King County contracts with two private non-profit organizations to provide methadone treatment: Evergreen Treatment Services and Therapeutic Health Services (T/H/S), which serve a total of 1,400 methadone patients. T/H/S operates clinics at two different sites, Summit and Midvale. The County also licenses Western Clinical Health Services (WCHS), which operates a private for-profit clinic and does not receive public funds.

Thirty years of extensive research have shown that methadone maintenance is an effective treatment for heroin addiction. Once stabilized on an adequate methadone dose, patients show improvement in a number of areas:

A decrease in the consumption of all illicit drugs;
A significant reduction in crime;
A decline in intravenous drug use and the number of people becoming HIV positive; and
Improvement in individual functioning, including health, employment, and well-being.

Based on these outcomes, several cost-benefit studies have concluded that for every dollar spent on methadone treatment, at least four dollars are saved in health and law enforcement costs.

Finding IV-1. A model methadone program would contain the following treatment components: 1) adequate doses of methadone; 2) effective counseling; and 3) a clinic philosophy of long-term maintenance.

Studies show the optimum daily stabilization dose of methadone for most patients to be between 60 mg. and 120 mg. Doses at these levels correspond to enhanced patient outcomes, including decreased heroin use and higher patient retention.

In addition to providing counseling to address the special needs of addicted patients, counselors are the primary link to other rehabilitative services such as medical and psychiatric referrals and vocational rehabilitation. These additional services are critical because most methadone patients have a range of medical, psychological, and financial problems.

A clinic philosophy of long-term maintenance recognizes the need for long-term treatment to address the physical and psychological aspects of addiction and ensure lasting changes in patient behavior. Clinics with this philosophy have lower in-treatment drug use and higher patient retention than abstinence-oriented clinics or clinics that limit time in treatment.

Finding V-1. 39% of patients received doses of methadone designated as ineffective by the national institute on drug abuse.

More than one-third (39%) of King County methadone patients in the audit sample routinely received doses designated as ineffective (below 60 mg.) by the National Institute on Drug Abuse. The percentage of patients receiving an effective dose ranged from 45% at the Midvale clinic to 85% at WCHS. Nine percent of the overall patient sample received inappropriate doses (under 40 mg.), with over half of those patients receiving treatment at Summit.

Finding V-2. Clinics did not consistently document if patients were referred to rehabilitative services.

According to the patient files, many patients reported depression, anxiety, or abusive relationships at admission. Additionally, patients often encountered other problems during treatment, such as housing, funding, or mental health issues. However, patient files often did not contain any documentation that patients had been referred to or received rehabilitative services.

Finding V-3. No standards have been developed to evaluate the performance of individual methadone programs.

While numerous studies have shown the overall effectiveness of methadone maintenance treatment, standards have not been developed to measure the effectiveness of individual clinics. Audit staff therefore could not evaluate the effectiveness of the County programs against accepted performance standards; instead we compared the outcomes of the King County programs to outcomes from major research studies.

Finding V-4. Opiate use by patients declined by time in treatment, although not as much as in a major study.

Illicit use of opiates by patients in the publicly-funded clinics declined with time in treatment. After 6 months in treatment, 51% of patients tested negative for opiates; after one year the number had increased to 65%. However, the decrease in opiate use was lower than the results of a major study, which found that 77% of methadone patients had ceased heroin use after the first six months in treatment.

Finding V-5. One-year patient retention rates of individual clinics varied widely, but were consistent with results from two major studies.

Time in treatment is one of the most important predictors of outcomes for methadone patients: A recent national study found that at least one year in treatment was necessary for significant changes in heroin use, employment, and criminal activity. Overall, 33% of the patients in the audit sample were still in treatment after one year. Evergreen had the highest one-year retention rate at 44%; Midvale and Summit had lower rates at 28% and 24%, respectively.

Although there was a large difference in retention rates between Evergreen and the T/H/S clinics, the rates were generally consistent with the results of two major studies. One study found an average one-year retention rate of 34%, with rates for individual clinics between 25% and 44%. The second study, of nine programs, found that 38% of all patients stayed in treatment for at least one year. Five programs had low rates between 7% and 25%, while two programs had rates over 50%.

Citing the retention rates in these two studies, one researcher concluded that a major shortcoming of substance abuse programs was that retention rates were too low. Given the importance of time in treatment to positive patient outcomes, it is crucial that clinics implement treatment interventions that will keep patients in treatment.

Finding V-6. Employment of patients in treatment for at least 6 months increased 44%.

Patients who remained in treatment for six months or more showed a 44% increase in employment. Eighteen of the 77 patients in treatment six months or more were employed at admission, while 26 were employed at last contact. In contrast, of the 43 patients who were in treatment less than six months, 11 were employed at admission, and 12 were employed at discharge.

Finding V-7. Many patient files did not contain information on patients' arrests, housing, or emergency room visits.

Although state regulations required clinics to record patient psychosocial data at intake and during treatment, many patient files in the audit sample did not contain adequate information to assess changes in patients' criminal activity, housing, and emergency room visits. In some cases audit staff could not find enough information to establish patient status at intake.

Finding V-8. Clinics imposed harsher detoxification schedules for non-payment of fees than for most other involuntary discharges.

All clinics in King County provided a 21-day involuntary detoxification for rule violations, including discharges for positive urinalyses and missed doses. This 21-day period allowed the patient a humane detoxification that minimized withdrawal symptoms. In contrast, patients being discharged for non-payment of fees were placed on a rapid detoxification schedule: patients at publicly-funded clinics had only seven days to complete detoxification, while patients at WCHS had five. For patients who paid the clinic fees before the end of the detoxification period, the frequency and rapidity of these detoxifications interfered with their stabilization on methadone.

The audit recommended that DASAS require a minimum 21-day financial detoxification schedule in its licensing agreement with all of the methadone clinics in King County.

Finding VI-1. Both the State and the County focused on administrative requirements rather than patient outcomes in monitoring methadone programs.

Both Washington State and King County focused primarily on compliance with administrative requirements in their review of methadone programs, and conducted very little review of patient outcomes. However, King County's contracts for methadone treatment included a provision for performance evaluation by the County. In 1996, the methadone clinics implemented the federal Methadone Treatment Quality Assurance System, a program to test an outcome-based measurement system, including changes in patient employment, arrests, and emergency room visits. Thus, the County had in place the foundation to implement program evaluation based on patient outcomes and program performance.

The audit recommended that DASAS institute requirements for regular performance reports as part of its contract with providers. The reports should contain the following information: patient retention rates; urinalysis results; methadone dose levels; and the number of clients utilizing additional referral services (e.g., mental health, vocational).

In addition, the audit recommended that DASAS, in conjunction with the clinics, develop specific patient outcomes (e.g., employment) to be regularly recorded in patient files and included in the performance reports.

The audit also recommended that DASAS use these performance reports and patient outcomes to develop outcome-based performance standards to be included in future contracts.

Finally, the audit recommended that DASAS increase its monitoring of patient files to ensure that counselors make appropriate and timely referrals for patients and follow up on the treatment of identified patient needs.

Updated: 06/24/02

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