Disaster Preparedness
Voucher Program Success
From the Editor
Correction Feedback
Pharmacist's Role in MMTP
Self Help Programs
Where to Get Info - TB Facts
Special Report Review
Patients Become Counselors
Methadone Symposium


Disaster Preparedness - Are You Ready?

The question we asked of A. T. Forum readers in our last edition (Vol. IV, #1, Winter, 1995) was: Does your clinic have a disaster plan?
Of those responding to our survey 59% said "yes"; 41% answered "no." However, based upon reader comments and our interviews of clinics around the country, the number of "no" responses was most likely understated. Several readers commented:
· A patient in New York City: "My counselor told me we don't have a plan; my worst fear fulfilled. Wouldn't this lead to some patients stockpiling methadone, just in case?"
· From Pennsylvania: "If there were a disaster, we can go to a local hospital to get medicated." (What if that hospital was also affected by the disaster?--Editor)
· California: "We have a plan for earthquakes, but it hasn't been reviewed or updated in five years."
· Florida: "Hurricanes are our biggest worry. We track developing storms and, if appropriate, give 2-3 days of (methadone) take-homes with state and federal approval." Yet, other readers reported that such plans are hampered by local government regulations covering take home dosages for fear of diversion.
· New Jersey: "Our (MMTP) comes under the umbrella of a hospital (in which they operate). So we are included in their emergency planning." (But, does this include a plan for emergency methadone dispensing?--Editor)

Most MMTPs Vulnerable
From reader responses, there are many interpretations of what constitutes a "disaster plan" or, for that matter, what might be a disaster worth planning for.
In recent times, there have been some legendary disasters. Hurricane Hugo lashed the Southeast in the summer of 1989. In the summer of 1993, a swollen Missouri River flooded whole communities in the Midwest. In January, 1994, Los Angeles was struck by the largest earthquake ever to directly hit a major American city. This past winter, floods due to California rains ravaged many cities and towns. Just last April 19, a deadly car bomb incident in Oklahoma City devastated an office building and disrupted business activities in the entire surrounding area.
However, clinic operators and directors who consider a disaster as an event only of epic proportions--therefore, something unlikely to occur--may be doing a disservice to themselves and their patients. A hail storm, cold snap, power outage, summertime brownout, flu epidemic, broken gas or water main, or bomb threat may pre-empt normal operations just as effectively as a riot, fire, flood, tornado, hurricane or earthquake; albeit less dramatically.
To learn more about how methadone clinics might deal with disasters, we spoke with Robert Holden, CCDT, Program Director at PIDARC in Washington, DC. Two years ago they had a disaster when overhead water pipes rusted through and burst causing extensive flooding and electrical hazards.
According to Holden, this wasn't something they had planned for, but they fortunately were able to contact the DEA and receive permission to move the methadone to another location in their building for dispensing. Luckily they were also able to salvage patient records from their flooded clinic, so proper doses could be administered. There was a very little disruption in service to patients.
Holden had anticipated some other disasters, such as snow days, for which they received advance FDA approval to close the clinic and give patients several days of take-home methadone. For other emergencies, he planned to "trip" patients to other methadone clinics in the area. However, if his patient records could not be salvaged, there would be a problem with them receiving proper dosing.
Just two days after our discussion, Holden called back to say he had a new plan in place to confidentially and securely store duplicate patient medication records at a second location. He also contacted other MMT programs in his area to arrange reciprocal patient dosing in the event of an emergency at any of their respective clinics.
We also spoke to a clinic director in Northern California about last winter's floods. Faced with the lack of a plan, dire necessity became the mother of invention when it came to dealing with this disaster.
Many patients were cut-off from the clinic, so he arranged for police and fire departments to take methadone supplies to more accessible distribution points. He was in touch with them by phone and fax to make certain patients got proper doses. He tells how one highly motivated patient did get to the clinic by somehow hitching a ride on a National Guard helicopter. But, that case was an exception.
Was this approach approved by the DEA? All he would say is, "When all else fails, I believe in doing what's right for the patient to prevent human suffering." He stressed that there is a need for better communication with regulatory agencies to develop pre-approved contingency plans dealing with various potential emergency situations.
We next interviewed several methadone clinic directors from Illinois and Texas. All had given some thought to severe weather, fires, bomb scares, utility outages and the like, and all hoped patients could be served by other clinics in such cases. However, there was some questions about whether or not other clinics would have sufficient stores of methadone to deal with a sudden surge in patient loads.
Also, none of the clinic directors had back-up copies of patient records stored off-site, and none had met with regulatory agencies to discuss specific plans. For obvious reasons, they asked that their names not be used in this article, but they did agree that our discussions with them were enlightening and would result in some positive actions.

Safety & Limited Service Disruptions Are Goals
In each disaster situation, the goal is to maintain clinic operations as close as possible to normal. For methadone maintenance treatment programs, there is a two-fold challenge: 1. the safety of workers and patients at the clinic when disaster strikes; 2. the continued care of patients who, in most cases, must come to the clinic for their methadone on a daily basis. A disaster preparedness plan is essential. It defines what you need to stay open during a disaster or, at the least, to recover in the shortest time possible.
In a disaster, every staff member should have an assignment of responsibility to make certain critical areas and services are covered. Priorities must be clearly defined. Consider appointing one person as a disaster preparedness coordinator to gather necessary information and organize a committee. Put plans in writing and distribute relevant portions to staff and patients.
Test your preparedness systems and hold disaster drills as appropriate. Many preparedness activities should be performed as part of a daily routine; such as, backing-up computer files and storing vital records secure and safe from theft, fire or water damage.
How will staff and patients be notified and instructed regarding disrupted clinic operations? Part of your disaster plan might include a "calling tree" whereby, once a designated coordinator initiates the message, each staff member and patient is assigned others to call in branching-out fashion. In some cases, it is best to have all persons call a central number outside of your area code. Contact your telephone company about the best way of establishing such a network.
Where will patients go for their methadone? Form a disaster consortium with other methadone clinics and/or hospitals and medical clinics in your area. Many disasters--like tornados or fires--are highly localized in their damage. Your clinic may be destroyed while another nearby is fully operating and able to serve your patients.
For some disasters, as with hurricanes or flooding, there may be advance warning of potential widespread disruptions. Can arrangements be made, along with any needed regulatory approvals, to provide patients with adequate take-home doses for the anticipated period of disruption?
In disaster planning it is wise to prepare for the worst that can happen. Then, if disaster strikes, you can quickly recover with little, if any, harm to human well-being or disruption in service.
Several helpful disaster planning resources are available. To obtain a list, check-off the appropriate box on the feedback card in this issue and mail it to us. (See also Disaster Planning Revisited)

Methadone Voucher Program; Success in SF

"Kick heroin" with free methadone. Take your pick of maintenance dosing for a month or medically supervised methadone withdrawal.
That was the offer BAART (Bay Area Addiction Research and Treatment, Inc.) made to addicts coming into the Prevention Point needle exchange program in San Francisco. Prevention Point serves about 900 individuals each week who exchange in excess of 20,000 needles.
During a three month trial period starting in July, 1994, a limited number of treatment vouchers were allotted for distribution each week. The program was funded by an educational grant from Mallinckrodt Chemical, Inc. and was under the direction of Emmett Velten, Ph.D., Clinical Development Director at BAART.
This test project was inspired by Velten's belief that there was a much greater demand for methadone-based treatment than traditional funding would allow. The question was, given the opportunity, how many street addicts would take advantage of short-term free treatment?
To help assess pent-up demand and individual motivation to seek treatment, the addicts had to use their vouchers either the same day they received them, or the next day at the latest. Over the three month test period, 145 vouchers were distributed to qualified heroin addicts requesting them and 114 were claimed for treatment. Thus, almost 80% of the vouchers were used the day of receipt or the next day at the latest. In addition, 13% of the people who used vouchers had never been in any formal treatment before.
As Velten predicted, the vast majority of voucher users (91%) selected the free 21-day methadone-based detoxification program. The problem with the 30 days of free methadone maintenance option was patients being able to pay for continued treatment in succeeding months. Most could not afford it.
According to Velten, the program was a huge success in terms of attracting participants. "We could have distributed al the vouchers easily in one week," he notes. The drawback was the BAART's two clinics for maintenance or detoxification in San Francisco could only handle so many new intakes each week.
How successful was detoxification for the majority choosing that option? It was equivalent to other individuals typically registering in BAART programs. According to Velten. "Most people who register for 21 day detox, don't go through the full treatment."
But, a definite plus was that all patients got a full medical screening, with opportunities for HIV, hepatitis and TB testing. They also received counseling and, often, referrals to longer term treatments. So, it allowed reaching a number of out-of-treatment heroin addicts who normally wouldn't receive any medical care or screening. The public long-term health benefits could be significant.
Velten believes the trial program effectively demonstrated that many addicts going to needle exchanges are genuinely interested in receiving addiction treatment if given the option, even on a short-term basis. At many of Prevention Point's 10 exchange sites, addicts lined-up early to be first in line for vouchers. Many more vouchers than allowed under their trial program budget could have been distributed and used.
to prevent street trafficking of vouchers, each had a unique number and basic information about the recipient was recorded. This information was checked against the person actually redeeming the voucher at the clinic.
For the future, Velten would like to see more extensive and longer-term programs with the ability to do follow-up on the patients after treatment. Velten indicated that a 1994 court decision expanded the availability of Medi-Cal funding for methadone maintenance in California. As a result, the registration at the BAART clinics increased by 20% to 25% within a few months. Like the voucher project, t his increase shows how great the demand is for treatment. Unfortunately, the California legislature is presently considering eliminating all drug and alcohol treatment as a Medi-Cal benefit.

Straight Talk...from the Editor

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Correction Feedback

In our last issue (Vol. 4, #1; Winter, 1995, page 6) a story featuring Stan Novick of NAMA stated that in the past 20 years not one new methadone clinic has been opened in New York State.
According to Ira Marion, in July, 1993, the Albert Einstein College of Medicine's Division of Substance Abuse started a new, full-service 350 patient clinic--Melrose on Track--in the Morrisania area of the South Bronx, Marion (Associate Executive Director, Division of Substance Abuse) indicates the clinic was operating a full capacity within six months of opening. Marion was surprised at how quickly the clinic filled up and is sure many new clinics are needed in New York.
Also, according to Willard Campbell III, Clinic Manager at the East End Clinic in Riverhead, NY, their program began operations in November of 1993.
Campbell comments, "Despite my minor correction of Novick's remark, I found his overall perspective to be, unfortunately, accurate. In our efforts to open a new program, we confronted all the myths and prejudices of which he spoke. i urge other institutions to confront the opposition and attempt to increase the availability of methadone treatment. The end results and benefits are well worth the hassles."
We thank both readers for their updated information.--Editor

Pharmacist's Role in MMTP

How might pharmacists participate in helping provide better patient care in methadone maintenance treatment programs? A.T. Forum spoke with John St. Peter, Pharm.D., BCPS. He is a consulting pharmacist and pharmacist in charge for the Addiction Medicine Program of Hennepin Faculty Associates, and Assistant Professor, College of Pharmacy at the University of Minnesota.

A.T. FORUM: From a pharmacist's perspective, how do you approach methadone maintenance treatment?
JOHN ST. PETER: We try to take an integrated approach to each patient's health care focusing on their major problems; in this case it's generally their addiction. You need to consider the demographics of whom you're treating. Here in Minnesota, we have an older addicted population; the mean age is almost 38 years old and the range is age 20 to 57. Virtually two-thirds of these people have multiple psychiatric and medical diagnoses. By default, then, these people may be involved in multiple medication therapies.
A.T.F.: What do you mean by multiple medications?
ST. PETER: Patients go through a two day intake process and a part of that is an accurate assessment of each person's concurrent medication history: including prescription and over-the-counter (OTC) medications, smoking, alcohol and caffeine intake. We also focus on the patient's analgesic use. Some of these medications, such as acetaminophen, have inherent toxicities in large quantities which can interact with hepatic drug metabolism. Many health care providers are knowledgeable about prescription medications but, when it comes to a broad spectrum of medications, you can benefit from the specialist approach of a pharmacist; much as we do with other medical specialties.
A.T.F.: Can some f the OTC drugs also diminish the potency of the methadone?
ST. PETER: That hasn't really been well studies but there are potentials. That's why in our clinic we hope to use the extensive information that we generate on our patients to help guide our care, and start to study some of those questions. While we know there are classic things that a lot of these patients take that can change methadone metabolism, drug therapy in this country is changing at an enormously rapid pace. We have whole new classes of medications that are going to be used heavily in our population due to their psychiatric and medical disorders. We want to make sure that our addition therapists have good access to drug information from the pharmacist who acts as the specialist in such matters.
A.T.F.: How do you organize the vast amount of information that becomes available on patients and their medications?
ST. PETER: With the advent of computerization and the electronic chart, it's getting easier for clinics to compile the information and have somebody assess possible drug interactions. Our clinic chose to automate some of the methadone dispensing and bookkeeping processes, freeing the pharmacist's time to serve as a clinician. I spend time working with our therapists to make sure that they are knowledgeable about taking a complete medication history. Most people tend to focus on prescription meds alone, whereas we try to put a complete picture together. If the patient is having more symptoms than we would expect, we encourage the therapists to examine the medication list.
A.T.F.: What about the potential for drug interactions leading to false positive urines?
ST. PETER: At this time, we haven't identified very many. We have new chemical entities coming out that we're using in conjunction with methadone and I venture to say that many of those aren't tested until you have a patient who's never been positive start coming up positive. Then you really need to stop and look at their concurrent prescription and OTC drug use.
A.T.F.: Earlier you mentioned the importance of understanding patient demographics.
ST. PETER: Yes, I think that many clinics don't fully appreciate the demographics of their patient populations. We have an ethnically diverse population here in Minnesota and certainly there are drug metabolism differences in those ethnic populations. For example, we know that there are drug metabolism differences between Orientals, Caucasians and African-Americans. There are also age-related changes in drug metabolism. Some of those differences relating specifically to methadone haven't been well defined in the literature because clinics have not been able to rapidly and in an organized manner gather the demographic information. With currently available computer technology, we can have some very basic demographics compiled as part of a management system and then begin to let individual patient needs determine their care.