Methadone dose increase and abstinence reinforcement for treatment of continued heroin use during methadone maintenance

Background: Although methadone maintenance is an effective therapy for hero in dependence, some patients continue to use heroin and may benefit from th erapeutic modifications. This study evaluated a behavioral intervention, a pharmacological intervention, and a combination of both interventions. Methods: Throughout the study all patients received daily methadone hydroch loride maintenance (initially 50 mg/d orally) and weekly counseling. Follow ing baseline treatment patients who continued to use heroin were randomly a ssigned to 1 of 4 interventions: (1) contingent vouchers for opiate-negativ e urine specimens (n = 29 patients); (2) methadone hydrochloride dose incre ase to 70 mg/d (n = 31 patients); (3) combined contingent vouchers and meth adone dose increase (n = 32 patients); and (4) neither intervention (compar ison standard; n = 28 patients). Methadone dose increases were double blind . Vouchers had monetary value and were exchangeable for goods and services. Groups not receiving contingent vouchers received matching vouchers indepe ndent of urine rest results. Primary outcome measure was opiate-negative ur ine specimens (thrice weekly urinalysis). Results: Contingent vouchers and a methadone dose increase each significant ly increased the percentage of opiate-negative urine specimens during inter vention. Contingent vouchers, with or without a methadone dose increase, in creased the duration of sustained abstinence as assessed by urine screening s. Methadone dose increase, with or without contingent vouchers, reduced se lf-reported frequency of use and self-reported craving. Conclusions: In patients enrolled in a methadone-maintainence program who c ontinued to use heroin, abstinence reinforcement and a methadone dose incre ase were each effective in reducing use. When combined, they did not dramat ically enhance each other's effects on any 1 outcome measure, but they did seem to have complementary benefits.