Reader Survey Results
Hepatitis Haunts MMTP's
From the Editor
Association, Texas Style
Nimby Alive in Chicago
Where to Get Info
Patients' Perspectives
Research Notes


Reader Survey Results

MMT Nurses As Counselors?
The question we asked of A.T. Forum readers in our last edition (Vol. III, #3, Fall, 1994) was: Should MMTP nurses also serve as addiction treatment counselors?
Roughly 70% of those responding to the survey said "yes"; 30% answered "no." Admittedly, however, our question may have been too broad. To some readers it questioned whether or not nurses should definitely be expected to work as counselors in addition to their other everyday responsibilities; this was not the intent. Also, the question does not specifically state that nurses must first have training as counselors.

Special Training Key to Nurse/Counselor Role
Written comments from readers suggest that almost all feel MMT nurses could make excellent counselors if they had the additional training necessary. As one program coordinator from Syracuse, New York, wrote:
"... we have many times utilized nursing staff in counselor positions after they have undergone the necessary addiction training and proven their competency in delivering quality treatment. Clearly, a nurse's knowledge of both normal physiology and pharmacology offers the ability to much more effectively understand and react to the changes physically and psychologically that occur in a client who is chemically dependent. A nurse also has the trained ability to quickly make assessments of clients...to make decisions on their current level of functioning."
Other comments expressed similar thoughts:
"Nurses need to take classes in pursuit of certification in the specialty of addictions nursing. There are two nationally certified organizations: National Nurses Society on Addictions; National Consortium of Chemical Dependency Nurses."-New Jersey
"Patients that have a nurse as a counselor benefit from a holistic viewpoint. Nurses are trained to educate, guide, as well as treat patients, thus making their services invaluable as counselors."-Nevada
"Nurses are able to identify problems through daily observation of clients. Disclosures of problems not otherwise known are often made at the dosing window."-Michigan
"One of the primary responsibilities of a nurse is to be a patient advocate and this population desperately needs someone on 'their side' to help educate the general population about this disease process and the appropriateness of MMTP."-California
Almost without exception, the nurse respondents were in favor of expanding their roles at MMT clinics to include patient counseling. It is a way for them to broaden their skills and make added contributions to patient care. They all also recognized that they would need some special training, possibly including certification, in chemical dependency counseling to be effective in such added responsibilities.

Objections to Nurses as Counselors
As might be expected, a number of responding counselors were concerned about nurses crossing over into their field of expertise. According to one counselor in New York, "They should devote their time to see that clients are given their right doses and medical treatments and leave counseling for the counselors." This was commonly expressed, even though an earlier survey a year ago in this publication (see Vol. III, #1) found that most counselors believed their case loads were "very difficult." From that, one would have thought they'd welcome any relief they could get.
Some respondents simply questioned where nurses would find the extra time to serve as counselors:
"At my facility there is little enough time for nurses to medicate and follow up on medical issues. Nursing time is simply not available for counseling activities."-New York
"We do all labels and dose changes by hand and spend more than 40 hours weekly with just medication related activities."-Texas
"Does an MMTP nurse really have time to be a counselor? It is my experience that they do not; requirements in the dosing room remain too demanding."-Alabama
For other respondents, their concerns about nurses as counselors went beyond time restraints and the need for special training:
"Nurses should be supported as clinicians and address medical problems; leaving counseling to ex-users who can better relate to patients. The (nursing) professionals will move in and take over where they really aren't wanted. They are better at nursing."-Indiana
"Nurses need to stick to what they do best medically."-Pennsylvania
"Nurses cannot be both dispenser who act in an authoritarian and controlling manner, and also perform a supportive and nurturing function. The two roles need to be separate."-New York
"Nurses with dual roles (medicate and counsel) have too much perceived power by the clients which interferes with quality therapy. This also would pit non-medicating counselors against medicating counselors among the clients."-Illinois
"Care need to be exercised so that comparisons are not encouraged among clients as to who has the better (i.e., more qualified) counselor."-New York
There were also a few comments from readers about pay scales for counselors versus nurse/counselors. In some cases, more educated and higher skilled nurse/counselors might command higher wages than the typical counselor which could stress a clinic's budget. Clearly, this and the other concerns expressed above are challenging issues for individual MMT programs to grapple with in their quests to provide optimum patient care.

Hepatitis Haunts MMTPs

Problems in controlling viral hepatitis have haunted MMT programs since their inception. Addicts carry as many as four different types: A, B, C and D. The serious complications of these disorders for addicts and the health care workers who serve them can be life-threatening or, at best, expensive to treat.
Mary Jeanne Kreek, M.D., (Professor at Rockefeller University, New York City) shared her research and insights regarding Hepatitis B with A.T. Forum. We also gathered research and commentary from Forest Tennant, M.D., Dr.P.H., regarding the importance of controlling Hepatitis C. Dr. Tennant is executive director of the Research Center for Dependency Disorders and Chronic Pain, Community Health Projects, Inc., in West Covina, California.

Hepatitis B - Controllable Curse
According to Dr. Kreek, it has been consistently shown from the beginning of her pioneering work back in the 1960s until the mid 1980s that Hepatitis B markers were present in over 80% to 90% of all heroin addicts entering treatment of any kind. Hepatitis B Virus (HBV) produces significant illness but has a low death rate. When present in actively replicating forms, it also permits infection with a small RNA viroid, Hepatitis Delta Virus (HDV).
HDV entered the drug abusing population in about 1972-73 and, in some populations, now actively infects as many as 30% of all people entering treatment. HDV has a far greater death rate and a more accelerated rate of illness than B alone. HDV causes its own disease but depends upon the presence of a replicating B virus for its ability to be infectious.
Dr. Kreek believes if HIV hadn't come along we would be focused on the devastating problems of HDV. "In our own clinics we had actually seen more deaths in the early years of AIDS from Hepatitis Delta than we did from AIDS. That's obviously changing as we get more new admissions of HIV infected patients. But it's still a major problem."
As patients come into methadone treatment a significant number are likely to have active HBV and can infect other people. And, patients' responses to HBV may be atypical due to immune system dysfunction which subjects them to severe forms of the disease. Dr. Kreek's research has shown, however, that the immune system function tends to normalize during long-term methadone maintenance treatment. Possibly due to immune function normalization, protective HBV antibodies begin to appear which can halt the progression of liver disease in MMT patients.
As a result of AIDS risk-reduction education efforts, Dr. Kreek notes that they are also seeing a reduction in the numbers of patients coming to drug treatment clinics that are Hepatitis B marker positive; i.e., have been exposed to the disease. Until 1985, the rate was always over 80% but it is now around 50% of heroin addicts entering MMTPs.
While this trend is encouraging, it also means that health care providers have an obligation to further help eradicate HBV since there is an effective vaccine to protect against it in those persons who've not been exposed.
About five years ago the Centers for Disease Control said that all school children should be vaccinated for Hepatitis B. To extend that, Dr. Kreek stresses that all health care personnel should be vaccinated, including everyone working in an MMTP. Additionally, patients coming into methadone treatment who are not marker positive for HBV infection should be vaccinated.
Hepatitis B is more easily spread than HIV. According to Dr. Kreek it takes only a minuscule inoculum of HBV-containing blood to infect anyone. Needle stick studies uniformly show that almost 100% of persons who get a needle stick with HBV containing blood will get the disease. A much lower percentage will get HIV from such a needle stick.
A further concern is that in AIDS patients, with their suppressed immune systems, there can be a reactivation of infectious Hepatitis B and concurrent Hepatitis D. This further supports the public health need to vaccinate health care workers as well as patients entering treatment who do not have Hepatitis B markers. They are going to be increasingly exposed to persons with AIDS who may experience a reactivation of their Hepatitis B and D.

Precautions Needed to Fight Hepatitis C and Other Contagious Diseases
Dr. Kreek notes that Hepatitis C Virus (HCV) studies have shown that 80% to 90% of heroin addicts are infected today. Much less is known about HCV than Hepatitis B, although HCV is today considered more prevalent and infectious than AIDS, and may lead to scarring of the liver, liver failure and liver cancer. There's no vaccine against HCV.
Dr. Tennant's research has found HCV to infect over 90% of intravenous drug users in California and is likely to be contagious in at least half of those infected. Similarly, on the east cost, Dr. Michael Fingerhood and associates at Johns Hopkins University in Baltimore reported 86% of IDUs tested positive for HCV. By way of comparison, the prevalence of HCV in the general population was estimated at 0.9% to 1.4% in one study of volunteer blood donors.
According to Dr. Tennant, "The most serious and disconcerting fact about Hepatitis C is that about 50% of no-addict, non-transfusion cases in the United States have no identified source of origin. ...as many as 20% to 30% of alcoholics and other non-intravenous drug users admitted to treatment test positive for Hepatitis C antibodies, and almost none of these give a history of intravenous drug use or transfusion."
Thus, while Hepatitis B seems to be slightly decreasing in numbers and is further controllable by vaccination, Hepatitis C seems to be quite prevalent among drug addicts and could pose a serious threat to the health care community as well. Dr. Tennant cautions that addiction treatment facilities must also be on guard against other contagious diseases carried by immune-impaired drug abusers including: Chlamydia, HIV syphilis, tuberculosis, gonorrhea, herpes, staphylococcus, streptococcus and Hepatitis A. This fourth form of hepatitis-Hepatitis A-is believed caused by fecal contamination of food or water. It is rarely life threatening, although fatigue and symptoms similar to the flu may occur.
Dr. Tennant stresses that addiction treatment facilities must develop infection control measures to protect staff, patients and the public. He has prepared a concise booklet entitled, "Prevention of the Spread of Hepatitis C and Other Contagious Diseases in Dependency and Recovery Facilities." It describes the successful procedures and policies that have been implemented in his clinics throughout California. it provides helpful and vital information for all clinic staff.

Straight Talk...from the Editor

Bringing Together the Message
Just as we were finishing up this edition, an interesting new book came across our desk. It's called RADICAL SURGERY: What's Next for America's Health Care (Times Books, NY) by Joseph A. Califano, Jr. (see mention of him in Research Notes). He makes some very eloquent observations that bring together many of the viewpoints expressed by persons interviewed in A.T. Forum over the years.
For one thing, he says, "Addiction is a chronic disease, more like diabetes and high blood pressure than like a broken arm or pneumonia, which can be fixed or cured by a single round of therapy. Continuing care is as critical to treating the alcoholic or drug addict as taking insulin or hypertension pills is to the diabetic or victim of high blood pressure."
Califano further observes, "Most public policies guiding the nation's various wars on drugs have failed because they have been so lopsidedly concentrated on law enforcement and interdiction. Yet one political leader after another orders up more of the same: more cops, more prisons, more tough sentences. Let's recognize these leaders, Republican and Democrat alike, for what they are: a chorus of politicians pounding the table harder and shouting louder, 'If all the king's horses and all the king's men can't put Humpty Dumpty back together again, then give us more horses and more men!'"
He refers to a 1994 Rand report which claimed that every dollar invested in treatment had greater impact on reducing drug abuse than up to 20 dollars spent on enforcement and interdiction. And, as we report in this issue (see Research Notes), a study in California found that each dollar spent on addiction treatment saves society seven dollars in other indemnity.

New Reader Survey Question...
Disasters happen: tornadoes, hurricanes, fires, floods, blizzards, labor strikes. Does your clinic have a plan for dealing with them so methadone or other medication dispensing can continue uninterrupted?
The survey question on our postage-free feedback card is: Does Your Clinic Have a Disaster Plan? Yes? No?
As always, your comments are most appreciated and will be reported as part of our summary. If you have an interesting disaster story and would like to be interviewed, let us know so we can share your experiences with our readers.
MAIL or FAX your responses to us-today-so we can include them in our next issue. Please note our new address and fax number:
A.T. Forum
1750 East Golf Road, Suite 320
Schaumburg, IL 60173
FAX: 847-413-0526
NOTE: You can also use the postage-free feedback card to be put on the mailing list.
-Editor

Association News

Methadone Treatment Association: Texas Style
What are the benefits of a state methadone treatment association? To help answer that question we interviewed Steve Tapscott, M.A., program sponsor of Narcotic Withdrawal Center, Inc. in Houston, TX and Chairman of the Texas Methadone Treatment Association.
Methadone has been dispensed in Texas since the early days of MMT in the 1960's. Today, there are 6,500 methadone patients in Texas, with 76% paying their own way for treatment. Until fairly recently there was no organization of providers.
A.T. FORUM: A few years ago Texas methadone programs were getting some bad publicity. Is that what motivated the organizing of your Association?
STEVE TAPSCOTT: The primary reason that we had problems down here was we weren't being adequately monitored and weren't engaged in any type of self-monitoring. So, it opened up the door to some abuses.
For the majority of our existence in Texas, methadone providers have basically been the stepchild of mental health. We hid in the cracks and walked around on eggshells because we didn't want to make any waves. State agencies didn't know what to do with us. the media didn't like us, and most of the population didn't understand us.
In 1992, we began to address what was happening with the methadone providers in our state. We needed a way of dealing with the media and the monitoring agencies. So, we organized a first round table discussion group in July, 1992 and a second one in December of 1992. We incorporated in November, 1993. Last October we had our first annual Texas Methadone Treatment Association conference in Fort Worth. It was a great success.
A.T.F.: What sort of response did you get from provider organizations?
TAPSCOTT: Our goal from the beginning has been to open up communication. We share information among ourselves and communicate with the various licensing and monitoring agencies. Our state methadone authority is underneath the Texas Department of Health; one of our licensing agencies is the Texas Commission on Alcohol and Drug Abuse (TCADA).
We began to talk with these people and put on workshops to help educate them on maintenance pharmacotherapy. It was surprising that TCADA really had no idea what to do with methadone. They were funding some programs, but these were twelve-step abstinence based approaches.
We owe a lot of gratitude to CSAT for helping us get started. Mark Parrino (of the American Methadone Treatment Association) also visited us on several occasions to talk about the importance of an association. And Dr. Tom Payte was very helpful and supportive.
TCADA recognized our Association as being the professional experts and we were allowed to write the standards for synthetic narcotic treatment programs in Texas. They're voluntary standards based on the "State Methadone Treatment Guidelines" developed by CAST.
A.T.F.: What activities is the Association engaged in at present?
TAPSCOTT: We've stayed focused on keeping the communication lines open. We have regular board and committee meetings and two association meetings a year. Since we've done all this it has closed the door to possible problem clinics. We're just not seeing them anymore.
A.T.F.: Do you have a formalized communication program?
TAPSCOTT: We send out quarterly newsletters. The Texas Department of Health and TCADA use us to disseminate information to all methadone providers, whether or not they're members of our Association.
The state agencies now work in harmony with us. Previously, they would develop regulations on their own and send them out to everybody. The individual providers would end up in Austin trying to fight what they were doing. Now the agencies talk to us, they work with us because we've taken the step to become self-governing.
A.T.F.: What benefits does a provider receive by paying dues to be a full member of your Association?
TAPSCOTT: For one thing, we are a member of the American Methadone Treatment Association and there are many benefits fro that, such as much lower rates on professional liability insurance. Mark Parrino took the time to educate an insurance provider on what we do, so we have rates that are one-fourth the cost of what they would be normally.
Another benefit is that part of the dues money is used to sponsor Texas methadone treatment conferences like the one we had last October. We plan to do that every year.
Overall, because of what we've accomplished, methadone providers in Texas have clout, we have credibility and we are recognized as the experts in the field of addiction treatment.
For inclusion in future issues, we invite readers to send A.T. Forum news of what their state methadone treatment associations are doing: special events, legislative action, etc.