A.T.F. Volume VI, #2. Spring, 1997
Methadone
at Work
Smack is Back- Big Time!
From the Editor
Events to Note
Reader Survey Responses
Methadone World Watch
Enlightened Belgium
Where to Get Info
Reader Survey Responses
Patient-Determined Dose Levels
In the last edition of A.T. Forum, and at our Web site - www.atforum.com - readers were asked to respond to two questions: How much input should MMT patients be allowed in determining their methadone dose levels? How might this affect their daily methadone doses?
Responses overwhelmingly supported the importance of patient input in determining dose level. And, the majority did not believe this would alter the current levels patients were receiving, provided the clinic was acting in a humane and medically supportive manner to begin with.
Three typical responses came in via e-mail (and permission was given to use names):
Howard Lotsof, president, NDA International, wrote: "As with any medication, patients should have a say in how much or little they receive. There should also be medical oversight to determine that the dose chosen by the patient is not having a negative effect, either by not providing the desired blockade of illicit opiates or by clearing faster than expected and putting the patient into withdrawal."
Beth Francisco, editor, Methadone Today, wrote: "What is the harm in letting the patient determine his/her own dose? Patients who have this choice remain in treatment longer, and that's beneficial. [Given this choice] some doses would increase no doubt, many would remain the same, and probably very few would be lower. Although, it is my understanding that most patients are very conservative when they are allowed to help determine their dose. I don't think there are many clinics that give patients a dose higher than they want - the problem is in the opposite direction."
Marc Shinderman, MD, Medical Director, Center for Addictive Problems, Chicago: "Dose determination should be a negotiation between the doctor and patient, based on clinical response [and, other measures]. Dose determination when done by patient choice alone results in average doses which are too low for blockade in [many] patients. When there is continued opiate abuse, increasing methadone dose must be a primary consideration. Methadone maintenance patients are no different than the rest of us who, as patients, tend to miss doses or take less than the doctor orders."
Following are some anonymous responses:
· "I have found for myself that the dosage I'm on is perfectly sufficient.... But, I believe I've behaved responsibly enough over the years to be able to determine the level of methadone I require - I'm not going to throw away all that I've gained just to get stoned again!"
· "I don't see any reason why I would want my dosage to change just because I can get what I want. I want to function properly in my daily life."
· "Not to allow me a say in my dose is to alienate me from my recovery process. Although at times I may not have had my own best interests at heart, I still had to have a sense that I was involved in my treatment."
· "Once a patient finds a therapeutic dose they usually stay with it. Neither wanting to be over- or under-medicated. It seems that at a lot of clinics patients aren't given the credit they deserve for being responsible with their medication."
· "A client should be able to increase or decrease their dose at their choosing to find a level that makes him/her feel comfortable. Granted, they should not be able to increase or decrease too much at one time."
· "In my program patients suggest their dose, and mostly that's what I prescribe. They know best what dose they need, as they have their physical condition as an indication. I think the situation would be better if methadone were not scheduled anymore."
· "At my clinic, patients who show signs of using are readily given increased doses. Many patients seem equally concerned about being on too high a dose as too low."
· "If the dose was okay, patients wouldn't want a change. But, as I understand it, most clinics give too low a dose, so given a choice many patients would want an increase."
Finally, another bit of research has been discovered
on the subject. As reported in the Brown University Digest of Addiction
Theory - "Participation in treatment decisions benefits methadone
maintenance patients." (October 1995) - 300 opioid addicts were
randomly assigned either to standard methadone maintenance treatment,
patient-regulated dose, or reduced counseling. Allowing patients to
self-regulate their methadone dose did not lead to a general escalation
of dose. In the twelfth month, illicit drug use and social performance
did not differ among the three groups that remained in treatment. The
authors concluded that the findings supported involving patients in
decisions regarding methadone dose.
It is easy to be lulled into believing that methadone maintenance treatment for heroin addiction started in the United States (which is true) and that it has not traveled to any extent beyond U.S. borders (which is not true). According to anecdotal reports, countries such as Canada, the United Kingdom, Switzerland, and the Netherlands have had a somewhat long history of prescribing methadone. Others, such as Germany, Spain, Belgium, and France have been rapidly evolving innovative programs. Australia has similarly developed and extended the provision of methadone.
The field is obviously rapidly evolving on a global basis. Now, a recently released survey sheds some added light on this subject.
Coming out of a 1995 workshop on the role of methadone maintenance in the care of narcotic addicts, Health Canada decided to gather information regarding methadone treatment in other countries worldwide. It was believed this might help them in revising Canada's own National Methadone Control Program.
Under the direction of Jean-Marie Ruel, MD, Special Medical Advisor, Bureau of Drug Surveillance, questionnaires were mailed to 32 countries selected from a United Nations list entitled "Competent National Authorities Under The International Drug Control Treaties." Of the 24 countries responding in some fashion, completed questionnaires were gathered from 75% (18) with active methadone treatment programs - see TABLE 1.
| Australia* | Israel* |
| Canada* | Italy* |
| Denmark* | Mexico* |
| England | Netherlands* |
| Finland* | New Zealand* |
| France* | Spain* |
| Germany* | Sweden |
| Hong Kong* | Switzerland* |
| Hungary* | USA* |
Long-term methadone maintenance is an accepted objective in 16 of the countries, as noted with an asterisk(*) on the chart. In England and Sweden eventual withdrawal is the only objective.
Several large countries responded without returning questionnaires:
· Argentina: "There is no significant consumption of heroin, therefore methadone treatment is not in place."
· Japan: "Methadone has not been used for the treatment of narcotic addiction and is not on the market."
· South Africa: "Legislation does not provide for any methadone maintenance. The reason being that this country to date has only small numbers of narcotic addicts. This scenario may obviously change depending on the recent influx of heroin into this country."
Ruel's group found that all of the countries responding to the questionnaires had in place some measures of control regarding methadone as of year-end 1995, with some controls being more predominant than others. TABLE 2 presents a ranked list of them, followed by the number of countries (out of 18 total) instituting them in parentheses.
| Requirements for urinalysis (17) |
| Restrictions on take-home medication (16) |
| Limits on daily dosage (12) |
| Need for special authorization to prescribe methadone (12) |
| Central registry of patients (9) |
| Limits on case load per physician (7) |
| Methadone only available in specialized treatment centers (6) |
| Methadone only available from physicians specialized in narcotic addiction treatment (6) |
| Limits on case load per clinic (4) |
The country with the most controls (8 of 9) was Israel, excluding only a central registry; France with merely two controls - urinalysis and daily dose limits - had the least. Canada had six controls, and the United States had five controls, which was roughly both the average and median number for all countries.
Further data collected by Ruel's group provides some interesting observations (again, the most current data are for year-end 1995):
· The U.S. had by far the largest population of methadone patients (115,000) and this remained stable between 1990 and 1995.
· However, in terms of patients per million inhabitants, the U.S. with 441/million was far below countries like Switzerland (2,000/million) and Hong Kong (1,818/million). Canada had 107/million.
· In terms of percent change in methadone patients between 1990-95, France led the pack with a 4,900%, increase from 52 to 2,600 (which was still a comparatively low ratio of 45 patients/million inhabitants). Spain was next highest with 853% growth, from 3,023 to 28,026.
· For unexplained reasons, Hong Kong had zero change between 1990-95, stagnating at 10,000 patients.
· Germany had 300% growth (from 5,000 to 20,000 patients). However, the respondent from Germany noted: "Unlike other Western countries, (methadone) substitution is a relatively new form of therapy in Germany. Until the middle of the eighties, [it] was totally rejected... it is important to know that this change came not mainly as a result of consideration of the addicts' problems, but because of the growing HIV-threat to the population [Italics added.]."
· Israel was the only country to report any decrease in the methadone patient population - going from 10,000 in 1990 to 1,200 in 1995. The respondent merely commented that some clinics were closed, and Ruel has been unable to reach them for explanation. [Perhaps this was just a typo in the response; OR, might it have had something to do with Israel's many stringent control measures? - Ed.].
Ruel concludes his study by acknowledging that the survey contacted only a select number of countries, chosen non-randomly, and the responses were somewhat limited. Still, he believes, "The results indicate that there has been an increase in the number of patients being treated with methadone in a majority of the countries where methadone is recognized as a valid method of treatment for narcotic addiction."
Ruel commented to A.T. Forum that one hypothesis arising from the survey is that controls may actually impede access to methadone treatment. "The observations of Dr. Reisinger in Belgium seem to confirm this hypothesis. As Health Canada aims to increase access to methadone maintenance treatment this might imply the removal of certain controls." However, he could not be more specific at this time.
For more information, Dr. Ruel may be contacted at: Phone - 613-954-6782; Fax - 613-957-0335; E-mail: <Jean-Marie_Ruel@isdtcp3.hwc.ca>.
For details of Belgium's methadone programs see Dr. Reisinger's presentation at the past AMTA conference in Phoenix (October 1995) at <http://www.users.interport.net/
~clueless/belgium.html>.
He may be contacted personally at <marc.reisinger@infoboard.be>.
Enlightened Belgium
As an aside, Belgium, which did not return a fully completed questionnaire for Ruel's survey, has had an interesting recent history with methadone. According to Marc Reisinger, MD, of the European Methadone Association in Brussels, Belgium had 5,000 methadone patients (500/million inhabitants) at the end of 1995, and this represented an increase of 1,300% between 1990 and '95.
Reisinger commented (via e-mail) to A.T. Forum that, as a result of strong lobbying efforts by the local medical community in the early 1990s, methadone became dealt with in Belgium as an ordinary medication, rather than as an experimental treatment accessible to only a limited number of patients and subject to rigid controls. More than 80% of patients could be treated by general practitioners, and the physician was free to prescribe larger quantities of methadone at less frequent intervals depending on the individual patient's progress.
He further noted that most patients received a one or two week supply of methadone, yet the presence of the drug on the black market decreased since fewer addicts were seeking methadone on the streets. Drug overdoses and criminality similarly decreased. "Thus, the very flexible method of prescribing methadone used today in Belgium seems to have resolved some problems and does not seem to have created any," he said.
Where to Get Info
New Manuals Enhance Treatment
The Institute of Behavioral Research (IBR) at Texas Christian University has developed a series of treatment enhancement manuals that may be of interest to clinic staff:
· Mapping New Roads to Recovery: Cognitive Enhancements to Counseling
· Time Out! For Me: AnAssertiveness/Sexuality Workshop for Women
· Time Out! For Men: A Communication Skills/Sexuality Workshop for Men
· Approaches to HIV/AIDS Education in Drug Treatment
· Straight Ahead: Transition Skills for Recovery
Ten-part workshop reinforces key recovery concepts. As with the other
manuals, complete materials are provided - such as instructions, lecture
notes, exercises and activities, handouts, and more - to conduct group
sessions.
The manuals are available through the Lighthouse Institute, a nonprofit organization. Prices range from $15 to $19, plus shipping/handling. To order or for more information call: 309/827-6026.
Further information about IBR research and publications
is available at their Web site- www.ibr.tcu.edu - or by calling 817/921-7226.