Retention, HIV Risk, and Illicit Drug Use during Treatment: Methadone Dose and Visit Frequency Howard M. Rhoades, PhD, Dan Creson, MD, PhD, Ronith Elk, PhD, Joy Schmitz, PhD, and John Grabowski, PhD Introduction Despite regulatory constraints, methadone has proven uniquely effective as a treatment for opiate dependence.'3 A j:.-f constellation of conditions permits patients to return to activities unrelated to drug abuse or to seek previously inaccessible opportunities. Methadone exemplifies the pharmacological substitution strategy for treating drug dependency while contribut- ing to the reduction of human immunodefi- ciency virus (HIV) transmission. Yet this strategy continues to meet resistance. It is ... not permitted in several states, and in oth- ers there are calls for its elimination. Notably, regulations governing methadone administration have been focused primarily on precluding "diversion," not on treatment efficacy46; in fact, current regulations effectively reduce treatment availability and effectiveness. A reexamination of pol- icy, practice, costs and implications for availability of services is needed. Methadone has been used for 3 decades, but optimal dosing and visit conditions are ill defined.5 Recent data from studies of cocaine dependency treatment indicate that reduced visit frequency 7 requirements enhance retention. In a demonstration research project with methadone, Senay et al.' found no diversion '',:' ^' by long-term patients receiving many methadone take-home doses. The issues regarding treatment with methadone have been critically reviewed.9l3 Dole and Nyswander' originally empha- ...... sized higher doses over longer periods on the basis of assumptions regarding the mod- ified neurochemistry of the user. However, other strategies have been favored, includ- ing "detoxification," which entails brief sta- bilization at the lowest sufficient dose fol- ... - lowed quickly by dose reduction. In practice, this has not produced impressive results. Patients may even return to other opiate use while the methadone dose is decreasing. 14 Illicit opiate use during methadone treatment should be dose dependent, with higher doses of methadone providing more effective substitution than lower doses. Yet the trend in the late 1970s and 1980s was toward lower doses. Recognition of needle sharing as a vector for HIV transmission may have stayed this trend, but problems still exist. The study described here systemati- cally addressed pragmatic issues influencing cost, effectiveness of treatment, and HIV spread. The main independent variables were methadone dose and visit frequency. Subjects and Methods Subjects Ninety men and 33 women (n = 123), aged 18 to 50 years (mean = 38.3, SD = 5.98), completed the consent process. Of 107 subjects completing a 2-week dosing stabilization period, there were 76 men and 31 women (mean = 38.2 years, SD = 5.95). Subjects were recruited through advertisements and referrals. All met crite- na of the Diagnostic and Statistical Manual The authors are with the Substance Abuse- Medications Development Research Center, Department of Psychiatry and Behavioral Sci- ences, School of Medicine, University of Texas-Houston. Requests for reprints should be sent to John Grabowski, PhD, Substance Abuse-Medications Development Research Center, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Texas-Houston, 1300 Moursund, Houston, TX, 77030. This paper was accepted May 30, 1997. January 1998, Vol. X8, No. I