**Practice 2: Counseling Frequency**

Once your clinic has implemented a quality improvement strategy for
methadone dosing and a system for measuring improvement, it may be
appropriate to begin reviewing your clinic's current policies regarding
one of the other three target practice areas discussed in the following
sections. Quality improvement can be made in more than one target
practice area at a time.

*"That was surprising* \[that our counseling frequency was low\]. *It
seems like we see patients all the time, but I guess it's just that we
see so many of them.*

---*clinic coordinator*

![](media/image1.wmf){width="1.65625in" height="1.604861111111111in"}

Opioid Agonist therapy (OAT) clinics provide a wide array of services
beyond simply dispensing methadone and LAAM. These services generally
include drug abuse counseling, urine monitoring, and social work
services, and may include medical and psychiatric care, employment and
educational counseling, and family services. While the major goal of OAT
is to reduce illicit opioid use, much more has come to be expected of
OAT, including reduced use of other drugs and alcohol, reduced criminal
behavior, increased productive activity, and increased psychological
well-being and social functioning (Cacciola, Alterman, Rotherford, McKay
& McLellan, 1998). Beyond adequate methadone dosing, controversy
continues regarding which elements of methadone maintenance therapy can
be considered "active ingredients." If methadone dosing alone were
sufficient to prompt client change in the multiple outcomes that OAT
clinics are expected to effect, unnecessary and expensive psychosocial
services could be eliminated and more patients could be enrolled in OAT
clinics. Logically, it seems unrealistic that dosing alone could have
such a broad impact on so many areas of patients' lives. In fact, there
is a strong clinical consensus that dosing alone does not meet
appropriate standards of treatment for opiate addiction.

The clinical consensus that patient contact beyond dosing is a necessary
ingredient in OAT is supported by a particularly well designed,
randomized, controlled study comparing three levels of psychosocial
services (McLellan, Arndt, Metzger, Woody, &O'Brien, 1993). Patients in
all conditions received a minimum dose of 60mg of methadone. Minimal
methadone services (MMS) consisted of virtually no counseling.
Counselors saw patients for 15-minute appointments once per month.
Standard methadone services (SMS) consisted of weekly counseling visits
in the first month. After the first month, if a patient showed
improvement (e.g., decreased illicit opioid-positive urine screens and
positive social change), counseling could be reduced to twice monthly.
Patients who did not improve, or whose performance declined, were asked
to attend sessions twice a week or more. Enhanced methadone services
(EMS) consisted of counseling, as described for SMS, plus on-site
medical and psychiatric, employment, and family therapy services. The
results indicated that patients receiving MMS had significantly greater
cocaine and illicit opioid use throughout the six-month treatment
compared to the patients assigned to SMS or EMS. In addition, patients
receiving SMS had significant changes in legal, family, and psychiatric
problems that were not seen in the MMS group. Patients receiving EMS
demonstrated significantly greater improvement than SMS patients in the
same areas did. Most significantly, 69% of patients in MMS were
protectively transferred to SMS because of eight consecutive illicit
opioid or cocaine positive urine screens or three emergencies requiring
immediate health care. Of the transferred patients, significant
reductions in illicit opioid and cocaine use were evident within four
weeks of the transfer with no change in methadone dose.

Kraft and her colleagues completed a cost-effectiveness study comparing
the three conditions from the above study (Kraft, Rothbard, Hadley,
McLellan, & Asch, 1997). They concluded that large amounts of support
for methadone patients (EMS) improve outcomes as compared to moderate
amounts of support (SMS), but only to a modest degree. On the other
hand, moderate amounts of support improve outcomes as compared to
minimum support (MMS) to a degree that offsets the additional expense of
increased counseling. They concluded that SMS is the most cost-effective
of the three treatment conditions, and that the findings of their
analysis suggest a level below which supplementary support should not be
allowed to fall.

In summary, it appears that "more is better" when considering services
to offer as part of an OAT program. However, the incremental benefit of
additional services may decline as more services are added. Given budget
constraints that may effect many clinics, a *minimum* standard of weekly
counseling visits in the first month of OAT involvement and monthly
counseling visits during the next year is a reasonable standard.
However, the design of the McLellen et al. (1993) study suggests that it
is not simply time spent with a counselor but rather the responsiveness
of the OAT program to patient behavior that affects patient outcomes.
Several other studies have found that involvement of the patient with
the program staff is an essential ingredient of effective OAT programs
(Broome, Simpson, & Joe, 1999; Hser, Grella, Hsieh, Anglin & Brown,
1999; Joe, Simpson, & Broome, 1999; Magura, Nwakeze, & Demsky, 1998).
Therefore, while monthly visits are set as a minimum standard for a
stable patient, programs are encouraged to increase counseling frequency
contingent on client behavior. For example, as in the McLellan study,
patients who do not demonstrate a reduction in illicit opioid-positive
urine tests in the first month of treatment should not have their
counseling schedule reduced, and patients who enter a period of crisis
(e.g., relapse, medical, interpersonal) should have their counseling
schedule increased. Additional services such as medical and psychiatric
care, employment counseling, and family services are encouraged.

If clinic leadership determines that increasing compliance with
counseling frequency is an appropriate QI goal, there are several
factors to consider. First, is it the clearly stated policy of the
clinic that new patients (i.e., enrolled less than one month) and
unstable patients (i.e., those testing positive for illicit substances)
should be seen by their case manager a minimum of once per week, and
that stable patients should be seen by their case manager a minimum of
once per month? If not, the first step toward meeting best-practice
recommendations is to make policy changes supportive of these
recommendations and to clearly communicate these expectations to the
clinic staff and patients.

If counseling frequency consistent with recommended levels is already
clinic policy, the next step would be to assess clinic caseloads. In
general, a caseload of no more than 50 clients is considered reasonable
for a full-time case manager. However, this number assumes that case
managers have a case mix that includes stable, long-term patients as
well as new and unstable patients who require significantly greater time
to manage. If a case manager has predominately new or unstable patients,
a caseload of 35 to 40 may be more reasonable. If this is not possible,
the clinic may have to limit the number of new intakes until the clinic
census stabilizes at a level that can be adequately served by the
existing staff.

If policies supporting counseling frequency recommendations are in place
and clearly communicated to staff, and caseloads are assessed to be
within a reasonable range, it may be a matter of educating staff about
the importance of regular case management contact to client outcomes.
The monthly *Case Management Forms* can be used by the clinic leadership
to monitor an individual case manager's progress toward meeting
counseling expectations.

Counseling frequency is a relatively simple practice to monitor, but
implementing changes may be more challenging, depending on your clinic's
current policies and available resources (e.g., staffing, program
funding).

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

Cacciola, J. S., Alterman, A. I., Rutherford, M. J., McKay, J. R., &
McLellan, A. T. (1998). The early course of change in methadone
maintenance. *Addiction, 93*(1), 41-49.

Kraft, M. K., Rothbard, A. B., Hadley, T. R., McLellan, A. T., & Asch,
D. A. (1997). Are supplementary services provided during methadone
maintenance cost-effective? *American Journal of Psychiatry, 154(*9),
1214-1219.

McLellan, A. T., Arndt, I. O., Metzger, D. S., Woody, G. E., & O'Brien,
C. P. (1993). The effects of psychosocial services in substance abuse
treatment. *Journal of the American Medical Association, 269*(15),
1953-1959.

Broome, K. M., Simpson, D. D., & Joe, G. W. (1999). Patient and program
attributes related to treatment process indicators in DATOS. *Drug and
Alcohol Dependence, 57*, 127-135.

Hser, Y., Grella, C. E., Hsieh, S., Anglin, M. D., & Brown, B. S.
(1999). Prior treatment experience related to process and outcomes in
DATOS. *Drug and Alcohol Dependence, 57,* 137-150.

Joe, G. W., Simpson, D. D., & Broome, K. M. (1999). Retention and
patient engagement models for different treatment modalities in DATOS.
*Drug and Alcohol Dependence, 57,* 113-125.

Magura, S., Nwakeze, P. D., & Demsky, S. Y. (1998). Pre- and
in-treatment predictors of retention in methadone treatment using
survival analysis. *Addiction, 93*(1), 51-60.