Can reinforcement-based interventions to reduce drug use successfully be adapted to routine opioid maintenance treatment?

INTRODUCTION: Comorbid substance related disorders are a major health problem for patients in opioid maintenance treatment (OMT). It was investigated whether a reinforcement scheme adapted to the regulatory and financial restrictions of routine treatment reduces concomitant drug use. METHODS: OMT patients from 7 clinics who were using cocaine, benzodiazepines, heroin or amphetamines were randomly allocated to either treatment as usual (n = 64) or treatment with an additional escalating reinforcement scheme (n = 72) in which a patient's number of weekly take-home dosages was increased after 1, 4, 8 and 12 consecutive weeks with drug-free urine specimens. Trial duration was 26 weeks. RESULTS: Completion rates were 64% for controls and 62.5% in the experimental group. Mean number of drug-free weeks was 11.3 (SD 8.5) for the control group and 9.8 (8.9) for the experimental group (p = 0.30). CONCLUSION: The intervention was not effective compared to routine treatment. Additional features might be necessary to achieve an effect, e.g. a higher frequency of urine sampling or use of other reinforcers. It has to be further investigated how interventions which have been proven effective in experimental studies can successfully be adapted to routine care conditions.

Longitudinal observation of a sample of German drug consumption facility clients.

INTRODUCTION: We aimed at investigating whether attendance of a drug consumption facility (DCF) was associated with both a reduction of drug-associated at-risk behavior and referral to the health care treatment system. METHODS: A sample of 129 consecutive clients out of those 256 who self-referred to the DCF during the 13-month observation period (i.e., from November 2002 to December 2003) was interviewed both at baseline and at 1-, 2-, 3-, and 6-month follow-ups. Subjects were repeatedly assessed using a structured approach based on both the European Addiction Severity Index (EuropASI) and the Deutsche Gesellschaft fuer Suchtforschung und Therapie (DG-Sucht). RESULTS: Typical DCF clients were males, in their early 30s, single, with no vocational training, and with a long history of injectable opiate addiction in the context of polydrug misuse. A recent discharge from prison was recorded in 37% of cases. Median length of DCF attendance was of 5 weeks; 22% of clients attended for less than 1 week. Although with respect to the period previous to recruitment at-risk behavior rates remained unchanged, by the 3-month follow-up 13 (10%) clients out of those 129 who had initially enrolled had taken advantage of the DCF counseling opportunities. Some 37% of clients were referred on to start a methadone treatment following their DCF experience. DISCUSSION: DCF attendance was not associated with reduction in at-risk behavior over time, but a need was here identified for additional intervention to be available in the DCF to address clients' psychosocial issues. Limitations of the present study include both issues related to the representativeness of the sample of clients here recruited and the lack of a control/comparison group.