**Practice 3: Program Orientation (Abstinence vs. Maintenance)**

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A treatment provider's orientation toward abstinence or maintenance
directly influences patient treatment outcomes, as the following
evidence-based summary explains. Provider and clinic level orientation
can be easily assessed using the 14-item *Abstinence Orientation Scale*
(AOS) (Caplehorn, Lumley and Irwig, 1998). How to score and interpret
this scale can be found following the evidence summary. Finally, there
are examples of how clinic coordinators and directors participating in
the OpiATE Initiative have used these materials to educate both
themselves and their staff regarding the benefits of a maintenance
oriented approach to OAT.

*"In general, there has been an attitudinal shift in some of the
counselors from the notion of detox orientation to maintenance
orientation; more of them are accepting of maintenance than they were
when we started this process a year ago. More of them are willing to
consider that methadone is a medication, just as insulin is a
medication."*

*---clinic coordinator*

Retention of patients in opioid agonist therapy (OAT) reduces heroin use
and criminality, health risk behaviors from drug injections, and HIV and
mortality rates. (Caplehorn, McNeil, & Kleinbaum, 1993). In fact,
patients who are receiving OAT are at one quarter the risk of dying
compared to addicts who are not currently receiving OAT (Caplehorn,
Dalton, Halder, Nisbet, & Petrenas, 1996). Therefore, it is important to
identify program characteristics that are correlated with treatment
retention. One treatment factor that has received significant research
attention is the orientation of the OAT program. Caplehorn and his
colleagues have identified what they refer to as an abstinence
orientation (Caplehorn, Irwig, & Saunders, 1996). Abstinence orientation
is characterized by beliefs that it is unethical to maintain patients on
an opioid agonist indefinitely, and that the goal of any treatment
program should be abstinence from all substances, including opioid
agonists. They compared OAT clinics whose physicians scored high on the
*Abstinence Orientation Scale* to clinics whose physicians scored low on
the scale and found that programs whose physicians were more committed
to an abstinence orientation had a significantly greater rate of
premature discharges. Caplehorn and his colleagues (1993) also compared
two clinics with very different treatment attitudes. Clinic 1 was
strongly abstinence oriented and attempted to limit OAT to no more than
two years. Clinic 2 provided long-term OAT maintenance. Clinic 1 had a
significantly shorter average time in treatment (less than clinic policy
of two years). Patients in Clinic 1 were twice as likely to leave
treatment in the second six-month period and three times more likely to
leave treatment in the third six-month period compared to patients in
Clinic 2.

In a survey of 172 OAT programs in the United States, D'Aunno and Vaughn
(1992) also found that an abstinence orientation was associated with
other treatment factors that are correlated with poor outcomes (i.e.,
shorter treatment periods, lower limits on methadone dose, and lower
average methadone dose). A strong abstinence orientation has also been
shown to correlate with clinic policies such as less patient
participation in dose strategy, more stringent take-home policies, and
more punitive responses to illicit drug use (Caplehorn et al., 1993).
Caplehorn and colleagues (1993) speculate that these types of clinic
policies lead to an "us-them" frame of mind that interferes with the
patients' ability to feel a connection to the treatment team and
subsequently interferes with program retention. Caplehorn, Hartel, and &
Irwig (1997) also reported that high *Abstinence Orientation* *Scale*
scores were negatively correlated with scores on a test of knowledge of
OAT risks and benefits. This finding supports increasing continuing
education funding and time to educate program staff regarding the
benefits of long-term OAT maintenance.

Poor outcomes have not only been documented in patients who drop out of
treatment but also in patients who are discharged after successful
treatment and withdrawal from OAT (Milby, 1988). Because of the
continued controversy over the ethics and expense of maintaining addicts
on OAT for indefinite periods of time, Magura and Rosenblum (2001)
completed a literature review to determine if it is ever wise to
encourage detoxification and if so, for which patients under what
conditions. Magura and Rosenblum looked at studies assessing
time-limited OAT programs, planned detoxifications from OAT, and
outcomes for patients leaving OAT for unspecified reasons. They
identified three main conclusions from their review: 1) most patients
who leave OAT are not identified by their clinic as ready for discharge,
2) among patients who begin a planned discharge, most leave treatment
before completing their detoxification, and 3) among patients who do
complete a planned discharge, most relapse to heroin. They concluded
that the number of patients who can achieve a narcotic-free state is
low. Even among patients who express high motivation to detox and who
are identified by clinic staff as rehabilitated and ready for discharge,
the majority return to narcotic use.

A study by Sees and colleagues (2000) provides an example of the kind of
findings that were summarized by Magura and Rosenblum's (2001) review.
This study compared one-year outcomes for patients randomly assigned to
methadone maintenance or to a 180-day, psychosocially enriched
detoxification treatment in which patients were maintained on methadone
for four months and then tapered off over the next two months. During
months six through twelve, aftercare services, including individual and
group psychotherapy and social services, were available to
detoxification patients. The findings indicated that there was no
significant difference in illicit opioid positive urines for the two
groups during the first four months of treatment when both were on
maintenance doses of methadone. Starting with month five, when
detoxification was initiated, the positive urine rate for the
detoxification group increased markedly compared to the maintenance
group and remained high through month twelve. In addition, the dropout
rate for the detoxification group increased as the methadone dose
decreased. The major finding was that the maintenance patients were
retained in treatment significantly longer than the detoxification group
(483 vs. 174 days). Both Sees and colleagues (2000) and Magura and
Rosenblum (2001) reach the conclusion that, given the dire consequences
to the addict and the cost to society of a return to injecting heroin
(e.g., increased criminality, HIV infection rates, and mortality),
[indefinite maintenance in OAT is the only satisfactory treatment
alternative for opiate dependence]{.underline}.

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#### [Selected References]{.underline}

Caplehorn, J. R. M., Dalton, M. S. Y. N., Haldar, F., Nisbet, J. G., &
Petrenas, A. (1996). Methadone maintenance and addicts'risk of fatal
heroin overdose. *Substance Use & Misuse, 31*, 177-196.

Caplehorn, J. R. M., Hartel, D. M., & Irwig, L. (1997). Measuring and
comparing the attitudes and beliefs of staff working in New York
methadone maintenance clinics. *Substance Use & Misuse, 32*(4), 399-413.

Caplehorn, J. R. M., Irwig, L., & Saunders, J. B. (1996). Physicians'
attitudes and retention of patients in their methadone maintenance
programs. *Substance Use & Misuse, 31*(6), 663-677.

Caplehorn, J. R. M., McNeil, D. R., & Kleinbaum, D.G. (1993). Clinic
policy and retention in methadone maintenance. *The International
Journal of the Addictions, 28*(1), 73-89.

D'Aunno, T. & Vaughn, T. E. (1992). Variations in methadone treatment
practices: Results from a national study. *Journal of the American
Medical Association, 267*(2), 253-258.

Magura, S. & Rosenblum, A. (2001). Leaving methadone treatment: Lessons
learned, lessons forgotten, lessons ignored. *The Mount Sinai Journal of
Medicine, 68*(1), 62-74.

Milby, J. B. (1988). Methadone maintenance to abstinence: How many make
it? *Journal of Nervous and Mental Disorders, 176*(7), 409-422.

Sees, K. L., Delucchi, K. L., Masson, C., Rosen, A., Clark, H. W.,
Robillard, H. (2000). Methadone maintenance vs. 180-day psychosocially
enriched detoxification for treatment of opioid dependence: A randomized
controlled trial. *Journal of the American Medical Association,
283*(10), 1303-1310.