Difficulties in a clinical application of methadone-dose contingency contracting

We review outcome of 14 methadone-maintenance patients who were offered a choice of administrative discharge or a methadone-dose contingency contract for continued drug abuse. In the three months before intervention, only 38% of urines were drug-free, while 55% were drug-free during the three-month intervention. Marked improvement occurred during the first month, while later the effect faded. Nine patients discontinued or reduced drug abuse, arriving at stable or fluctuating dose, and did not detoxify. Five others continued drug abuse, eventually reducing their methadone doses to zero. The procedure at least temporarily reduced drug abuse among the former group, but lack of uniformity in applying contingencies may have weakened the effect. Considering the spreading AIDS epidemic, we review the confusing literature on management of still-abusing methadone maintenance patients and suggest a protocol for their treatment.