A NEW APPROACH TO PRESCRIBING:

The Structured Methadone Programme in Action

by Stuart Hall.

As part of the Department of Health's evaluation of methadone treatment the Kaleidoscope project in Kingston was chosen as one of eight projects to run a structured methadone project, starting in February 1995 and running for a year. The programme, which covers 50 Kaleidoscope clients and drawn mainly from the existing 300 methadone clients, consists of daily supervised dispensing of methadone as already exists with the current methadone prescribing undertaken at the project. What is different about the structured programme though is the added element of regular high intervention counselling with a designated key worker and other on-site rehabilitation services. The basic aims are consequently to achieve improvements in the areas of drug use, physical and psychological health and social functioning. However, clients on the programme also have to agree to routine urine testing, just as they do on the existing programme.

As with the other seven pilot projects around the country it is being independently evaluated by Dr Michael Gossop of the National Addiction Centre based at the Maudsley Hospital in London. In addition clients who take part in the structured methadone programme will also be included in the National Treatment Outcome Research Study (NTORS) which has been com-missioned by the Department of Health's Effectiveness Review Task Force. Its aim is to monitor the progress of up to 1,000 clients on the programme attending a range of treatment services over a two year period. These include residential rehabilitation, outpatient /community based methadone reduction treatment, outpatient methadone maintenance and inpatient Drug De-pendence Unit treatment. At the end of the structured programme the NTORS study will continue to follow up the progress of the clients, whether they remain in treatment or not, for another year.

THE STRUCTURED METHADONE PROGRAMME

The structured methadone programme was unveiled by the Department of Health in December 1994, with approximately œ900,000 allocated for eight pilot studies.

The Government's aim is to examine the level of support and care best suited to those receiving oral methadone, with services ranging from specialist hospital clinics to a community centre for drug users.

The programme is based on the 1993 Advisory Council on the Misuse of Drugs (ACMD) report AIDS and Drug Misuse Update, which recommended that "structured oral methadone maintenance programmes be set up initially on a pilot basis to test out the benefits both in terms of public and individual health and in cost-effectiveness".

The results of the programme will be fed into the Department of Health's Effectiveness Review, which is due to report to ministers in early 1996.

The programme is being piloted by the Avon Drug Problem Team; Bradford Alcohol and Drug Resource Centre; Dr John Cohen (London); Kaleidoscope (Kingston, London); Riverside Mental Health Trust; Newcastle City Health; Dr M Ross of the Ashwell Medical Centre; and the Leeds Addiction Unit.

Admission to the Structured Programme

Prior to the commencement of the programme Kaleidoscope had 300 clients on methadone prescrib-ing. When the structured programme was being set up 50 places were offered to clients who had previously been screened for suitability for the standard methadone prescribing programme. In addition, however, a client wanting to start on the structured programme has to agree to goals to achieve over the year. When analysed as a whole most of the clients choose to try and reduce their methadone use, with a another group putting reduction in illicit drug use as a priority. However, Kaleidoscope's medical team manager Rosalie Chamberlin stresses that while clients can progress to detoxification or GP prescribing, the primary aim is not one of reduction. And she points out the fact that there are many other goals like improving relationships which fall under the structured programme's possible aims for individual clients.

DRUGS INVOLVED IN OVERDOSE DEATHS OF DRUG ADDICTS PREVIOUSLY NOTIFIED TO THE HOME OFFICE BY YEAR OF DEATH

The Programme in Practice

The main difference between the two methadone programmes is the amount of time the clients receive under the structured programme. Though as Chamber-lin explains it also requires a great deal more time and input from the client, with a set appointment time to see key workers. "I think all the clients on the structured programme have benefited to some degree, mainly because of the one-to-one contact they have and just having someone to share their problems with. This helps to keep them focused on the goals they have set for themselves," Chamberlin said.

As an example of the impact the structured programme has already had Chamberlin pointed to one female client who had been on methadone for approximately six years before starting on the new programme. "She had got into a comfortable situation here before starting on the structured programme, as being a shy person she was not particularly willing to ask for help, but with the continual input from a key worker she has made great strides." Her case also illustrates the flexibility of the structured programme approach. Because of her success in meeting her goals the client now picks her methadone from the chemist rather than having to come into Kaleidoscope on a daily basis for her 'script.

At the outset all clients are initially required to attend on a daily basis for supervised methadone dispensing. This is reviewed after three months and, if there has been progress towards treatment goals, the number of days attendance required per week may be reduced. "Other individually tailored incentives will also be offered to encourage progress towards the clients' own treatment goals," Chamberlin added. However, one possible result of the programme for some clients is the danger they will drop out of it by not keeping their appointments for whatever reason, and consequently no longer receive the key worker support. In this case Chamberlin points out they will still receive methadone under the existing prescribing programme. However, one safeguard Kaleidoscope has undertaken to insure against this happening on the programme is to allow some clients to come in on a set morning each week to a drop-in service when key workers and doctors will be available.

An unexpected knock-on effect of the programme has been the sense of mutual support built up by those clients participating in it. Part of the reason for this is the influence of social events, with picnics proving more successful than formal group sessions in building mutual support. More ambitious holiday outings have also proved successful, in allowing a space for more relaxed peer group discussion away from the intensive one-on-one work with key workers. This group solidarity is reinforced on a daily basis by the extra facilities available, such as shiatsu, which Chamberlin says has been particular popular. However, she is also keen to point out the expansion of services due to extra resources (two extra session doctors, two nurses and two extra part-time social workers) means that other clients on the existing methadone prog-ramme can utilise the service as well.

A female doctor was recruited to the programme to cope with the needs of the disproportionate number of female clients, just over 40 per cent compared with around 25 per cent on the existing methadone programme. One possible reason for this is drawn from the fact that all the women on the structured programme use Kaleidoscope's child care facilities. It may also be that the peer group effect of taking to other women helps convinces other female clients to take part.

The apparent success of the structured methadone programme does beg questions as to the possible reorientation of existing services in light of the initial findings. Chamberlin said the impact of key workers in particular could mean greater use of one-to-one counselling in the future, and that where possible extra services would be continued. But there are undoubtedly limits to what can be done once the money and services brought in via funding for the structured programme end. For while there are obvious qualitative benefits already emerging in terms of clients' self-respect and motivation which are of interest to researchers, it could be that any expansion of such treatment is dependant on more quantifiable gains in terms of a reduction in methadone or illicit drug use.

Stuart Hall is policy officer at Release Publications Ltd.  html 1995 drugtext web-lab