Supervised daily consumption, contingent take-home incentive and non-contingent take-home in methadone maintenance ☆ G. Gerra a, ⁎, E. Saenz a , A. Busse a , I. Maremmani b , R. Ciccocioppo c , A. Zaimovic d , M.L. Gerra e , M. Amore e , M. Manfredini f , C. Donnini f , L. Somaini g a Drug Prevention and Health Branch, United Nations Office on Drugs and Crime, Vienna, 1400, Austria b Department of Psychiatry, Addiction Medicine, University of Pisa, 56100 Pisa Italy c Department of Experimental Medicine and Public Health, University of Camerino, 62032 Camerino, Italy d “Programma Dipendenze “ Ser.T, AUSL Parma, 43100 Parma, Italy e Division of Psychiatry, Dept. of Neurosciences, University of Parma, Parma, Italy f Dipartimento di Genetica, Biologia dei Microrganismi, Antropologia, Evoluzione, University of Parma, Parma, Italy g “Dipartimento Dipendenze” Health Local Unit BI, 13900 Biella, Italy abstract article info Article history: Received 30 April 2010 Received in revised form 3 December 2010 Accepted 3 December 2010 Available online 10 December 2010 Keywords: Methadone Contingent take-home Non-contingent take-home Methadone maintenance therapy (MMT) has been found effective in treating heroin addiction. Serious consideration should be given to the modality of methadone distribution, as it influences not only treatment outcome but the attitudes of policy makers and the community, too. On one hand, the choice of take-home methadone removes the need for daily attendance at a methadone clinic, which seems to improve patients' quality of life. On the other, this method, because of its lack of supervision and the absence of strict consumption monitoring, runs the risk of methadone misuse and diversion. In this study, we compared A) supervised daily consumption, B) contingent take-home incentives and C) non-contingent take-home in methadone maintenance in three groups of heroin-addicted patients attending three different MMT programmes. Retention rates at 12 months were significantly higher in contingent take-home patients (group B) than in those with supervised daily consumption (group A) and the non-contingent take-home (group C). Retention rates were higher in group A than in group C patients. Compared to patients in groups A and B, those in group C showed fewer negative urinalyses and higher rates of self-reported diversion and episodes of crime or violence. Results indicate a more positive outcomes following take-home methadone associated with behavioural incentives and other measures that aim to facilitate treatment compliance than those following daily supervised consumption. By contrast, non-contingent take-home methadone given to non-stabilized patients is associated with a high rate of diversion, along with more crime episodes and maladaptive behaviours. © 2011 Elsevier Inc. All rights reserved. 1. Introduction Methadone efficacy in preventing opioid withdrawal, reducing craving and lessening illicit opioid use has been firmly established. Methadone maintenance treatment (MMT) has also been associated with significant reductions in crimes committed by patients, their enhanced social productivity (Lewis, 1997) and a reduced risk of HIV infection (Rhoades et al., 1998, Sees et al., 2000, Avants et al., 1999). MMT does not disrupt normal daily activities (Breslin and Malone, 2006; Seymour et al., 2003) because it is not intoxicating or sedating. Moreover, due to its limited rewarding and euphorigenic action (Jasinski and Preston, 1986), methadone helps patients focus on work and relationships, while limiting compulsive heroin-seeking (Kreek, 2000). Considering its proven efficacy, appropriate strategies should be developed to allow methadone use not only for severely stigmatized and marginalized patients but also for those who are socially integrated, by minimizing the burden of attending treatment programmes and compliance tied to complex rules for supervised daily consumption (Zaller et al., 2009, Radcliffe and Stevens, 2008). There remains the problem that inappropriate methadone use and drug diversion are widespread in MMT programmes (Breslin and Malone, 2006; Lewis, 1997; Fountain et al., 2000; Bell and Zador, 2000). Several studies have shown that a majority of methadone- related deaths can be directly attributed to methadone diversion, often in patients not enrolled in any MMT programme (Seymour et al., 2003; College of Physicians & Surgeons of Ontario, 2005; Fountain et Progress in Neuro-Psychopharmacology & Biological Psychiatry 35 (2011) 483–489 Abbreviations: MMT, methadone maintenance therapy; SCID, structural clinical interview for axis I disorders; SIDP, structural interview for personality disorders; SCL- 90, symptoms check list 90. ☆ The views expressed herein are those of the author(s) and do not necessarily reflect the views of the United Nations. ⁎ Corresponding author. Drug Prevention and Health Branch, Division for Operations, United Nations Office on Drugs and Crime, Room D1438, P.O. Box 500, 1400 Vienna, Austria. Tel.: +43 1 26060 4123; fax: +43 1 26060 74123. E-mail address: gilberto.gerra@unodc.org (G. Gerra). 0278-5846/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.pnpbp.2010.12.002 Contents lists available at ScienceDirect Progress in Neuro-Psychopharmacology & Biological Psychiatry journal homepage: www.elsevier.com/locate/pnp