Hi, which therapeutic communities are those mentioned in this study?

Anthony Slater.

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 Methadone patients in the therapeutic community: a test of equivalency
Sorensen J.L., Andrews S, Delucchi K.L. et al. Request reprint
Drug and Alcohol Dependence: 2009, 100, p. 100-106.

Residential therapeutic communities have demonstrated effectiveness, yet
for the most part they adhere to a drug-free ideology incompatible with
the use of methadone. This study used equivalency testing As explained
in the source paper, equivalence testing is a statistical technique
often used to show that a new medication is indistinguishable from an
approved standard medication. Outcomes from the two treatments (in this
case therapeutic community residence with versus without methadone
maintenance) are declared equivalent if the confidence interval for the
difference between them is completely within 20% plus and minus the
value of outcomes from the standard treatment. An equivalence test can
find that two treatments are not equivalent yet a traditional test can
also find that they fail to differ to a statistically significant degree
(for an illustration see
http://www.mors.org/meetings/test_eval/presentations/C_Warner.pdf). In
other words, a finding of equivalence is not the same as simply finding
a failure to differ. to explore the consequences of admitting
opioid-dependent clients currently on methadone maintenance treatment
into a therapeutic community. The study compared 24-month outcomes
between 125 methadone patients and 106 opioid-dependent drug-free
clients with similar psychiatric histories, criminal justice pressures
and expected lengths of stay, who were all newly enrolled in a
therapeutic community. Statistical equivalence was expected between
groups on retention in the therapeutic community and illicit opioid use.
Secondary hypotheses posited statistical equivalence in the use of
stimulants, benzodiazepines, and alcohol, as well as in HIV risk
behaviours. As hypothesised, the average number of days in treatment was
statistically equivalent for the two groups (166.5 for the methadone
group and 180.2 for the comparison group). At each assessment, the
proportion of the methadone group testing positive for illicit opioids
was indistinguishable from the proportion in the comparison group. The
equivalence found for illicit opioid use was also found for stimulant
and alcohol use. The groups were statistically equivalent for
benzodiazepine use at all assessments except at 24 months where 7% of
the methadone group and none in the comparison group tested positive.
Injection- and sex-risk behaviours were equivalent at all observation
points. The authors concluded that in these therapeutic community
settings, methadone patients fared as well as other opioid users,
providing additional evidence that therapeutic communities can
successfully be modified to accommodate methadone patients.


 Generally considered incompatible treatment modalities, this is one of
the few studies to show that a therapeutic community environment can be
combined with methadone maintenance, and the first to do so in respect
of a residential community. As the authors stress, it is important to
remember that these were not the usual run of communities. For decades
they had embraced methadone patients and made modifications Among those
mentioned in the source article are the designation of a methadone
counsellor who plays a vital role in the process of helping the
programme modify its services to accept and treat methadone patients.
Counsellors periodically offer methadone sensitivity training sessions
to staff and patients, providing education and confronting stigma about
methadone maintenance. They also conduct weekly methadone therapy groups
for residents on methadone. Residents who opt to attempt withdrawal from
methadone have greater access to alternative therapies and medical
services. to meet their particular needs and increase their acceptance
by staff and residents. It's also possible that these modifications and
the presence of methadone patients changed the environment for
non-methadone residents too. Residents were not randomly allocated to
the two regimens but entered the facilities in the normal way. All had
the kind of experience of opiate use which would have made them eligible
for methadone maintenance, they were matched However, the three key
variables identified in the abstract were very simply matched in an
either/or way rather than in terms of degrees. on some key variables and
differed little on most others, yet before, during and after leaving the
communities, far more of the methadone group were in methadone
treatment. The implication is that the major remaining difference
between the two groups of residents lay in their preferences for
alternative routes to recovery - complete abstinence, or abstinence from
illegal drugs supported by substitute prescribing. The outcomes seem to
suggest that in welcoming and suitably modified communities, residents
who favour these different routes end up abstinent from illegal drugs in
roughly the same numbers and converge somewhat Two years after joining
the communities 70% of the methadone group were still being prescribed
methadone compared to 30% of the non-methadone group, a narrowing of the
gap of 95% versus 12% recorded at entry to the programmes. in their
preferences for how to attempt to maintain this. They also show that
many from both camps At six months after treatment entry, when most of
the residents had left the therapeutic community treatment system, about
a third tested positive for opiates rising to about a half at 18 months.
Stimulant use showed the same upward trajectory but at a lower level,
reaching about 40% positive by 18 months. do not totally succeed. What
we don't know, however, is how the residents fared in other ways such as
reintegration and mental and physical well being.
Though this study seems unique, previous reports have documented the
integration of non-residential day care therapeutic communities with
methadone programmes, demonstrating that patients who opt for this
additional support evidence Perhaps because of their greater motivation
and in this study, degree of psychological distress, as well as any
impact of the community. greater remission in opiate and cocaine use.
Other studies have established that with staff facilitation, 12-step
mutual aid groups can (but not always See for example an account of the
initially low take-up and stuttering progress of such groups in a
Norwegian clinic in: Espegren O. Twelve step programme and methadone
maintenance treatment. In: Waal H., Haga E., eds. Maintenance treatment
of heroin addiction: evidence at the crossroads. Oslo: Cappelens, 2003,
p. 321-333. smoothly) be integrated with methadone treatment and that
patients who choose this option seem to benefit. Such initiatives are
line with the cooperation between the founders of Alcoholics Anonymous
and Vincent Dole, founder of methadone maintenance, who served on AA's
board.
Simultaneous integration of residential rehabilitation and methadone is
by no means unknown in Britain, In particular in the form of the ROMA
rehabilitation houses in London which specialised in methadone patients.
Their work was documented in: Glanz A. ROMA; Talgarth road. Report of an
information-gathering exercise. London: DHSS, 1983. but far more common
is the serial integration of these modalities within a client's
treatment journey. In Scotland's DORIS study of drug treatment services,
within 33 months most clients starting residential rehabilitation had
left and spent a period on methadone. In England's similar NTORS study,
perhaps a third had done so within a year. In neither case do we know
how many rehabilitation clients had traversed the opposite route, though
its seems likely In NTORS three-quarters of the total sample (ie, not
just those entering residential rehabilitation) had been prescribed
methadone in the past two years. that many had.
Thanks for their comments on this entry in draft to James L. Sorensen of
the UCSF at San Francisco General Hospital. Commentators bear no
responsibility for the text including the interpretations and any
remaining errors.





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