self selected dose increases were “just right.” Clients’ judgements of the adequacy of their stable methadone dose, shown in the next to last column of Table 3, did not appear to predict their ‘choice on dose self regulation opportunities. Seven clients indicated that their stable dose was “just right? yet 5 of these selected dose increases at every opportunity, and took the maximum allowable dose increase on 28 of 30 opportunities. On the other hand, the two clients who self administered the smallest proportion of the allowable supplemental methadone both judged their stable dose to be “just right.” The final column of Table 3 indicates the classes of drugs for which each client showed urinalysis positives during the dose self regulation study. Use of drugs other than methadone was prevalent, but its extent and nature did not appear related to
Supplementary
methadone self administration
65
clients’ choices on self regulation opportunities. Examination of trends in urinalysis data for periods before, during and after the experiment revealed no changes in illicit drug use. DISCUSSION
This study has shown that methadone maintained clients will take advantage of the opportunity to self regulate their dose for a single day and will typically give themselves substantial dosage increments. This constitutes a behavioral demonstration that dose self regulation and, more specifically, that self administered dose increases of up to 20 mg function as reinforcers for these clients. Dose self regulation was identified as a potential reinforcer in a previous questionnaire study (Stitzer & Bigelow, 1978) which asked clients to rank order several clinic privileges according to their desirability; only methadone take home privileges and receiving $30 cash were ranked as more desirable than single day dose self regulation. The present study provides behavioral confirmation of this previous suggestion that dose self regulation might act as a reinforcer. These data are congruent with much clinical experience in methadone maintenance treatment programs, where client requests for dose increases are common. Clearly, methadone maintenance does not in itself eliminate addicts’ disposition to self administer supplementary narcotics. This study identified a reinforcer readily available within methadone clinics which might be incorporated into behavioral contingency management treatment efforts. A previous study (Stitzer et al., 1977) has demonstrated that methadone program privileges can be used as contingent reinforcers to alter patients’ behavior in desirable directions. The opportunity to self regulate methadone dose for a single day may also serve effectively as a contingent reinforcer but the extent to which it can contribute to achieving significant therapeutic goals has yet to be determined. Interestingly, there was little indication in the present study that clients could feel the effects of the dose increases which they gave to themselves. The lack of effects on symptomatology self reports after 10-20 mg dose increases supports and extends previous observations from our laboratory that acute dose changes of this magnitude are not highly discriminable to methadone maintained clients (Stitzer & Bigelow, 1976). The finding is also consistent with reports from another clinic that dosage alterations of this magnitude have no perceptible effect on client symptomatology (Goldstein er al., 1975; Horns et al., 1975). The question arises, then, as to why clients self administered dose increases which they apparently could not feel. One possibility, of course, is that the dose changes did have pharmacological effects to which the self report instruments were insensitive. Thus, it is possible that dose increases either reduced minor withdrawal symptoms or induced some degree of euphoria. It should be noted, however, that dose increases were not selected only by those clients who might be thought to have minor withdrawal sympt0ms-e.g. recent enrollees in methadone treatment or clients reporting their dose to be “too low;” maximal dose increases were also selected by long term maintenance clients who reported their doses to be “just right.” A second possibility is that the self administration of supplementary methadone may reflect not so much the pharmacological effects of the drug but more the behavioral disorder of drug dependence. Past history and conditioning influences may have produced in these clients a general disposition to excessive drug use, in which they are inclined to self administer available drugs regardless of whether the effects are discriminable. Four clients (WLR, ROR, MRJ, SMR) limited their methadone supplementation to 50% or less of the total available dosage increment. Consideration of a variety of demographic, historical and current characteristics of these clients revealed that the best predictor of low supplementary methadone self administration was a combination of being maintained at low dose (< 50 mg) and being satisfied with that dose (i.e. describing it as “just right”). A.“.4 I-1
MAXINESTITZER,GEORGEBIGELCIW and
66
.
IRA
LIEBSON
Methadone self administration may constitute a useful procedure for assessing certain aspects of drug dependence. For example, permitting the self administration of supplemental methadone may provide an experimental model of the phenomenon of relapse to illicit opiate use. To the extent that an addict patient’s future outcome may be dependent upon developing an ability to decline readily available drugs, choices on dose self regulation opportunities may provide an evaluative index of the current ability or inclination to abstain from illicit drug use, and thereby may constitute one measure of the current degree of behavioral dependence on drug use. The suggestion that drug self administration in experimental contexts may predict relative treatment outcomes and thereby serve as an assessment tool has been made previously with respect to alcoholism by Miller et al. (1974) and by Funderburk & Allen (1977) both of whom have shown experimental ethanol self administration to predict subsequent treatment outcome. Choices on dose self regulation opportunities did appear to predict whether clients would subsequently detoxify voluntarily from methadone. Four clients (FLW, WLR. MRJ, SMR) selected and completed a voluntary methadone detoxification within one year following the study. Subsequent voluntary detoxification was more likely among those clients who self administered the least supplementary methadone and among clients maintained at a low methadone dose (also in part self-determined by patients). Clients with both low dose (~50 mg) and low supplementation (< 50%) during self regulation were most likely to detoxify (2 out of 2); clients with one characteristic were less likely to detoxify (2 out of 4); and clients with neither were least likely to detoxify (0 out of 17). These relationships are based upon small numbers and require replication, but they are suggestive of a predictive utility of the dose self regulation procedure. REFERENCES Berry, G. J. & Kuhn, K. L. Dose-related response to methadone: Reduction of maintenance dose. of 5th National
Funderburk. Alcohol
Conference
on Methadone
Treatment,
F. R. & Allen, R. P. Assessing the alcoholic’s disposition Intoxication
and
Withdrawal-1ll.b.
Studies
Plenum Press, 1977. Garbutt. G. S. & Goldstein, A. Blind comparison Proceedings
of 4th National
Conference
in Alcohol
to drink. In M. M. Gross, (Ed). pp. 601-620. New York:
Dependence.
of three methadone maintenance dosages in 180 patients.
on Methadone
Treatment.
1972. 41 I-414.
Goldstein, A. & Judson, B. Efficacy and side effects of three widely different methadone doses. of 5th National
Conference
on Methadone
Treatment,
Medical
Association,
Proceedings
1973. 21-44.
Goldstein, A., Hansteen, R.. W. & Horns, W. H. Control of methadone American
Proceedings
1973. 972-979.
dosage by patients. Journul
of the
1975. 234(7), 734-737.
Horns. W. H.. Rado, M. & Goldstein. A. Plasma levels and symptom complaints in patients maintained on dailv dosage of methadone HCI. Journal of Clinical Pharntacolwy and Therapeutics. 1975. 17, 636649. Ling. W.. Charuvastra. V. C.. Kaim. S. C. & Kiett. C. J. Methadyl acetate and methadone as maintenance treatments for heroin addicts. Archives of Genera/ Psychiatry. 1976. 23. 709-720. Miller, P. M.. Hersen. M.. Eisler. R. M. & Elkin. T. E: A retrospective analysis of alcohol consumption on laboratory tasks as related to therapeutic outcome. Behariour Research and Therapy. 1974. 12. 73-76. Stitzer. M. & Bigelow, G. Stabilization on methadone: Symptomatology and discriminability of methadone dose alterations. Proceedings of the Committee on Problems of Drug Dependence. National Academy of Sciences, 1976, 10031017. Stitzer. M. & Bigelow. G. Contingency management in a methadone maintenance program: Availability of reinforcers. international Journal if Addictions, 1978. In press. Stitzer. M.. Bigelow, G.. Lawrence, C.. Cohen, J., D’Lugoff, B. & Hawthorne. J. Medication take-home as a reinforcer in a methadone maintenance program. Addictive Behaviors. 1977. 2. 9-14.
BIGELOWand IRA
LIEBSON
Department of Psychiatry. Baltimore City Hospitals and Department of Psychiatry and Behavioral Sciences. The Johns Hopkins University School of Medicine
Abstract-The presentstudy
derives from two related questions: (I) Can methadone dose alterations act as reinforcers‘! (2) Do methadone dose alterations affect symptomatology of methadone maintained clients’? Twenty three clients were offered six opportunities to alter their own methadone dose on a single day by as much as f20mg. Dose increases were selected on the vast majority of occasions (94.3%). Thus. supplemental methadone did function as a reinforcer for these clients. There was little evidence that dose increases which clients chose had any appreciable subjective effects. Neither symptomatology self reports nor judgements of dosage adcq.lacy were significantly altered following acute methadone dose increases. The amount of supplemental methadone which clients self administered could not be predicted by demographic characteristics. by length of time enrolled in maintenance treatment. by type or amount of illicit supplementary drug use. or by adequacy judgements of stable methadone dose. However. dosage self regulation may have predictive potential as a measure of dcgrec of behavioral dependence on narcotic drugs.
The subject of methadone dosage occupies considerable time and attention in methadone maintenance clinics. Numerous dose alterations, the majority of which are dose increases, may be given to individual clients during the course of “maintenance” treatment, presumably in response to symptomatic complaints (Stitzer & Bigelow, 1976). The factors which maintain dosage adjustment, however, are not clear. Dosage alterations may influence how clients feel either as a result of their pharmacological effects or their status as a placebo procedure. Several studies have compared groups of clients maintained on different dosages of methadone and found no difference in overall level of reported comfort, drug craving or opiate use as a function of methadone doses above 50 mg (Berry & Kuhn, 1973; Garbutt & Goldstein, 1972; Goldstein & Judson, 1973) but some studies suggest that doses of 30-50 mg may be inferior to higher dosages in terms of client comfort and continued opiate use (Garbutt & Goldstein, 1972; Goldstein & Judson, 1973; Ling et al., 1976). On the other hand, client comfort may not be the real issue in dosage adjustment. Rather, higher doses of methadone may be acting as reinforcers and may thereby maintain the behavior of dosage bargaining so long as client efforts are occasionally rewarded with increased dosages. The present study derives from two related questions: (1) Can methadone dose changes act as reinforcers? (2) Do methadone dose alterations affect symptomatology of methadone maintained clients? To explore these questions, clients were offered the opportunity to regulate their own methadone dose for single days on several occasions. In one previous study (Goldstein et al., 1975) outpatient methadone maintenance clients were given the chance to alter their methadone dose by 5 mg each week. Most clients raised their dose at some point during the study, but median dosage increased by only 10 mg during 25 study weeks. However, doses above 50 mg resulted in loss of take-home privileges; thus, many clients were essentially faced with a choice between higher methadone doses or continuing take-home privileges. In addition, the size of each dose increase allowed was quite small. The present study asks whether methadone maintenance clients will alter their dose on a single day basis when no choice or loss of privileges is involved and when acute dose changes as large as 20mg can be obtained. If clients reliably *This research was supported by USPHS grant No. DA-01472 and Research Scientist Development Award NO. DA-00050 from the National Institute on Drug Abuse. Send reprint requests to Dr M. Stitzer. Baltimore City Hospitals, D-S-West 4940 Eastern Ave.. Baltimore. MD 21224. 61
MAXINESTITZER.GEORGEBIGELKIW and IRA LIEINN
62
take advantage of this opportunity, then methadone dose alteration can be considered a reinforcing event. In addition, if clients choose to alter their doses, the detectibility of these dosage alterations can be assessed on symptom self report measures. METHODS
Participants
Participants were 23 male methadone maintenance clients. Demographic and addiction history characteristics are summarized in Tables 1 and 3. Most participants showed at least occasional urinalysis positives for one or more drug class; clients whose samples were consistently negative for drugs other than methadone were typically channeled into other studies. However, four clients participated who had clean urines throughout their participation (see Table 3); two of these (JBA, RSN) had previously participated in experimental dose alteration studies which had exposed them to dose alterations as large or larger than those available in this study. Procedure
Clients reported to the clinic seven days per week, and drank their daily methadone dose mixed in cherry syrup vehicle (Methadose@) under nurses’ observation. Clients were told that occasionally they could alter their dose up or down for a single day at a time, and that the point of the study was to see what clients choose to do when given an opportunity to alter their methadone dose. Dose self regulation opportunities generally occurred twice a week on Tuesdays and Fridays for 3 consecutive weeks., On self regulation days clients could alter their dose up or down by as much as 20 mg or 50% of their stable dose, whichever was smaller. Only two clients, with stable doses of 20 mg (FLW) and 30 mg (MRJ). were limited to maximum dose changes smaller than 20 mg. Clients selected their dose by completing a brief questionnaire. No more than 3 clients ever participated simultaneously in this study, which was conducted over a period of 14 months; data from each client are therefore relatively independent. Urine samples were collected under observation at the clinic on Mondays and Fridays and occasionally on Wednesdays, and were analyzed for evidence of supplementary drug use. Table 1. Characteristics
of study participants (N = 23) Median
Range
Age (yr)
28
Years of education Years of addiction Months of previous methadone treatment Methadone dose (mg) Weeks enrolled at this clinic prior to study
I2 8
19-39 8-14 2-15
10 50
G-95 2&80
3.5
2-64.5
Table 2. Distribution of patient choices on methadone dosage self regulation opportunities Percent of opportunities (N = 141) Dow
94.3
increases
Largest available increase chosen 507; or more of largest available increase chosen Less than 50% of largest available increase chosen Dose decwaws No dose change
Total
16.6 12.1 5.1 2.8 2.8 99.9
Supplementary Table
methadone
3. Individual
Client
Methadone dose (mg)
Weeks at stable methadone dose
CIM CHW cos WAA BUJ WIG JAM KEM MAV WID TRR SNR BAJ TGP NLD BDW YAA TUW FLW WLR ROR MRJ SMR
80 55 50 60 60 50 50 50 80 50 60 45 50 50 50 60 50 50 20 50 50 30 40
TRS TR 1.5 1.0 TR TR 2.5 TR TR 1.5 2.0 34.5 63.5 1.5 2.0 I.0 19.5 7.0 2.5 2.5 2.5 2.5 3.0
self administration
dose self regulation
Percent of total allowabic supplemental methadone taken 100 100 100 100 100 100 too 100 100 100 100 100 100 91.7 91.7 87.5 87.5 83.3 83.3 50.0 50.0 38.9 12.5
63
data
Dose adequacy judgcmcnt* 3.8 3.6 4.0 3.9 5.0 4.0 4.0 5.0$ 3.0 4.2 3.8 3.w 3.0 4.0 3.8 4.2 4.5s 4.0 3.0 4.0 3.7$ 3.0 3.2
Drug classes positive during studyt MBTO BTO TO MT BT TO MT TO T T
0 M MT T M T MT M M
*Shown are average scores obtained on 47 dose self regulation days for each client. These represent adequacy judgements of the client’s regular methadone dose. Dose adequacy judgements are as follows: I = much too high. 2 = a little too high. 3 = just right. 4 = a little too low. 5 = much too low. t Drug classes are identified as follows: M = opiates. B = barbiturates. T = benzodiazepine tranquilizers. 0 = other drugs. $ For clients who transferred to this clinic from another program. weeks at stable methadone dose arc indeterminate. 3 These clients did not complete daily reports. Shown arc average scores on twice weekly reports completed during the study period.
Prior to receiving the daily methadone dose, each client completed a 59-item symptom checklist describing the extent to which they had experienced various symptoms during the previous 24 hr on a scale of 0 (not at all) to 3 (severe). These were scored by summing responses on items grouped into 5 symptom clusters. The five symptom clusters were narcotics withdrawal, narcotics overdose, psychological complaints, sleep and sexual disturbances, and miscellaneous complaints. Items in these symptom clusters were chosen on the basis of known side effects of chronic narcotics use, as well as common symptoms of intoxication and narcotics withdrawal. In addition, clients were asked to judge the adequacy of the dose they received the previous day on a Spoint scale from “much too high” to “much too low.” The scores on each of 5 symptom clusters as well as the dose adequacy item were averaged for each client on days prior to dose self regulation opportunities, on days when dose self regulation opportunities occurred and on days after dose self regulation. It is on the latter day that clients report the effects of altered doses which they received on the previous dose self regulation day. These three average scores were rank-ordered for each client and a Freidman 3-way analysis of variance for rank scores used to determine whether scores tended to be consistently altered as a result of dose alterations. The analysis examined only those occasions when clients increased their dose. RESULTS
Table 2 shows clients’ choices on 141 dose self regulation opportunities. Dose increases were chosen on the vast majority of opportunities (94.3%) with maximum allowable dose increases being chosen on 76.6% of opportunities. Dose decreases were selected on only 4 occasions (2.8%) and no dose change was selected on 2.8% of opportunities.
MAXINE STITZER, GEORGE BIGELOW and IRA LIEB~ON
64
+20-
0 Y
-2o-
--
---L%-a-C
WLI Successive
~___._
PLW
~___
MI,
Dose Self-Regulation
5MI .
Roe
Opportunities
Each square shows dose alterations chosen by an individual methadone maintenance client on six consecutive occasions. Data shown are from the IO study participants who chose something other than the maximum available supplementary methadone on at least one occasion. The horizontal lines at zero represent each client’s stable methadone dose. Points above this line represent dose increase choices, points below the line represent dose decrease choices. and points falling on the line represent choices of no dose alteration. For clients FLW and MRJ maximum allowable dose alterations were + IO and + I5 mg. respectively. All other clients could alter their dose by f20mg on each occasion when self regulation was offered.
Thirteen of the 23 clients (56.5%) self administered the maximum available supplemental methadone on every occasion that dose self regulation was permitted. Six other clients self administered 83-92x of the total available supplemental methadone. Only 4 clients took as little as 50% or less of the total supplemental methadone available to them. Sequence of dose choices over consecutive self regulation opportunities is shown in Fig. 1 for the 10 clients (43.4%) who did not always choose the maximum allowable dose increase. Five clients (TGP, NLD, BDW, WLR, FLW) tended to choose progressively larger dosage increments dver successive occasions. The other 5 clients exhibited no systematic pattern in their choices over successive occasions. The dose decreases observed in two clients (TUW, ROR) most likely represent errors made by clients in filling out their request sheets. Client ROR, for example, switched from 20 mg decreases to 20mg increases after one of the clinic nurses pointed out to him that he had been choosing dose decreases. There is little evidence that the dose increases which clients chose for themselves had any appreciable subjective effects, or produced any significant side effects. No significant differences were found for any cluster of symptomatology self reports on the day before, the day of, or the day after self administered methadone dose increases (Freidman 3-way analysis of variance for rank scores). Also, methadone dose increases did not reliably alter clients’ judgement of the adequacy of their medication dosage. Of the 13 clients who routinely judged their stabilization dose to be “too low” and who filled out forms daily during the experiment, 10 continued to judge their dose as “too low” even when they requested and received dose increases; only three clients (WAA, JAM, WID) consistently altered their dose adequacy judgements to indicate that their self selected dose increases were “just right.” Clients’ judgements of the adequacy of their stable methadone dose, shown in the next to last column of Table 3, did not appear to predict their ‘choice on dose self regulation opportunities. Seven clients indicated that their stable dose was “just right? yet 5 of these selected dose increases at every opportunity, and took the maximum allowable dose increase on 28 of 30 opportunities. On the other hand, the two clients who self administered the smallest proportion of the allowable supplemental methadone both judged their stable dose to be “just right.” The final column of Table 3 indicates the classes of drugs for which each client showed urinalysis positives during the dose self regulation study. Use of drugs other than methadone was prevalent, but its extent and nature did not appear related to
Supplementary
methadone self administration
65
clients’ choices on self regulation opportunities. Examination of trends in urinalysis data for periods before, during and after the experiment revealed no changes in illicit drug use. DISCUSSION
This study has shown that methadone maintained clients will take advantage of the opportunity to self regulate their dose for a single day and will typically give themselves substantial dosage increments. This constitutes a behavioral demonstration that dose self regulation and, more specifically, that self administered dose increases of up to 20 mg function as reinforcers for these clients. Dose self regulation was identified as a potential reinforcer in a previous questionnaire study (Stitzer & Bigelow, 1978) which asked clients to rank order several clinic privileges according to their desirability; only methadone take home privileges and receiving $30 cash were ranked as more desirable than single day dose self regulation. The present study provides behavioral confirmation of this previous suggestion that dose self regulation might act as a reinforcer. These data are congruent with much clinical experience in methadone maintenance treatment programs, where client requests for dose increases are common. Clearly, methadone maintenance does not in itself eliminate addicts’ disposition to self administer supplementary narcotics. This study identified a reinforcer readily available within methadone clinics which might be incorporated into behavioral contingency management treatment efforts. A previous study (Stitzer et al., 1977) has demonstrated that methadone program privileges can be used as contingent reinforcers to alter patients’ behavior in desirable directions. The opportunity to self regulate methadone dose for a single day may also serve effectively as a contingent reinforcer but the extent to which it can contribute to achieving significant therapeutic goals has yet to be determined. Interestingly, there was little indication in the present study that clients could feel the effects of the dose increases which they gave to themselves. The lack of effects on symptomatology self reports after 10-20 mg dose increases supports and extends previous observations from our laboratory that acute dose changes of this magnitude are not highly discriminable to methadone maintained clients (Stitzer & Bigelow, 1976). The finding is also consistent with reports from another clinic that dosage alterations of this magnitude have no perceptible effect on client symptomatology (Goldstein er al., 1975; Horns et al., 1975). The question arises, then, as to why clients self administered dose increases which they apparently could not feel. One possibility, of course, is that the dose changes did have pharmacological effects to which the self report instruments were insensitive. Thus, it is possible that dose increases either reduced minor withdrawal symptoms or induced some degree of euphoria. It should be noted, however, that dose increases were not selected only by those clients who might be thought to have minor withdrawal sympt0ms-e.g. recent enrollees in methadone treatment or clients reporting their dose to be “too low;” maximal dose increases were also selected by long term maintenance clients who reported their doses to be “just right.” A second possibility is that the self administration of supplementary methadone may reflect not so much the pharmacological effects of the drug but more the behavioral disorder of drug dependence. Past history and conditioning influences may have produced in these clients a general disposition to excessive drug use, in which they are inclined to self administer available drugs regardless of whether the effects are discriminable. Four clients (WLR, ROR, MRJ, SMR) limited their methadone supplementation to 50% or less of the total available dosage increment. Consideration of a variety of demographic, historical and current characteristics of these clients revealed that the best predictor of low supplementary methadone self administration was a combination of being maintained at low dose (< 50 mg) and being satisfied with that dose (i.e. describing it as “just right”). A.“.4 I-1
MAXINESTITZER,GEORGEBIGELCIW and
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.
IRA
LIEBSON
Methadone self administration may constitute a useful procedure for assessing certain aspects of drug dependence. For example, permitting the self administration of supplemental methadone may provide an experimental model of the phenomenon of relapse to illicit opiate use. To the extent that an addict patient’s future outcome may be dependent upon developing an ability to decline readily available drugs, choices on dose self regulation opportunities may provide an evaluative index of the current ability or inclination to abstain from illicit drug use, and thereby may constitute one measure of the current degree of behavioral dependence on drug use. The suggestion that drug self administration in experimental contexts may predict relative treatment outcomes and thereby serve as an assessment tool has been made previously with respect to alcoholism by Miller et al. (1974) and by Funderburk & Allen (1977) both of whom have shown experimental ethanol self administration to predict subsequent treatment outcome. Choices on dose self regulation opportunities did appear to predict whether clients would subsequently detoxify voluntarily from methadone. Four clients (FLW, WLR. MRJ, SMR) selected and completed a voluntary methadone detoxification within one year following the study. Subsequent voluntary detoxification was more likely among those clients who self administered the least supplementary methadone and among clients maintained at a low methadone dose (also in part self-determined by patients). Clients with both low dose (~50 mg) and low supplementation (< 50%) during self regulation were most likely to detoxify (2 out of 2); clients with one characteristic were less likely to detoxify (2 out of 4); and clients with neither were least likely to detoxify (0 out of 17). These relationships are based upon small numbers and require replication, but they are suggestive of a predictive utility of the dose self regulation procedure. REFERENCES Berry, G. J. & Kuhn, K. L. Dose-related response to methadone: Reduction of maintenance dose. of 5th National
Funderburk. Alcohol
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F. R. & Allen, R. P. Assessing the alcoholic’s disposition Intoxication
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Goldstein, A. & Judson, B. Efficacy and side effects of three widely different methadone doses. of 5th National
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Goldstein, A., Hansteen, R.. W. & Horns, W. H. Control of methadone American
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Horns. W. H.. Rado, M. & Goldstein. A. Plasma levels and symptom complaints in patients maintained on dailv dosage of methadone HCI. Journal of Clinical Pharntacolwy and Therapeutics. 1975. 17, 636649. Ling. W.. Charuvastra. V. C.. Kaim. S. C. & Kiett. C. J. Methadyl acetate and methadone as maintenance treatments for heroin addicts. Archives of Genera/ Psychiatry. 1976. 23. 709-720. Miller, P. M.. Hersen. M.. Eisler. R. M. & Elkin. T. E: A retrospective analysis of alcohol consumption on laboratory tasks as related to therapeutic outcome. Behariour Research and Therapy. 1974. 12. 73-76. Stitzer. M. & Bigelow, G. Stabilization on methadone: Symptomatology and discriminability of methadone dose alterations. Proceedings of the Committee on Problems of Drug Dependence. National Academy of Sciences, 1976, 10031017. Stitzer. M. & Bigelow. G. Contingency management in a methadone maintenance program: Availability of reinforcers. international Journal if Addictions, 1978. In press. Stitzer. M.. Bigelow, G.. Lawrence, C.. Cohen, J., D’Lugoff, B. & Hawthorne. J. Medication take-home as a reinforcer in a methadone maintenance program. Addictive Behaviors. 1977. 2. 9-14.
