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A. Thomas McLellan, PhD; Isabelle O. Arndt, MD, PhD; David S. Metzger, PhD; George E. Woody, MD; Charles P. O'Brien, MD, PhD

JAMA. 1993;269(15):1953-1959.

Abstract
Objective.
—To examine whether the addition of counseling, medical care, and psychosocial services improves the efficacy of methadone hydrochloride therapy in the rehabilitation of opiate-dependent patients.

Design.
—Random assignment to one of three treatment groups for a 6-month clinical trial: (1) minimum methadone services (MMS)—methadone alone (a minimum of 60 mg/d) with no other services; (2) standard methadone services (SMS) —same dose of methadone plus counseling; or (3) enhanced methadone services (EMS)—same dose of methadone plus counseling and on-site medical/psychiatric, employment, and family therapy.

Setting.
—The methadone maintenance program of the Philadelphia (Pa) Veterans Affairs Medical Center.

Subjects.
—Ninety-two male intravenous opiate users in methadone maintenance treatment.

Results.
—While methadone treatment alone (MMS) was associated with reductions in opiate use, 69% of these subjects had to be "protectively transferred" from the trial because of unremitting use of opiates or cocaine, or medical/ psychiatric emergencies. This was significantly different from the 41% of SMS subjects and 19% of EMS subjects who met the criteria. End-of-treatment data (at 24 weeks) showed minimal improvements among the 10 MMS patients who completed the trial. The SMS group showed significantly more and larger improvements than did the MMS group; and the EMS group showed significantly better outcomes than did the SMS group. Minimum methadone services subjects who had been "protectively transferred" to standard care showed significant reductions in opiate and cocaine use within 4 weeks.

Conclusions.
—Methadone alone (even in substantial doses) may only be effective for a minority of eligible patients. The addition of basic counseling was associated with major increases in efficacy; and the addition of on-site professional services was even more effective.

(JAMA. 1993;269:1953-1959)

Author Affiliations
From the Penn-VA Center for Studies of Addiction, Department of Psychiatry, Philadelphia Veterans Affairs Medical Center, and the Department of Psychiatry, University of Pennsylvania Medical School, Philadelphia.

Footnotes
Reprint requests to Department of Psychiatry, Penn-VA Center for Studies of Addiction, University Avenue, Bldg 7, Philadelphia, PA 19104 (Dr McLellan).

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