Attitudes of Methadone Program Staff toward Provision of Harm Reduction and Other Services

Abstract

Objective

The need for expansion of health services provided in drug treatment programs has been widely discussed since the beginning of the HIV epidemic among drug users. Service expansion has focused on various types of services including medical services (e.g., primary care) and harm reduction services (e.g., provision of sterile syringes).

Methods

A staff survey was conducted in eight methadone maintenance clinics in the New York/New Jersey area to assess attitudes towards the provision of harm reduction and other services in methadone clinics, and the relationship of these attitudes to other variables.

Participants

A total of 114 staff members in eight methadone maintenance clinics completed the survey.

Results

The majority of staff was supportive of adding services, over 90% supported medical services, and the majority supported harm reduction services such as syringe access and disposal services. Higher education and HIV knowledge levels were significant correlates of favorable attitudes toward service provision.

Conclusion

Support for providing harm reduction services in methadone maintenance clinics was found. Enhancing knowledge of staff regarding various types of health services, and engaging them in how best to institute new services, should be undertaken when new services are planned.

Introduction

Discussions regarding the expansion of health services in methadone maintenance treatment programs (MMTP) have intensified since the HIV/AIDS epidemic in the 1980s (Samet, 2001; Selwyn et al., 1993). These discussions have focused on expansion of medical services (e.g., hepatitis-related prevention) and harm reduction services (e.g., provision of clean syringes to injectors). While many programs have expanded services, debates still continue, many relating to cost and other resource considerations. For example, in a nationwide sample of drug treatment programs in the United States, Strauss et al. (Strauss et al., 2003) found that while MMTP programs were more likely to provide hepatitis C (HCV) prevention and care services than drug-free programs, only about one-third of MMTP programs tested all their patients for HCV. In terms of harm reduction services, there are also concerns about drug treatment programs appearing to condone continued injection behaviors (Schoenbaum et al., 1996). Assessing attitudes of clinic staff towards providing various services is an important consideration in decision-making regarding expansion of services, and in planning their implementation. This is especially important in light of findings by Goddard (Goddard, 2003) that education regarding harm reduction approaches may lead to changes in drug treatment professionals’ attitudes toward harm reduction.

As part of an intervention study that trained methadone patients to conduct HIV/AIDS outreach, a survey was administered to staff in MMTP clinics. The survey included questions on attitudes about providing a range of medical and harm reduction services to clinic patients. Measures of communication between staff, administration and clinic patients were included, based on prior research indicating that staff communication was related to health service provision (Lehman et al., 2002). This paper reports on the results of that survey, and examines the relationship between these attitudes and other variables.

Methods

During 2005–2008, an intervention study was conducted in eight MMTP clinics in New York/New Jersey (Deren, Kang, Mino, & Guarino, in press; Colón, Deren, Guarino, Mino, & Kang, 2010). The intervention trained patients who were familiar with drug use in Puerto Rico to conduct HIV-related outreach to other Puerto Rican drug users who had formerly used drugs in Puerto Rico. As part of the study, a survey was administered to clinic staff, at baseline and at follow-up intervals, to assess MMTP staff attitudes toward the provision of harm reduction services in MMTP clinics. In addition to items specific to harm reduction services (e.g., providing access to sterile syringes and safe syringe disposal), a range of other types of services was included (e.g., vocational training, hepatitis C testing, etc.). These were included to obtain comparative attitudinal data for services likely to show a range of acceptability to staff. This paper reports on the baseline data, collected before clinics were assigned to study conditions. All procedures and forms were approved by the Institution Review Board (IRB) of the grantee organization (NDRI, Inc.), and the IRBs of the participating clinics. Six clinics in New York and two in New Jersey participated in the study.

Data Collection

The self-administered survey was anonymous, requiring approximately 15 minutes for completion. It was administered in group format to all staff in each clinic, after a brief presentation was made about the upcoming intervention study and informed consent was obtained. Lunch was provided during the project presentation, no additional staff incentives were provided for completing the survey. Data collected included sociodemographics (gender, age, race/ethnic group) and questions about education level and employment (job title, number of years employed in MMTP programs). Staff were also asked to report on the recent (prior 3 months) service referrals they made for clients, including medical services, psychiatric/psychological services, needle exchange or pharmacy needle services. In addition, an HIV knowledge test was administered, consisting of 10 True/False questions related to HIV, e.g., “sharing of injection paraphernalia, like cookers and rinse water, cannot transmit HIV or hepatitis.” The HIV knowledge score was the percent correct, and total scores could range from 0 to 1.0. Staff were asked about their level of satisfaction with communication in their clinic between administration, staff, themselves and patients (responses were very/somewhat dissatisfied, neutral, somewhat/very satisfied). They were also asked their views about the provision of specific services in MMTP clinics. The question was: “Do you think it is a good idea to offer the following services in MMTP clinics?”, and the choices were “very/somewhat bad idea, neutral, somewhat/very good idea.” Staff were asked about the provision of the following seven services (selected to provide a range of types of services): vocational training, acupuncture, hepatitis A and B vaccinations, hepatitis C testing, Primary Care, access to sterile syringes and safe syringe disposal. Program staff were instructed to seal completed questionnaires in an envelope that was collected by research project staff.

Data Analysis

Chi-square tests for nominal variables (e.g., race/ethnicity) and Pearson correlation coefficients for continuous variables (e.g., HIV knowledge) or ordinal variables (e.g., education) were used in univariate analysis. Variables associated with each of the dependent variables at p<.10 were subsequently entered into multiple logistic regression models, using attitudes toward provision of each of the services as dependent variables. In addition to examining the relationship between socio-demographic, education and employment-related characteristics with attitudes, the relationship between staff satisfaction with communication in the clinic and attitudes toward services was also assessed, as communication may be critical to the implementation and success of new programming in treatment programs (Lehman et al., 2002).

Results

Characteristics of Participants

A total of 114 MMTP staff participated in the survey (Table 1). Staff were primarily female (68%), aged over 40 (70%), and minority (42 % African American and 27% Hispanic)

Table 1.

Socio-demographic characteristics of staff Participants in 8 Clinics (N=114)

	Percent
Gender (Female)	68
Age
<31	14
31–40	16
41–50	31
>50	39
Race/Ethnicity
African-American	42
Hispanic	27
White	15
Other	16

About one-quarter of all participants had at least a Master’s degree and about half had job titles of counselors or social workers (Table 2). Over 40% of the staff had been employed in MMTPs for at least 11 years. HIV knowledge scores averaged 78% correct.

Table 2.

Education and Employment-related Characteristics of Staff Participants in 8 Clinics (N=114)

	Percent
Education Level
High School graduate	16
Associate’s degree	10
Bachelor’s degree/Nursing degree	48
Master’s degree or higher	26
Job Title
Supervisors	12
Counselors/Social workers	51
Medical staff (Nurse, Physician’s Assistant)	20
Administrative staff	17
Number of years employed in MMTPs
<1	7
1–5	31
6–10	21
11+	41
HIV knowledge: mean (SD)	.78 (.15)

Attitudes toward Service Provision

Variability was found in attitudes toward the provision of different types of services, although there were high levels of support for most services (Table 3). Medical services were considered to be a “good or very good idea” by almost all participants, over 90% for each of the services listed. Harm-reduction services were also endorsed by the majority of participants, with 68% responding that it was a good or very good idea to provide access to sterile syringes and 81% endorsing provision of safe syringe disposal. Almost all (91%) agreed that vocational training was a good or very good idea, as did 63% of participants in regard to acupuncture.

Table 3.

Attitudes toward Provision of Services (N=114)

Type of Service	Bad/very bad idea	Neutral	Good/Very good idea
Medical Services
HAV and HBV vaccination	4%	5%	91%
HCV testing	3	3	94
Primary care	3	4	93
Harm Reduction Services
Access to sterile syringes	10	22	68
Safe syringe disposal	6	13	81
Other
Vocational training	0	9	91
Acupuncture	12	25	63

Satisfaction with Communication in Clinics

Staff were asked about level of satisfaction in communication between five different groupings “you and other staff, you and patients, administration and you, staff and patients, and administration and staff.” The majority (at least 75%) reported satisfaction with the communication between themselves and other staff, themselves and patients, and staff and patients (Table 4). Only about one-half, however, were satisfied with communication between themselves and administration or between administration and staff.

Table 4.

Level of Satisfaction with Communication in MMTP Clinics (“how satisfied are you with the level of communication in your clinic between the following……?” (N=114)

	Very/somewhat dissatisfied	Neutral	Very/somewhat satisfied
You and other staff	8%	11%	81%
You and patients	4	7	89
Administration and you	29	19	52
Staff and patients	10	15	75
Administration and staff	32	17	51

Service Referrals

Data on service referrals during the past three months were examined only for those who reported having a caseload (67%) and 90% of them reported making any referrals to the services listed. The most frequent referrals were to: Psychiatric or psychological services (76%); medical services (74%); detox program (62%); drug rehab services (57%); vocational services (55%); housing assistance (49%); entitlement (e.g., SSI) (41%); legal services (26%); and needle provision services (syringe exchange programs or pharmacy syringe sales) (24%).

Correlates of Attitudes toward Service Provision

Sociodemographic, education, and employment-related variables, and the measures of clinic communication satisfaction were examined in relationship to attitudes about each service separately (Table 5). Variables related to service attitudes (at p<.10) were: age (older participants were less favorable to provision of sterile syringes and syringe disposal and more favorable to acupuncture); race/ethnicity (Blacks were more favorable to HAV/HBV vaccination, primary care, and syringe disposal); education (higher education level was related to favorable attitudes about HAV/HBV vaccination, HCV testing, vocational training, and negatively related to provision of sterile syringes), and HIV knowledge (higher knowledge scores were related to more favorable attitudes toward HAV/HBV vaccination, HCV testing, primary care and vocational training). Among the variables measuring satisfaction with communication, only the measure of satisfaction between staff and patients emerged as a significant predictor, and was positively related to HAV/HBV vaccination and HCV testing. In further analysis, a logistic regression which included each of the significant correlates was conducted (data not shown in tabular form), and dichotomized dependent variables into very/somewhat good idea/neutral and very/somewhat bad idea. The variables that remained significant in multivariate logistic regression analysis (using the p<.05 level) were: higher education and HIV knowledge levels as correlates of positive attitudes toward HAV/HBV vaccination: and higher education level as a predictor of positive attitudes toward providing HCV testing.

Table 5.

Bivariate Relationships with Attitudes toward Service Provision (N=114)

Correlates	Medical			Harm Reduction		Other
	HAV+ HBV vaccination	HCV testing	Primary care	Sterile syringes	Syringe disposal	Vocational training	Acupuncture
Age a	−.08	−.02	−.07	−.17+	−.20*	.10	.17+
Race/ethnicity	11.95+	7.35	11.50+	4.22	12.10+	2.32	4.59
Education a	.17+	.16+	.15	−.17+	.04	.17+	−.15
Job title	3.62	6.42	3.69	6.99	2.61	3.15	5.88
Number of. years employed in MMTP a	−.02	.05	.08	−0.5	−.12	.05	.12
HIV knowledge a	.33***	.22*	.25**	−.05	−.01	.16+	.09
Satisfaction w/communication
You and other staff	6.43	2.69	1.63	2.56	1.39	1.02	3.30
You and patients	1.20	2.41	1.06	2.46	5.98	1.33	1.99
Administration and you	2.52	3.33	2.39	.92	1.33	.62	2.02
Staff and patients	17.82***	7.84+	4.70	4.22	4.50	1.82	2.58
Administration and staff	3.32	3.97	.99	4.74	1.83	2.17	2.33

^aPearson correlation coefficients were used; all other variables were based on chi-square tests.

⁺p < .10;

^*p ≤ .05;

^***p ≤ .001

Discussion

The majority of MMTP staff were supportive of adding services to methadone clinics. Over 90% supported medical services such as primary care and hepatitis-related services, and vocational services. While support for harm-reduction services was lower, with 81% endorsing provision of safe syringe disposal and 68% endorsing providing access to sterile syringes, it is important to note that most of those who did not think these services were a good or very good idea reported being neutral about these services as opposed to seeing them as “bad ideas.” About one-quarter of staff reported referring their clients to services that primarily provided safe syringes, indicating that some endorsement of providing syringe services was already in operation. While the number of referrals for syringe services were relatively low, this is difficult to interpret since information about the percent of patients who were injecting was not obtained. Some drug treatment providers have found that harm reduction services, including access to sterile syringes, are compatible with drug treatment services, in terms of enhancing health-promoting behaviors (McNeely et al., 2006).

While bivariate analyses showed that sociodemographic and other variables were related to attitudes toward provision of services, in multivariate models, only education level and HIV knowledge remained significant correlates of service provision. This may indicate that enhancing HIV knowledge and knowledge regarding types of health services may be the primary means of influencing staff attitudes. A relatively brief training session has been found to impact attitudes toward harm reduction approaches, so that education or training efforts may not require extensive resources or staff time commitments (Goddard, 2003). Communication within the clinic was not found to be related to attitudes toward services in the multivariate models. However, the relatively low level of satisfaction with communication with clinic administration indicates that this may be an important element to address, especially when planning implementation of new services.

There were several limitations to this study. The sample of clinics was relatively small and all were located in a circumscribed geographic area in the northeast. Thus, the generalizability of these findings to other clinics or modalities and to other geographic locations may be limited. In addition, information as to why staff believed it was a “good” or “bad” idea to provide each service was not collected. Nonetheless, results of this study indicated that there may be support for enhancing a range of service in methadone clinics, including medical as well as harm-reduction services. Recent research on other harm reduction services. e.g., the use of naloxone for overdose reversal (Worthington et al., 2006) and safe injection facilities (Stolz et al. 2007) raises the possibility that programs may want to consider provision or referral for other harm-reduction services. Exploration of how best to institute new services, incorporating the input of administration, staff and patients should be undertaken as part of the implementation process.