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significant impact on the program’s ability to meet the medical
needs of its patients.

Improvement in Psychiatric and Psychosocial Functioning

As in other modalities of addiction treatment, co-occurring disorders
are the norm, not the exception. In fact there is some evidence that
heroin users who seek treatment have higher rates of psychiatric
disorders such as depression than those who do not. Mood and
anxiety disorders (especially Post Traumatic Stress Disorder, or
PTSD) are the most common. Psychotic conditions unrelated to drug
use are relatively uncommon, but most clinics have a small number of
severely mentally ill patients enrolled in their programs. In general,
methadone is compatible with psychotropic medications, though some
must be carefully monitored. Appropriate treatment of a co-existing
psychiatric condition improves treatment outcome. Unfortunately,
many clinics to not have the resources to address such conditions
effectively. It is increasingly common for counseling staff to be
exposed to cognitive behavioral techniques supported by research
evidence. It is unclear how well they are prepared to implement these
interventions. Although research-based interventions for PTSD exist,
they generally require a higher level of clinical skill and it is unusual
to find specific program components within clinics, despite the high
prevalence of this disorder in both men and women.

Employment, pursuit of education, and family functioning are key
psychosocial indicators that improve when given appropriate forms of
attention. Enhanced services result in improvement in these areas,
especially if there is a tight fit between the specific services offered
and the patient’s problem profile (McLellan, Arndt, Metzger, Woody,
& O'Brien, 1993; McLellan et al., 1997; McLellan et al., 1998).
Although both accreditation and state regulations stress the importance
of using a focused treatment plan to guide counseling sessions,
counselors report that complex demands for documentation reduce the
time they have available to attend to patient needs. Case management
becomes increasingly difficult as community resources are lost.