Individual Drug Counseling
The most common type of psychosocial treatment in opioid agonist maintenance is individual drug counseling. Counselors are typically persons at the masters level or below who deliver a behaviorally focused treatment aimed to identify specific prob-lems, help the patient access services that may not be provided in the clinic (e.g., medical, psychiatric, legal, family/social), stop substance use and improve overall adjustment. Functions that counselors perform include monitoring methadone and LAAM doses and requesting changes when needed, reviewing urine test results, responding to requests for take-homes doses, assisting with family problems, responding to crises, writing letters for court or social welfare agencies, recommending inpatient treat-ment when necessary, and providing support and encouragement for a drug-free lifestyle
Counseling usually addresses both opioid and nonopioid use. Although nicotine (tobacco) use is not always included, the increased emphasis on adverse health effects of smoking has re-sulted in more attention to stop smoking at all levels, including drug counseling. Counselors and patients typically have weekly, 30- to 60-minute sessions during the first weeks or months of treatment with reductions in frequency to biweekly or monthly depending on progress. The frequency of counseling can vary widely depending on the severity of the patient’s problems, clinic requirements and counselor workload.
The importance of regular counseling was clearly demon-strated in a study by McLellan and coworkers (1993) in which patients were randomly assigned to minimal counseling (one 5- to 10-minute session per month), standard counseling (one 45-minute session per week), or enhanced counseling (standard plus on-site referral to psychiatric, medical and family/social services). Results showed a dose–response relationship with the minimal condition doing significantly worse than standard, and enhanced counseling doing the best overall; however, about 30% of patients did well in the minimal counseling condition. This study clearly demonstrated the positive benefits achieved by drug counseling and showed that, for most patients, counseling is necessary to bring out the maximum benefits from agonist maintenance.
Though most counseling is individual, some programs use group therapy exclusively and others do not use it at all. Most agonist programs that use groups have them only for patients with focal problems such as HIV disease, PTSD, homelessness, or loss of close personal relationships. Many programs encourage patients to participate in self-help groups, but ask them to select a group that accepts persons who are on agonist maintenance treat-ment. Some programs have self-help groups that meet on site. Counselors, like psychotherapists, can vary widely in the results they achieve. This variability seems more related to the ability to form a positive, helping relationship than to specific techniques.
Contingency management techniques are always included in drug counseling, if only to fulfill regulations about requiring progress in treatment as a condition of providing take-home doses; studies have shown that such contingencies can be helpful. For ex-ample, an opportunity to receive take-home medications in return for drug-free urine tests is a powerful and practical motivator for many patients. More flexibility in dispensing take-home doses as contingencies for positive behaviors could be an additionally useful result of the regulatory reforms that were described earlier. Another contingency that is easily applicable and which some programs have used with positive results is requiring a negative alcohol breath test prior to dispensing the daily dose of methadone or LAAM.
Though counseling and other services are effective en-hancements of agonist treatment, compliance is often an issue and clinics vary in the way they respond to this problem. Some remind patients of appointments, others do not permit patients to be medicated unless they keep appointments, and others suspend patients who miss appointments. For noncompliant patients, a powerful contingency is requiring certain behaviors for patients to remain on the program, a procedure that is often formalized in a “treatment contract”. Here, the patient is given the option of stopping heroin and other drug use, keeping regular counseling appointments, looking for work, or correcting other behaviors that need improvement as a condition for remaining in treatment. Patients who fail are administratively detoxified, suspended for months to years, and referred to another program, although the referrals are not always successful. The long-term effects of this form of contingency management have not been well studied.