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


Self Help Programs

12-Step Groups for Methadone Patients

For some time, questions have been raised about Methadone Maintenance Treatment in combination with alcoholism treatment, and the acceptance of methadone patients within traditional 12-step groups. However, it appears that the treatment for alcoholism in methadone-maintained patients might follow the same time-tested approaches f the alcoholism field; without necessarily withdrawing patients from methadone.
According to Enoch Gordis, M.D., writing the first edition of Alcohol Alert (National Institute on Alcohol Abuse and Alcoholism; August 1988), the prevalence of alcoholism among MMT patients is about 50%. Among patients who discontinued methadone maintenance, the relapse rates into continued heroin use were high--70% to 80%, he claimed. He firmly states that, requiring individuals t terminate methadone maintenance as a condition of acceptance into alcoholism treatment should be rejected as a standard practice.
Dr. Gordis proposed that, methadone (as used in a methadone-maintenance program) is pharmaceutically different from heroin and alcohol. It is also a therapeutically prescribed drug for treating a medical condition; much like insulin or digitalis are used for chronic disorders.
With this in mind, where might methadone patients fit into traditional 12-step programs?
Duncan McGonagle, RN reports (in "Methadone Anonymous: A 12-Step Program," J. Psychosocial Nursing, 1994, Vol. 32, No. 10.) that, over the years, methadone-maintained alcoholics and addicts were not readily accepted by either Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) groups because methadone was viewed as an addictive drug. hence, they were not allowed to fully participate in meetings as long as they continued to take their methadone (even though methadone was physician prescribed just like any other medication).
In 1991, Gary Sweeney, seeing the need for a separate program that would better serve the interests of methadone patients, many of whom were also alcoholics, founded Methadone Anonymous (MA). McGonagle notes that MA views methadone as a therapeutic agent used in recovery (much as Antabuse (disulfiram) would be for an alcoholic). Participants in MA are free to continue taking methadone or discontinue its use, but methadone itself is not viewed as a drug in the street sense, but as a medication.
MA is based upon the 12-step model of AA started in 1935. AA has successfully served countless thousands of alcoholics over the decades, and also served as a model for NA (founded in 1953) and many other 12-step self-help groups.
The name "Methadone Anonymous" for such a group may have created some confusion. Traditionally, "_______ Anonymous" groups promoted abstinence from whatever word preceded Anonymous: alcohol, narcotics, gambling, overeating, etc.
This issue has been raised i previous edition of A.T. Forum (see letters in Vol. III, #1, and Vol. III, #2). Perhaps, it would be more "politically correct" in the case of MA to call it a "Methadone 12-Step Group." However, the name itself may not be as important as the group's mission. According to McGonagle, there seems to be no confusion among MA participants that their continued use of prescribed methadone is an individual decision; abstinence from opiates and other mind-altering chemicals, including alcohol, is the foremost goal of their recovery.
MA follows all of the time-proven principles and practices of AA and NA. And, according to Sweeney and McGonagle, chapters are expanding nationwide and even internationally. Addiction treatment professionals may want to examine and recommend the potential benefits of participation in such groups targeted to the particular needs of methadone patients and their families.
For more information, Gary Sweeney--who is President, National Board of Directors, Methadone Anonymous, USA--can be contacted at 410-837-4292, or write Methadone Anonymous World Services, Inc., 163 Third Avenue, Suite 1334, New York, NY 10003.

Where to Get Info

TB Facts for Clinic Workers
In the United States, the decline in tuberculosis cases has ended, largely due to the AIDS epidemic. An estimated 10 to 15 million persons are infected with TB and, in some areas, as many as 58% of persons with TB are also HIV seropositive.
Alcohol abusers and IVDUs are at especially high risk. Patients in drug treatment programs who have active, infectious TB pose an occupational hazard to health care workers that must be controlled.
Three short pamphlets from the U.s. Department of Health and Human Services discuss these issues in understandable language that would benefit all addiction treatment clinic staff:
· "What Drug Treatment Centers Can Do To Prevent Tuberculosis"
· "TB Facts for Health Care Workers"
· "TB/HIV, the Connection: What Health Care Workers Should Know"
The pamphlets are all available from the TB control program offices in most states, or write to:
Information Services, NCPS, CDC
Mailstop E-06
1600 Clifton Rd., NE
Atlanta, GA 30333
A request also may be made via voice mail at: 404-639-1819.

Special Report Review

Methadone Treatment Regulation; New Challenges for Change
Federal Regulation of Methadone Treatment (240 pages) is a newly published report (1995) that seems destined to become MUST reading for all methadone policy makers and enforcers, treatment professionals, clinic trainees, and even patients or their advocacy groups seeking a better understanding of MMTP.
The report results from the work of a distinguished committee selected by the Institute of Medicine and is published by the National Academy Press. The 22 committee members included several who have contributed to past issues of A.T. Forum: Drs. Mary Jeanne Kreek, Tom Payte, Ed Senay; and lawyer Lisa Mojer-Torres. Fact gathering by the committee included visits to numerous MMT clinic around the United States.
The title may be somewhat limiting, for the contents go far beyond federal regulations to explore every vital aspect of methadone therapy. Topics include: pharmacology and medical factors in treatment, patient characteristics, methadone diversion concerns, financing of treatment, standards for optimal treatment, clinical practice guidelines, and action plans.
The specific charge to the committee was to examine current standards for narcotic addiction treatment and the regulation of methadone treatment. Options for modifying those standards and regulations are recommended, and a great many concrete suggestions for better clinical practice are put forward. Of particular interest for persons first entering the field of MMT, there is a historical perspective of FDA approved methadone use dating back to 1947, plus an examination of the regulatory trends and rationales over the years.
The committee concludes that, "Current policy...puts too much emphasis on protecting society from methadone, and not enough on protecting society from the epidemics of addiction, violence, and infectious diseases that methadone can help reduce." Methadone is unique in that it (and, more recently, LAAM) are the only opiates authorized for treating opiate dependent persons. The committee finds that the current regulations follow a belief that the risks to society of methadone outweigh the benefits to society to such an extent that extraordinary controls are necessary "above and beyond those applicable to any other therapeutic drug in the United States."
The committee concedes that certain enforceable requirements are needed to prevent substandard or unethical clinical practices that could have socially undesirable consequences (such as diversion of methadone). But, they argue that raising the standard of treatment should entail authorizing greater clinical discretion in medical treatment and reducing the extent of government regulations. "There is no compelling medical reason, in the committee's view, for regulating methadone differently from all other medications approved by the FDA, including schedule II controlled substances."
They further insist that the assessment and treatment of opiate addiction should be based on clinical diagnostic criteria contained in practice guidelines rather than set forth by government doctrines. For example, in the case of methadone dosing, each patient's dose should be determined on an individual basis as a result of clinician judgement. While the initial dose might not exceed 30mg/day to protect the safety of a newly admitted patient (as is currently mandated), the committee recommends that ALL other dosing restrictions should be removed from the regulations.
Further, the committee encourages minimizing the administrative burden associated with both federal and state regulation of methadone. uniform procedures should be developed allowing inspections by only one level of government or a single agency which would be satisfactory to all other levels. At the same time, much of the responsibility for maintaining quality control should be shifted from government officials to clinicians who follow accepted practice guidelines.
As one example of a practice guideline suggested by the committee, the term "detoxification treatment" should be replaced by "medically supervised withdrawal (MSW)." No time limit should be specified for MSW and new regulations should clearly accept that it is not appropriate for all opiate addicts. The expectation also is expressed that involuntary administrative withdrawals can be curtailed via alternative clinical approaches and, when absolutely necessary, such actions will be medically supervised following protocols geared to the humane treatment of patients.
Certainly, a great deal more could be said about the dramatic and far-reaching recommendations in this extensive report. Hopefully, the above highlights suggest why it will no doubt be the subject of many thoughtful meetings and discussions in the months, maybe even years to come.
To order this publication (ISBN #0309052408; cost approx. $37, including 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)
(Coming in A.T. Forum...our next edition will review another recently published report by the Institute of Medicine entitled: The Development of Medications for the Treatment of Opiate and Cocaine Addictions: Issues for the Government and Private Sector. Eager readers may order a copy now from the National Academy Press as listed above (approx. cost, $37 + shipping) ISBN #0309052440.)

Beth Israel Patients Become Counselors

Last fall, Beth Israel Medical Center (New York City) Methadone Maintenance Treatment Program held the second graduation of their Counselor Trainee Training Program (CTTP). This program was originally suggested by Stan Novick, Activity Program Coordinator and John Orraca, Patient Liaison, and developed in response to the dwindling pool of applications for position openings as MMTP counselors at Beth Israel. Program Administrator Sal Damiani supported their efforts and arranged for funding.
After an extensive screening process, 12 individuals who were in treatment at the MTP were selected from 71 applicants. The minimum requirements included at least four years of continuous success in methadone treatment, a high school diploma or equivalency, and reading/writing/math skills at the 8th grade level.
They participated in 12 weeks of classroom training and were then graduated to a Counselor Trainee Position for two years of on-the-job training experience. After this period, they will become eligible for full-time counselor positions.
One of the trainees has over 20 years successful experience in MMT and, during that time, returned to school to become a Registered Nurse. "I went into the Counselor Trainee Training Program believing that as a nurse and patient I knew all about methadone," she says. "But, I was in for quite an awakening."
"The methadone patient knows little or nothing about their treatment modality and that's a shame," she continues. "With the knowledge I gained, my whole attitude has changed and I'm a better person and patient because of it. Most importantly, I learned that it's okay for me to be on methadone."
The first year of the CTTP was 1990. Five of the original seven trainees in that class have become full-time MMTP counselors at Beth Israel.

Heartland Methadone Symposium

As we foretold in our last edition, A.T. Forum in conjunction with the State of Missouri Department of Mental Health Division of Alcohol and Drug Abuse hosted a one-day methadone symposium in Columbia, MO, on May 3, 1995. Over 50 people from six states attended. The symposium was funded by an educational grant from Mallinckrodt Chemical, Inc.
Mark Parrino, President of the American Methadone Treatment Association, discussed changing federal and state policies regarding methadone treatment. He expressed grave concern that managed care initiatives (e.g. 1115 Waivers) will make it difficult for methadone patients to gain access and to remain in methadone treatment. Some state legislatures (e.g. New Hampshire) have prohibited methadone treatment, while others have attempted to limit maximum doses (e.g. Georgia) and limit medicaid funding (e.g. California and New York). Parrino stressed that the methadone treatment community must remain unified and present a common message to lawmakers.
J. Thomas Payte, M.D., President of Drug Dependence Associates, San Antonio, TX, presented an approach for ensuring adequate methadone maintenance dosing based upon individual patient needs. A widely respected author and lecturer, he is a proponent of "adequate dosages," clinically determined, which correlate with reduced illicit drug use and improved patient retention in treatment. In his opinion, the concepts of high dose or low dose should be discarded, and should not be decided by regulatory agencies or legislative policy.
As Payte has often noted, the methadone maintenance doses of 80-120 mg/day recommended by Dole and Nyswander in the 1960s are still valid in many cases today. Yet, studies show that a vast majority of current patients are receiving suboptimum doses which are inadequate to prevent their continued narcotic use.
Teresa Hagan, Ph.D. discussed women's issues related to MMTP, emphasizing that there is a need for more gender-sensitive treatment for drug abusers. Fear of prosecution for drug use causes many women who might want or need medical care to shun it.