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

Reader Survey Results

Who Should Pay for MMT?
Patients? Public funding? A mix of the two? Those were the questions asked of A.T. Forum readers in our last edition (Vol. III, #2, mailed in August, 1994).
The vast majority, 81% of respondents, opted for either a set mix of patient/public funding or a sliding scale fee schedule for patients. Curiously, a few patients responded to the survey, so results mainly reflect the views of addiction treatment professionals. Let's examine each area, with some typical comments.

Few Believe Patients Should Pay for 100% of MMT
Only 12% of those responding felt patients alone should pay for MMT.
"Our program philosophy is that part of our clients' recovery process is for them to be responsible and accountable for their behavior, actions and obligations. This includes the costs of their treatment."
"Society is responsible for some help in getting persons on their feet, but society does not owe anyone...there should be no free rides for capable persons."
"Addicted persons receiving public funds should be responsible to fulfill community service work to repay society for their treatment and to ensure that money is replaced so that another addicted person may receive help."-Clinic Exec. Dir., Maryland.
To qualify this, most respondents to this choice seemed to recognize that it might take many patients some time after first entering treatment to be in a position to pay their own way 100%.

100% public Funding Not Popular
A mere 7% of respondents believed public funds should cover the entire cost of MMT. Here are two reasons given:
"It's cheaper to pay to treat addiction than to pay for consequences of untreated addiction."-Director of Administration, New York
"MMT is so cost effective it should be free to all who need or want it."-Assoc. Executive Director New York

A Mix of Patient/Public Funding Preferred
A majority of all respondents, 57%, felt that a mix of patient payments and public funds should be used. Twenty-four percent believed a 50/50 mix would be most appropriate (patients pay half, public funding pays half). The rest (33%) had various opinions scattered over every percentage mix imaginable (e.g., 25/75, 75/25, 80/20, 20/80, etc., etc.).
"Public funding should be available during the patient's first two years of treatment. Thereafter, patients should be able to pay something if there are no physical/mental disabilities."-Clinic Director, New York.
"Complete public funding promotes an abuse of the system."-Director of Staff Education, Pennsylvania.
"Treatment should be available on demand. But patients should be responsible for part of payment, even if it involves funded volunteer work."-Case Manager, Massachusetts

Sliding Fee Schedule Favored
About 24% of respondents favored a sliding scale fee structure allowing patients to pay according to economic ability.
"Payment for methadone treatment should be based on verified patient income. This may result in patient responsibility for 0% to 100% of cost."-Certification Specialist, Washington
"One hundred percent public in beginning, sliding scale later on in treatment."-Research Sociologist, North Carolina
"Clients should pay based upon ability, with the state picking up the balance. Public support should last no more than two years, with certain exceptions approved by the SSA."-Clinic Director, Oregon
A letter sent in from an MMTP patient in Baltimore summed up some pertinent points expressed by many respondents. He wrote that a problem with the MMTP system involves the long-term patient. He's been on MMTP for over ten years and has distinguished himself both academically and in achieving personal financial goals. He has no need for the frequent monitoring, counselors, other support staff, and paperwork that are mandated for the neophyte. Yet, he claims, he is charged the same for his MMTP as an entering patient.
He say, "I am aware of some experimental MMTPs which have been using 'medical maintenance' or long-term 'take homes.' I wonder if as a result of these programs, MMTPs have also reduced costs. Shouldn't those cost-savings be passed on to stable, long-term patients?"

Methadone-on-Wheels Serves Isolated Cities

When the city of Brockton, southwest of Boston, MA, balked at a local methadone clinic, the answer was to transport methadone daily into the community for convenient pick-up by local addicts. That's the plan Leonard Kupsc put into action in 1987. He's President of Boston-based Habit Management Inc. (dba Habit Management Institutes).
Brockton politicians, i a classic NIMBY (Not In My Back Yard) uproar, feared that Kupsc's original proposal of a free-standing methadone clinic in their community would attract addicts from all surrounding areas. So Kupsc suggested a mobile program in which he would daily deliver methadone only to local addicts and then move on to other communities.
Surprisingly, the Brockton police chief, a strong opponent of Kupsc's clinic proposal, enthusiastically supported the idea of mobile methadone and offered use of the police station as a distribution point. The FDA, DEA and local public health authorities were all very supportive of this innovative idea.
Kupsc got the idea from reading about a Dutch program which bussed a variety of services to addicts; besides methadone, the Dutch dispensed clean needles and condoms, and conducted physical exams. For his program, Kupsc renovated two 32 ft. Winnebago mobile homes with necessary facilities and the security measures approved by the authorities.
One van served as a back-up in case of emergencies, since the program needed to operate every day of the year in all kinds of weather.
To maximize use of the van, Kupsc set up an eight-hour, 120 mile round-trip route serving several other communities southwest of Boston, in addition to Brockton. The van was staffed by a driver, a unit manager who also acted as a security person, and a nurse.
Patient intakes were done at the Boston home base of the vans at Habit Management Inc. But delivering methadone to patients in their local communities and also having them come into Boston on a regular basis for comprehensive services (a two hour round trip) would have defeated the purpose of the mobile methadone program. A major challenge in the beginning was convincing outpatient drug-free services in each community to provide counseling for the van patients, but this was accomplished.
However, one failure of the program that currently continues is in not getting full support from local hospitals in providing emergency backup for the vans. While Kupsc says that they've only missed one or two days (during the nearly seven years of operation) by not being able to get the van to a location, it would have been comforting to know that patients could go to a local hospital for emergency dosing.
Today, Kupsc's program serves 185 patients on two mobile routes. He has three new vans, smaller than the original Winnebago models, that are completely customized for his needs; again, one van serves as an emergency backup.
While the mobile methadone program has been successful for privately owned, for-profit Habit Management Inc., Kupsc fairly admits it is not the very best approach. "My major criticism (of the program)," he says, "is that it lets communities off the hook for not standing up and saying, 'we have to treat people in our community', and it gives politicians a way to block establishment of comprehensive free-standing clinics, which I think are the best form of treatment. I think mobile methadone is a solution, but it's not the ideal solution."
"I think where mobile methadone makes the most sense is when you have a big inner city population and you want to create satellite dispensing units around a mother clinic," Kupsc observes. It seems that in the final analysis, the vans are only methadone dispensaries on wheels; which in itself serves a vital need. But, addicts also need convenient access to the full range of comprehensive services that will help sustain their opioid abstinence over time.

Straight Talk...from the Editor

Let Us Hear From You
Thank you, to the many readers who responded to our "Who Should Pay for MMT?" survey question. As always, we hope you find our reader survey results of interest.
Those typically responding, however, still make up a somewhat small percentage of our total international readership. We make it easy for you, with a postage-paid return card in each issue. Take a few minutes to jot down a comment or opinion and send it in.
Also, let us know if there is a survey question you would like to have us ask in an upcoming edition of A.T. Forum. Or, is there a topic we've overlooked or someone we should interview? We'll credit you for the suggestion.

Reader Survey Question...
As a follow-up to our interview with Ms. Phelan in this issue, our reader survey question is:
Should MMTP Nurses Also Serve As Addiction Counselors? Yes? No?
Also, please let us know if you are aware of any nationwide associations or special interest groups for clinic nurses that deal specifically with methadone maintenance treatment. We will publish a list in our next edition.
As always, your comments are most appreciated and will be reported as part of our summary. MAIL or FAX your responses to us-today-so we can include them in our next issue:
A.T. Forum
1750 East Golf Road
Schaumburg, IL 60173
FAX: 847-413-0526
NOTE: You can also use the postage-free feedback card to be put on the mailing list.
Stewart B. Leavitt, Ph.D., Editor

Update-Medical Maintenance

Over a year ago, A.T. Forum reported on the only two medical maintenance research projects in the U.S. (see Vol. II, #2). Medical maintenance is the ongoing treatment by primary care physicians affiliated with MMTPs of rehabilitated methadone maintenance patients. These patients are stable, employed, not abusing drugs and not in need of all the support services typically offered by a methadone clinic. We followed up to learn the outcomes of those studies.

A Step Forward at Beth Israel
According to Nina Peyser, executive Director of the Chemical Dependency Institute at Beth Israel Medical Center in New York City, they've had great success with their new research protocol designed to answer questions raised by the FDA a year ago. In fact, the FDA has extended approval for the research project and will allow 30 new medical maintenance research subjects in addition to the original 100. In September (1994), Beth Israel was in the process of recruiting the additional patients.
Peyser notes that the New York State Office of Alcoholism and Substance Abuse Services has been very supportive of the program and is collaborating with Beth Israel in the new research design. Funding has not been an issue; patients must be self-supporting and pay their own way, and Beth Israel and the state are donating their time and efforts for the research.
If, over the next six months, they are able to demonstrate that medical maintenance is an appropriate alternative to and equally as effective as the regular MMTP approach, Peyser expects the FDA will allow medical maintenance to be available on a much broader scale.
For a report on the Beth Israel study, interested readers should consult: Novick, D.M., et al. "Outcomes of treatment of socially rehabilitated methadone maintenance patients in physicians' offices (medical maintenance): follow-up at three and a half to nine and a fourth years." J. Gen. Intern. Med., V9(3): 127-130 (1994). The authors report that of 100 patients after 42-111 months in treatment, 72 remained in good standing; 15 had unfavorable discharges (11 for cocaine use, three for misuse of medication, one for administrative violations); seven voluntarily withdrew from methadone in good standing (after receiving it for 9.1 to 24.4 years); four died; one transferred to a chronic care facility; and one voluntarily left the program.
The authors conclude: "Carefully selected methadone maintenance patients in medical maintenance have a high retention rate and a low incidence of substance abuse and lost medication. Voluntary withdrawal from methadone maintenance after one or two decades is possible." The authors believe that medical maintenance should be lade available to appropriate patients in other localities.

Chicago Program at a Standstill
Edward Senay, M.D. with the University of Chicago Department of Psychiatry and Director of Interventions Research initiative, had a medical maintenance research program similar to Beth israel's with two exceptions: only six months of good performance in a traditional MMTP was required as a patient qualification, and, while most patients paid for their own treatment, Senay's research depended upon by NIDA.
Senay studies nearly 300 patients over a five year period. And, like Beth Israel, he experienced roughly a 75% success rate for medical maintenance patients. In August of 1993, funding ran out for the program and it was not renewed by NIDA. The program was disbanded and patients were returned to their original clinics for traditional MMT.
As we went to press, Senay was hopeful that the concept of medical maintenance could be expanded via research studies he is proposing in Washington, D.C. and Baltimore.

Legal Notes

1994 SSA Reform Act Signed
Last August, President Clinton signed into law the Social Security Administration Reform Act of 1994. SSI (Supplemental Security Income) benefits for alcoholism or drug addiction will be limited to 36 months, except where the beneficiary is otherwise disabled. SSDI (Social Security Disability Insurance) will be treated similarly, except that the 36-month limit will not apply in months in which "appropriate" treatment is not available.
According to a briefing paper distributed by the Legal Action Center, Washington, D.C., the 36 month limit will not begin until 180 days after the Act's enactment. Thereafter, for SSI recipients, the 36 months begin to run with the first month in which the beneficiary has applied. Retroactive lump sum benefits will be paid gradually at a rate no greater than twice the normal benefit amount. For SSDI recipients, the 36 months begin when treatment becomes available and 180 days after enactment.
Covered individuals will be required to undergo appropriate substance abuse treatment at a facility approved by the Secretary of HHS and have a representative payee which can be an approved social service agency, government agency, relative, friend, etc. At least one Referral and Monitoring Agency (RMA) will be established i each state to identify eligible treatment programs, refer individuals for placement, and monitor compliance. Benefits will be suspended for each incident of noncompliance with SSI or SSDI treatment requirements according to a variable schedule.
The legislation also provides for several studies and demonstration projects. For more information, readers might contact the Legal Action Center at: 202-544-5478.