Determination of thallium in urine, blood, and hair in illicit opioid users in Iran.

CONTEXT: Heavy metals, including thallium and lead, are introduced to illicit drug users' body as a result of using drugs such as cocaine and heroin. OBJECTIVE: This study aimed to determine urine, blood, and hair thallium (Tl) concentrations in illicit opioid users along with the relevant clinical signs and symptoms consistent with thallotoxicosis and to compare them with the corresponding variables in the control non-opioid user group. MATERIALS AND METHODS: This case-control study was conducted on 50 illicit opioid users who had abused opioids continuously for more than a year, referred to Amirie Drug Abuse Treatment Clinic in Kashan, Iran. The control group included 50 non-opioid users. Thallium concentrations in urine, blood, and hair were assessed in both groups (n = 100) using electrothermal (graphite furnace) atomic absorption spectrometry (ET AAS, GF AAS). RESULTS: In the studied group, the median (interquartile range) concentrations of thallium in urine, blood, and hair were 54.8 ± 79.9 µg/L, 14.5 ± 11.1 µg/L, and 5.4 ± 3.7 µg/g, respectively; these values were 4.8 ± 5.2 µg/L, 2.5 ± 2.4 µg/L, and 1.4 ± 1.1 µg/g, respectively, in the control group. There were significant differences in urine, blood, and hair thallium concentrations between the study group and the control group (p < 0.001). There were significant correlations between duration of illicit opioid use and urine thallium concentrations (r = 0.394, p = 0.005) and hair thallium concentrations (r = 0.293, p = 0.039), but not with blood thallium concentrations (r = 0.246, p = 0.085). Urine and blood thallium concentrations of illicit opioid users with clinical signs and symptoms consistent with thallotoxicosis of weakness (p = 0.01), depression (p = 0.03), and headache (p = 0.03) were higher than users without these problems. DISCUSSION AND CONCLUSION: The results of the study showed that thallium concentrations in urine, blood, and hair in illicit opioid users were significantly higher than the comparable concentrations in the control group. This can be due to the use of illicit opioids adulterated with thallium. Also, this study showed long-term illicit opioid use may lead to thallium exposure. In addition, cigarette smoking was associated with increased thallium exposure.

Managing Chronic Pain in Cancer Survivors Prescribed Long-Term Opioid Therapy: A National Survey of Ambulatory Palliative Care Providers.

CONTEXT: Chronic pain, or pain lasting more than three months, is common among cancer survivors, who are often prescribed long-term opioid therapy (LTOT). OBJECTIVE: Our objective was to explore palliative care providers' experiences with managing chronic pain in cancer survivors prescribed LTOT, specifically in ambulatory palliative care settings, and their strategies for overcoming challenges. METHODS: We recruited providers through leading national palliative care organizations who manage chronic pain in cancer survivors. Asked to consider only cancer survivors with chronic pain when responding, participants completed an online survey that included questions about use of opioid risk mitigation tools, confidence in addressing opioid misuse behaviors and discussing/recommending management approaches, and access to addiction treatment. RESULTS: Of 157 participants, most were physicians (83%) or nurse practitioners (15%). Most reported using opioid risk mitigation tools such as urine drug testing (71%), opioid treatment agreements (85%), and practitioner database monitoring programs (94%). Participants were confident (7-8/10) managing the most commonly encountered opioid misuse behaviors (missing appointments, marijuana use, and using more opioids than prescribed) and in their ability to recommend nonpharmacologic and nonopioid pharmacologic treatments for chronic pain (10/10). They were least confident prescribing naloxone or managing addiction (5/10); only 27% reported having training or systems in place to address addiction. Only 13% had a waiver to prescribe buprenorphine. CONCLUSION: Palliative care providers are comfortable with many aspects of managing chronic pain in cancer survivors on LTOT, although challenges persist, including the lack of systems-based approaches and training in addiction treatment.

Substance Use Disorder Treatment Following Clinician-Initiated Discontinuation of Long-Term Opioid Therapy Resulting from an Aberrant Urine Drug Test.

BACKGROUND: It is unclear whether substance use disorder (SUD) treatment is offered to, or utilized by, patients who are discontinued from long-term opioid therapy (LTOT) following aberrant urine drug tests (UDTs). OBJECTIVE: To describe the proportion of patients who were referred to, and engaged in, SUD treatment following LTOT discontinuation and to examine differences in SUD treatment referral and engagement based on the substances that led to discontinuation. DESIGN: From a sample of 600 patients selected from a national cohort of Veterans Health Administration patients who were discontinued from LTOT, we used manual chart review to identify 169 patients who were discontinued because of a UDT that was positive for alcohol, cannabis, or other illicit or non-prescribed controlled substances. MAIN MEASURES: We extracted sociodemographic, clinical, and health care utilization data from patients' electronic medical records. KEY RESULTS: Forty-three percent of patients (n = 73) received an SUD treatment referral following LTOT discontinuation and 20% (n = 34) engaged in a new episode of SUD treatment in the year following discontinuation. Logistic regression models controlling for sociodemographic and clinical variables demonstrated that patients who tested positive for cannabis were less likely than patients who tested positive for non-cannabis substances to receive referrals for SUD treatment (aOR = 0.44, 95% CI = 0.23-0.84, p = 0.01) or engage in SUD treatment (aOR = 0.42, 95% CI = 0.19-0.94, p = 0.04). Conversely, those who tested positive for cocaine were more likely to receive an SUD treatment referral (aOR = 3.32, 95% CI = 1.57-7.06, p = 0.002) and engage in SUD treatment (aOR = 2.44, 95% CI = 1.00-5.96, p = 0.05) compared to those who did not have a cocaine-positive UDT. CONCLUSIONS: There may be substance-specific differences in clinician referrals to, and patient engagement in, SUD treatment. This suggests a need for more standardized implementation of clinical guidelines that recommend SUD care, when appropriate, following LTOT discontinuation.

Using Client's Routine Urinalysis Records From Multiple Treatment Systems to Model Five-Year Opioid Substitution Treatment Outcomes.

BACKGROUND: At global, national, and local level, the need for ongoing, timely and cost efficient, comprehensive drug treatment monitoring, and evaluation systems have clearly been well recognized. OBJECTIVES: To test the feasibility of linking laboratory data and client intake data and its usefulness for modeling retrospectively, for the first time, 5-year longitudinal drug treatment outcomes in an Irish opiate treatment setting. METHODS: A multisite, retrospective, longitudinal cohort study was implemented to evaluate outcomes for opiate users based on 1.7 million routine urinalysis results collected from 4,518 individuals presenting for opioid substitution treatment in Ireland from January 2006 to December 2010. RESULTS: Analysis of opiates, cocaine, benzodiazepine, and cannabis use at treatment intake, 6 months and at 1-5 year follow-ups revealed differences in urinalysis protocols; significant differences in age of first drug use between those using and not using opiates at 5 years; significant decreases in opiate use; increases in benzodiazepine use and significant increasing effects of concurrent cocaine and benzodiazepine use on the odds of using opiates. Time series analysis of weekly proportions opiate positive predicted 16% (95% confidence interval: 7%-25%) of clients would be opiate positive 5 years postinitial intake. CONCLUSIONS IMPORTANCE: Underutilized urinalysis data can be used to address the need for cost effective, efficient evidence of drug-treatment outcomes across time, place, and systems. Linking and matching the cross-sectional data across sites and times also revealed where improvements in electronic records could be made.

Interim buprenorphine treatment in opiate dependence: A pilot effectiveness study.

BACKGROUND: Interim methadone treatment (i.e., temporary medication-only treatment) has been tested in a few U.S. studies as a method for facilitated referral to and initiation of opioid maintenance treatment in heroin dependence. However, despite the favorable safety profile of buprenorphine compared with methadone, interim treatment with buprenorphine rarely has been tested and reported in the scientific literature. The present pilot effectiveness study aims to assess the feasibility of an interim buprenorphine treatment for initiation of individuals with opiate dependence into full-scale opioid maintenance treatment, and to study baseline predictors of successful transfer to full-scale treatment. METHODS: Interim treatment was introduced in a high-threshold setting with waiting lists to opioid maintenance treatment. Consecutive patients on the waiting list were offered the option to enter interim treatment. The interim program was a medication-only condition with supervised daily doses of buprenorphine-naloxone. The main outcome was successful transfer to full-scale opioid maintenance treatment, which required a drug-free urine sample. RESULTS: Forty-four patients entered interim buprenorphine treatment. Among them, 57% (n = 25) were successfully transferred to full-scale treatment after an average of 44 days. Remaining patients could not be transferred, generally because they did not manage to become drug-free. Successful transfer to full-scale treatment was associated with a lower baseline Alcohol Use Disorders Identification Test (AUDIT) score (4.4 vs. 12.6; P < .001) and tended to be associated with lower cannabis use (5.2 vs. 10.4 days during the past 30 days; P = .06) and lower heroin use (7.2 vs. 9.9 days; P = .09) prior to baseline. In a logistic regression analysis, only lower AUDIT score predicted successful treatment entry. CONCLUSIONS: According to these pilot data, supervised buprenorphine-naloxone in a medication-only interim treatment condition appears to be a feasible way to improve treatment initiation in a high-threshold setting. Polydrug use, including higher levels of alcohol consumption, may predict a more complicated course in interim treatment.

Treatment changes following aberrant urine drug test results for patients prescribed chronic opioid therapy.

BACKGROUND/OBJECTIVE: Urine drug testing (UDT) may be used to help screen for prescription opioid misuse. There are little data available describing usual pain care practices for patients who have aberrant UDT results. The goal of this research was to evaluate the clinical care for patients prescribed chronic opioid therapy (COT) and have an aberrant UDT. DESIGN: Retrospective cohort study. SETTING: VA Medical Center in the Pacific Northwest. PARTICIPANTS: Patients with chronic pain who were prescribed COT and had a UDT result that was positive for an illicit or nonprescribed substance. MAIN OUTCOME MEASURES: This was an exploratory study designed to document usual care practices. RESULTS: Participants' (n = 83) mean age was 49.5 (SD = 9.6) and 81.5 percent were male. The most common substances detected on UDT were marijuana (69 percent) or a nonprescribed opioid (25 percent); 18 percent had a UDT positive for two or more substances. Plans to modify treatment were documented in 69 percent of cases. The most common treatment change after aberrant UDT results was instituting more frequent UDTs, which occurred in 43 percent of cases. Clinicians documented plans to alter their opioid prescribing (eg, terminating opioids, requiring more frequent fills, changing opioid dose, or transitioning to another opioid) in 52 percent of cases, but implemented these changes in only 24 percent. DISCUSSION: Current methods for optimizing treatment after obtaining aberrant UDT results should be enhanced. To improve the utility of UDT to reduce prescription opioid misuse, additional interventions and support for clinicians need to be developed and tested.

History of drug use predicts opioid treatment agreement violation.

OBJECTIVE: To determine reasons and describe characteristics of patients who violate their opioid treatment agreement. DESIGN: Cross-sectional retrospective study. PARTICIPANTS: New patients aged 18 years or above attending a multidisciplinary comprehensive pain management clinic from January 2012 to June 2012. MAIN OUTCOME MEASURE: Reason for discharge from the clinic. RESULTS: Of the 234 subjects in the study, 38.5 percent were discharged due to treatment agreement violation. A majority had a self-reported history of tobacco use, followed by alcohol and marijuana. The mean age of discharge was 45.1 years (SD 11.6) and they were discharged on average in 7.4 months after their first clinic visit. The primary reason for discharge was for an inappropriate urine drug screen (UDS) with illicit drug use being the most common at 40 percent and marijuana being the most common illicit drug. Subjects reporting a history of any drug use were nearly seven times more likely to be discharged. Hydrocodone was the most common nonprescribed opioid found in the UDS for those discharged for using nonprescribed opioids. CONCLUSION: Inappropriate UDS is a main factor for discharge due to violation of the opioid treatment agreement. Those with self-reported current or prior drug use were more likely to be discharged from the clinic.

Chronic opioid therapy risk reduction initiative: impact on urine drug testing rates and results.

BACKGROUND: In response to epidemic levels of prescription opioid overdose, abuse, and diversion, routine urine drug tests (UDTs) are recommended for patients receiving chronic opioid therapy (COT) for chronic pain. However, UDT ordering for COT patients is inconsistent in primary care, and little is known about how to increase UDT ordering or the impact of increased testing on rates of aberrant results. OBJECTIVE: To compare rates and results of UDTs for COT patients before versus after implementation of an opioid risk reduction initiative in a large healthcare system. DESIGN: Pre-post observational study. PATIENTS: Group Health patients on COT October 2008-September 2009 (N = 4,821), October 2009-September 2010 (N = 5,081), and October 2010-September 2011 (N = 5,498). INTERVENTION: Multi-faceted opioid risk reduction initiative. MAIN MEASURES: Annual rates of UDTs and UDT results. KEY RESULTS: Half of COT patients received at least one UDT in the year after the initiative was implemented, compared to only 7 % 2 years prior. The adjusted odds of COT patients having at least one UDT in the first year of the opioid initiative were almost 16 times (adjusted OR = 15.79; 95 % CI: 13.96-17.87) those 2 years prior. The annual rate of UDT detection of marijuana and illicit drugs did not change (12.6 % after initiative implementation), and largely reflected marijuana use (detected in 11.1 % of all UDTs in the year after initiative implementation). In the year after initiative implementation, 10.7 % of UDTs were negative for opioids. CONCLUSIONS: The initiative appeared to dramatically increase urine drug testing of COT patients in the healthcare system without impacting rates of aberrant results. The large majority of aberrant results reflected marijuana use or absence of opioids in the urine. The utility of increased urine drug testing for COT patient safety and prevention of diversion remains uncertain.

Urine specimen detection of concurrent nonprescribed medicinal and illicit drug use in patients prescribed buprenorphine.

Patients being treated with buprenorphine usually have a history of opioid dependence and may be predisposed to misuse of drugs. Concurrent drug misuse increases the risk of life-threatening drug interactions. This retrospective data analysis observed which nonprescribed and illicit drugs were most commonly detected in the urine of patients from pain management clinics taking buprenorphine with or without a prescription. GC, LC/MS and LC-MS-MS were used to quantify 20,929 urine specimens. The most prevalent illicit drug used in both the groups (prescribed and nonprescribed buprenorphine) was marijuana, followed by cocaine. The most prevalent nonprescribed medications abused by both the groups were benzodiazepines, followed by oxycodone and hydrocodone. The overall prevalence of illicit and nonprescribed drug use was significantly higher in subjects who used buprenorphine without a prescription versus prescribed use. Of the concurrent use of marijuana and cocaine with buprenorphine, cocaine is most concerning since it decreases exposure to buprenorphine (lower area under the concentration-time curve and maximum concentration). The concurrent use of nonprescribed benzodiazepines with buprenorphine can cause excess sedation leading to respiratory depression and even death. These findings highlight the importance of educating patients about these potential toxicities. Furthermore, pain providers should consider expanding the spectrum of drugs that they monitor in patients under treatment.

Sense of coherence as a stable predictor for methadone maintenance treatment (MMT) outcome.

We studied stability of sense of coherence (SOC) over time and in relation to the outcomes of former heroin addicts in MMT. Between September of 2003 and April of 2006, all 90 newly admitted patients to a MMT clinic in Tel Aviv were studied and followed up for one year. A SOC (inner resources) questionnaire was done at baseline and after one year. Use of opiates, cocaine, benzodiazepines, cannabis and amphetamines in the 13 months after admission was recorded, and defined as positive if at least one urine test for any drug was positive. After one year, 77 (85.6%) stayed in treatment. SOC scores were similar at baseline and after one year, but were lower among 42 patients who still abused any drugs (118.8 + 27.4), compared with the 35 patients who did not (128.5 + 26.5, Repeated measures, Groups p = 0.003, Time effect p = 0.5, Time*Group p = 0.003). Cumulative retention revealed that 30 patients with SOC scores greater than 130 had longer retention (3.5 years, 95% CI 3.2-3.9) as compared with 60 patients with SOC scores of 130 or less (2.9 years, 95% CI 2.5-3.3). SOC is a stable parameter that can serve as a predictor for success in MMT, both as retention in treatment and drug abstinence.

Auricular acupuncture as an adjunct to opiate detoxification treatment: effects on withdrawal symptoms.

It was hypothesized that auricular acupuncture would lead to reduced severity of opiate withdrawal symptoms and craving when provided as an adjunct to methadone detoxification. The study used a randomized, placebo-controlled study design. The sample consisted of 83 drug misusers who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for opiate dependence. Daily measures of withdrawal severity and craving were taken using the Short Opiate Withdrawal Scale and an eight-item craving questionnaire. Urine screening was used as an objective assessment of treatment adherence. The study hypothesis was not confirmed. Auricular acupuncture had no effect upon withdrawal severity or craving when provided as an adjunct to a standard methadone detoxification treatment. The results are consistent with the findings of other studies that failed to find any effect of acupuncture in the treatment of drug dependence. The failure to find any clinical gains from the adjunctive use of auricular acupuncture during detoxification from opiates raises concerns about the widespread acceptance of this intervention.

Sublingual buprenorphine and methadone maintenance treatment: a three-year follow-up of quality of life assessment.

This study was conducted to compare long-term outcome effects on the quality of life (QOL) of oral methadone with sublingual buprenorphine maintenance treatment. The QOL status of opioid-dependent patients was assessed using the German version ("Berlin Quality of Life Profile") of the Lancashire Quality of Life Profile. Physical symptoms were measured using the Opiate Withdrawal Scale (OWS). Urine tests were carried out randomly to detect additional consumption. In the first study period, 53 opioid-dependent subjects were enrolled and 25 could be reached after 3 years. The retention rate was 50% for methadone and 45% for buprenorphine (p = 0.786). Baseline values of the total sample (completers and noncompleters) QOL and somatic complaints did not show significant differences between the two treatment groups. QOL characteristics at 6 months of treatment of the buprenorphine completer and noncompleter groups differed significantly regarding job (p = 0.013), family, and total score of physical symptoms (p = 0.002), in which the completer group showed the more favorable values. Concerning physical symptoms at 36 months, logistic regression revealed significantly less stomach cramps (p = 0.037) and fatigue and tiredness (p = 0.034) in buprenorphine compared to the methadone. Moreover, the buprenorphine-maintained group showed significantly less additional consumption of benzodiazepines (p = 0.015) compared with methadone participants. It is concluded that opioid addicts improved their QOL and health status when treated with methadone or buprenorphine. In summary, regarding QOL and health status, the present data indicate that buprenorphine is also a useful long-term alternative for maintenance treatment of opioid-dependent patients.

The GC-MS detection and characterization of reticuline as a marker of opium use.

Reticuline (a precursor of opium alkaloids) was detected and characterised as its trimethylsilyl ethers, acetyl esters and methyl ethers by GC-EIMS and GC-CIMS in opium and the urine of opium users after hydrolysis by acid or beta-glucuronidase as coextractive of morphine. Because this compound cannot be detected in heroin and poppy seeds, it is suggested as a differentiating marker between opium and heroin use, opium and poppy seeds use, or opium and "pharmaceutical" codeine use in cases when opiate use has been confirmed by detection of morphine and codeine in the urine. As well as being a constituent of opium, reticuline in the urine of opium users may also result from the metabolic demethylation of the three other benzyltetrahydroisoquinoline opium alkaloids: codamine, laudanosine and laudanine.

Reliability and validity of opiate use self-report in a population at high risk for esophageal cancer in Golestan, Iran.

OBJECTIVE: To assess the reliability and validity of self-reported opium use in a rural Iranian population at high risk for esophageal cancer in preparation for a large cohort study. METHOD: 1,057 subjects ages 33 to 84 years were recruited from Gonbad city and three surrounding villages in Golestan province of Iran and completed a questionnaire and provided biological samples. The history and duration of using opium, smoking tobacco, chewing nass, and drinking alcohol were measured by questionnaire in the entire cohort. A subgroup of 130 people was reinterviewed after 2 months to assess reliability. Validity of the opium question was assessed by comparing the questionnaire responses with the presence of codeine and morphine in the urine of 150 selected subjects. RESULTS: Self-reported opiate use is reliable and valid in this population. The reliability of ever opium use and duration of opium use had kappa's of 0.96 and 0.74, respectively. The validity of self-reported opium use was also high. Using urine codeine or morphine as the gold standard for use of opium, self-report had a sensitivity of 0.93 and a specificity of 0.89. CONCLUSIONS: The self-reported use of opium can provide a reliable and valid measurement in this population and will be useful for studying associations between opium use and occurrence of esophageal cancer and other diseases.

The GC-MS detection and characterization of reticuline as a marker of opium use.

Reticuline (a precursor of opium alkaloids) was detected and characterised as its trimethylsilyl ethers, acetyl esters and methyl ethers by GC-EIMS and GC-CIMS in opium and the urine of opium users after hydrolysis by acid or beta-glucuronidase as coextractive of morphine. Because this compound cannot be detected in heroin and poppy seeds, it is suggested as a differentiating marker between opium and heroin use, opium and poppy seeds use, or opium and "pharmaceutical" codeine use in cases when opiate use has been confirmed by detection of morphine and codeine in the urine. As well as being a constituent of opium, reticuline in the urine of opium users may also result from the metabolic demethylation of the three other benzyltetrahydroisoquinoline opium alkaloids: codamine, laudanosine and laudanine.

Interpreting conflicting findings from clinical trials of auricular acupuncture for cocaine addiction: does treatment context influence outcome?

OBJECTIVE: To compare findings from two consecutive clinical trials of auricular acupuncture for cocaine addiction conducted at the same site in order to explore consistency of treatment effects. SUBJECTS: One hundred and sixty-five (165) cocaine-dependent, methadone-maintained patients (study 1, n = 82; study 2, n = 83). INTERVENTIONS: Subjects in both studies were randomly assigned to auricular acupuncture, a needle insertion control condition, or a no-needle relaxation control. Treatment sessions were offered five times weekly for 8 weeks. The two studies were equivalent in design, except that unlike study 1, study 2 offered subject payments for attendance and did not include weekly group counseling. OUTCOME MEASURES: Cocaine use assessed by three times weekly urine screens constituted the primary outcome. Secondary measures included retention in treatment, treatment attendance, treatment credibility, therapeutic alliance, and acute effects of treatments. RESULTS: Intent-to-treat analysis showed that patients assigned to acupuncture in study 1, but not in study 2, were significantly more likely to provide cocaine-negative urine samples relative to the two control conditions. CONCLUSIONS: The positive effect for acupuncture found in study 1 was not found in study 2. Even though the two studies were similar, reasons for this inconsistency cannot be determined definitively, but may be because of differences in psychosocial context and payment contingencies between the two studies, or the lack of effectiveness of acupuncture in this application. The need to critically consider the influence of treatment context and other potential moderating variables on outcome in order to draw conclusions regarding treatment effectiveness is discussed.

[Comparison of identification methods of compounds from the opium alkaloids groups on Remedi HS instrument with immunoassay methods]. / Porównanie metody identyfikacji zwiazków z grupy alkaloidów opium na aparacie Remedi HS z metodami immunologicznymi.

The biological material of 28 abusers of compounds from the group of opium alkaloids were toxicologically analysed. To preliminary estimation of psychoactive substances ingestion the immunoassay methods (EMIT or FPIA) were used. The received results of total estimation compounds from opium alkaloids and their metabolites were compared to the ones obtained from high-performance liquid chromatography identification method with using Remedi HS. In the evaluated materials of all patients morphine, codeine, N-desmethylcodeine were identified. The presence of 6-mono-acethylmorphine was found in the urine of only 4 patients, which indicates the instability and a little amount of heroine in "kompot" of domestic production. The identification method can be used for simultaneous estimation of other substances of abuse from the groups of amphetamines and phenothiazines.

Integrative modeling of client engagement and outcomes during the first 6 months of methadone treatment.

Integrative models containing client and treatment components were tested in a sample of 396 daily opioid users from three methadone maintenance treatment sites. Measures included client motivation at intake as well as repeated assessments of therapeutic engagement (relationships between clients and their counselors, session attendance, and results of urine testing) during the first 6 months of treatment. There was a positive effect of pretreatment motivation on greater engagement and a reciprocal positive relationship between components of engagement and their effects on lowering drug use throughout treatment. Further analyses addressed differential effects of group versus individual counseling and showed that group session attendance was associated with higher rates of drug-negative urines.

Increasing employment of opioid dependent outpatients: an intensive behavioral intervention.

The impact of a new, mandatory employment requirement in a community-based methadone treatment program was evaluated. All patients who had been in the methadone substitution program for at least 1 year but who were not currently employed (n = 36) were required to enhance their treatment with 20 h of employment (paid or volunteer). Patients with significant psychiatric or medical disabilities were excluded from the routine treatment requirement. Patients were informed by counseling staff that they had 2 months to secure employment. Those who did not accomplish the goal within that time period were transferred to more intensive weekly counseling (i.e. up to 8 h/week) for 10 weeks, with the enhanced counseling focusing primarily on resistance to the employment goal. Patients who remained resistant to the treatment plan were eventually started on a 21 day methadone taper until employment was verified. Seventy-five percent of the patients secured employment and maintained the position for at least 1 month. Positions were found in an average of 60 days. Most patients (78%) continued working throughout the 6-month follow-up. Those who failed to find work or maintain employment engaged in more illicit drug use. These results demonstrate that behavioral contingencies can motivate many methadone maintenance patients to obtain verified employment in the community.