Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

28. Matching and Differential Therapies 647methadone-maintained individuals. Thus, a range of psychosocial treatmentshave been evaluated for their ability to address these drawbacks of methadonemaintenance, as well as to enhance and extend the benefits of methadonemaintenance. Several types of behavioral approaches have been identified aseffective in enhancing and extending the benefits of methadone maintenancetreatment, and these are summarized below (Carroll, 2001).Before describing specific approaches that have been demonstrated to beeffective in enhancing the effectiveness of opioid maintenance therapies, thecontext for such approaches should be set by a brief review of a study thatauthoritatively established the importance of psychosocial treatments evenin the context of a pharmacotherapy as potent as methadone. McLellanand colleagues (1993) randomly assigned 92 opiate-dependent individuals to(1) methadone maintenance alone, without psychosocial services; (2) methadonemaintenance with standard services, which included regular meetingswith a counselor; and (3) enhanced methadone maintenance, which includedregular counseling plus on-site medical/psychiatric, employment, and familytherapy, in a 24-week trial. Although some patients did reasonably well in themethadone-alone condition, 69% of this group had to be transferred out of thiscondition within 3 months of the study inception, because their substance usedid not improve or even worsened, or because they experienced significantmedical or psychiatric problems that required a more intensive level of care. Interms of drug use and psychosocial outcomes, the best outcomes were seen inthe enhanced methadone maintenance condition, with intermediate outcomesfor the standard methadone services condition, and the poorest outcomes forthe methadone-alone condition. This study illustrates that although methadonemaintenance treatment has powerful effects in terms of keeping addicts intreatment and making them available for psychosocial treatments, a purelypharmacological approach is not sufficient for the large majority of patients,and better outcomes are closely associated with higher levels of psychosocialtreatments.More recently, among the most exciting findings regarding how the benefitsof agonist maintenance therapies can be enhanced for a range of individualshas been the use of contingency management to reduce the use of illicit drugsin addicts who are maintained on methadone. In these studies, a reinforcer isprovided to patients who demonstrate specified target behaviors, such as providingdrug-free urine specimens, accomplishing specific treatment goals, orattending treatment sessions. For example, using methadone take-home privilegesas rewards contingent on reduced drug use is an approach that capitalizeson an inexpensive reinforcer that is potentially available in all methadonemaintenance programs. Stitzer, Iguchi, Kidorf, and Bigelow (1993) have doneextensive work in evaluating methadone take-home privileges as a reward fordecreased illicit drug use. In a series of well-controlled trials, this group of