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Methadone Patients Should Not Be Allowed to Persist in Cocaine Use

by Jonathan Caulkins and Sally L. Satel

Cocaine abuse by methadone maintenance patients is a problem that is almost as old as methadone maintenance itself (Chambers et al., 1972), but its extent and severity grew substantially during the 1980s (Condelli et al., 1991). Now even articles in normally staid academic journals are describing it with terms such as "urgent" and "crisis" (Kolar et al., 1990; Margolin et al., 1997). Many studies find substantial minorities of methadone patients use cocaine (US GAO, 1990), and several studies have found cocaine prevalence rates in particular programs exceeding 70%, including among pregnant women (Kidorf and Stitzer, 1993).

Cocaine abuse is bad for the patient physically, psychologically, and economically, and threatens public safety and health through its connection with criminality and HIV risk. (Hartel et al., 1995; Bux et al., 1995).⁽¹⁾ Clinics' options in dealing with cocaine-using patients are limited by the lack of markedly effective pharmacotherapies for cocaine use.⁽²⁾ (Avants et al. 1994; Margolin et al., 1997).

A Possible Response

Various researchers have suggested that the situation demands more aggressive efforts (e.g., Bux et al., 1995). One such effort would be to expel patients who repeatedly test positive for cocaine from the methadone program, just as patients are expelled for drug sales or for threatening or attacking other patients or staff.

Even severely addicted persons have shown sufficient ability to control their behavior to make incentive management a realistic option (Kleiman, 1997). Contingency management interventions with methadone patients have produced significant changes in behavior using as incentives vouchers that have monetary value, take home privileges, and the size of the methadone dose (e.g., Silverman et al., 1996; Schmitz et al., 1998; and Stitzer et al., 1986, respectively). Indeed, we would suggest that the threat of expulsion be used in conjunction with and only after the failure of these more incremental incentives.

Expulsion for cocaine use would not be a departure in principle; many programs actually have policies stating that patients who repeatedly test positive can be expelled. But those policies are infrequently enforced. The most common reason for not enforcing the rules seems to be concern that expulsion increases the individual's risk of contracting or spreading HIV/AIDS.

Nevertheless, some programs follow through on the threat of expulsion for a variety of reasons. Four reported in the literature demanded that patients obtain a job (Kidorf et al., 1998), comply with prophylactic tuberculosis treatment (Elk et al., 1993), and test clean (Dolan et al., 1985; McCarthy and Borders, 1985). All four reported success in getting the patients to comply. One that required patients to remain drug-free (McCarthy and Borders, 1985) actually had higher retention rates in the group assigned to structured testing than in the randomly assigned control group. Note also that one of the most successful morphine maintenance clinics of the 1920s, the Shreveport, Louisiana clinic, demanded that its "clients" hold jobs (Jonnes, 1996).

Is It Beneficial?

Whether frequent testing and expulsion for repeatedly failing tests is beneficial depends on what happens and on whose welfare is being considered. One possible result is that the individual stops using cocaine.⁽³⁾ Clearly that is good for all concerned.

A variety of outcomes are possible if the individual persists in use. Ideally, the individual would be referred to and would enter a more intensive form of treatment, such as day treatment or sober-living homes.⁽⁴⁾ In that case, testing helps match intensive interventions to individuals who do not respond to less costly interventions. Another possible outcome is that patients expelled from one program shift to another, less strict methadone program. In these cases of pushing the patient from one treatment program to another, there are some benefits and some costs, but no dramatic effects one way or another to the individual or society generally.

Even the more severe consequences that ensue if the expelled individual does not enter treatment elsewhere are less substantial at the social level than they are at the individual level, due to the prospect of replacement. There are about 800,000 heavy heroin users (ONDCP, 1998), and only about 115,000 people enrolled in methadone programs (SAMHSA, 1995), so there are many potential candidates for slots made vacant by expulsion. That result may be bad for the expelled individual, but it is good for the newly admitted person. It is also probably a net gain for society assuming the new patient does not use cocaine (or expulsion and replacement continue until the slot is filled by someone who does not use cocaine).

Suppose the expelled individual neither enters another treatment program nor is replaced, thereby reducing the total number of people in treatment. The expelled individual is probably worse off. Since there is ample evidence that methadone reduces not just heroin consumption but also cocaine use and drug injection, at first one might think there is no need to qualify that statement. However, what we know with a high degree of confidence is that methadone is beneficial on average, based on results with treatment and control groups. It is possible that methadone is beneficial for most individuals, but for others it may merely prompt a switch from intensive, risky heroin use to intensive, risky use of another drug, such as cocaine.

Even when expulsion leads to greater or riskier drug use by the individual expelled, it is still not obvious that society as a whole would be worse off because giving teeth to rules against drug use by patients could improve outcomes of other patients in the clinic. A clinic is, after all, a community of patients, and that community is contaminated and the staff's credibility damaged when some of its members use drugs without reaction by the staff. Patients struggling with abstinence feel demoralized when they see their colleagues using drugs while ostensibly in treatment to alter their lifestyle. Furthermore, a common suggestion for relapse prevention is to avoid people, places, and situations that trigger cocaine cravings. It is hard for a patient to avoid such cues if they visit a clinic every day in which a substantial minority of the other patients are using cocaine, particularly if cocaine dealers loiter near the clinic in order to sell to the other patients. Clinic directors have obligations to the rest of their patients, just as they do toward those who persistently use cocaine despite clinical interventions (e.g., enhanced counseling, inpatient respite, etc.).

These considerations can be summarized in a matrix that shows who benefits or loses as a function of the outcome of a testing program that is backed by the threat of expulsion. (See Figure 1.) The individuals tested are worse off unless the chance of expulsion is low, which is probably why threats to expel are rarely carried out today. Other patients in the clinic are clear winners, and society as whole benefits in most circumstances. Society as a whole would be worse off only if, (1) the tested individual persists in use, (2) more intensive interventions are not available, (3) the individual does not switch to a less strict methadone program, (4) the individual is not replaced by someone on the waiting list, (5) the individual was someone for whom methadone led to less and less risky drug use, not merely substituting one drug for another, and (6) the harm of expulsion to such individuals outweighs the benefit other patients in the clinic derive from the clinic not tolerating cocaine use. Whether all six conditions pertain in most or only a few clinics is an empirical question, but there certainly is not a prima facie case that testing with expulsion is bad for society.

Figure 1: Consequences of Drug Testing Methadone Patients

(+ = benefit; = loss; 0 = no effect; NA = not applicable)

^aIf the tested patient is expelled and treated elsewhere, the individual vacates one treatment slot but fills another; there is no net change in the number of slots available to those waiting for treatment.

Is it Ethical?

If testing methadone patients has pragmatic appeal the remaining question is whether it is ethical to punish misbehavior by denying medical benefits. We do not, for example, deny a diabetic insulin if he or she indulges in an ice cream sundae.⁽⁵⁾

The ethics depend in part on whether methadone is seen as individual medical treatment or as a public health and welfare program. Demanding certain behavior in return for government support is now common: e.g., evicting people from public housing for dealing drugs, cutting off welfare and food stamps for those who refuse to seek work, and withholding cash benefits from mothers who do not cooperate in establishing paternity without good cause (e.g., because it would pose a physical risk to the mother and/or child). Some might charge that these policies are mean-spirited and counter-productive, but the fact that they exist suggests that the majority of Americans do not believe they are unethical.

In addition, cocaine use involves committing a crime and supporting an illicit industry that does great social damage. Finally, when a patient at a methadone clinic uses cocaine, that disrupts clinic operations and hurts other patients. Addicts' cravings are real and difficult to suppress. Exposing recovering addicts to people who persist in using cocaine can do real not merely notional harm to those trying to avoid relapse. If a cocaine-using methadone patient were being treated by a private doctor (not possible under current regulations, which perhaps ought to be changed) it might be appropriate to make the interests of that particular patient paramount. However, when the methadone is dispensed by a publicly-funded clinic for whose services demand outstrips supply and whose existence is justified at least in part by claims of advancing public health (e.g., by reducing crime and controlling the spread of infectious disease), other rules ought to apply.

Conclusion

We should consider making methadone contingent upon not using cocaine. Doing so might substantially reduce cocaine abuse among current methadone patients. Some would fail to control their cocaine use, but expelling them would free up their slots for other, more compliant patients while reinforcing the clinic's commitment to the behavioral standards it sets.

Methadone is a valuable program that is subject to frequent attacks, most recently from Mayor Guiliani of New York. Indeed, the Mayor is responding to a methadone culture in New York City that revolves around the public clinic. Many patients are spottily employed if they work in the legitimate economy at all, depend on public entitlements and Medicaid, and use other drugs. Ideally, methadone should be a catalyst for improved social functioning, not simply another aspect of a dependent lifestyle. Methadone would be a more successful, and probably more respected, treatment if it guaranteed that its patients were not simply replacing one drug (heroin) with another (cocaine).

References

Avants SK, Margolin A, Kosten TR. 1994. Cocaine abuse in methadone maintenance programs: integrating pharmacotherapy with psychosocial interventions. J Psychoactive Drugs. 26(2):137-146.

Bux DA, Lamb RJ, Iguchi MY. 1995. Cocaine use and HIV risk behavior in methadone maintenance patients. Drug Alcohol Depend. 37(1):29-35

Chambers CD, Taylor WJ, Moffett AD. 1972. The incidence of cocaine abuse among methadone maintenance patients. Int J Addict. 7(3):427-441

Condelli, WS, Fairbank, JA, Dennis, ML, Valley Rachal, J. 1991. Cocaine Use by Clients in Methadone Programs: Significance, Scope, and Behavioral Interventions. J Substance Abuse Treatment. 8:203-212.

Dolan MP, Black JL, Penk WE, Robinowitz R, DeFord HA. 1985. Contracting for Treatment Termination to Reduce Illicit Drug Use Among Methadone Maintenance Treatment Failures. J Consult Clin Psychol. 53(4):549-551

Elk R, Grabowski J, Rhoades H, Spiga R, Schmitz J, Jennings W. 1993. Compliance with tuberculosis treatment in methadone-maintained patients: behavioral interventions. J Subst Abuse Treat. 10(4):371-382

Hartel DM, Schoenbaum EE, Selwyn PA, Kline J, Davenny K, Klein RS, Friedland GH. 1995. Heroin use during methadone maintenance treatment: the importance of methadone dose and cocaine use. Am J Public Health. 85(1):83-88

Jonnes, J. 1996. Hep-Cats, Narcs, and Pipe Dreams: A history of America's romance with illegal drugs. Scribners, New York

Kidorf M, Hollander JR, King VL, Brooner RK. 1998. Increasing employment of opioid dependent outpatients: an intensive behavioral intervention. Drug Alcohol Depend. 50(1):73-80

Kidorf M, Stitzer ML. 1993. Descriptive analysis of cocaine use of methadone patients. Drug Alcohol Depend. 32(3):267-275

Kleiman, MAR. 1997. Coerced Abstinence: A Neo-Paternalistic Drug Policy Initiative. In Lawrence A. Mead, ed., The New Paternalism, Brookings Institution Press.

Kolar AF, Brown BS, Weddington WW, Ball JC. 1990. A treatment crisis: cocaine use by clients in methadone maintenance programs. J Subst Abuse Treat. 7(2):101-107

Margolin A, Avants SK, Rounsaville B, Kosten TR, Schottenfeld RS. 1997. Motivational factors in cocaine pharmacotherapy trials with methadone-maintained patients: problems and paradoxes. J Psychoactive Drugs. 29(2):205-212

McCarthy JJ, Borders OT. 1985. Limit setting on drug abuse in methadone maintenance patients. Am J Psychiatry. 142(12):1419-1423.

Office of National Drug Control Policy. 1998. The National Drug Control Strategy, 1998. The White House, Washington, DC.

Schmitz JM, Rhoades HM, Elk R, Creson D, Hussein I, Grabowski J. 1998. Medication take-home doses and contingency management. Exp Clin Psychopharmacol. 6(2):162-168

Silverman K, Higgins ST, Brooner RK, Montoya ID, Cone EJ, Schuster CR, Preston KL. 1996. Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy. Arch Gen Psychiatry. 53(5):409-415.

Stitzer ML, Bickel WK, Bigelow GE, Liebson IA. 1986. Effect of methadone dose contingencies on urinalysis test results of polydrug-abusing methadone-maintenance patients. Drug Alcohol Depend. 18(4):341-348.

Substance Abuse and Mental Health Services Administration (SAMHSA). 1995. Overview of the FY94 National Drug and Alcoholism Treatment Unit Survey (NDATUS): Data from 1993 and 1980-1993. Rockville, MD: US Department of Health and Human Services.

US General Accounting Office (GAO). 1990. Methadone Maintenance: Some Treatment Programs Are Not Effective: Federal Oversight Needed. (GAO/HRD-90-104). Washington, DC: US GPO.

COMMENT

Expulsion as a Sanction for Persistent Cocaine Use by Methadone Clients:

The Case for an Experiment

Caulkins and Satel address an important issue, and make a dramatic suggestion. They may well be right in their prediction of the outcomes, and I, for one, find their ethical case compelling, conditional on the accuracy of their empirical predictions.

However, on empirical grounds their case does not seem as strong to me as it does to them. Yes, we know that contingency management works with addicted patients. Yes, we know that threatening soldiers or physicians with expulsion or delicensure for drug use can reduce the rates of drug use in those populations. But the contingency management programs that have been shown to work with addicted patients involve small rewards (or, more rarely, penalties) that can be invoked repeatedly, not one-time drastic sanctions. As Caulkins and Satel point out, the current repertoire of methadone clinics includes, or should include, small-stakes contingency management. Where it does not, then the step of adding testing and minor sanctions is both logically and operationally prior to the question of using the more drastic sanction of expulsion.

The argument for strengthening the system of testing and minor sanctions seems strong. But the argument for adding expulsion to that system depends on facts not yet in evidence. We would have to know that adding the threat of expulsion to a contingency management program increased its efficacy enough to offset any additional costs.

This suggests an experiment, or series of experiments, using the clinic as the unit of analysis. Take some number of clinics currently using some form of testing and contingency management; convince the managements and staffs to be willing to add expulsion to their repertoire as part of an experiment; and then randomize, with some clinics actually making the change and others not. After some months of administrative shakedown and patient adaptation, we would be able to observe the difference made by the added threat.

Gary Emmett has noted a methodological problem here that points at a policy problem. If the "experimental" and "control" sites are within the same catchment area, the results could be polluted by low-compliance patients moving from the tougher to the softer program, making the softer program look artificially worse. Reflection on that problem suggests that the impact of tougher contingency-management programs, with or without expulsion, will be somewhat different - not obviously better or worse, but different - at the system level than at the individual-program level. That, in turn, suggests that an experiment would ideally be run with cities, rather than programs, as the units of analysis. But perhaps we should not let the best be the enemy of the good in this case; some experimental results, even slightly flawed ones, are better than none.

In the absence of the results of such an experiment, the policy recommendation to proceed with expulsions seems premature. My conjecture would be that the difference between a good contingency management program without expulsion and a good contingency management program with expulsion would be small, but the difference between either one and a sloppy or absent program would be large.

Nor should we assume that, if there is a difference, it will favor the more severe sanction. While expulsion may increase the motivation of the patient to cease cocaine use, it may also decrease the motivation of the staff to help a difficult patient succeed, thus weakening the therapeutic alliance from one side if not both. Given the uncertainty, the experiment ought to precede the policy change.

Mark Kleiman

c/o Federation of American Scientists

307 Massachusetts Ave., NE

Washington, DC 20002

1. ¹ Cocaine use is associated with greater use of heroin, drug injection, and sexual intercourse without condoms than is observed in methadone patients who are not using cocaine. There is no way to know whether the association is causal or spurious, but inasmuch as cocaine use leads to impulsiveness and loss of control generally, some of the association may well be causal.

2. ² Interventions evaluated in the literature include desipramine, amantadine, buprenorphine, bupropion (alone and in combination with buprenorphine), pemoline, fluoxetine, carbamazepine, bromocriptine, selective serotonin reuptake inhibitors (e.g., Prozac), and simply raising the daily methadone dosage, sometimes over 300 mg per day.

3.

³ E.g., Dolan et al. (1985) report that 11 of 21 patients eliminated illicit drug use.

4.

⁴ Kidorf et al. (1998) report that 7 of the 9 failing to comply with the work requirement were referred to a higher level of care. Most did not go, but 5 of the 9 were known to have entered another methadone program or to have re-entered the original program after finding work.

5.

⁵ Although we do not withhold insulin, some would argue that a persistently non-compliant diabetic could be charged higher health insurance premiums or otherwise be penalized.