Methadone treatment practices and outcomes associated with them: An application of institutional theory.

Abstract

This study proposes that institutional theory is a useful perspective for explaining the adoption of methadone treatment practices. Institutional theorists argue that in fields, such as methadone treatment, characterized by weak markets and poorly understood technologies, organizations adopt structures and practices to conform to the demands of critical external actors. In so doing, they are seen as legitimate and gain access to important resources (D'Aunno, Price and Sutton, 1991; Meyer and Rowan, 1977). A second purpose of this study is to explore whether institutional forces have direct or indirect effects, through the treatment practices adopted, on client outcomes (i.e. tenure in treatment and the use of needles to inject drugs while still in treatment). Results of path analysis using data from a nationally representative sample of 133 methadone treatment units show that the expectations of key external actors, such as government regulators, professional associations, and public opinion, influence treatment practices after explicitly controlling for the effects of market forces and task contingencies. They also show the influence of managers' ideological stances on treatment practices. One implication is that future empirical research should explore how organizations react to the effects of conflicting expectations, or expectations that conflict with organizational ideology. This study provides strong, nationally representative evidence that the low dose-temporary substitute approach is the dominant methadone treatment paradigm and that this approach is less effective than the high dose-maintenance approach. Several suggestions for policy and practice are made. First, federal and state regulations should provide flexibility at the upper end of dose levels. In other words, treatment staff should be given the wherewithal to adequately medicate their clients. Second, the correlations between client characteristics and treatment practices suggest that licensing bodies should determine whether certain types of clients are systematically receiving inferior treatment. Finally, there should be education campaigns, aimed at both treatment practitioners and the general public, regarding the effectiveness of high methadone doses and long-term maintenance for treating heroin addiction.