Research Report European Addiction Research
Eur Addict Res 2015;21:211–216 DOI: 10.1159/000375491
Received: September 6, 2014 Accepted: January 24, 2015 Published online: April 21, 2015
Effectiveness of Rapid Intake into Methadone Treatment: A Natural Experiment in Israel Maayan Lawental School of Social Work, University of Haifa, Haifa, Israel
Abstract The effect of intake procedures on treatment entry and retention was examined in a natural experiment, in which a methadone maintenance clinic in Israel admitted 127 clients by employing a rapid intake procedure (maximum of 3 days before the initiation of treatment was offered). Using information gathered from patient files, these clients were retrospectively compared to a control group (n = 121) who underwent the clinic’s regular intake procedure (between 3 weeks and 3 months). Outcome measures included entry into treatment and subsequent retention in treatment (at 3, 6 and 12 months). Results show that 81% of clients from the rapid intake group entered treatment compared to only 57% from the regular intake group. Treatment retention was similar for both groups. In addition, Jewish clients were more likely to enter treatment via the rapid intake procedure than clients from other religions, and women were retained in treatment longer than men, regardless of the type of intake procedure. Results of this single-site study lend support to the effectiveness of rapid intake procedures as a way to engage clients in treatment and carry significant implications for improving access into treatment. © 2015 S. Karger AG, Basel
© 2015 S. Karger AG, Basel 1022–6877/15/0214–0211$39.50/0 E-Mail [email protected] www.karger.com/ear
Introduction
Numerous studies in the field of substance abuse point to methadone maintenance treatment as an integral aspect of treating and reducing the harms associated with heroin addiction [1, 2]. Within these studies, emphasis is given to the task of encouraging addicts to enter treatment [3–6] and retaining them over time [7, 8]. It has been suggested that for treatment to be successful, clients must be retained for at least 90 days [7] since clients who receive less than this minimal period of treatment do not differ from those who do not receive treatment at all [9– 11]. Waiting to begin treatment may be a barrier for potential clients as they consider entering treatment [3, 12–15]. Research has shown that longer waiting times are associated with lower rates of entry into treatment [4, 5, 16, 17] and higher [13, 18] or no change in retention rates [4]. A recent study in Israel found that longer waiting lists were a predictor of higher 1-year retention rates, yet suggested that this may be due to significant differences in sociodemographic characteristics between the groups. Most notably, the waiting list group was older and self-referring. Furthermore, the researchers did not have characteristics of those who did not enter treatment to begin with [19]. As the researchers in this study (the design of which was a natural experiment) did not examine treatment entry Dr. Maayan Lawental School of Social Work University of Haifa Mount Carmel, Haifa 31905 (Israel) E-Mail mlawental @ gmail.com
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Key Words Methadone maintenance treatment · Rapid intake · Retention rates
Materials and Methods Setting The Haifa Drug Abuse Treatment Center has offered outpatient services for opiate addicts residing in the Haifa metropolitan area for over 30 years. Within this setting, substance abuse is regarded as a biopsychosocial chronic condition, which requires the intervention of an interdisciplinary team during all stages of treatment, including intake. The center treats patients who are characterized, beyond their addiction to drugs, by multiple psychological, psychiatric, medical, familial and occupational difficulties. Most are also involved in criminal activities. Among other services, the center offers medication-assisted treatment. For all patients, intake of methadone is supervised (at least until they are assessed to be stabilized, when on occasion they may be provided with take-home doses) and urine samples are taken 2–3 times a week. Procedure Upon hearing that the centers’ methadone clinic opted to adopt a rapid intake procedure in order to add 100 patients to its roster, independent of any research goals, we took the opportunity to retrospectively examine patient files and gather information regarding treatment entry and retention (at 3, 6 and 12 months). As a result, this study was a natural experiment, comparing 127 opiateusers who went through a rapid intake process with 121 opiateusers who went through the regular intake process offered at the clinic (i.e. treatment as usual). The Two Conditions Regular intake procedures to the center are conducted by a specialized intake committee comprised of social workers, a psychologist, a physician and a nurse. The committee carefully assesses data gathered about clients and determines his or her course of
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Eur Addict Res 2015;21:211–216 DOI: 10.1159/000375491
treatment. This process typically takes approximately 3 weeks (but may take up to 3 months), during which each potential client must provide 3 urine samples to determine presence of opiates, undergo extensive medical and psychosocial evaluations which include lab work (testing for HIV, HCV and other infectious diseases is included), and complete a comprehensive interview with a social worker and/or psychologist which can span across three sessions. Following this procedure, a client will be matched with a social worker and begin individual and group sessions, as well as methadone maintenance treatment (based on the intake committee’s recommendation). Similar intake procedures are employed in other centers in Israel. When the center received funds to expand its methadone maintenance program, the organization chose to employ a rapid intake procedure for several months in order to ensure that all treatment slots were occupied. Following this period, the centers’ regular intake procedures were reinstated. During this period any client who sought treatment was asked to submit one urine sample to determine the presence of opiates, meet once with the center’s physician and undergo brief psychosocial assessment during a half-hour session with a social worker. This rapid intake procedure ensured that clients were offered admission into treatment no more than 3 days after requesting it (and in many cases they were offered admission on the same day). Following the offer of admission, this group began receiving methadone immediately. Simultaneously, clients went through the more comprehensive assessment procedure similar to the one employed during regular intake (additional urine tests, medical and psychosocial assessment). The intake committee then convened with the role of determining continuation of treatment. Data Source and Measures Data for this study were extracted by center personnel from client records (both computerized and handwritten), and a deidentified dataset was provided for data analysis. Thus, all procedures were in accord with the Helsinki Declaration of 1975. In addition to the independent variable, the type of intake, comprehensive background information was collected (sociodemographic variables, medical, criminal and treatment histories). Since there was no random assignment into conditions, we wanted to explore and control for any differences between the two groups that might be of importance. No significant differences were found between the two groups on any of the background variables. The dependent variables were (1) entry into treatment [dichotomous (yes/no)] and (2) retention in treatment at 3, 6 and 12 months [dichotomous (yes/no)]. An attempt was made to calculate the number of days in treatment as a continuous variable. However, due to some inconsistencies with the data collection procedures at the clinic, this attempt did not yield reliable results. Statistical Analysis Using SPSS 19, the two groups were compared on all background variables and dependent variables using χ2 and t tests. In order to explore entry into treatment and retention at 3, 6 and 12 months, logistic regression was employed. Additional regression models were conducted in order to explore the interactive effect of rapid/regular intake and 12 months retention with gender, religion, marital status and immigration status; these variables have been shown in previous literature to be significant predictors of treatment entry and retention.
Lawental
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rates [19], which is the main dependent variable in the current study, the current study may serve to compliment and shed light on their results. The present study examined whether the type of intake procedure affected substance abusers entry into treatment and retention in treatment, in a methadone maintenance clinic in Israel. The clinic received funds to add 100 treatment slots and opted to do so by using a significantly shorter intake procedure for all clients seeking treatment until the new treatment slots were filled. This setting allowed for a comparison between those who were offered admission into treatment via rapid intake and those who were not. It was hypothesized that (1) more clients will enter treatment following a rapid intake procedure than those who will enter through the usual intake procedure, and (2) that retention would not differ across these two groups. These hypotheses were also tested in relation to gender, religion, marital status and immigration status.
Table 1. Differences between the groups on entry into treatment and retention variables
Variable
Values Regular intake (n = 121)
Rapid intake (n = 127)
Total sample (n = 248)
χ2 test
n
%
n
%
n
%
χ2
14.88*** 1
d.f.
Entered treatment
yes no
71 50
58.7 41.3
103 24
81.1 18.9
174 74
70.2 29.8
Retained for at least 3 months
yes no
63 8
88.7 11.3
89 14
86.4 13.6
152 22
87.4 12.6
2.06
1
Retained for at least 6 months
yes no
54 17
76.1 23.9
76 27
73.8 26.2
130 44
74.7 25.3
0.12
1
Retained for at least 1 year
yes no
46 25
64.8 35.2
66 37
64.1 35.9
112 62
64.4 35.6
0.01
1
*** p < 0.001.
rapid intake group; χ2(1) = 0.7, n.s.]. For 67.3% of the sample, it was not the first treatment attempt [67.8% in the regular intake group and 66.9% in the rapid intake group; χ2(1) = 0.2, n.s.], while 65.6% reported ever being arrested [67.7% in the regular intake group and 63.9% in the rapid intake group; χ2(1) = 0.35, n.s.]. Over a third of the sample (35.5%) reported past suicide attempts [38.9% in the regular intake group and 32.7% in the rapid intake group; χ2(1) = 0.83, n.s.], while 28.2% of clients reported past psychiatric hospitalization [33.8% in the regular intake group and 28% in the rapid intake group; χ2(1) = 2.07, n.s.] and 30.4% were diagnosed with a mental illness [34.5% in the regular intake group and 27.3% in the rapid intake group; χ2(1) = 1.18, n.s.]. 60.2% of the clients were diagnosed with hepatitis C [54.8% in the regular intake group and 64.5% in the rapid intake group; χ2(1) = 1.86, n.s.] and 4.2% tested positive for HIV [2.4% in the regular intake group and 5.6% in the rapid intake group; χ2(1) = 1.22, n.s.].
Pretreatment Background Variables and Sample Description No statistical significant differences were found between the groups on all pretreatment background variables that were examined including sociodemographic variables, criminal history, treatment history, medical and mental health diagnosis. Of all clients in the sample, 85% were male [86.8% in the regular intake group and 82.7% in the rapid intake group; χ2(1) = 0.8, n.s.] and 58.1% were born in Israel [56.2% in the regular intake group and 59.8% in the rapid intake group; χ2(1) = 1.18, n.s.], while 35.9% were from the former Soviet Union. Of those, 77.9% were considered new immigrants, having immigrated to Israel after 1990 [82.7% in the regular intake group and 73.1% in the rapid intake group; χ2(1) = 1.4, n.s.]. The average age of the sample was 36.7 years [35.8 in the regular intake group and 37.7 in the rapid intake group; t(177) = –0.7, n.s.] and the large majority of clients were unmarried [i.e. single, separated or divorced; 72.2% in the regular intake group and 77.2% in the rapid intake group; χ2(1) = 0.59, n.s.], with an average of 1.3 children [1.24 in the regular intake group and 1.5 in the rapid intake group; t(243) = –0.7, n.s.]. 67.4% of all clients were Jewish [65.1% in the regular intake group and 69.5% in the rapid intake group; χ2(1) = 0.92, n.s.]. The average number of school years attended was 9.7 [9.95 in the regular intake group and 9.49 in the rapid intake group; t(241) = –0.32, n.s.], and 89.7% reported no employment in the 3 months leading to initiation of treatment [91.4% in the regular intake group and 88.1% in the
Entry into Treatment and Retention The results indicated that more subjects from the rapid intake group entered treatment compared to subjects in the regular intake group [81.1% compared to 58.7% respectively, χ2(1) = 14.88, p < 0.001]. Treatment retention was similar in both groups. 89.4% of all clients were retained for at least 90 days [88.7% in the regular intake group and 86.4% in the rapid intake group, χ2(1) = 2.06, n.s.], 74.7% of all clients were retained for at least 180 days [76.1% in the regular intake group and 73.8% in the rapid intake group, χ2(1) = 0.12, n.s.] and 66.4% remained in treatment 12 months or more [64.8% in the regular intake group and 64.1% in the rapid intake group; χ2(1) = 0.01, n.s.; table 1].
Effectiveness of Rapid Intake into Methadone Treatment
Eur Addict Res 2015;21:211–216 DOI: 10.1159/000375491
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Results
Table 2. Bivariate logistic regression models and interaction effects for entry into treatment
Predictors
B
OR
95% CI
p
Intake (rapid/regular)
1.106
3.022
1.7, 5.36
0.000***
Intake Gender (male/female)
1.092 –0.681
2.979 0.506
1.68, 5.3 0.21, 1.23
0.000***
Intake Gender Intake × gender
1.514 –0.501 –0.474
4.545 0.606 0.623
0.75, 27.42 0.2, 1.87 0.09, 4.15
0.099 0.383 0.624
1.094
2.986
1.68, 5.3
0.000***
0.278
1.321
0.73, 2.38
1.442 0.478 –0.523
4.227 1.613 0.593
1.53, 11.67 0.76, 3.43 0.17, 2.04
0.005** 0.214 0.406
Intake Marital status (married/not married)
1.119 0.742
3.061 2.101
1.72, 5.45 0.97, 4.54
0.000***
Intake Marital status Intake × marital status
1.014 0.502 0.758
2.758 1.653 2.133
1.48, 5.14 0.65, 4.2 0.36, 12.64
0.001*** 0.291 0.404
Intake Religion (Jewish/other)
1.035 0.532
2.814 1.702
1.54, 5.16 0.92, 3.16
0.001*** 0.091
Intake Religion Intake × religion
0.266 0.002 1.279
1.304 1.002 3.594
0.5, 3.37 0.45, 2.24 1.03, 12.57
0.584 0.997 0.045*
Intake Immigration status (born in Israel or immigrated before 1990/immigrated after 1990) Intake Immigration status Intake × immigration status
The results also indicated that clients accepted for treatment through rapid intake were 3 times more likely to enter treatment than those accepted through the regular intake procedure [OR = 3.02 (1.7–5.36), p < 0.001]. Jewish clients were more likely to enter treatment via the rapid intake procedure than non-Jewish clients [OR = 3.6 (1.03–12.57), p < 0.5] and women were retained in treatment longer than men, regardless of the type of intake procedure [OR = 0.29 (0.11– 0.8), p < 0.5]. No significant statistical differences were found comparing married versus not married subjects and new immigrants versus native and veteran immigrants (table 2).
Discussion
The aim of this study was to explore whether a rapid intake process is effective in bringing clients into treatment and retaining them over time. The study found that clients accepted for treatment through a rapid intake procedure were 3 times more likely to enter treatment than those ac214
Eur Addict Res 2015;21:211–216 DOI: 10.1159/000375491
cepted through the regular intake procedure, while retention in treatment did not differ between the groups. Results of this study point to the effectiveness of rapid intake procedures as a way to bring clients into treatment. These results support in Israel what various studies have demonstrated in other countries. For instance, one study found that 59% of clients accepted through rapid intake entered treatment compared to only 33% in a regular intake [5]. One explanation for these results may be that clients are often in crisis when contacting the clinic and they may have only temporarily overcome internal or external barriers. Another possible explanation is that clients may be ambivalent towards seeking treatment and longer waiting periods gives them additional time to contemplate their decision and perhaps renege. Furthermore, this study complements a previous study in Israel which found better retention rates with rapid intake (a finding not replicated here), yet did not measure entry into treatment [19]. Results of both studies taken together further strengthen the importance of rapid intake as Lawental
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* p < 0.05, ** p < 0.01, *** p < 0.001.
in which this clinic was compared to other clinics in Israel, overall client characteristics were very similar, as were organizational aspects of treatment, such as intake procedures and waiting times. Though the two groups were compared with regard to many background variables and no statistical differences were found, it is still possible that subjects in the rapid intake group were somehow different than those in the regular intake group concerning important variables that could not be measured such as motivation for treatment or distance from the clinic. The literature has shown that motivation in particular is an important predictor of treatment entry and retention (e.g. [7, 8, 17]), and should be considered in future research.
Future Directions
Limitations This study has several limitations. This was a natural history study, which took advantage of an organizational change at a specific clinic. Therefore, the sample was a convenience sample and subjects were not randomly assigned into the two conditions. Furthermore, the study was done retrospectively using information gathered from administrative files at the clinic. It is possible that clients of this clinic are different than those of other clinics and therefore the results of this study are not generalizable to other clinics. However, this is unlikely. In previous studies
Despite the study’s limitations detailed above, the unique real-world setting in which the study took place support the validity of its results and thus carry some implications for policy and practice. It is recommended that policymakers and treatment providers in Israel consider issues surrounding the early stages of treatment. Though decisions regarding the length of intake are often based on organizational constraints, efforts can be made to reduce some of the barriers to treatment entry by shortening the intake procedure as much as possible. However, it is important to remember that intake procedures are only one aspect in the overall treatment process of substance abusers. Adopting rapid intake can save many resources, which can be diverted to other stages of the treatment process, such as outreach, case management or ancillary services (e.g. transportation, childcare). Furthermore, adopting rapid intake procedures has the potential to bring more drug users into treatment, and consequently may help minimize various harms associated with drug use, both personal and societal (e.g. disease, accidents, unemployment, etc.). Although this potential may be largely dependent upon the clinic’s ability to foster collaborations with other organizations, it is of critical importance when considering the high rates of infectious diseases such as HIV or HCV in this population. Finally, the site in which this study was conducted as well as several other sites in Israel who serve comparable drug using populations are undergoing major organizational changes. These include changes that are likely to damage efforts to admit and retain clients, such as privatization, structural changes, staff turnover and even shifts in location (and therefore access to treatment services). If planned in advance, rapid intake procedures can serve as a cost-effective way to mitigate this potential damage.
Effectiveness of Rapid Intake into Methadone Treatment
Eur Addict Res 2015;21:211–216 DOI: 10.1159/000375491
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a way to engage and retain clients in methadone maintenance treatment, a form of treatment that is crucial in treating heroin addicts and reducing individual and societal level heroin use harms [1, 2]. In a study that explored substance users perceptions regarding barriers to treatment, over 50% reported that waiting was a significant barrier for them [15]. It has been suggested that a possible explanation for the success of rapid intake procedures lies with the immediate feedback that users are given. Potential clients may feel rewarded for their efforts and thus motivated to begin treatment [5]. Retention in treatment was not predicted by the type of intake procedure. Previous results regarding retention have been mixed. While some studies have found that rapid intake procedures predict longer periods of retention (e.g. [4, 20]), others have found no correlation between length of the intake procedure and period of time retained in treatment (e.g. [5, 21]). In all studies, it seems once clients are admitted into treatment via rapid intake, they are retained in treatment at least as long as all other clients. The study also showed that Jewish clients are more likely to enter treatment via the rapid intake procedure than non-Jewish clients (though for both groups rates of entry into treatment are higher than in the regular intake group). This may be due to other barriers facing non-Jewish minorities in Israel from entering treatment. For instance, it is possible that they reside further away or are of lower economic status. Both of these factors have been suggested as barriers to treatment [12]. Finally, the study found that women are retained in treatment longer than men, regardless of the type of intake procedure. Many studies point to significant differences between men and women with regard to etiology of substance abuse as well as treatment. Though results regarding gender differences in retention rates are mixed, there is widespread agreement that men and women have different needs that must be taken into account when designing interventions [22].
References
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8 Simpson DD, Joe GW, Rowan-Szal GA: Drug abuse treatment retention and process effects on follow-up outcomes. Drug Alcohol Depend 1997;47:227–235. 9 Simpson DD, Sells SB: Effectiveness of treatment for drug abuse. Adv Alcohol Subst Abuse 1982;2:7–29. 10 Simpson DD: The relation of time spent in drug abuse treatment to posttreatment outcome. Am J Psychiatry 1979;136:1449–1453. 11 Simpson DD: Treatment for drug abuse: follow-up outcomes and length of time spent. Arch Gen Psychiatry 1981;38:875–880. 12 Appel PW, Ellison AA, Jansky HK, Oldak R: Barriers to enrollment in drug abuse treatment and suggestions for reducing them: opinions of drug injecting street outreach clients and other system stakeholders. Am J Drug Alcohol Abuse 2004;129–153. 13 Hoffman KA, Ford JH, Tillotson CJ, Choi D, McCarty D: Days to treatment and early retention among patients in treatment for alcohol and drug disorders. Addict Behav 2011; 36:643–647. 14 Peterson JA, Schwartz RP, Mitchell SG, et al: Why don’t out-of-treatment individuals enter methadone treatment programmes? Int J Drug Policy 2010;21:36–42.
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15 Redko C, Rapp RC, Carlson RG: Waiting time as a barrier to treatment entry: perceptions of substance users. J Drug Issues 2006; 36: 831– 852. 16 Festinger DS, Lamb RJ, Marlowe DB, Kirby KC: From telephone to office: intake attendance as a function of appointment delay. Addict Behav 2002;27:131–137. 17 Hser Y-I, Maglione M, Polinsky ML, Anglin MD: Predicting drug treatment entry among treatment-seeking individuals. J Subst Abuse Treat 1998;15:213–220. 18 Bell J, Caplehorn JR, McNeil DR: The effect of intake procedures on performance in methadone maintenance. Addiction 1994; 89: 463– 471. 19 Peles E, Schreiber S, Sason A, Adelson M: Long waiting period to enter methadone maintenance treatment: relation to patient characteristics and outcome. Eur Addict Res 2012;18:149–152. 20 Woody G, O’Hare K, Mintz J, O’Brien C: Rapid intake: a method for increasing retention rate of heroin addicts seeking methadone treatment. Compr Psychiatry 1975; 16: 165– 169. 21 Desmond DP, Esquivel M, Maddux JF: Rapid admission and retention on methadone. Am J Drug Alcohol Abuse 1995;21:533. 22 Greenfield SF, Brooks AJ, Gordon SM, et al: Substance abuse treatment entry, retention, and outcome in women: a review of the literature. Drug Alcohol Depend 2007;86:1–21.
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1 Effective medical treatment of opiate addiction. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. JAMA 1998;280:1936–1943. 2 McLellan AT, Lewis DC, O’Brien CP, Kleber HD: Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA 2000; 284: 1689–1695. 3 Booth RE, Corsi KF, Mikulich SK: Improving entry to methadone maintenance among outof-treatment injection drug users. J Subst Abuse Treat 2003;24:305–311. 4 Dennis ML, Ingram PW, Burks ME, Rachal JV: Effectiveness of streamlined admissions to methadone treatment: a simplified time-series analysis. J Psychoactive Drugs 1994; 26: 207–216. 5 Festinger DS, Lamb RJ, Kirby KC, Marlowe DB: The accelerated intake: a method for increasing initial attendance to outpatient cocaine treatment. J Appl Behav Anal 1996; 29: 387–389. 6 Gryczynski J, Schwartz R, O’Grady K, Jaffe J: Treatment entry among individuals on a waiting list for methadone maintenance. Am J Drug Alcohol Abuse 2009;35:290–294. 7 Booth RE, Corsi KF, Mikulich-Gilbertson SK: Factors associated with methadone maintenance treatment retention among street-recruited injection drug users. Drug Alcohol Depend 2004;74:177–185.
Eur Addict Res 2015;21:211–216 DOI: 10.1159/000375491
Received: September 6, 2014 Accepted: January 24, 2015 Published online: April 21, 2015
Effectiveness of Rapid Intake into Methadone Treatment: A Natural Experiment in Israel Maayan Lawental School of Social Work, University of Haifa, Haifa, Israel
Abstract The effect of intake procedures on treatment entry and retention was examined in a natural experiment, in which a methadone maintenance clinic in Israel admitted 127 clients by employing a rapid intake procedure (maximum of 3 days before the initiation of treatment was offered). Using information gathered from patient files, these clients were retrospectively compared to a control group (n = 121) who underwent the clinic’s regular intake procedure (between 3 weeks and 3 months). Outcome measures included entry into treatment and subsequent retention in treatment (at 3, 6 and 12 months). Results show that 81% of clients from the rapid intake group entered treatment compared to only 57% from the regular intake group. Treatment retention was similar for both groups. In addition, Jewish clients were more likely to enter treatment via the rapid intake procedure than clients from other religions, and women were retained in treatment longer than men, regardless of the type of intake procedure. Results of this single-site study lend support to the effectiveness of rapid intake procedures as a way to engage clients in treatment and carry significant implications for improving access into treatment. © 2015 S. Karger AG, Basel
© 2015 S. Karger AG, Basel 1022–6877/15/0214–0211$39.50/0 E-Mail [email protected] www.karger.com/ear
Introduction
Numerous studies in the field of substance abuse point to methadone maintenance treatment as an integral aspect of treating and reducing the harms associated with heroin addiction [1, 2]. Within these studies, emphasis is given to the task of encouraging addicts to enter treatment [3–6] and retaining them over time [7, 8]. It has been suggested that for treatment to be successful, clients must be retained for at least 90 days [7] since clients who receive less than this minimal period of treatment do not differ from those who do not receive treatment at all [9– 11]. Waiting to begin treatment may be a barrier for potential clients as they consider entering treatment [3, 12–15]. Research has shown that longer waiting times are associated with lower rates of entry into treatment [4, 5, 16, 17] and higher [13, 18] or no change in retention rates [4]. A recent study in Israel found that longer waiting lists were a predictor of higher 1-year retention rates, yet suggested that this may be due to significant differences in sociodemographic characteristics between the groups. Most notably, the waiting list group was older and self-referring. Furthermore, the researchers did not have characteristics of those who did not enter treatment to begin with [19]. As the researchers in this study (the design of which was a natural experiment) did not examine treatment entry Dr. Maayan Lawental School of Social Work University of Haifa Mount Carmel, Haifa 31905 (Israel) E-Mail mlawental @ gmail.com
Downloaded by: Siriraj Medical Library, Mahidol University 198.143.39.97 - 1/26/2016 6:37:33 PM
Key Words Methadone maintenance treatment · Rapid intake · Retention rates
Materials and Methods Setting The Haifa Drug Abuse Treatment Center has offered outpatient services for opiate addicts residing in the Haifa metropolitan area for over 30 years. Within this setting, substance abuse is regarded as a biopsychosocial chronic condition, which requires the intervention of an interdisciplinary team during all stages of treatment, including intake. The center treats patients who are characterized, beyond their addiction to drugs, by multiple psychological, psychiatric, medical, familial and occupational difficulties. Most are also involved in criminal activities. Among other services, the center offers medication-assisted treatment. For all patients, intake of methadone is supervised (at least until they are assessed to be stabilized, when on occasion they may be provided with take-home doses) and urine samples are taken 2–3 times a week. Procedure Upon hearing that the centers’ methadone clinic opted to adopt a rapid intake procedure in order to add 100 patients to its roster, independent of any research goals, we took the opportunity to retrospectively examine patient files and gather information regarding treatment entry and retention (at 3, 6 and 12 months). As a result, this study was a natural experiment, comparing 127 opiateusers who went through a rapid intake process with 121 opiateusers who went through the regular intake process offered at the clinic (i.e. treatment as usual). The Two Conditions Regular intake procedures to the center are conducted by a specialized intake committee comprised of social workers, a psychologist, a physician and a nurse. The committee carefully assesses data gathered about clients and determines his or her course of
212
Eur Addict Res 2015;21:211–216 DOI: 10.1159/000375491
treatment. This process typically takes approximately 3 weeks (but may take up to 3 months), during which each potential client must provide 3 urine samples to determine presence of opiates, undergo extensive medical and psychosocial evaluations which include lab work (testing for HIV, HCV and other infectious diseases is included), and complete a comprehensive interview with a social worker and/or psychologist which can span across three sessions. Following this procedure, a client will be matched with a social worker and begin individual and group sessions, as well as methadone maintenance treatment (based on the intake committee’s recommendation). Similar intake procedures are employed in other centers in Israel. When the center received funds to expand its methadone maintenance program, the organization chose to employ a rapid intake procedure for several months in order to ensure that all treatment slots were occupied. Following this period, the centers’ regular intake procedures were reinstated. During this period any client who sought treatment was asked to submit one urine sample to determine the presence of opiates, meet once with the center’s physician and undergo brief psychosocial assessment during a half-hour session with a social worker. This rapid intake procedure ensured that clients were offered admission into treatment no more than 3 days after requesting it (and in many cases they were offered admission on the same day). Following the offer of admission, this group began receiving methadone immediately. Simultaneously, clients went through the more comprehensive assessment procedure similar to the one employed during regular intake (additional urine tests, medical and psychosocial assessment). The intake committee then convened with the role of determining continuation of treatment. Data Source and Measures Data for this study were extracted by center personnel from client records (both computerized and handwritten), and a deidentified dataset was provided for data analysis. Thus, all procedures were in accord with the Helsinki Declaration of 1975. In addition to the independent variable, the type of intake, comprehensive background information was collected (sociodemographic variables, medical, criminal and treatment histories). Since there was no random assignment into conditions, we wanted to explore and control for any differences between the two groups that might be of importance. No significant differences were found between the two groups on any of the background variables. The dependent variables were (1) entry into treatment [dichotomous (yes/no)] and (2) retention in treatment at 3, 6 and 12 months [dichotomous (yes/no)]. An attempt was made to calculate the number of days in treatment as a continuous variable. However, due to some inconsistencies with the data collection procedures at the clinic, this attempt did not yield reliable results. Statistical Analysis Using SPSS 19, the two groups were compared on all background variables and dependent variables using χ2 and t tests. In order to explore entry into treatment and retention at 3, 6 and 12 months, logistic regression was employed. Additional regression models were conducted in order to explore the interactive effect of rapid/regular intake and 12 months retention with gender, religion, marital status and immigration status; these variables have been shown in previous literature to be significant predictors of treatment entry and retention.
Lawental
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rates [19], which is the main dependent variable in the current study, the current study may serve to compliment and shed light on their results. The present study examined whether the type of intake procedure affected substance abusers entry into treatment and retention in treatment, in a methadone maintenance clinic in Israel. The clinic received funds to add 100 treatment slots and opted to do so by using a significantly shorter intake procedure for all clients seeking treatment until the new treatment slots were filled. This setting allowed for a comparison between those who were offered admission into treatment via rapid intake and those who were not. It was hypothesized that (1) more clients will enter treatment following a rapid intake procedure than those who will enter through the usual intake procedure, and (2) that retention would not differ across these two groups. These hypotheses were also tested in relation to gender, religion, marital status and immigration status.
Table 1. Differences between the groups on entry into treatment and retention variables
Variable
Values Regular intake (n = 121)
Rapid intake (n = 127)
Total sample (n = 248)
χ2 test
n
%
n
%
n
%
χ2
14.88*** 1
d.f.
Entered treatment
yes no
71 50
58.7 41.3
103 24
81.1 18.9
174 74
70.2 29.8
Retained for at least 3 months
yes no
63 8
88.7 11.3
89 14
86.4 13.6
152 22
87.4 12.6
2.06
1
Retained for at least 6 months
yes no
54 17
76.1 23.9
76 27
73.8 26.2
130 44
74.7 25.3
0.12
1
Retained for at least 1 year
yes no
46 25
64.8 35.2
66 37
64.1 35.9
112 62
64.4 35.6
0.01
1
*** p < 0.001.
rapid intake group; χ2(1) = 0.7, n.s.]. For 67.3% of the sample, it was not the first treatment attempt [67.8% in the regular intake group and 66.9% in the rapid intake group; χ2(1) = 0.2, n.s.], while 65.6% reported ever being arrested [67.7% in the regular intake group and 63.9% in the rapid intake group; χ2(1) = 0.35, n.s.]. Over a third of the sample (35.5%) reported past suicide attempts [38.9% in the regular intake group and 32.7% in the rapid intake group; χ2(1) = 0.83, n.s.], while 28.2% of clients reported past psychiatric hospitalization [33.8% in the regular intake group and 28% in the rapid intake group; χ2(1) = 2.07, n.s.] and 30.4% were diagnosed with a mental illness [34.5% in the regular intake group and 27.3% in the rapid intake group; χ2(1) = 1.18, n.s.]. 60.2% of the clients were diagnosed with hepatitis C [54.8% in the regular intake group and 64.5% in the rapid intake group; χ2(1) = 1.86, n.s.] and 4.2% tested positive for HIV [2.4% in the regular intake group and 5.6% in the rapid intake group; χ2(1) = 1.22, n.s.].
Pretreatment Background Variables and Sample Description No statistical significant differences were found between the groups on all pretreatment background variables that were examined including sociodemographic variables, criminal history, treatment history, medical and mental health diagnosis. Of all clients in the sample, 85% were male [86.8% in the regular intake group and 82.7% in the rapid intake group; χ2(1) = 0.8, n.s.] and 58.1% were born in Israel [56.2% in the regular intake group and 59.8% in the rapid intake group; χ2(1) = 1.18, n.s.], while 35.9% were from the former Soviet Union. Of those, 77.9% were considered new immigrants, having immigrated to Israel after 1990 [82.7% in the regular intake group and 73.1% in the rapid intake group; χ2(1) = 1.4, n.s.]. The average age of the sample was 36.7 years [35.8 in the regular intake group and 37.7 in the rapid intake group; t(177) = –0.7, n.s.] and the large majority of clients were unmarried [i.e. single, separated or divorced; 72.2% in the regular intake group and 77.2% in the rapid intake group; χ2(1) = 0.59, n.s.], with an average of 1.3 children [1.24 in the regular intake group and 1.5 in the rapid intake group; t(243) = –0.7, n.s.]. 67.4% of all clients were Jewish [65.1% in the regular intake group and 69.5% in the rapid intake group; χ2(1) = 0.92, n.s.]. The average number of school years attended was 9.7 [9.95 in the regular intake group and 9.49 in the rapid intake group; t(241) = –0.32, n.s.], and 89.7% reported no employment in the 3 months leading to initiation of treatment [91.4% in the regular intake group and 88.1% in the
Entry into Treatment and Retention The results indicated that more subjects from the rapid intake group entered treatment compared to subjects in the regular intake group [81.1% compared to 58.7% respectively, χ2(1) = 14.88, p < 0.001]. Treatment retention was similar in both groups. 89.4% of all clients were retained for at least 90 days [88.7% in the regular intake group and 86.4% in the rapid intake group, χ2(1) = 2.06, n.s.], 74.7% of all clients were retained for at least 180 days [76.1% in the regular intake group and 73.8% in the rapid intake group, χ2(1) = 0.12, n.s.] and 66.4% remained in treatment 12 months or more [64.8% in the regular intake group and 64.1% in the rapid intake group; χ2(1) = 0.01, n.s.; table 1].
Effectiveness of Rapid Intake into Methadone Treatment
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Results
Table 2. Bivariate logistic regression models and interaction effects for entry into treatment
Predictors
B
OR
95% CI
p
Intake (rapid/regular)
1.106
3.022
1.7, 5.36
0.000***
Intake Gender (male/female)
1.092 –0.681
2.979 0.506
1.68, 5.3 0.21, 1.23
0.000***
Intake Gender Intake × gender
1.514 –0.501 –0.474
4.545 0.606 0.623
0.75, 27.42 0.2, 1.87 0.09, 4.15
0.099 0.383 0.624
1.094
2.986
1.68, 5.3
0.000***
0.278
1.321
0.73, 2.38
1.442 0.478 –0.523
4.227 1.613 0.593
1.53, 11.67 0.76, 3.43 0.17, 2.04
0.005** 0.214 0.406
Intake Marital status (married/not married)
1.119 0.742
3.061 2.101
1.72, 5.45 0.97, 4.54
0.000***
Intake Marital status Intake × marital status
1.014 0.502 0.758
2.758 1.653 2.133
1.48, 5.14 0.65, 4.2 0.36, 12.64
0.001*** 0.291 0.404
Intake Religion (Jewish/other)
1.035 0.532
2.814 1.702
1.54, 5.16 0.92, 3.16
0.001*** 0.091
Intake Religion Intake × religion
0.266 0.002 1.279
1.304 1.002 3.594
0.5, 3.37 0.45, 2.24 1.03, 12.57
0.584 0.997 0.045*
Intake Immigration status (born in Israel or immigrated before 1990/immigrated after 1990) Intake Immigration status Intake × immigration status
The results also indicated that clients accepted for treatment through rapid intake were 3 times more likely to enter treatment than those accepted through the regular intake procedure [OR = 3.02 (1.7–5.36), p < 0.001]. Jewish clients were more likely to enter treatment via the rapid intake procedure than non-Jewish clients [OR = 3.6 (1.03–12.57), p < 0.5] and women were retained in treatment longer than men, regardless of the type of intake procedure [OR = 0.29 (0.11– 0.8), p < 0.5]. No significant statistical differences were found comparing married versus not married subjects and new immigrants versus native and veteran immigrants (table 2).
Discussion
The aim of this study was to explore whether a rapid intake process is effective in bringing clients into treatment and retaining them over time. The study found that clients accepted for treatment through a rapid intake procedure were 3 times more likely to enter treatment than those ac214
Eur Addict Res 2015;21:211–216 DOI: 10.1159/000375491
cepted through the regular intake procedure, while retention in treatment did not differ between the groups. Results of this study point to the effectiveness of rapid intake procedures as a way to bring clients into treatment. These results support in Israel what various studies have demonstrated in other countries. For instance, one study found that 59% of clients accepted through rapid intake entered treatment compared to only 33% in a regular intake [5]. One explanation for these results may be that clients are often in crisis when contacting the clinic and they may have only temporarily overcome internal or external barriers. Another possible explanation is that clients may be ambivalent towards seeking treatment and longer waiting periods gives them additional time to contemplate their decision and perhaps renege. Furthermore, this study complements a previous study in Israel which found better retention rates with rapid intake (a finding not replicated here), yet did not measure entry into treatment [19]. Results of both studies taken together further strengthen the importance of rapid intake as Lawental
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* p < 0.05, ** p < 0.01, *** p < 0.001.
in which this clinic was compared to other clinics in Israel, overall client characteristics were very similar, as were organizational aspects of treatment, such as intake procedures and waiting times. Though the two groups were compared with regard to many background variables and no statistical differences were found, it is still possible that subjects in the rapid intake group were somehow different than those in the regular intake group concerning important variables that could not be measured such as motivation for treatment or distance from the clinic. The literature has shown that motivation in particular is an important predictor of treatment entry and retention (e.g. [7, 8, 17]), and should be considered in future research.
Future Directions
Limitations This study has several limitations. This was a natural history study, which took advantage of an organizational change at a specific clinic. Therefore, the sample was a convenience sample and subjects were not randomly assigned into the two conditions. Furthermore, the study was done retrospectively using information gathered from administrative files at the clinic. It is possible that clients of this clinic are different than those of other clinics and therefore the results of this study are not generalizable to other clinics. However, this is unlikely. In previous studies
Despite the study’s limitations detailed above, the unique real-world setting in which the study took place support the validity of its results and thus carry some implications for policy and practice. It is recommended that policymakers and treatment providers in Israel consider issues surrounding the early stages of treatment. Though decisions regarding the length of intake are often based on organizational constraints, efforts can be made to reduce some of the barriers to treatment entry by shortening the intake procedure as much as possible. However, it is important to remember that intake procedures are only one aspect in the overall treatment process of substance abusers. Adopting rapid intake can save many resources, which can be diverted to other stages of the treatment process, such as outreach, case management or ancillary services (e.g. transportation, childcare). Furthermore, adopting rapid intake procedures has the potential to bring more drug users into treatment, and consequently may help minimize various harms associated with drug use, both personal and societal (e.g. disease, accidents, unemployment, etc.). Although this potential may be largely dependent upon the clinic’s ability to foster collaborations with other organizations, it is of critical importance when considering the high rates of infectious diseases such as HIV or HCV in this population. Finally, the site in which this study was conducted as well as several other sites in Israel who serve comparable drug using populations are undergoing major organizational changes. These include changes that are likely to damage efforts to admit and retain clients, such as privatization, structural changes, staff turnover and even shifts in location (and therefore access to treatment services). If planned in advance, rapid intake procedures can serve as a cost-effective way to mitigate this potential damage.
Effectiveness of Rapid Intake into Methadone Treatment
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a way to engage and retain clients in methadone maintenance treatment, a form of treatment that is crucial in treating heroin addicts and reducing individual and societal level heroin use harms [1, 2]. In a study that explored substance users perceptions regarding barriers to treatment, over 50% reported that waiting was a significant barrier for them [15]. It has been suggested that a possible explanation for the success of rapid intake procedures lies with the immediate feedback that users are given. Potential clients may feel rewarded for their efforts and thus motivated to begin treatment [5]. Retention in treatment was not predicted by the type of intake procedure. Previous results regarding retention have been mixed. While some studies have found that rapid intake procedures predict longer periods of retention (e.g. [4, 20]), others have found no correlation between length of the intake procedure and period of time retained in treatment (e.g. [5, 21]). In all studies, it seems once clients are admitted into treatment via rapid intake, they are retained in treatment at least as long as all other clients. The study also showed that Jewish clients are more likely to enter treatment via the rapid intake procedure than non-Jewish clients (though for both groups rates of entry into treatment are higher than in the regular intake group). This may be due to other barriers facing non-Jewish minorities in Israel from entering treatment. For instance, it is possible that they reside further away or are of lower economic status. Both of these factors have been suggested as barriers to treatment [12]. Finally, the study found that women are retained in treatment longer than men, regardless of the type of intake procedure. Many studies point to significant differences between men and women with regard to etiology of substance abuse as well as treatment. Though results regarding gender differences in retention rates are mixed, there is widespread agreement that men and women have different needs that must be taken into account when designing interventions [22].
References
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