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
No Medicaid for Methadone
No More Medicaid for Methadone In Illinois;
Is This a National Trend?
As of July 1, 1995, Illinois ceased providing Medicaid coverage for
methadone maintenance treatment. This was a result of the state's concern
over the growth in Medicaid spending for substance abuse treatment,
according to Mary Ann Anderson, Executive Director, Illinois Alcoholism
and Drug Dependence Association in Springfield.
Prior to this, Illinois, along with California and New York, were the
three states most aggressively pursuing Medicaid funding for substance
abuse treatment, including methadone. Illinois was also instrumental
in enrolling addiction treatment patients in the Supplemental Security
Income (SSI) program which provides Medicaid eligibility.
Anderson notes Illinois will return to using state general revenue funds
and federal block grant money to support methadone treatment services.
However, this means the state can severely limit the number of people
who can receive treatment and the scope of services offered. "That's
the big difference between Medicaid and other types of funding,"
says Anderson. "Because of Medicaid's entitlement nature, as long
as new Medicaid recipients walk into a clinic and need services, the
methadone clinic continues to grow." Medicaid helps reduce waiting
lists and also encourages treatment providers to offer more services
for needy patients; they know the money will be available to cover costs.
Anderson fears that, "even though Chicago is experiencing a resurgence
in heroin use, we are going to have a limited capacity in the methadone
treatment system." Another action by the state was to establish
a capitated weekly funding limit of about $60 for each patient to include
the physician, nursing, dispensing, toxicology testing, counseling and,
of course, the methadone itself. Hence, programs must look for new ways
to trim their costs and re-duce the scope of offered services, while
still complying with minimum state and federal regulations.
Anderson speculates that the state is using this new plan as a transitional
measure to bring runaway Medicaid expenditures under control. Once clinics
adjust to operating under a capitated type of system, Medicaid for methadone
may be reinstated at some future time, but with new restrictions to
curtail program expansion.
Might this be the start of a trend spreading to other states? Anderson
believes California is already more sophisticated in dealing with managed
care and controlling Medicaid spending. "I don't think they would
give away the federal matching Medicaid funds just to control their
state obligation the way Illinois is doing," she says. She's less
certain about New York, but believes both New York and California have
a greater appreciation for the cost savings in primary medical care
and other indemnity gained via methadone treatment programs. "They
know this investment in addiction treatment is saving them a great deal
of money in other ways."
"I'm very disturbed at what's happening at the state and federal
levels," says Eldoris Mason, M.S., R.N. She is President and CEO
of The BRASS Foundation, Inc. in Chicago; two of their five clinics
provide MMTP services. "Their actions seem so inconsistent with
what we believe are the real needs of patients. This discrimination
against a particular population of citizens is extremely disturbing;
that is, those persons whose drug of choice is heroin (or other opiates)
and whose drug treatment includes the prescription of methadone. What
I see happening in Illinois is what I consider a premature anticipation
of what will happen at the federal level regarding managed care, as
well as possible reductions in future funding."
She says, "The funds (as allowed under the new state program) are
inadequate to provide comprehensive treatment. And, comprehensive treatment
for these people, for all substance abusers, is the only reasonable
treatment goal." Basically, under this new approach, all a clinic
is required to do is be in compliance with FDA and DEA regulations.
According to Mason, some Chicago area clinics have already started laying-off
staff and cutting back services. The ultimate result, she believes,
will be fewer services for fewer patients in need. Mason is not reducing
staff until they have a better understanding of their patient census
and future needs. "We have to explore our legal and ethical liability
to continue serving those patients. You can't just drop them out of
treatment and say, `Sorry old boy/gal, we don't have enough funds for
you to be here.'"
Mason is perplexed by the economic justifications of Illinois' approach
to the issues. "There's something illogical about using state revenue
funds for these programs in order to contain Medicaid costs, when the
state would otherwise get a 50 cent return for each state dollar spent
on Medicaid." In essence, the state is leaving a great deal of
"money on the table" before considering other approaches.
"We must continue, at all levels of government, to talk about drug
addiction as a major physical and mental health problem in this country,"
she says. "There are root causes behind these disorders and they
need to be seriously examined. Yet our funding is not designed to deal
with those issues."
IOM Report Review
Why Aren't There More
Anti-Addiction Medications?
"Pharmacology for the treatment of drug addiction has received
far too little attention, despite the clinical success of methadone,
which dates back to the 1960s. Over the last 30 years, only two additional
medications have been approved for the treatment of opiate addiction
- naltrexone and ...LAAM - and it is important to note that both these
medications were developed in the 1960s and early 1970s. There is still
no approved medication for the treatment of cocaine addiction."
During this same 30-year period, serious medical and social problems
associated with addiction have escalated, especially involving HIV/AIDS
and multiple-drug-resistant TB.
The above statements present the initial premise of a report we promised
to review in our last edition of A.T.F.: The Development of Medications
for the Treatment of Opiate and Cocaine Addictions: Issues for the Government
and Private Sector. This recent (1995) 250-page report was developed
by a 14 member interdisciplinary Institute of Medicine (IOM) Committee.
The focus was upon anti-addiction medications for opiate and cocaine
addictions, although it was recognized that alcohol and nicotine are
two addictive drugs with the most widespread negative impact on society
overall.
According to the Committee's report, since pharmacotherapy for opiate
addiction (i.e., methadone) has been proven successful, "it seems
reasonable to assume that effective medications could be useful in treating
cocaine addiction." Without ruling out the potential for even better
medications to deal with opiate addiction, the Committee believes that
such medications might also enhance other treatment modalities, expand
the range of treatment options available, and per-mit more cost-effective
outpatient approaches to treatment.
The obvious question becomes: Why haven't more anti-addiction medications
come on the scene?
The Committee notes that pharmacotherapy, as an adjunct to other treatment
modalities, has not received sufficient support from the federal government,
nor has the private sector been active in developing anti-addiction
medications. Reasons behind this are complex .
The report observes that, the major disincentives to pharmaceutical
R&D for anti-addiction medications include: an inadequate science
base on addiction and the prevention of relapse (especially for cocaine);
an uncertain market environment which includes such issues as: treatment
financing, lack of trained specialists for the treatment of drug addiction,
federal and state regulations, market size, pricing issues, societal
stigma, liability issues, difficulties in conducting clinical research,
and a lack of sustained federal leadership.
The Committee strongly emphasizes that unless basic research is adequately
funded, "it will be difficult to make the necessary progress in
the scientific knowledge base." And, this will continue to hamper
the development of medications. The report recommends a coordinated
effort via designated national drug abuse research centers.
Despite the lack of new anti-addiction medications, the report reiterates
the success and cost-effectiveness of current treatments, especially
methadone. The Committee recommends expanding the treatment capabilities
of the states; shifting money from supply control programs to treatment,
and providing additional money to increase treatment where there are
waiting lists. They further note the need for greater leadership, especially
at a federal level; better cooperation among the various state and federal
agencies and research centers involved; less restrictive regulation
which encumbers research and development; and, of course, more funding
for research, development and treatment.
An important finding of the report is that, "clearly, the absence
of a large, vocal advocacy group that would voice strong support a nd
lobby for treatment funding and research contributes to the lack of
federal leadership and the dearth of anti-addiction medications."
Maybe, that's the crux of the problem. As the saying goes, "the
squeaky wheel gets the most oil." The drug addiction treatment
field doesn't seem to be making loud enough noises calling for action.
To order this publication (ISBN #0309052440; cost approx. $37 + shipping),
write:
National Academy Press
2101 Constitution Ave., N.W.
P.O. Box 285
Washington, DC 20055
OR, call: 800-624-6242 (202-334-3314 in Washington, DC)
Clinic as a Family System
The Methadone Clinic As a Family System
A.T. Forum has yet to focus on the role of social workers who serve
as counselors in methadone maintenance treatment programs. We spoke
with Karen R. Koenig, LICSW who is the Clinical Supervisor at the Addiction
Treatment Center of New England. Their program serves about 200 MMTP
clients in the greater Boston Area.
Koenig came to our attention via a paper she authored describing how,
in many cases, the methadone clinic serves the role of surrogate family
to clients. As such, the clinic plays a significant role in the client's
life, she says, "not only because it dispenses methadone - in most
cases, the client's lifeline to the possibility of normal functioning
- but because it is often their primary caregiver." Understanding
this relationship can be used to therapeutic advantage in assessing
the client's past family relationships, which were often detrimental,
in order to develop new strategies to help the client lead a more healthful
and productive life both within and outside the clinic family setting.
This model also has implications for establishing clinic practices and
policies.
A.T. FORUM: How did your clinic as a family model come about?
KAREN KOENIG: So much of what clients bring to the clinic seems to involve
their concerns about dependency. To be able to work with those feelings
and make connections to a client's family issues is helpful; such as,
things that have gone wrong with them growing-up in dysfunctional families
and have been exacerbated by either their drug abuse or the lifestyle
of living on the street. In many cases, the good feelings they have
about being taken care of by the clinic and all the negative feelings
they have about authority figures, people being in charge of their lives,
comes out during therapy.
A.T.F.: We sometimes get letters from patients complaining about the
control they give up at methadone clinics. There's resentment in those
letters. How does your model deal with that?
KOENIG: In two ways: first, by assessing what's really happening, what's
being perceived by the client. As therapists, sometimes we aren't aware
of how we use power, or we don't appreciate things from the client's
perspective - and we can do better. So, for example, I always try to
look realistically at our policies; are they humane? Second, on another
level, we need to consider if these feelings are replicating the client's
negative views of an authority/caregiver as it relates to their previous
family history?
A.T.F.: What is the importance of the client's childhood?
KOENIG: Clients frequently explicitly use the metaphor of clinic as
family in complaining of being treated like children. I think so much
has to do with working through the first attachments - those first trusting
relationships with family - and then working through trusting relationships
at the clinic that lead to healthy separation to a certain extent. This
relates to the whole autonomy/dependency issue. If clients can work
through that all over again, and do it the right way with our guidance,
they are able to stay in recovery and off illicit substances.
As I think of the family system, I also think of helping versus hurting
relationships. Clients get really confused as to whether we' re here
to help them or hurt them. That has to do with how they grew up and
perceived caretakers - they have suffered such harm that they get confused
between help and hurt. In the clinic, we become their primary caretakers,
and if I say to a client, "You can't continue to come to therapy
stoned," that feels hurtful to them when I'm really being helpful.
Once the metaphor of clinic as family is accepted by the client, it
can be used to talk about many behaviors and feelings that are generated
by client clinic contact. For example, issues of perceived preferential
treatment of other clients can be viewed in the con- text of sibling
rivalry.
A.T.F.: It sounds like the issues you're trying to deal with could take
somebody quite a long time to work through in therapy.
KOENIG: It does take a long time. The focus of this clinic is to curtail
drug abuse, but we also want to look at drug abuse as a symptom of underlying
psychological problems and to resolve those issues. Having been here
over seven years I've seen some dramatic changes in clients, but they
take a long time. Much the same as it takes the first couple years of
our childhood to really attach to parents, it takes about two years
for clients to establish the kind of solid trusting relationship that
they need in order to get down to serious work in therapy.
Unfortunately, the typical approach to drug addiction in this country
is to deal with the addiction behavior as opposed to dealing with the
underlying causes which are much harder to treat. In doing that, we
replicate the errors of our clients by seeking immediate gratification.
A.T.F.: Does long term methadone maintenance allow you more time to
deal with the underlying causes of addiction?
KOENIG: Methadone maintenance does help keep a client in therapy and
off the street (not using opiates). It enables them to function as normally
as they can while dealing with family-oriented issues from their past
and present.
Sometimes, to address a client's on-going illicit drug use, in addition
to therapy sessions, they need the methadone dose raised because it
is too low and not holding them. We are willing to raise the dose up
to our ceiling (100 mgs/day) to help keep them free of illicit drugs.
We haven't gone above that, but that doesn't mean we might not change
our policy if appropriate.
TB Crisis Spurs Action
MDRTB Outbreak Spurs Action in Chicago
In the last edition of A.T. Forum [Spring, 1995, p. 5], we noted that
tuberculosis cases are on the rise in the United States, largely due
to the HIV/AIDS epidemic. Alcohol abusers, IV drug users and the medically
underserved are at special risk. TB also poses an occupational hazard
for healthcare workers at drug treatment clinics. As a case study example,
Paul Buchholz, A.C.S.W., Program Director at El Rincon Community Clinic
in Chicago shared their experiences in dealing with a significant TB
outbreak in Chicago's West Town community.
El Rincon is a 23-year-old narcotic treatment program serving 270 clients
in an inner city neighborhood. Eighty-five percent are Hispanic and
96% are IVDUs. The clinic's waiting list continues to grow and 37% of
admitted patients are HIV positive.
After the death of a client's spouse due to tuberculosis in May, 1994,
multi-drug resistant TB was discovered in the clinic population. According
to Paul, their calls to the Chicago Board of Health brought almost instant
response. Examinations of clinic staff - PPD anergy, X-ray, sputum battery
- discovered that 17% had converted to TB positive. A screening of all
clients revealed that 14% converted to positive from annual or intake
physicals.
A Daily Observed Therapy Program was begun immediately for five staff
and 35 clients. Four infectious clients were treated in isolation, eight
were hospitalized for various periods of time, and five clients died
within five months - all were HIV positive.
El Rincon invited the local Commissioners of Health and Human Services
and the Departments of Health responsible for both HIV/AIDS and TB to
share in their problem solving and treatment planning. Chicago Department
of Health HIV/AIDS categorical funding was made available via grant
and, in addition to other building renovation, they were able to install
a sophisticated balanced filtration/disinfection H.E.P.A. (High Efficiency
Particulate Air) system to treat the environment.
Since installation of the filtration equipment at the beginning of this
year, plus tightened procedures, El Rincon has experienced zero positive
conversions among their staff and existing clients. Paul strongly recommends
admission and infection control procedures to prevent "unknown"
admissions and treatment of infectious individuals, and the early identification
of others already in a program so they can be accommodated in a safe
manner.
El Rincon has concluded that anergy testing and X-rays prior admission
will continue to be necessary in their circumstances, as traditional
testing may be compromised by HIV. TB status must also be known of every
person with significant contact with their client population and staff.
Their onsite methadone and daily observed TB treatment procedures have
improved compliance and saved lives. Five of ten multi-drug resistant
TB infected clients have fully recovered and progression of the disease
has been prevented in more than 60 clients and staff.
There are many indicators that should alert clinic administrators to
potential problems, says Buchholz. High risk populations - including
immune deficient persons, high rates of alcoholism and IV drug users,
a high ratio of medically indigent clients, and other factors- especially
suggest the need for risk assessment. Additionally, the physical condition
of the clinic, particularly air quality, and the adequacy of staff training
and procedures are of vital concern.
Buchholz stresses that every clinic should give serious thought to TB
and make certain they have implemented appropriate medical procedural
and environmental controls.
For further information Paul Buchholz may be reached at:
El Rincon
1874 North Milwaukee Ave.
Chicago, IL 60647
PHONE: 312-276-0200
Where to Get Info
Perspectives to Pursue
A quite interesting, and free, newsletter published by The University
of Florida College of Medicine is called The Facts About Tobacco, Alcohol
and Other Drugs. Many A.T. Forum readers may find it worth their attention.
Each quarterly edition features interviews with prominent figures in
the field of addiction treatment, facts about current trends, and research
abstracts from major journals. As the title implies, any and all addictive
drugs are considered appropriate subjects for comment in this publication.
As one example, the Summer 1995 edition features comments by Enoch Gordis,
M.D., Director of NIAAA, in his address to last spring's conference
of the American Society of Addiction Medicine: "Science creates
progress and hope," he is quoted as saying. "Alcoholism stigma
can be impacted by science.... Alcoholism is a true disease and not
a weakness of will or character or subject to the theory of personal
responsibility." The full text offers more insight into this perspective.
For a free subscription to this publication write or call:
University of Florida College of Medicine
Addiction Prevention & Treatment
P.O. Box 100244-JHMHSC
Gainesville, FL 32610-0244
PHONE: 904-392-0140