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Leaving Methadone Maintenance Treatment: TheRole of Personality Traits and Psychic StatusMarlene Stenbacka a , Lena Brandt b & Louise Lettholm aa Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Swedenb Department of Medical Epidemiology, Karolinska Institute, Stockholm, SwedenPublished online: 07 Sep 2011.

To cite this article: Marlene Stenbacka , Lena Brandt & Louise Lettholm (2004): Leaving Methadone MaintenanceTreatment: The Role of Personality Traits and Psychic Status, Journal of Psychoactive Drugs, 36:2, 227-234

To link to this article: http://dx.doi.org/10.1080/02791072.2004.10399733

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Leaving Methadone Maintenance

Treatment: The Role of Personality

Traits and Psychiatric Statust

Marlene Stenbacka, Ph.D.* ; Lena Brandt, B.A. * * & Louise Lettholm, B.Sc. * * *

Abstract-This study investigates personality traits and psychiatric status among 174 methadone patients ( 12 1 men and 53 women) and 387 untreated controls ( 19 1 men and 196 women) in Sweden in 1993 and 1994. The methadone patients were followed up to 1998 with respect to being expelled from treatment. Pretreatment factors, like home background and behavioral factors, were studied in relation to treatment outcome. The methadone patients were interviewed using a structured questionnaire about alcohol and drug use and psychological, social, and behavioral factors. To obtain data about personality traits, the patients were asked to fill in a questionnaire, the Karolinska Scales of Personality (KSP) questionnaire. The male methadone patients had significantly (p < 0.0001 ) higher scores o n somatic anxiety, muscular tension, impulsiveness, and psychasthenia, and significantly lower scores with regard to socialization, social desirability, and inhibited aggression compared with the controls. Compared with the female controls, the female methadone patients differed most significantly (p < 0.000 1 ) in respect of socialization. Low socialization, social desirability, detachment, feelings of guilt, and suspicion were most predictive for later expulsion from treatment. Nearly half of the methadone patients who suffered from human immunodeficiency virus (HIV) infection had difficulties with compliance with the treatment and were later expelled. The results suggest that awareness of personality traits and psychiatric status may be crucial for a better methadone treatment outcome.

Keywords-methadone, opiates, personality factors, treatment

Many studies on methadone maintenance treatment in the past decades have described the effect of methadone on different outcome variables, such as opiate abuse, criminality,

tThis study was supported by the Swedish Council for Social Research (project No. 93-0128:1B) and the National Board of Health and Welfare. The authors are grateful to Anders RomelsjO, M.D., Ph.D., for valuable comments on the manuscript. Marlene Stenbacka directed the study and wrote the article. Lena Brandt analyzed the data and participated in the interpretation of the results. Louise Lettholm contributed to the writing and gave valuable comments on the manuscript.

*Project Leader, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.

Journal of Psychoactive Drugs 227

inpatient care, and IDV infection (Stenbacka, Leifman & Romelsjt} 2002; Ball & Ross 199 1 ; Ball et al. 1988; Dole, Nyswander & Werner 1968; Dole & Nyswander 1967, 1965).

••Statistician, Department of Medical Epidemiology, Karolinska Institute, Stockholm, Sweden.

•••Chief Psychologist, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.

Please address correspondence and reprint requests to Dr. Marlene Stenbacka, Karolinska Institute!, Department of Clinical Neuroscience, Magnus Huss, Karolinska Hospital, M4: 4, S-171 76 Stockholm, Sweden; email : marlene.stenbacka@spo.sll.se.

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Methadone treatment was first given after World War II, when it was used in outpatient programs. Today, it is common in most countries where there is heroin misuse (EMCDDA 2000; Murray 1998; Digiusto et al. 1996; Ball & Ross 199 1 ). The criteria for inclusion in a methadone treatment program in Sweden are restrictive, including at least four years of continuous intravenous use of heroin as the primary drug and being at least 20 years of age. In a 1990s survey of drug users who had been in contact with the Social Welfare Department in Stockholm, Sweden, 884 opiate abusers were identified, 220 of whom were in metha­done programs and 664 of whom were untreated (Finne 1997). A greater percentage of the methadone patients (34%) than of the untreated opiate users ( 18%) had been treated for psychiatric symptoms. Also, the employment rate was higher among methadone patients than in the untreated group. A total of 23% of the methadone patients and 48% of the untreated opiate abusers were homeless. Human immu­nodeficiency virus (HIV) infecti0n was more frequent among methadone patients (22%) than among untreated opiate users (5%; Finne 1 997).

Studies on opiate abuse using the American Psychiat­ric Association's Diagnostic and Statistical Manual of

Mental Disorder, Third Revised Edition (DSM-III; APA 1980), have shown that about 70% of patients meet the cri­teria for at least one personality disorder other than opiate abuse (Cacciola et al . 1996; Rounsaville, Weissman & Kleber 1992; Kosten, Kosten & Rounsaville 1989; Kosten, Rounsaville & Kleber 1985). The percentage of mood dis­orders and antisocial personality disorders has been reported to be much higher among substance users than in the gen­eral population (Chatham et al. 1 995; Regier, Narrow & Rae 1990). Other studies have shown that several psychiat­ric diagnoses in substance abusers, especially major depression and antisocial personality disorder, are often as­sociated with high rates of continued substance use and poor psychosocial improvement (Joe, Simpson & Hubbard 1991). Out of 10,000 clients who participated in a Treatment Out­come Prospective Study (TOPS) in the 1980s, 60% reported symptoms of depression in the year before admission (Hubbard et al. 1984). In another TOPS study, of 590 methadone pa­tients recruited from 21 treatment clinics in United States, it was found that relapse to use of opiates was less frequent in patients offered treatment by mental health professionals (Joe, Simpson & Hubbard 1991).

In a study by Rutherford and colleagues ( 1995), a lower percentage of female opiate users (6.5% to 30%) than of male opiate users (40% to 50%) were reported to have antisocial personality disorders. An antisocial personality has often been associated with criminal behavior and drug use, both of which, especially criminality, appear to be less frequent among women. In an earlier study of Swedish methadone patients, criminality and intravenous drug use were more frequent among men than among women during the four years prior to admittance to treatment (Stenbacka

Journal of Psychoactive Drugs 228

Leaving Methadone Maintenance

& Romelsjo 1997), whereas the reduction of both crimi­nality and opiate use during maintenance treatment was equally evident in both sexes (Stenbacka, Leifman & Romelsjo 2003).

How methadone patients with differing severities of psychiatric symptoms and intensities of substance use respond to treatment seems unclear (Alterman, McLellan & Shifman 1993). Alterman and colleagues ( 1993) report that among both alcoholic and drug-dependent patients, those patients with more severe mental problems received more help for medical, alcohol, family/social, and psychiat­ric problems and therefore had a better treatment outcome than did those with less severe mental symptoms. On the other hand, McLellan and colleagues ( 1983) found that patients who suffered less from psychiatric problems showed greater improvement in response to treatment than did those with more problems, who often did not improve at all. In a 2.5-year follow-up study of opiate users entering methadone treatment, substance use and poor psychiatric functioning were more common among patients who had personality disorders than among those who did not. No differences between the groups was found with regard to employment, family/social, legal, and medical status (Kosten, Kosten & Rounsaville 1989). Nace and Davis (1993) report that in their study, drug users with personality disorders admitted to a substance abuse program reported improvement with respect to drug use but not to either alcohol use or satisfaction with their life situation. Nurco and colleagues ( 1 989) found that persons who were more socially adjusted before starting treatment had a better prognosis for remaining in treatment. Studies on anxiety and depression have shown that the concept of identity in drug users changes dramatically during periods of abstinence (Lilja & Larsson 1996), when they experi­ence uncertainty about the new, drug-free life situation. Avoidance of drug-using friends and places where sub­stance abuse is common often prevents the patients from relapsing to opiates, but often also leads to feelings of lone­liness, guilt, and anxiety, and even a depressive mood (Lilja & Larsson 1996).

In this study, the authors analyzed personality traits and self-reported psychiatric status among a group of methadone patients entering treatment in 1993 and 1994 and followed up in 1998 with respect to expulsion from treatment. In the analysis, two questions were addressed: ( 1 ) do methadone patients differ from the general popula­tion with regard to personality traits? and (2) do personality traits and self-reported psychiatric status have any predic­tive value for later expulsion from treatment?

GOALS

The goals of the study were to: ( 1 ) analyze personality traits for a group of 174 metha­

done patients compared with a control group representing the general population; and

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(2) investigate self-reported psychiatric status and back­ground factors in relation to expulsion from treatment.

MATERIALS AND METHODS

Subjects About half of all opiate users on methadone treatment

from all the four programs in Sweden in 1993-1994 were selected for the interview. Every second person from the list of the patients was chosen for the interview. The selec­tion was performed according to age, gender, and time since start of treatment. One criterion was that patient should have been on methadone treatment for at least six months and were stabilized on their current methadone doses. Oth­erwise, the patients could suffer from different withdraw! symptoms caused by inappropriate methadone dosage. The mean methadone dosage was 80 to 90 mg/day. Trained interviewers interviewed 205 methadone patients to obtain family background and social and psychologi­cal conditions, and each interview took between one and two hours. All interviewers performed test interviews which were videotaped and analyzed by a professional who corrected obvious mistakes. The patients were also asked to fill in the Karolinska Scales of Personality (KSP) questionnaire, which measures personality traits. Thirty-one patients ( 15%) who had not filled in the ques­tionnaires on the majority of the personality traits and psychiatric status were excluded from the study. The study population therefore consisted of 174 ( 121 men and 53 women) out of 205 methadone patients who were in treatment in 1993 and 1 994. Their average age was 37.9 years, and the average age for the men was 39.6 years. The personality traits were compared with those of an untreated control group of 1 9 1 men and 196 women representing the general population. This same group has previously been considered as a normal population and used as a control group in other studies (Gustavsson et al . 2000; Gustavsson 1 997).

Procedure Two sources of information were used: ( 1 ) the inter­

views; and (2) the KSP questionnaire. The interviews were performed in 1 993 and 1 994

using a structured questionnaire about home background factors, personality, physical health, and drug and alcohol use. Questions were also asked concerning drug use among parents. The possible answers were "never," "rarely," "sometimes," and "often." The questions about psychiat­ric status asked whether the subjects suffered from depression, hallucinations, anxiety, suicidal thoughts, con­centration problems and difficulties in controlling violence. The reply alternatives were "never," or "yes, during my lifetime," or "during the last three months." The questions were similar to those in the Addiction Severity Index ques­tionnaire (Zanis, McLellan & Corse 1997).

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Leaving Methadone Maintenance

To obtain information about personality traits, the patients were asked to fill in the KSP questionnaire origi­nally developed by Schalling ( 1978, 1977). The inventory is mainly a test battery initially compiled as a tool useful in research and in finding biological correlates of relevant personality traits. It consists of 135 items grouped into 15 different scales. The subject has to choose one out of four possible levels of agreement: "do not agree at all," "do not agree very well," "agree fairly well," and "agree exactly." The scales have been described in detail elsewhere (Portala et al. 2001 ; Gustavsson et al. 2000; Gustavsson 1997). The 15 scales are:

( 1 ) Socialization: the ability to identify with rules and norms in society;

(2) Impulsiveness: acting immediately; not planning, being impulsive;

(3) Avoidance of monotony: avoiding routine, needing constant change and action (seeking sensation);

(4) Psychic anxiety: worrying, low self-confidence, being sensitive;

(5) Somatic anxiety: suffering from autonomic (physi­cal) disturbances, being restless, panicky;

(6) Muscular tension: feeling tense and stiff, not being relaxed;

(7) Detachment: avoiding involvement with others, being withdrawn;

(8) Psychasthenia: being easily fatigued and uneasy when facing new situations and tasks;

(9) Irritability: being irritable, lacking patience; (10) Verbal aggression: getting into arguments, berat­

ing people when annoyed; ( 1 1 ) Indirect aggression: sulking, slamming doors when

angry; ( 1 2) Inhibited aggression: lacking the ability to speak

up and be self-assertive in social situations; ( 13) Guilt: being distressed, being ashamed of own bad

thoughts; ( 14) Suspicion: being suspicious of others; and ( 15) Social desirability: conforming socially; being

friendly, helpful, feeling the need to satisfy others. The validity of the questionnaire has been discussed

elsewhere (Gustavsson et al . 2000; Gustavsson 1 997). Gustavsson (1997) found that the KSP demonstrated sta­bility and construct validity over time. The test-retest and internal consistency reliability has elsewhere been described as satisfactory, except for the aggression scales, which have been termed "not so satisfactory" (Bergman et al. 1983).

The study protocol was approved by the Research Eth­ics Committee of the Karolinska Institute in Stockholm, Sweden. The methadone patients were then recruited through means of a search of records about expulsion from treatment in the programs up to 1998. Some patients (n = 49) had difficulties in complying with treatment and were con­sequently expelled from the treatment, mostly due to use of drugs besides methadone or to violation of the rules of

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TABLE 1 Personality Traits in 1993-1994 Among Methadone Patients and a Control Group from the General Population

Measured by the Karolinska Scales of Personality (KSP) Questionnaire•••••

Methadone, Women (N=53) Methadone, Men (N=l30) T-test Versus T-test Versus

Control Group Control Group Mean (SD) (P-value) Mean (SD) (P-value)

Psychic anxiety 48.0 ( 10.4) 0.27 53.3 ( 1 1 .3) 0.04* Somatic anxiety 53.8 ( 12.6) 0.07 59.2 ( 1 1 .9) <0.000 1 **** Muscular tension 56.7 ( 13.7) 0.003* * 60.6 ( 1 5 .0) <0.0001 **** Avoidance of monotony 43.8 ( 1 0.7) 0.03* 4 1 .2 (9.7) 0.09 Impu1si veness 54.2 ( 1 1 .03) 0.02* 56.2 (9.9) <0. 000 I • • ** Socialization 30.6 ( 13 .4) <0.0001 **** 30.3 ( 12.0) <0.0001 **** Social desirability 49.3 (9.9) 0.89 45.8 (7.6) <0. 000 1 ** •• Psychasthenia 53. 1 ( 13 .7) 0. 1 6 58.0 ( 1 0. 1 ) <0.0001 •••• Detachment 48.2 ( 1 3.5) 0.77 48.7 ( 1 1 .4) 0.24 Suspicion 55.8 ( 13 .0) 0.002** 53.7 ( 1 1 .4) 0.006** Guilt 46.2 (9.3) 0. 14 44.9 (9.2) 0.05* Irritability 48.5 ( 10. 1 ) 0.34 5 1 .7 ( 10.0) 0. 19 Indirect aggression 5 1 .8 ( 10. 1 ) 0.24 52.8 (7.5) 0.03* Verbal aggression 52.9 ( 1 0.9) 0.09 53.8 (8.9) 0.007** Inhibited aggression 52.7 ( 1 0.2) 0.02* 52.7 ( 1 1 .4) <0.0001 ••••

•p < 0.05 **P < 0.01 •••p < 0.001 ••••p < 0.0001 . •••••T-test scores with the probability value (P-value). The T-test i s performed on raw points compared with the control group

according to age distribution and gender.

the program, including manipulation of the dose or urine samples. No patients voluntarily left the treatment.

Analysis of Data The association between personality trait factors and

expulsion from methadone treatment was measured with discriminant analysis and Cox regression analysis. The raw scores of the KSP were transformed into T-scores (x-mean of healthy volunteers/standard deviation (SD) of healthy controls x 10+50). The control group comprised 191 men and 196 women from the general population. Age and sex dif­ferences were taken into consideration when using T-scores.

RESULTS

The personality traits among methadone patients com­pared with the control group are shown in Table 1 . The male methadone patients differed most significantly from the men in the control group by scoring differently in seven out of the 15 personality traits. They had significantly (p < 0.0001 ) higher scores on somatic anxiety, muscular tension, impul­siveness, and psychasthenia and significantly lower scores in socialization, social desirability, and inhibited aggres­sion. The female methadone patients mostly differed in single personality traits (e.g., socialization) from the women in the control group (p < 0.0001 ). Both female and male methadone patients had significantly higher (p < 0.01) scores on suspicious traits than the control group.

Journal of Psychoactive Drugs 230

By 1998, 49 (28%) patients had left the methadone maintenance treatment and four (2%) persons had died dur­ing the follow-up period (Table 2). Nearly one-third (27%) of those patients who reported alcohol or substance abuse (illicit drugs, use of sedatives and/or hypnotics, or alcohol use) among their fathers or mothers had unwillingly left treatment, compared with 38% of those who did not report family drug use. Individual problems (running away from home, problems at school, problems with friends) were frequent among the patients. Of the 94% who reported any behavioral problems, 29% were later expelled. Nearly half (43%) of those patients who had experienced separations (came from broken homes) at a young age (thee years or younger) and around one-fourth of those whose parents had separated later (when the patients were four to 15 years old) or whose families had not separated were expelled from the treatment. Sixteen out of 33 ( 48%) HIV-positive patients had difficulties with compliance with treatment. Early experience (less than 1 9 years of age) with illicit drugs was also strongly associated (59%) with being expelled from treatment.

The impact of drug-using behavior during treatment on later expulsion due to misconduct was also analyzed. It was found that nearly half (44%) of those patients who reported no decrease in, or cessation of, substance abuse during the last three months were expelled from treatment, compared with 25% of those who had no problems with discontinuing narcotic use. Cessation of, or reduction in,

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TABLE 2 Background and Psychiatric Symptoms Among 174 Methadone Patients

Interviewed in 1993-1994 in Relation to Expulsion from Methadone Treatment

Background Factors Male Female Living condition

Single Married/cohabiting Other

Broken home No three years old or less four to 1 5 years

Drug use in the family* No Yes

Behavioral problems** No Yes

HIV No Yes

Age at first drug use <15 15-19 >20

Psychological Factors Depression

Never Lifetime Last three months

Anxiety Never Lifetime Last three months

Hallucinations Never Lifetime Last three months

Concentration problems Never Lifetime Last three months

Violence problems Never Lifetime Last three months

Suicidal thoughts Never Lifetime Last three months

Total (n=174) Expelled (n=49) N (%)

1 2 1 39 (32) 53 10 ( 19)

9 1 26 (29) 73 2 1 (29)

9 2 (22)

1 1 2 3 0 (27) 23 10 (43) 38 9 (24)

1 3 5 (38) 161 44 (27)

1 1 2 ( 1 8) 163 47 (29)

141 33 (23) 33 16 (48)

82 24 (30) 7 1 20 (29) 1 3 2 ( 1 5)

96 28 (29) 52 15 (29) 25 6 (24)

8 1 25 (31) 57 14 (24) 35 10 (28)

148 43 (29) 1 9 3 ( 16) 2 0

88 24 (28) 30 6 (20) 54 1 8 (33)

148 42 (28) 22 6 (27)

2 0

1 1 1 35 (32) 54 15 (28)

6 2 (33)

Note: The figures do not always add up to 174 in the left column or to 49 in the right column because of missing values. HIV=hurnan immunodeficiency virus.

*This included illicit drugs/hypnotics/sedatives and alcohol use. ••Running away from home, problems at school, and problems with friends

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TABLE 3 Canonical Discriminant Analysis of Personality Traits and Expulsion from Methadone Treatment*

F-Test

Psychic anxiety Somatic anxiety Muscular tension Avoidance of monotony Impulsiveness Socialization Social desirability Psychoasthenia Detachment Suspicion Guilt Irritability Indirect aggression Verbal aggression Inhibited aggression

*Total sample standardized canonical coefficients.

alcohol abuse was not associated with being expelled from treatment. Very few patients reported alcohol consumption during treatment.

One-third of patients who reported concentration dif­ficulties during the last three months were later expelled from treatment, as were one-third of patients who stated that they had had suicidal thoughts during the last three months. Among those patients (n = 77) who had ever in their lifetime or during the last three months suffered from serious depression, 27% were expelled. Many persons (n = 92) had suffered from anxiety. Of these, 24 (26%) were expelled.

Results of a canonical discriminant analysis including all personality traits in relation to expulsion from treatment (p = 0.34) are shown in Table 3. Low socialization (p = 0.57), social desirability (p = 0.36), detachment (p = 0.4 1), guilt (p = 0.57), and suspicion (p = 0.44) were most strongly associated with expulsion from the program.

DISCUSSION

A main finding of the study is that low socialization, guilt, and suspicion were most predictive for later expul­sion from treatment (Table 3). Previous studies have found that deviant and norm-breaking behavior at a young age and the feeling of being excluded from society may be associated with difficulties in forming close and stable relationships in adult life and with less resistance to drug use (Stattin, Romelsjo & Stenbacka 1997).

It was also found that HIV-positive status was strongly associated with later expulsion from treatment. Nearly half ( 1 6 patients out of 33) of the methadone patients who suf­fered from HIV infection were later expelled. One possible explanation for the high rate of expulsions in this group is that an HIV diagnosis is in itself a traumatic experience,

Journal of Psychoactive Drugs 232

Expulsion from Treatment (P = 0.34)

-0.02 0.08

-0.26 0.24 0.20 0.57 0.36

-0.45 0.4 1 0.44 0.57 0.05

-0.3 1 -0.39 -0.20

which could lead to relapse to alcohol and illicit drugs. This was especially true prior to the introduction of the new and more effective medications for HIV-positive patients. Opiate abusers who are seriously ill from HIV infection can apply for a new treatment period if their doc­tors find this necessary for recovery from opiate abuse. In an earlier study on inpatient care among methadone patients, it was found that HIV-positive patients who had two main­tenance treatment periods had a higher rate of inpatient care between the treatment periods than during the main­tenance treatment. The rates of inpatient care did decrease during the second treatment period, but more so among HIV-negative patients. It was obvious that HIV patients seek treatment while waiting for the second maintenance treatment period (Stenbacka, Leifman & Romelsjo 2003, 1998). This is in line with results of other studies, which emphasize factors like patient characteristics, the availabil­ity of programs, patient motivation, and the dose of methadone as predictors for the treatment outcome (Ball & Ross 199 1 ; Caplehorn & Bell 199 1 ).

Brooner and colleagues ( 1997), in their study of 7 1 6 opiate users seeking methadone treatment, report that psy­chiatric disorders were documented in nearly half of the group. Antisocial personality disorder and major depres­sion were the most common diagnoses. The authors found a positive relationship with psychiatric comorbidity and severity of substance use and poor outcome. In a survey of 501 patients seeking treatment for drug problems at an addiction research and treatment facility in Toronto, Canada, Ross and colleagues ( 1 988) found that 78% of the sample had a psychiatric disorder in addition to sub­stance use and nearly two-thirds had a current mental disorder. This is in line with the present findings, namely, that those patients who reported psychiatric problems and

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especially suicidal thoughts were often expelled from treat­ment. However, in a review of 36 studies of integrated treatment of substance abuse and psychiatric illness, it was found that programs which offered integrated treatment of both substance abuse and psychiatric illness had better treatment outcomes than did programs which treated psychiatric illness and substance abuse separately, either in time or with separate teams (Drake et al. 1998, 1997; Meuser, Drake & Wallach 1998).

Another finding was that the methadone patients had significantly higher scores on suspicious traits than the con­trol group, which could lead to problems with cooperation with the staff of the methadone program and less trust in the counselor. One must also assume that many methadone patients, often from adolescence, have lived in criminal gangs or neighborhoods. Outside this community, the patients feel uncomfortable and stigmatized as drug users. This may affect the patients in a negative way in terms of becoming more careful with, and suspicious of, contact with the general population and the authorities. This could nega­tively affect treatment outcomes and rehabilitation.

The methadone patients in this study had more somatic anxiety, suffered more from muscular tension and psychas­thenia, were less socialized, and had a higher tendency to impulsiveness than did the control group from the general population. One possible reason for the differences between methadone patients and the control �;roup is that the patients were not aware of their own feelings due to the effects of the methadone, which may lead to mental fatigue and dif­ficulties in controlling impulsive behavior.

The female methadone patients differed less in per­sonality factors from the control group than did the men. More than one-third of the women were married or cohab­iting and they also often took care of the children. A clinical impression is that female methadone patients more often take responsibility for maintaining the social structure of the family, look after the children, manage the family's economy as well as the household, and make things run in a structured way. Another possible explanation, therefore, is that the female methadone patients were less involved in criminal activities and more often sought treatment for their drug use and for infectious and HIV diseases before starting maintenance treatment than the male methadone patients.

Leaving Methadone Maintenance

However, the women did have significantly lower scores in socialization than the control group. In a study by Gunne and colleagues ( 1995), 70% of 105 female heroin users were prostitutes and the rest relied on criminality to fund their own drug use. Other studies have shown that female opiate users do not directly take part in the criminal activities but often help their male counterparts by selling stolen goods, standing guard, acting as a decoy, and so on.

One problem with the study is that methadone may have an effect on the personality factors of the patients. Methadone blocks the effects of heroin and stops the crav­ing for the substance; also, it has a pain-relieving effect. This means that the drug may have a suppressant effect on personality factors, such as muscular tension and psychic anxiety. In Sweden, however, maintenance treatment is very controlled and if patients manipulate the dosage (and sell or buy drugs) they are at risk of being expelled from the treatment. Patients in treatment programs regularly have to give plasma and urine samples for control of other sub­stances as well as methadone.

It must be assumed that opiate abusers who apply for methadone maintenance treatment do so voluntarily and expect improvements in many respects and consequently change their drug-related behavior. Therefore, as previously mentioned, selection of presumably motivated patients who apply for methadone treatment could partly explain the good outcome of maintenance treatment (Strain et al. 1994; Maisto, McKay & Connors 1990; Magura et al. 1987). Most patients who go on treatment have previously been treated for narcomania by detoxification, often several times before the current treatment. Another explanation for the good outcome of the treatment could be that the social welfare authorities recommend methadone treatment to opiate abus­ers with poor living conditions or poor health status.

So far, studies have focused on medical and biological factors as being most important in relation to treatment of substance use. However, identification of psychological problems is of great value when meeting the patients' needs, especially at the beginning of the treatment period, when the dropout rate seems to be highest (Stenbacka & Romelsjt> 1997). Such identification and, possibly, treatment of psy­chological problems may be crucial to the patients' improvement as well as to society as a whole.

REFERENCES

Alterman, A.l.; McLellan, T. & Shifman, R.B. 1993. Do substance abuse patients with more psychopathology receive more treatment? Journal of Nervous Mental Diseases 1 8 1 : 576-82.

American Psychiatric Association (APA). 1980. Diagnostic and Statistical Manual of Mental Disorders, Revised Edition. Washington, D.C.: American Psychiatric Association.

Ball, J.C. & Ross, A. 1991 . The Effectiveness of Methadone Maintenance Treatment. New York: Springer Verlag.

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Ball, J.S.; Lange, W.R.; Meyers, C.P. & Friedman, S.R. 1988. Reducing the risk of AIDS through methadone maintenance treatment. Journal of Health and Social Behaviour 29: 214-26.

Bergman, H.; Bergman, I.; Engelbrektson, K.; Holm, L.; Johannesson, K. & Lindberg, S. 1983. Psykologhandboken. [Manual for Psychologists] Stockholm, Sweden: Magnus Huss Clinic, Karolinska Hospital.

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