title: Improving psychosocial health and employment outcomes for individuals receiving methadone treatment: a realist synthesis of what makes interventions work.
abstract: BACKGROUND
  For over 50 years, methadone has been prescribed to opioid-dependent individuals as a pharmacological approach for alleviating the symptoms of opioid withdrawal. However, individuals prescribed methadone sometimes require additional interventions (e.g., counseling) to further improve their health. This study undertook a realist synthesis of evaluations of interventions aimed at improving the psychosocial and employment outcomes of individuals on methadone treatment, to determine what interventions work (or not) and why.
  
  
  METHODS
  The realist synthesis method was utilized because it uncovers the processes (or mechanisms) that lead to particular outcomes, and the contexts within which this occurs. A comprehensive search process resulted in 31 articles for review. Data were extracted from the articles, and placed in four templates to assist with analysis. Data analysis was an iterative process and involved comparing and contrasting data within and across each template, and cross checking with original articles to determine key patterns in the data.
  
  
  RESULTS
  For individuals on methadone, engagement with an intervention appears to be important for improved psychosocial and/or employment outcomes. The engagement process involves attendance at interventions as well as an investment in what is offered. Three intervention contexts (often in some combination) support the engagement process: a) client-centered contexts (or those where clients' psychosocial and/or employment needs/issues/skills are recognized and/or addressed); b) contexts which address clients' socio-economic conditions and needs; and, c) contexts where there are positive client-counselor and/or peer relationships. There is some evidence that sometimes ongoing engagement is necessary to maintain positive outcomes. There is also some evidence that complete abstinence from drugs (e.g., cocaine, heroin) is not necessary for engagement.
  
  
  CONCLUSIONS
  It is important to consider how the contexts of interventions might elicit and/or support clients' engagement. Further research is needed to explore how an individual's background (e.g., involvement with different interventions over an extended period) may influence engagement. Long-term engagement may be necessary to sustain some positive outcomes although how long is unclear and requires further research. Engagement can occur without complete abstinence from such drugs as cocaine or heroin, but additional research is required as engagement may be influenced by the extent and type of drug use.
authors.affiliation: School of Health and Human Performance, Dalhousie University, 6230 South Street, P.O. Box 15000, Halifax, NS B3H 4R2 Canada ; Atlantic Health Promotion Research Centre, Dalhousie University, 1318 Robie Street, Halifax, NS B3H 3E2 Canada.
authors.forename: Lois A
authors.initials: LA
authors.lastname: Jackson
authors.affiliation: School of Population & Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3 Canada.
authors.forename: Jane A
authors.initials: JA
authors.lastname: Buxton
authors.affiliation: AIDS Saint John, 62 Waterloo St, Saint John, NB E2L 3P3 Canada.
authors.forename: Julie
authors.initials: J
authors.lastname: Dingwell
authors.affiliation: University of New Brunswick, 2140 Hanwell Rd, Hanwell, NB B3C 1 M8 Canada.
authors.forename: Margaret
authors.initials: M
authors.lastname: Dykeman
authors.affiliation: School of Health and Human Performance, Dalhousie University, 6230 South Street, P.O. Box 15000, Halifax, NS B3H 4R2 Canada ; Atlantic Health Promotion Research Centre, Dalhousie University, 1318 Robie Street, Halifax, NS B3H 3E2 Canada.
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Gahagan
authors.affiliation: School of Health and Human Performance, Dalhousie University, 6230 South Street, P.O. Box 15000, Halifax, NS B3H 4R2 Canada.
authors.forename: Karen
authors.initials: K
authors.lastname: Gallant
authors.affiliation: School of Social Work, Dalhousie University, Suite 3201-1459 LeMarchant Street, PO Box 15000, Halifax, NS B3H 4R2 Canada.
authors.forename: Jeff
authors.initials: J
authors.lastname: Karabanow
authors.affiliation: Community Health & Epidemiology, Dalhousie University, 5790 University Ave., 4th Floor, Halifax, NS B3H 1 V7 Canada.
authors.forename: Susan
authors.initials: S
authors.lastname: Kirkland
authors.affiliation: School of Health and Human Performance, Dalhousie University, 6230 South Street, P.O. Box 15000, Halifax, NS B3H 4R2 Canada ; Atlantic Health Promotion Research Centre, Dalhousie University, 1318 Robie Street, Halifax, NS B3H 3E2 Canada.
authors.forename: Dolores
authors.initials: D
authors.lastname: LeVangie
authors.affiliation: College of Pharmacy, Dalhousie University, 5968 College St, Halifax, NS B3H 4R2 Canada.
authors.forename: Ingrid
authors.initials: I
authors.lastname: Sketris
authors.affiliation: National Addiction Centre, King's College London, PO48, 4 Windsor Walk, Denmark Hill, London, SE5 8BB UK.
authors.forename: Michael
authors.initials: M
authors.lastname: Gossop
authors.affiliation: Mental Health, Children's Services, and Addictions Branch, Nova Scotia Department of Health and Wellness, PO Box 488, Halifax, NS B3J 2R8 Canada.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Davison
keywords: Client-centered; Employment outcomes; Engagement; Methadone treatment; Opiates; Opioids; Positive relationships; Psychosocial health; Realist synthesis; Socio-economic conditions