The Role of Retention in MMTP

At the recent National Methadone Conference, Ward S. Condelli, Ph.D., and J. Thomas Payte, M.D., presented a session on "Strategies for Improving Retention" in Methadone Maintenance Treatment Programs. A.T. Forum first interviewed Dr. Payte, Medical Director of Drug Dependence Associates in San Antonio, Texas, for our second issue (Vol. 1, #2). We contacted him again for his firsthand views of retention issues.
A.T. FORUM: When did you first become interested in the importance of patient retention in methadone treatment?
Dr. PAYTE: In 1990, I started doing a review of the literature. What struck me was the apparent assumption, which I thought was somewhat arrogant, that problems in retention were most likely due to patient characteristics. The predictors of retention or dropout rates were based on patient characteristics, while there was very little being done or studied at that time about program characteristics to see what might influence retention.
I began to visualize the problem as an "old leaky wooden bucket" where the bucket represented the program and the water represented our patients. We had an abundant supply of patients, so the fact that a number were leaking out didn't seem to e very problematic. However, when we finally recognized this as a problem, we began to study the water (patients) rather than plugging the leaks in the bucket (program).
A.T.F.: In your presentation you discussed several areas-such as ease of clinic access, quality of social services and individualized treatment-as being more important than the particular characteristics of the patients.
PAYTE: Program characteristics are the things that we certainly have more control over. So I think that's where we need to focus our attention.
Accessibility of the clinic is very important in terms of operating hours, geographical distances, parking. We're proposing anew building for our program and one of the things we want to put in is a special area for children while the parents are with their physician or counselor.
A.T.F.: Do you think community based clinics would be better than any kind of centralization?
PAYTE: I don't mind centralization if there are satellites. I think when single programs get so big that you bring a lot of people into a small area on a frequent basis, the opportunities for problems, diversion and illegal activities increase. I would prefer to see as a program gets bigger and bigger that they develop remote medication dispensing units. This is something we're looking at now in retail pharmacies and community hospitals in the small towns surrounding San Antonio.
A.T.F.: So patients would go to satellite locations for their methadone, but then go someplace else for comprehensive services?
PAYTE: They'll still come into the main clinic for counseling, physician contacts and other services. We hope that, by not having to drive long distances daily for observed doses, this might bring more of the rural population into treatment. Sometimes patients are fifty to one hundred miles away, and if they spend all their time in a car they can't hold down any kind of a normal job. I think we need to look at the needs of the patient in terms of what can we do that will provide the necessary elements of treatment, but in a manner that provides a minimum of disruption in a patient's life. Every time they have to come into the clinic, family activities, educational activities or occupational activities are somehow impacted. We want to make sure that the time spent at the clinic is very useful and our focus is to help the patient have as "normal" a lifestyle as possible, given the obvious limitations of being on a medication that may be very long-term.
A.T.F.: Is the mere length of time spent in treatment an important factor?
PAYTE: Ward Condelli and George Dunteman presented a 1993 study demonstrating the percentage of patients using heroin after exposure to various lengths of time in treatment (see, "Exposure to Methadone Programs and Heroin Use," Am. J. Drug Alcohol Abuse, 19 (1), pp. 65-78 (1993)). They started their study a year prior to treatment when 100% of patients were using heroin.
Then they compared several lengths of treatment: short term exposure to methadone treatment, less than 3 months; long-term exposure, 3 or more months; and continuous exposure, meaning patients never left the program, or left but were exposed to other programs for more than 40 weeks during a follow-up year. Those heroin users who had even short-term exposure decreased to 39%, which was similar to the 40% of patients with long term exposure. The important finding was that only 17% of those patients in continuous exposure to methadone treatment used heroin during the previous year.
The debate continues about he duration of therapy; I strongly feel that there should be no arbitrary time limits on treatment and it should be continued for as long as the patient wants and benefits from continued treatment.
A.T.F.: In terms of the quality of social services and their impact on retention, what would be some important factors?
PAYTE: Quality has to do with the training and experience, as well as the attitude and motivation, of the individual staff person. Well trained people may provide very poor quality service if they have a negative attitude towards the patient; they may not relate well to patients and there may be other kinds of barriers.
A.T.F.: We hear stories of methadone being used in punitive or other ways to manipulate patients' behaviors. How do you feel about that?
PAYTE: A number of people have used methadone as a part of contingency contracting, both as a negative and positive reward. At a policy level, both from the American Society of Addiction Medicine and the American Methadone Treatment Association, we generally support the position that dosage is a clinical consideration and should never be used as a carrot on a stick in terms of any kind of contingency contracting. All other areas are probably fair game for contingency contracting.
I think it is entirely appropriate to modify take home privileges when patients don't participate in treatment or progress toward rehabilitation; not because they're being punished, but because they're not demonstrating their responsibility to take care of the medication.
But, I've also talked to a lot of patients who have been on different programs and it's discouraging to hear the extent of complaints and horror stories about their experiences. In some treatment systems there's so much water (so many patients) to go into the leaky bucket (program) that they don't really care whether patients stay in treatment or not. Just as soon as one patient drops out there's somebody else waiting to take that slot.
A.T.F.: To what extent might patients be expected to pay for the better quality of social services and individualized treatment that improve retention?
PAYTE: In most cases, patients come into treatment unemployable, they are physically sick and, of course, they're addicted. Then as they stabilize, quit using illicit drugs, gain physical health, and become employable they certainly should participate more in the cost of their treatment.
However, it also is a fact that, the way programs are structured and the way regulations are designed, program costs remain fairly constant regardless of the patient's time in treatment. What I'm hoping to see in the future is a move toward more after-are and medical maintenance at considerably reduced costs.
Simply supplying the medication should not be that expensive, and the patient that requires no counseling and one visit with the physician every six months to a year should not have to be paying $40 or $50 dollars a week. I think we can cut those fees in half.
A.T.F.: Are financial concerns a serious threat to retention or even admission to a program?
PAYTE: I have worked in both the public sector and the private sector. In recent years we've seen a need for a more comprehensive level of services that sicker patients require. We're starting to see more dual diagnosis and psychiatric co-morbidity, we're seeing more poly drug addictions and multiple drug use, increases in the severity of social and economic problems such as homelessness, and we're seeing more medical complications with Hepatitis-C and HIV. On a fee-for-service basis, if you're in an area that does not have a good third party reimbursement system, such as Texas, the indigent addict is just completely out of luck. We're applying for funding to provide services to 100 medically indigent addicts, with a focus on minority females.
I think the way to go is a blending of the public and the private sector that will make treatment on demand available at the point of entry. But then a part of the ongoing treatment system would be to make these patients more and more responsible for their care, so as they progress through the system a smaller portion of the burden falls on the taxpayers.
A.T.F.: If costs could be reduced as patients are retained in treatment, could more patients then be admitted to treatment as a result?
PAYTE: A significant commitment of financial resources would still be required up front, because most of the patients coming into treatment cannot afford it. Our concern is the number of medically and otherwise indigent addicts for whom there is no treatment available. We see addicts who are desperate and about the only thing we can offer them is to get them arrested and hope that they may end up in treatment through some kind of court referral.
A.T.F.: At the recent National Methadone Conference it was mentioned that for every dollar spent on treatment, four to seven dollars are saved in other ways. So it seems that even if there is a high initial cost to bring these people into treatment, the ultimate savings can be fourfold.
PAYTE: Absolutely. There's no questions about that and those numbers have been around for some time. If you look at the cost to provide the kind of comprehensive care we're talking about in a methadone program it would be $5,000 to $6,000 per patient per year. Most programs actually operate around $2,500 to $3,000 per patient per year.
But the direct and indirect costs to the community for the untreated addict approaches $50,000 or more per year. And when you begin to think about the spread of HIV, drug resistant tuberculosis and other diseases, it just keeps branching out and the costs escalate.
I think one problem is that some of those costs are so diffuse that you can't actually track all the public health and social welfare consequences of addiction. But, when a community starts making available blocks of money for treatment, that amounts to real dollars. So, we persist in this false economic assumption that we can't afford this treatment.
I've said for years we can't afford not to treat this population. I think it's ridiculous to have four or five addicts who are not in treatment for every on that's in treatment. This is another side of the retention issue. We have a problem with patients dropping out of treatment. But, if there are a half million to one million active chronic heroin addicts out thee, why aren't they beating down my door and the doors of all the other clinics? Why are most of them not even coming into treatment? What we have is a "dropping-in problem."
A.T.F.: What's keeping these addicts away?
PAYTE: For one thing, these addicts know treatment is not easily available. Most of the publicly funded clinics have waiting lists. Addicts don't think in terms of, "If I put my name down today, maybe I can get admitted next month."
Second, treatment may not be acceptable to them. e need to look at patient acceptance as we design our programs; not necessarily what's best from a clinical standpoint, but what's best to bring more people into treatment and retain them there.
A third reason, if we stretch a little bit, is the availability of drugs on the street. If there's high quality heroin cheaply available on every street corner, addicts are less likely to seek treatment; especially if treatment is difficult to get into or if there are other barriers.
So, in sum, I think we need a user friendly system that is affordable from the outset. And we need the commitment of adequate resources to really provide an intense, high level of total care for the first year or two. Then, after three or four years, these retained patients who are socially rehabilitated, trained and employed could be paying their own way and the cost of the treatment will drop dramatically. I think it would cost maybe $50 to $75 a month to have a patient on medical maintenance, including the professional time, fees and the medication.