Survey of client satisfaction with methadone maintenance programmes

AIMS AND METHOD The aim of the study was to elicit clients’ satisfaction with the methadone maintenance service and their views regarding opiate users not in the service. A self-completion questionnaire with 40 questions covering various aspects of service delivery was given to clients on this programme. RESULTS Of a total of 52 questionnaires, 31 (60%) were returned. There was a high level of overall satisfaction (93%) with the service and staff, but there were significant problems related to prolonged waiting times and access to ancillary services. There were also practical difficulties related to prescriptions. Over half of the clients (54%) used additional illicit opiates.

The aim of the study was to elicit clients' satisfaction with the methadone maintenance service and their views regarding opiate users not in the service.A self-completion questionnaire with 40 questions covering various aspects of service delivery was given to clients on this programme.

RESULTS
Of a total of 52 questionnaires, 31 (60%) were returned.There was a high level of overall satisfaction (93%) with the service and staff, but there were significant problems related to prolonged waiting times and access to ancillary services.There were also practical difficulties related to prescriptions.Over half of the clients (54%) used additional illicit opiates.

CLINICAL IMPLICATIONS
It is likely that addressing identified problem areas may influence treatment outcome in this challenging group.Staff should maintain optimism in helping the clients who, as seen by this survey, value their advice.
Client satisfaction surveys add an important consumer perspective to the evaluation of treatment programmes.Surveys may be the only means for clients to express their views about new services that are needed (World Health Organization, 2000).
Despite strong evidence for the efficacy of methadone in the treatment of heroin dependence, the relapse rates are quite high in routine clinical practice (Newman & Whitehill, 1979;Hubbard et al, 1989;Gossop et al, 2002).Treatment outcome can be influenced by several factors, such as client characteristics, diversity of needs, expectations and satisfaction of clients (Joe et al, 1991a).
Previous studies have attempted to study needs of a broad group of substance misuse clients, such as those in harm reduction programmes, needle exchanges, inpatient detoxification centres, rehabilitation units, as well as clients on methadone maintenance programmes (Joe et al, 1991b;Fountain et al, 2000).
Methadone maintenance treatment constitutes the bulk of treatment modalities and workload.The needs of clients having this treatment are different in terms of duration of treatment, complexity of psychosocial disadvantages and physical health problems, compared with other users and we aimed to examine their needs.

Method
The study was conducted in a drug treatment centre based in Darlington in North-East England.The centre provides methadone maintenance treatment as well as counselling, harm minimisation and detoxification programmes, and works in liaison with social services, housing and local psychiatric services.The clients are referred to the service by primary care, social services, probation and psychiatric services.A self-referral system is in place.
A self-completion questionnaire was based on the World Health Organization Client Satisfaction Evaluation Workbook (World Health Organization, 2000), in consul- tation with staff.It was designed to be completed in 10 min and consisted of 40 questions, which explored client characteristics, accessibility to services and treatment, attitudes to prescriptions, response from staff and access to ancillary services.Clients were required to answer using 'yes/no' tick boxes and a space was provided for comments to each question.A separate section of the questionnaire was designed to elicit clients' views on why other drug users were not using the service.
Clients were handed the questionnaire during their visit to the centre with a letter explaining the study.To maximise the response rate, anonymity was assured and they were asked to return the questionnaire via a dropbox.They were encouraged to complete the questionnaires privately but if clarification was required were encouraged to contact any member of the staff.
All clients attending our centre for methadone maintenance programmes were considered eligible.As the centre provides weekly prescriptions, we were able to contact all of them over a 2-week period.

Results
A total of 52 clients were eligible; 31 (60%) returned the completed questionnaires.Results describing client characteristics are listed in Table 1.

Access to services
Initial assessment at the centre is carried out by a member of the multidisciplinary team -Stage A. Clients suitable for the methadone maintenance programme are then referred to the addiction psychiatrist for methadone prescription -Stage B. Between Stage A and Stage B, ancillary services are provided.Waiting times are shown in Tables 2 and 3. Most clients identified the long waiting times as a problem and reported that they expected to be assessed within a week of the initial referral.

Services and centre facilities
Questions were asked about location, privacy, waiting areas, facilities for the disabled, etc.; 93% expressed satisfaction with the service and 70% were pleased with the facilities.
A standard practice in most drug treatment centres is to engage clients into a treatment contract, which requires them to provide regular urine samples, avoid any additional opiates, etc.A breach of contract may lead to discharge from the service.When asked if clients who defaulted from the contract should be discharged from the treatment programme, 45% of clients disagreed.
Staff at the centre Most clients (27, 87%), reported no problems in accessing their keyworker.Overall, most clients reported feeling accepted by keyworkers and had received valuable advice from them.

Prescriptions
The prescription of methadone falls under the aegis of the Home Office.Prescriptions are required to be precise and legible.Unfortunately, minor mistakes are frequently uncovered by local pharmacies.Most services require clients to consume methadone under pharmacy supervision.Clients' views were obtained and several related difficulties were identified: 5 (16%) felt they were not often consulted in treatment decisions; time delays or incorrect dose were reported by 15 clients (48%); 6 (19%) reported difficulties in accessing the pharmacy.Clients also commented on the lack of privacy when taking methadone and the negative attitude of pharmacy staff.Six (19%) felt that daily supervised medication was discriminatory.However, 27 (87%) were satisfied with the dose of methadone.

Ancillary services
There were 28 clients (90%) who reported that they had received information on safe drug use and injecting.This is important because of the high proportion of additional illicit opiate users (see Table 1).Twelve (39%) said they would have liked more information, and 8 (26%) felt they needed more advice on psychological, social, legal and other issues.

Non-users of the service
The questionnaire was also designed to elicit information on drug users who were not engaged in the service.Clients were asked to consider one or more of four options (see Table 4).Most clients advised shortening the long waiting times to attract more users.Some other suggestions included: 'advertising', '24 hour, 365 days service' and 'addicts to nominate addicts'.

Discussion
The survey shows that a large proportion of users are affected by long waiting lists.There was a long delay before initial assessment and then obtaining a prescription.Most clients have diverse social, legal, housing, financial and psychological needs, which can cause chaotic lifestyles and affect using the service.Information and advice regarding these topics was requested by 8 clients (26%).Pre-treatment psychological adjustment and social support are shown to result in good treatment outcomes (Hubbard et al, 1989;Joe et al, 1991a;McLellan et al, 1993).Reduction in waiting times is therefore an opportunity to provide help.
Kumar & Rajwal Methadone maintenance programmes original papers Nearly half of the respondents experienced practical problems in obtaining prescriptions.Although only 12% were dissatisfied with their individual prescribed dose of methadone, 54% reported additional use of opiates.This is a significant proportion and may reflect difficulties faced in obtaining a prescription and under-prescription.The latter, is important as low dose methadone has been linked to poor compliance (Joe et al, 1991b;Caplehorn et al, 1993).
The survey also showed that clients feel discriminated against and a lack of privacy in taking methadone under supervision in a pharmacy.Daily supervised consumption has the advantage of ensuring safe consumption but can also violate personal dignity and dominate daily routine, affecting chances of employment and rehabilitation of the individual.These views need consideration in the planning of future services.
It was interesting to note that about half the clients disagreed with discharging those who defaulted contractual agreements.This may indicate that most clients consider violation of contract as a very real possibility during the course of treatment.From a service point of view, the contract is a practical as well as psychological boundary, which services need to impose, and the issue needs further exploration.
Although client satisfaction surveys can reflect unrealistic expectations, research on mental health service users shows that they can effectively discriminate between services that differ in quality (Lebour, 1983;Sheppard, 1993).The sample size in this study was small but reflected local services similar to those in any treatment centre which caters for a mixed semi-urban and rural population.
The response rate was moderate at 60%, as it can be difficult to engage substance misusers (Kay & Peters, 1992;Fountain et al, 2000).One of the features of the study was that the sample included clients with comorbid mental health problems.Owing to the high prevalence of mental health problems in a substance misuse population it is important that their views are included in the planning of services.
The survey indicated that most users have overall satisfaction with the service.There are problems regarding long waiting times, poor awareness in nonusers and with prescriptions.These findings could be further strengthened by conducting focus group interviews, which may help in planning future services.

Declaration of interest
None.

Table 1 .
Client characteristics

Table 2 .
Waiting times in Stage A