Philip L. Herschman

Predictors of Patient Retention in Methadone Maintenance Treatment

This study sought to determine whether select pretreatment demographic and in-treatment clinical variables predict premature treatment discharge at 6 and 12 months among patients receiving methadone maintenance treatment (MMT). Data were abstracted from electronic medical records for 1,644 patients with an average age of 34.7 years (SD = 11.06) admitted to 26 MMT programs located throughout the United States from 2009 to 2011. Patients were studied through retrospective chart review for 12 months or until treatment discharge. Premature discharge at 6- and 12-month intervals were the dependent variables, analyzed in logistic regressions. Clinical predictor variables included average methadone dosage (mg/d) and urinalysis drug screen (UDS) findings for opioids and various nonopioid substances at intake and 6 months. Pretreatment demographic variables included gender, race/ethnicity, employment status, marital status, payment method, and age at admission. UDS findings positive (UDS+) for cocaine at intake and 6 months were found to be independent predictors of premature discharge at 12 months. UDS+ for opioids at 6 months was also an independent predictor of premature discharge at 12 months. Higher average daily methadone dosages were found to predict retention at both 6 and 12 months. Significant demographic predictors of premature discharge at 6 months included Hispanic ethnicity, unemployment, and marital status. At 12 months, male gender, younger age, and self-pay were found to predict premature discharge. Select demographic characteristics may be less important as predictors of outcome after patients have been in treatment beyond a minimum period of time, while others may become more important later on in treatment.

Effects of injectable extended-release naltrexone (XR-NTX) for opioid dependence on residential rehabilitation outcomes and early follow-up

BACKGROUND AND OBJECTIVES Little is known about the use of extended-release naltrexone (XR-NTX) during residential rehabilitation, and its effects on early outcomes and rates of follow-up treatment. This study examined patient characteristics and rates of treatment completion and engagement in post-residential care of opioid dependent patients who received XR-NTX during residential rehabilitation, compared with patients who did not receive this medication. METHODS Electronic records for opioid dependent patients from three Pennsylvania residential detoxification and treatment facilities (N = 7,687) were retrospectively analyzed. We determined the proportion of patients who received XR-NTX (INJ), and compared rates of treatment completion and engagement in follow-up care relative to a naturalistic control group of patients recommended for, but not administered, XR-NTX (Non-INJ). Data on whether the patient initiated follow-up care were available from one site (N = 3,724). RESULTS Overall, 598 (7.8%) patients were recommended for XR-NTX and of these, 168 (28.1%) received injections. Compared to non-INJ patients, INJ patients were less likely to leave against medical advice (4.8% vs. 30.2%, p < .001) and more likely to initiate follow-up care (37.7% vs. 19.7%, p < .001). These differences remained significant after controlling for demographic covariates using regression analysis. CONCLUSIONS XR-NTX was associated with higher rates of residential and early post-residential care engagement in patients with opioid dependence. SCIENTIFIC SIGNIFICANCE XR-NTX may be an effective adjunct in the residential treatment and aftercare of patients with opioid dependence.

A naturalistic comparison of the effectiveness of methadone and two sublingual formulations of buprenorphine on maintenance treatment outcomes: findings from a retrospective multisite study.

OBJECTIVE This study sought to compare the effectiveness of the 3 most commonly prescribed maintenance medications in the United States indicated for the treatment of opioid dependence in reducing illicit drug use and retaining patients in treatment. METHOD Data were abstracted from electronic medical records for 3,233 patients admitted to 34 maintenance treatment facilities located throughout the United States during the period of July 1, 2012, through July 1, 2013. Patients were grouped into 1 of 3 medication categories based on their selection at intake (methadone [n = 2,738; M dosage = 64.64 mg/d, SD = 25.58], Suboxone [n = 102; M dosage = 9.75 mg/d, SD = 4.04], or Subutex [n = 393; M dosage = 12.21 mg/d, SD = 5.31]) and were studied through retrospective chart review for 6 months or until treatment discharge. Two measures of patient retention in treatment and urinalysis drug screen (UDS) findings for both opioids and various nonopioid substances comprised the study outcomes. RESULTS The average length of stay (LOS) in terms of days in treatment for the methadone group (M = 169.86, SE = 5.02) was significantly longer than both the Subutex (M = 69.34, SE = 23.43) and Suboxone (M = 119.35, SE = 20.82) groups. The Suboxone group evinced a significantly longer average LOS relative to the Subutex group. After adjustment for relevant covariates, patients maintained on methadone were 3.73 times (95% confidence interval [CI]= 2.82-4.92) and 2.48 times (95% CI = 1.57-3.92) more likely to be retained in treatment at 6 months than patients prescribed Subutex and Suboxone, respectively. The 6-month prevalence rates of positive UDS findings for both opioids and nonopioid substances were similar across medication groups. CONCLUSIONS Comparable rates of illicit drug use at 6 months may be expected irrespective of maintenance medication, while increased retention may be expected for patients maintained on methadone relative to those maintained on Suboxone or Subutex.

AiRCare: A naturalistic evaluation of the effectiveness of a protracted telephone-based recovery assistance program on continuing care outcomes

BACKGROUND & OBJECTIVE Substance use disorder treatments are increasingly being contextualized within a disease management framework. Within this context, there is an identified need to maintain patients in treatment for longer periods of time in order to help them learn how to manage their disease. One way to meet this need is through telephone-based interventions that engage patients, and include more active outreach attempts and involvement of the patients family. This study sought to evaluate the effectiveness of three formats of an intensive 12-month post-discharge telephone-based case management approach (AiRCare) on adherence to continuing care plans and substance use outcomes. METHODS Data were abstracted from electronic medical records for 379 patients (59.9% male) discharged from a residential treatment program located in the southwestern U.S. from 2013 to 2015. Patients were categorized into one of three groups and received telephone contacts based on their self-selection upon admission to residential treatment (i.e., patient only, family only, and both patient and family). Outcome variables included re-engagement and re-admission rates, quality of life, abstinence rates at 6 and 12 months, and compliance with continuing care plans. RESULTS & CONCLUSIONS Favorable short- and long-term outcomes were found for the majority of patients, irrespective of case management group. There appeared to be some value in the addition of family contacts to patient contacts with respect to reducing risk for 12-month re-admission to residential care. These positive but preliminary indications of the effectiveness of AiRCare require replication in a well-powered, randomized controlled trial.

The Role of Patient Payment Method in Premature Discharge from Methadone Maintenance Treatment

Abstract Background: Premature discharge is a pervasive problem in methadone maintenance treatment (MMT), and is associated with numerous adverse outcomes. Although a number of demographic variables have consistently been found to impact MMT retention, method of payment has received considerably less attention. A notable limitation of prior work is that most studies classify all patients who leave treatment early, irrespective of reason, as treatment dropouts and fail to account for specific reasons. Objective: This study sought to determine whether method of payment for MMT services was associated with differential reasons for premature discharge. Methods: The sample was comprised of 4158 patients prematurely discharged from 33 MMT facilities located throughout the U.S. from 2009 to 2012. Patients were classified into two groups based on their method of payment: self-pay and insurance (largely Medicaid). Patients were studied through retrospective electronic chart review. Results: Binary logistic regression indicated that insurance patients who were prematurely discharged were significantly more likely to be discharged due to a program-initiated reason (administrative), while self-pay patients were more likely to be discharged due to a patient-initiated reason (against medical advice) after controlling for significant intake demographic and clinical covariates. Conclusions: Further research is needed to determine whether insurance patients may require different supports in place compared to self-pay patients in order to improve compliance with program guidelines (e.g. behavioral contracts providing a detailed description of rules both at admission and throughout treatment with an emphasis on the potential consequences of noncompliance), and whether self-pay patients may benefit from motivational incentives and interventions to remain engaged in treatment.

Patient adherence to multi-component continuing care discharge plans

Intuitively, it is assumed that greater patient adherence to treatment recommendations in substance use disorder (SUD) treatment is associated with favorable outcomes, but surprisingly, there is limited research systematically examining the adherence-outcome relationship in the context of the continuing care phase post-discharge from residential treatment. This study sought to determine the effect of adherence to multi-component continuing care plans on long-term outcomes among patients following the primary treatment episode. Data were abstracted from electronic medical records for 271 patients (59.0% male) discharged from a U.S. residential program between 2013 and 2015. Patients were categorized based on their level of adherence to their individualized continuing care discharge plan, and studied through retrospective record review for 12months post-discharge. 12-month outcomes included past 30-day and continuous abstinence, re-admission, and quality of life. With the exception of re-admission rate, fully adherent patients demonstrated significantly better results on all study outcomes at 12months compared to patients who were partially or non-adherent. Fully adherent patients were 9.46 times (95% CI: 5.07-17.62) more likely to be continuously abstinent through 12months relative to the other adherence groups. Fully adherent patients were 7.53 times (95% CI: 2.41-23.50) more likely to report a positive quality of life at 12months relative to the other adherence groups. The findings support the widely held contention that greater adherence to continuing care discharge plans is associated with favorable long-term outcomes, and provide insight into realistic outcomes expectations for patients who are adherent to their multi-component continuing care discharge plans.

Importance of short-term continuing care plan adherence on long-term outcomes among patients discharged from residential substance use treatment

ABSTRACT Background: Patients adherent to their recommended treatment regimen demonstrate favorable outcomes. However, it is unclear whether there are specific short-term continuing care performance variables indicative of better long-term prognosis. Objective: This study determined the impact of attendance at an outpatient appointment within 7 days post-discharge from residential treatment on 12-month outcomes. Method: Data were abstracted from electronic medical records for 275 patients (58.9% male) discharged from a single residential treatment program. All discharge plans included a 7-day outpatient appointment with a provider in their home community. Patients were dichotomized based on their attendance at the initial appointment to yield a re-engagement variable. Twelve-month outcomes included past 30-day and continuous abstinence rates, quality of life, and long-term adherence to continuing care plans. Results: Patients attending their initial outpatient appointment within 7 days of discharge evidenced better long-term outcomes relative to patients who did not with respect to continuous abstinence (75.4% vs. 37.3%), past-30-day abstinence (92.0% vs. 70.6%), quality of life (94.2% vs. 78.4%), and adherence (66.4% vs. 9.8%). Re-engagement remained a significant predictor of continuous abstinence and quality of life at 12 months after controlling for 12-month adherence and relevant demographic characteristics. Conclusion: Treatment providers are encouraged to emphasize the relative importance of attending initial post-discharge appointments in achieving successful long-term outcomes. Allocation of resources to enhance engagement during residential treatment may be justified in that there may be value in actively encouraging patients to participate in continuing care activities, particularly shortly following discharge.

Outcome predictors for patients receiving methadone maintenance treatment: findings from a retrospective multi-site study

Abstract This study sought to determine whether select pre-treatment demographic and in-treatment clinical variables are associated with urinalysis drug screen (UDS) findings for opioids among patients receiving methadone maintenance treatment (MMT). Data were abstracted from electronic medical records for 2,410 patients admitted to 26 MMT programs from 2009–2011. Patients were studied through retrospective chart review for 12 months. UDS findings for opioids at 3-, 6-, 9-, and 12-month intervals were the outcome variables. Clinical variables included average daily methadone dosage and UDS findings for cocaine, amphetamines, cannabinoids, and benzodiazepines at intake and the various 3-month intervals. UDS+ for cocaine at intake and 3 months were found to be independent predictors of a UDS+ for opioids at 9 months. UDS+ for amphetamines and cannabinoids were found to predict UDS+ for opioids at various intervals. Higher daily methadone dosage was found to predict opioid abstinence at 9 months. Significant demographic predictors of UDS+ for opioids at various intervals included older age, unemployment, Hispanic ethnicity, and being male, single, separated, or non-self-pay. Overall, few of the demographic and clinical variables appear to provide a basis for a priori judgment about whether or not a patient presenting for MMT is likely to have a favorable long-term outcome. However, the findings do suffice to assist in making systematic improvements in MMT planning and in identifying particular subgroups of patients at risk for poor treatment response early on in the MMT process.