A.T.F. Volume IV, #3. Fall, 1995
AMTA on Leading Edge
"Graying" of Methadone?
Straight Talk From the Editor
No Medicaid for Methadone
IOM Report Review
Clinic as a Family System
TB Crisis Spurs Action
Where to Get Info
AMTA on Leading Edge
As a prelude to the November 1995 AMTA Conference in Phoenix [see notice
on page 4 in this issue], A.T. Forum spoke with Mark Parrino, MPA. He
is president of the American Methadone Treatment Association, Inc. which
is sponsoring the conference.
A.T. FORUM: What is the most critical issue AMTA is working on right
now?
MARK PARRINO: AMTA is working with federal and state agencies to develop
a consistent methadone policy, in responding to the issues of managed
care and shifting responsibilities from federal to state authorities.
There is a flurry of activity at the federal level in the aftermath
of The Institute of Medicine report on methadone regulations, Federal
Regulation of Methadone Treatment. [See, our review of that report in
A.T. Forum, Vol. IV, #2, p. 6 - ed.]
The Federal Inter-agency Methadone Policy Review Board has forwarded
correspondence to the Assistant Secretary of Health in HHS to provide
greater methadone oversight at the state level, with less involvement
from the federal authorities. Treatment/ practice guidelines in addition
to increased credentialing standards could be used to replace current
federal operating requirements.
The Drug Enforcement Administra-tion is also restating its concerns
about methadone diversion as a result of the IOM report. An IOM chapter,
which evaluated the role of methadone diversion to be minimal in nature,
the but DEA is saying that the report misstated the problem of methadone
diversion. As a result, the DEA released a twenty page report describing
methadone diversion incidents in considerable detail.
A.T.F.: Essentially, what did the DEA say?
PARRINO: The report provided anecdotal references and referenced DAWN
data, indicating that there was one reported heroin death for every
eight methadone related overdose deaths. This represents inaccurate
reporting.
AMTA has been discussing this matter with federal agency officials in
Washington, requesting that the FDA in conjunction with the CDC (Center
for Disease Control) and CSAT and NIDA coalesce to bring forensic experts
together to develop an accurate case definition for a methadone toxicity
overdose. The current data are flawed and the DEA is arriving at improper
conclusions.
A.T.F.: What other issues are at the forefront right now?
PARRINO: We have asked NIDA to conduct a multi-site study evaluating
the comparative effectiveness of private (profit oriented) methadone
programs vs. publicly funded methadone programs. We have asked NIDA
to determine if there is any significant difference in the quality of
care that is rendered to patients in such facilities or in patient outcome.
It is hoped that these results will remove the issue of public vs. private
from our policy debate.
A.T.F.: AMTA, then, serves as a catalyst for change?
PARRINO: We are encouraging federal and state methadone regulatory bodies,
researchers and methadone treatment providers to work together to develop
a sound methadone-related policy to improve our treatment system. There
appears to be interest on the part of both federal and state authorities
to do just this. We plan to convene a number of policy making forums
in Phoenix to further open such communications and share information
in order to craft a more meaningful and consolidated strategic plan
to improve methadone treatment in the era of managed care and the anticipated
changes in federal law. We have asked the Office of National Drug Control
Policy to be involved in this Conference and they have agreed to do
so.
A.T.F.: Are there critical changes brewing due to the Republican Congress
elected in 1994?
PARRINO: Yes, and the changes could be devastating! For one thing, I
suspect that SSI benefits are going to be eliminated completely for
patients who have alcohol and drug abuse problems. Last year in Congress
the SSI benefit was reduced from being open-ended to a limit of 36 months.
Now, the Senate Finance Committee has pressed for total elimination.
A.T.F.: What about Medicaid?
PARRINO: The problem there is twofold: first, at the federal level,
it looks like Congress is going to implement a Medicaid block grant
to shift the program to the states; second, you will then have the states
getting a Medicaid block grant which will presumably give them more
flexibility in setting up their own Medicaid reimbursement program.
Essentially, you will have the states establishing their own managed
care programs. So, you get a state alcohol/drug abuse treatment system,
which is only a part of each state's healthcare system, having to compete
with all other programs for those Medicaid dollars. The states will
have to work within a newly established cap while they are also creating
managed care programs through waiver applications to HCFA. The state's
alco-hol/drug abuse treatment system will have to compete with other
healthcare dollars and mental health dollars in an era of shrinking
resources. It represents another waive of instability in the structure
of substance abuse treatment programs. [See also, "MMTP Issues"
in this edition of A.T.F. - ed.]
A.T.F.: Where's your "battlefield," so to speak; at the federal
or state level?
PARRINO: The real battles are in the states. The pattern is often an
angry reaction by the states - that drug treatment is not a good investment.
They ask, "Why do we still need this program in our state?"
Often, we have to convince state governments that they DO have a real
opiate addiction problem and that methadone treatment is a good investment.
I optimistically believe more states will begin developing methadone
treatment services. And the pressure for that is probably going to come
from an influx of private programs. For example, in one state, an administrator
asked me, "Why do you think, Mr. Parrino, that private programs
have so aggressively pressed to get methadone services opened here?"
And I said, "Because, you're not funding public programs by using
federal block grant moneys and available Medicaid funds to develop methadone
treatment services. There is a demonstrated need in your community for
such services, and if you don't do it, others will ."
For more information, readers should contact AMTA.
217 Broadway, Suite 304
New York, NY 10007
PHONE: 212-566-5555
FAX: 212-349-1073
"Graying" of Methadone?
We have an aging population in the United States, so in addition
to the many other benefits of methadone treatment, it may have created
a whole generation of older, gray-haired patients in recovery. If this
is true, what special needs might these older patients have?
At one time, it was generally believed that opiate addicts did not survive
into old age; they either died or were incarcerated. In fact, according
to Herman Joseph, Ph.D. - research scientist with the New York Office
of Alcoholism and Substance Abuse Services - during the early days of
methadone research in the 1960s there was an upward age limit of forty
for methadone patients. At the time, there was a theory that addicts
tended to mature out of addiction and that past age 40 there weren't
very many needing treatment. That age restriction, however, was wisely
rescinded in the early 1970s.
According to the Substance Abuse and Mental Health Services Administration,
in 1994 slightly over 11% of all methadone patients were 45 or older.
However, some leaders in the field, such as Elizabeth Khuri, M.D. at
Cornell Medical Center, believe the percentage is actually much higher.
At Beth Israel Medical Center, with the largest methadone treatment
program in the United States - they have over 8,000 MMTP patients -
a 59% majority are 40 years of age or older. Sixteen percent of all
their patients are 50 years of age or older according to Patricia Friedman,
M.S., Research Associate. Friedman also observed from her most current
data that older patients, have on average been in treatment longer than
younger patients; 48% of those aged 50 or older were in treatment 10
years or more, versus only 16% of those under age 50.
Charles Eaton, Acting Director of the Office for Drug Abuse Intervention,
New York City Department of Health, observes that almost all of the
research relating to older people and drug use and abuse has focused
on prescription drug misuse and/or alcoholism. During the 1970s and
`80s the existence of a population of opiate dependent elderly was essentially
ignored and that trend continues today .
However, during the 1980s, Dr. Joseph was surprised to find a cluster
of quite elderly methadone patients in New York City, dispelling the
myth that addicts didn't survive into old age. In fact, six of those
he studied were born in the 1890s and a good number were born before
1915. Joseph's findings were reported in a book coauthored by Courtwright
and Des Jarlais, called Addicts Who Survived (University of Tennessee
Press, Knoxville, TN, 1989).
Those interviewed for this article agreed that older MMTP patients experience
many of the same medical and social problems as anyone else their age.
These may include the need to take medications for heart, blood pressure,
gastrointestinal, mental, and other disorders. Dr. Joseph emphasizes
that elderly patients do very well on methadone, "[it] is a very
safe medication with no known toxicity and no interaction with other
drugs." However, as pharmacist John St. Peter noted in our last
edition of A.T. Forum [Vol IV, #2, p. 4], "There are age-related
changes in drug metabolism. Some of those changes relating specifically
to methadone haven't been well defined...." Also, as newer classes
of drugs are developed for geriatric disorders, there may be a need
to monitor their possible interaction with methadone.
Some of our interviewees expressed concerns that the psychosocial needs
of older MMTP patients may not be adequately met. Eaton points out,
the problems experienced by many of these older patients are unrelated
to prescribed or illicit drugs; they have difficulty maintaining a steady
income, problems with transportation, physical limitations or medical
problems that are worsened by age, and the like. Many need the sort
of services provided by social service agencies: legal aid, help finding
shelter and food, etc.
Regarding MMTP clinic counseling, Eaton believes, "The counselors
and staff generally have large case loads and lack the time or expertise
to work with the special problems of older patients." Dr. Khuri
concurs that there is a need for mature counselors who can understand
the life changes of the older patient; younger counselors may be at
a disadvantage in this regard. She feels there possibly should be specialized
programs for older MMTP patients. Those patients who have been in an
MMTP for some time may not need ongoing counseling and could best be
served by private physicians who can also deal with their medical problems.
At this time, there seem to be more questions than answers regarding
the older patient and methadone. Certainly, this is an area worthy of
further research and discussion among addiction treatment professionals.
Provide us your opinions on the feedback card inserted in this edition
of A.T.F. or write to us. A follow-up report will appear in our next
edition. (See Follow-Up:
Graying of Methadone)
Straight Talk From the Editor
Four Years Old & Growing
This edition of A.T. Forum marks the beginning of our fourth year of
publication, since our premier edition was launched in the summer of
1992. We've been encouraged by your many positive responses to this
publication. A.T.F. readers may be found in all of the United States
as well as a great many other countries worldwide.
We'd also like to acknowledge and thank the sponsors of this independently
researched and produced publication: Mallinckrodt Chemical, Inc., St.
Louis, MO. They provide ongoing funding for this project under an educational
grant.
Also, Mallinckrodt deserves mention for the other support they've provided
over the past several years to the addiction treatment community. The
list of their specific commitments is long but, to be brief, they broadly
include: demonstration grants, support for patient advocacy groups,
assistance in fundraising efforts for individual programs, nationwide
educational symposiums for professionals, and new product research and
development. Their dedication to making the difference in furthering
the cause of addiction treatment programs for opiate addicts seems exemplary.
Is Change Brewing on the Horizon?
Over the past few years, we've seen few dramatic changes in the addiction
treatment field and, in particular, methadone maintenance. With the
publication of two new reports from the Institute of Medicine, as reviewed
in this edition and our previous edition of A.T . Forum, discussion
of many critical issues may heat-up. Certainly, the agenda for the upcoming
AMTA Methadone Conference is filled with opportunities to address such
concerns and change may become the order of the day. But, will it be
changed for the better?
We'd like your comments regarding a new issue raised in this edition
- older methadone patients. Please respond to our question: What are
the special needs of MMTP patients who are age 50 or older? Use the
attached feedback card to list a few needs that come to mind.
As always, your other comments about our publication are most welcome
and appreciated. Write or fax us at: A.T. Forum
1750 East Golf Rd., Suite 320
Schaumburg, IL 60173
FAX: 847/413-0526
Stewart B. Leavitt, Ph.D., Editor