Reader Survey Results
Methadone-on-Wheels
From the Editor
Medical Maintenance
Legal Notes
MMT Nurses as Counselors
Equal Access to MMT
Where to Get Info
Research Notes


MMT Nurses Can Also Effectively Serve as Counselors

A.T. Forum interviewed Lorae Phelan, RN, MS, CAC, to get her perspectives on issues important to nurses. She is Nurse Manager of North Charles Institute of the Addictions in Cambridge, MA; a clinic which treats 185 methadone patients.
A.T. FORUM: What is or should be the role of nurses in MMT clinics?
LORAE PHELAN: The role of MMT nurses is to safely administer the medication to their clients. What I mean by safely is that methadone is a narcotic that may have negative medical sequela with certain other prescriptive or nonprescriptive drugs on board. While administering the medication, nurses are performing rapid physical and psychological assessments of the client and are looking for indicators of illness, intoxication or drug withdrawal. If evidenced, the methadone is withheld and a formal assessment is conducted.
At our clinic, nurses are also counselors with individual caseloads and lead 2 or 3 groups per week.
A.T.F.: Is that typical of many clinics?
PHELAN: I don't think it is. At the clinics that I know of, nurses are utilized for the administration of the medication, mostly known as "dosing nurses."
A.T.F.: What do you see as the benefits of having nurses as counselors?
PHELAN: I think clients benefit a great deal from having a nurse/counselor for their treatment. Nurses are trained and educated to view the person holistically. Treatment modalities are formulated from bio-psychosocial and, for some, spiritual assessments. Nurses are also educated in pharmacology and have a greater comprehension of medications and their actions, interactions and adversities than counselors who are not familiar with this knowledge. At times, physical abnormalities affect the mind and the mood. I think nurses are more likely to quickly detect such aberrations and make the proper intervention.
A.T.F.: To do what you're saying don't nurses need more extensive training than they normally receive?
PHELAN: That depends on the individual nurse's academic education and experience. However, all of our clinical staff receive a year long addictions treatment course through the Harvard Affiliated Center for Addictions Treatment.
A.T.F.: What are some of the greatest challenges that nurses run into in their responsibilities?
PHELAN: Some MMT clients use illicit drugs and may have them on board when they come for their dose. Often they are savvy enough to pull themselves together for the brief appearance in the dosing clinic and pass the "rapid assessment" of the nurse. Later, the nurse may learn of the client's using and wonder if they missed something. This is very hard for a nurse whose priority is always client safety.
Another challenge is not always knowing the client's medical history. If they present with symptoms, we don't know if it's a pre-existing condition or not or what medication they're on, and often the client doesn't know either. Of course we will ascertain that information when a formal assessment is completed but that is time-consuming. Not knowing is anxiety provoking in times of crisis.
A.T.F.: How are MMT nurses typically viewed? Are they held in high esteem?
PHELAN: Among our clients, I would say yes. With the nursing profession and society in general, I would say no.
A.T.F.: Why is that?
PHELAN: There's a negative stereotype associated with MMT. Many in the nursing profession are not well educated in additions, especially in MMT. All too often, methadone is not recognized as a legitimate medication by the nursing profession. Our clients are viewed as drug addicts or dope fiends first rather than as clients in need of care. The stigma assigned to the client is sometimes extended to the client caretaker, i.e., the nurse. This is felt through the disrespect that nurses encounter when interfacing with other professionals while performing client case management.
A.T.F.: You've been using the term 'client' as opposed to 'patient,' why is that?
PHELAN: Client I think is actually more respectful than patient; they are consumers who pay for services and treatment. The term patient is more an in-hospital description and not as commonly used in the out-patient sector.
I have a question for you. Are there any nurses associations for MMT nurses?
A.T.F.: Do you think there'd be enough interest on the part of nurses like yourself to participate in such an organization?
PHELAN: Good question! I know I would be interested. Perhaps we'll hear from your readers with their answers to this question.

Equal Access to MMT a Right of Everyone

In a landmark legal case, a California federal judge has declared that state residents who qualify for government-subsidized medical treatment cannot be denied methadone maintenance treatment just because they don't happen to live in one of the 25 counties that have MMT program. A.T. Forum interviewed Reda Sobky, M.D., Ph.D., the conscientious addiction treatment professional who initiated the lawsuit. Dr. Sobky is Medical Director and Founder of Humanistic Alternatives to Addiction, Research, and Treatment (HAART) in San Francisco.
A.T. FORUM: How did your lawsuit come about?
DR. SOBKY: We were informed by Alameda county three years ago (1991) that they were no longer going to fund Medicaid beneficiaries for methadone maintenance. We indicated that was inappropriate and probably illegal, as Medicaid coverage is required by federal law and legislated on the federal level.
The county refused to give in, so we contacted the state. In the process we discovered that the program is required by federal law to be statewide and that Medicaid eligible methadone patients also had other rights that were being disregarded in the State of California.
A.T.F.: What were some of those rights?
SOBKY: Methadone patients should receive the service in a reasonable timeframe, and the scope and duration of treatment should be adequate to address their problem. Historically in California people waited three to four years for Medi-Cal supported slots (Medi-Cal is the California name for Medicaid.)
A.T.F.: So you used as the plaintiff?
SOBKY: Yes, there is a provision in American law that allows a physician to sue on behalf of a patient. With the assistance of San Francisco attorney Amitai Schwartz, we went before U.S. District Judge David F. Levi in Sacramento and asked him to examine the rights of those patients and give us preliminary injunctive relief and hopefully a summary judgment. Halfway through the suit we qualified a certain number of patients from the clinic so that they could be part of a class action suit.
The judge immediately gave us a preliminary injunction. He also found that there were six other counties in California, besides Alameda county, that had private methadone treatment but no access for Medi-Cal patients. However, federal Medicaid law provides beneficiaries access to the same community resources that are available to persons who can pay their own way. But, in those seven counties, there was no such access.
The state contacted the seven counties and asked their drug program administrators if they would accept the contract with the state and act as a conduit for funding to fulfill the judge's order. Six out of the seven counties refused. So, the judge required the state to contract directly with clinics in those counties.
The judge further noted that if one person had to stay on a waiting list for three years to get into treatment while another person was able to get into treatment immediately, it constituted discrimination. The judge issued a ruling which said that no Medicaid beneficiary may be denied access to methadone maintenance due to lack of funds or budgetary constraints and that the wait has to be reasonable.
A.T.F.: What is reasonable?
SOBKY: I think it's a local decision depending on the services available, but I would say between 30 and 120 days maximum.
Another important point in the judge's ruling is that the scope (e.g. quality) of the services must be comparable to the services provided to cash paying patients. And the duration of treatment has to be sufficient so as to mitigate the effects of the disease or disorder; it is based on medical necessity, not on an arbitrarily fixed period of time. All of this just finally happened last July (1994).
A.T.F.: How many counties in California have methadone maintenance programs?
SOBKY: Twenty-five counties out of 50 total.
A.T.F.: So, if a patient didn't live in one of those 25 counties, he/she was out of luck when it came to getting support from Medi-Cal for methadone treatment; is that right?
SOBKY: That was before the judge's injunction. Now patients are allowed to commute to the closest clinic to them no matter which county it's in. The program is statewide, so counties are prohibited from discriminating against patients based on their addresses.
A.T.F.: Are there any further implications of this case?
SOBKY: Part of the reason why this lawsuit was necessary is that there is a tremendous confusion in the drug treatment field about the treatment rights of Medicaid beneficiaries versus other community-specific programs. Medicaid access right are in federal law and are mandated; they are entitlements and are not subject to negotiation with the state or individual counties.
However, there are also discretionary funds, such as block grants, which legitimately may be used in community-specific efforts. There are also county funds which the county raises through taxes, and those can be used in any way to serve the particular community. But, federal Medicaid funds that are matched by state funds to provide benefits to the poor are not subject to a county process of reallocation. That is a very important legal principal and it needs to be understood nationally.
A.T.F.: What should our readers in other parts of the U.S. be doing?
SOBKY: It's very important for addiction treatment professionals around the country to look at the situations in their own states and see if methadone maintenance has been declared a benefit or not. If it has been declared a benefit and money has been obtained from the federal government through Medicaid to serve those patients, then the program has to conform to federal requirements in terms of equal access, scope of services and duration of treatment.
A.T.F.: Are drug addiction patients at a disadvantage when it comes to realizing their full rights and benefits under the law?
SOBKY: I believe that many rights and privileges which medical patients in general enjoy are not enjoyed by drug treatment patients because they are stigmatized. They do not have an organized consumer lobby or consumer organizations to litigate and assert their rights under the law. That's why I had to take the action I did.

Where to Get Info

A Phone Number to Note
Put this number in your personal phone book and let your fingers do the walking to a vast array of vital information: 800-788-2800.
Via this single number, callers can reach all seven federal alcohol and drug clearinghouses which are sponsored either by the Department of Health and Human Services, the Department of Justice, or the Department of Housing and Urban Development.
The info sources include: National Clearinghouse for Alcohol & Drug Information; National Criminal Justice Reference Service; Drug Information & Strategy Clearinghouse; National AIDS Clearinghouse; Drug Abuse Information & Treatment Referral Line; Drug-Free Workplace Helpline; Drugs & Crime Data Center & Clearinghouse.
This network of resources provides ready access to thousands of helpful documents, plus personalized assistance to solve a problem or meet the special needs of patients. Some clearinghouses publish regular newsletters which are available for the asking.

Guidelines Help Direct Treatment of Patients with AIDS or HIV
"Guidelines for Facilities Treating Chemically Dependent Patients At Risk for AIDS or Infected by HIV" is must reading for clinic personnel. This 34-page booklet was first developed by the American Society of Addiction Medicine (ASAM) in 1987 and updated in 1991.
The guidelines authoritatively describe how staff members can respond effectively, safely, and humanely to the needs of patients who have AIDS, HIV infection, or are at risk for HIV infection.
Some topics include: Precautions for caregivers; testing and counseling; symptoms of HIV infection, dealing with family members and significant others; legal concerns and other service needs; preventing transmission.
A sample patient consent form for HIV antibody testing is provided, as are references for additional reading and a listing of resources for further help and information. To receive a copy contact: American Society of Addiction Medicine, 5225 Wisconsin Avenue, NW, Ste. 409, Washington, D.C. 20015. Phone: 301-656-3920

Research Notes

APA Takes a Stand on MMT
In a significant move the distinguished Council on Addiction Psychiatry of the American Psychiatric Association (APA) has officially endorsed the value of Methadone Maintenance Treatment.
They state, "Methadone maintenance is an effective treatment for helping heroin addicts to stop or reduce heroin use. With adequate doses, the value of methadone maintenance in AIDS prevention strategies has been demonstrated.
"Methadone maintenance (at adequate doses of 60-100 mg/day) has shown higher program retention than any other treatment modality. Psychosocial treatment in addition to methadone medication can substantially improve the outcome of rehabilitation of heroin addicts. Methadone maintenance requires years for adequate rehabilitation, and some patients will need methadone for their lifetimes, as a diabetic needs insulin.
"While some methadone programs need improved oversight and enforcement of treatment guidelines, many heroin addicts wanting and needing methadone maintenance are on waiting lists because of inadequate public funding and support."

High Dose, Indefinite MMT Reduces Risk of Death in Heroin Addicts
A long-term follow-up was made of 307 heroin addicts admitted into a high-dose Australian MMTP in the early 1970s. It was found that addicts were nearly three times more likely to die outside of a methadone maintenance program compared to those in a program.
It was further estimated that patients given a daily methadone dose of 80 mg were nearly twice as likely to be discharged during the first three years of maintenance as those given 120 mg/day. The study also noted that a change in clinic policy from abstinence to indefinite maintenance reduced to one-third the patients' risk of leaving after three years of treatment. The authors conclude that, to minimize heroin addicts' risk of death, they should be offered indefinite, high-dose methadone maintenance.
(Caplehorn, J.R. "Retention in Methadone Maintenance and Heroin Addicts' Risk of Death." Addiction, 89:2, 203-209 (1994).)