A.T.F. Volume V, #3. Fall, 1996 Page 2

A.T. Forum on the Internet
Medical Methadone Survey
From the Editor
Meetings to Note
Staff Attitudes & MMT Success
Methadone Under Managed Care
Where to Get Info

Staff Attitudes & MMT Success

Do Staff Attitudes Impact MMT Success?
Abstinence-Orientation Challenged
"Researchers and administrators should pay more attention to the effect of staff attitudes on the quality of care given methadone maintenance patients." That's the conclusion of two new and important reports from Australia authored by Doctors John R.M. Caplehorn, Les Irwig and John B. Saunders [*see complete references below].
It has often been observed in the past, and discussed here in A.T. Forum, that many methadone maintenance treatment (MMT) programs' policies seem inconsistent with available scientific evidence of the modality's effectiveness. This has been blamed on poor program administration, lack of funding, and/or inadequate staff training. Now, along come startling findings that some MMT staff members - who are fully aware of the potentially life-saving benefits of long-term MMT - are more influenced by their personal beliefs [i.e., biases and prejudices] that support restricting methadone doses, limiting the availability and duration of treatment, and expelling patients prematurely from programs for any noncompliance.
Past studies have found positive associations between maximum methadone dose and retention in MMT programs, along with reductions in continued heroin use while in treatment. Yet the authors note, despite such evidence, staff in many methadone programs around the world continue to refuse heroin addicts adequate-dose and indefinite methadone maintenance.
Instead, such programs promulgate an abstinence-oriented approach which seeks to achieve a lifestyle quickly free of illicit drugs, after which methadone is gradually withdrawn. Patients who do not comply with program rules are usually expelled prematurely from treatment. The authors point out that, "There is no evidence that these policies improve post-treatment outcome." In fact, compared to patients in indefinite MMT programs, other studies conducted by Caplehorn found that patients in abstinence-oriented programs were more likely to use heroin during treatment, be prematurely discharged from treatment, and relapse after discharge.

Attitudes Overshadow Knowledge

Given such evidence against the benefits of abstinence-oriented policies, the authors investigated whether methadone program staffs base their treatment policies more on their own personal beliefs and attitudes toward addiction than on their knowledge of methadone maintenance. A first study surveyed 90 staff members at ten public methadone maintenance clinics in Sydney.
A 100 item questionnaire was developed to assess such factors as: commitment to the goal of abstinence, support for the use of disciplinary sanctions to enforce compliance, attitudes toward illicit drug use in general, and knowledge of methadone maintenance as a treatment modality. The questionnaires were statistically tested for validity and reliability.
The programs surveyed were found to differ significantly as to their policies regarding abstinence-orientation versus long-term MMT, and the major factor determining such differences was staff attitudes. In brief, staff support for abstinence-oriented policies was closely tied to their disapproval of illicit drug use, negative views of long-term methadone, and support for the use of punitive sanctions. They would strongly agree with such statements as:
·Drug addiction is a vice and a menace to society.
· Modern society is too tolerant toward drug addicts.
· Persons convicted of the sale of illicit drugs should not be eligible for parole.
· Methadone patients should only be given enough methadone to prevent the onset of withdrawal.
· Methadone maintenance patients who continue to use illicit opiates should have their dose of methadone lowered.
· Methadone should be gradually withdrawn once a maintenance patient has ceased using illicit opiates.
· It is unethical to maintain addicts on methadone indefinitely and, left to themselves, most methadone patients would stay on methadone for life.
· The clinician's principal role is to prepare methadone maintenance patients for drug-free living.
· Confrontation is necessary in the treatment of drug addicts.
The authors of the study were surprised to learn that even abstinence-oriented MMT staff were relatively well-informed about the benefits of methadone treatment. Over 75 percent of clinic workers surveyed believed that methadone maintenance reduced heroin addicts' uses of illicit opiates and their criminal activities; over 95 percent believed MMT reduced mortality. A higher proportion of staff were aware of the benefits of MMT than were aware of possible adverse effects (e.g., slightly less than two-thirds knew methadone could contribute to constipation).
Yet, even though well-versed in methadone's benefits, many staff surveyed still did not agree that addicts should be offered indefinite methadone treatment. This suggests that further staff education programs are unlikely to change a clinic's orientation. According to the authors, the best approach might be to assess staff attitudes prior to hiring in an effort to make certain their beliefs are consistent with clinic policies and practices.
[NOTE: Caplehorn has just completed a similar survey among staff in 14 New York City MMT programs that showed essentially the same results/problems as in Australia. That report will be published in the future.]

Physicians' Attitudes Also Help Or Hinder Success

The second study reported by the authors, investigated the influence of physicians' commitments to abstinence-oriented policies on the retention of patients in what are essentially medical methadone maintenance programs. The study included 280 patients treated by ten primary care physicians over an eight year period in Sydney, Australia.
Those physicians were allowed to treat individual heroin addicts and prescribe methadone, which the patients were then provided on a nearly everyday basis at private methadone dispensing facilities or at commercial pharmacies. The survey from the earlier study was used to assess each physician's orientation; whether toward abstinence or long-term methadone treatment.
It was found that those physicians with an abstinence-orientation had a retention rate in treatment of only about one third that of their fellows who had a more long-term outlook. Also, as the authors note, "The more strongly physicians were committed to abstinence-oriented policies, the more likely patients were to be prematurely discharged from their programs."
One reason abstinence-oriented physicians had worse retention rates was because they generally used lower maximum doses of methadone. And, even when higher doses were given in such programs, patients usually only received a maximum dose for a short period of time before undergoing a prolonged withdrawal period; whereas, with an indefinite maintenance orientation the maximal daily dose was sustained over time as determined by patients' individual needs.
It appears that under a medical methadone maintenance model, the underlying attitudes and belief systems of the individual physician could play a pivotal role in the successful outcomes of treatment. A concern is that, no matter how positive the benefits of medical methadone maintenance may seem, under the guidance of some physicians the successes achievable can be completely negated. That's something to seriously ponder.
*For details see: Caplehorn, J.R.M., et al. Attitudes and Beliefs of Staff Working in Methadone Maintenance Clinics. Substance Use & Misuse, 31(4), 437-452, 1996. And; Caplehorn, J.R.M., et al. Physicians' Attitudes and Retention of Patients in their Methadone Maintenance Programs. Substance Use & Misuse, 31(6), 663-677, 1996. Correspondence should be addressed to John R.M. Caplehorn, Department of Public Health, Building A27, University of Sydney, N.S.W., 2006, Australia; e-mail to - johnc@pub.health.su.oz.au.

ATTITUDE SURVEY AVAILABLE: If you would like a copy of the MMTP staff attitude survey mentioned in this article for personal information and possible use in your clinic, mark the reader response card in this issue of A.T. Forum and mail it in. See also MMTP Staff Attitude Survey

Methadone Under Managed Care

What Will Happen to Methadone Under Managed Care?
Risks for MMT Patients
Certainly, the push toward national health care reform has been a catalyst driving new thinking and planning in the United States. Without a federally backed reform initiative, individual states have become quite creative in developing experimental models for delivering health care while controlling costs. And, according to Mark Parrino, president of the American Methadone Treatment Association (AMTA), throughout the U.S., methadone maintenance treatment (MMT) providers are gravely concerned about the future of their ability to continue offering comprehensive services in the era of managed care.
In a special "Managed Care" issue of TIE Communique` [published by CSAT, Spring 1995], Susan Becker, Director, Division of State Programs, wrote that despite the promises of health care reform, there are also great risks for those receiving treatment for substance abuse via the publicly funded system. "Our clients tend to be poor, with little political clout, and they have serious needs and problems not typical of those covered in private managed care plans," she says.
"Managed care is essentially a system for providing acute care - and substance abuse is a complex, chronic, and recurring condition," Becker adds. "Under the current insurance system, many patients use up all their acute substance abuse treatment benefits before reaching recovery; these patients must fall back on the publicly funded system to complete their treatment."
A nagging question is: What if public funds are not properly geared to the needs of those patients?
Managed care has been lauded as eliminating unnecessary and inappropriate health care, thereby reducing costs. The most common form of managed care is an HMO (Health Maintenance Organization), but there are other models. Detractors note that, when misapplied, managed care can reduce accesses to or the scope of services, reduce the quality of care, and reduce special services for needy populations.

States Develop Own Managed Care Initiatives

Many MMT providers are concerned that the long-term impact of managed care approaches will limit their fees and restrict their ability to provide patients access to essential services. At present, without a program of national health care reform, the federal Health Care Financing Administration (HCFA) has allowed states to adopt their own managed care approaches to curtail the spiraling costs of federally funded health care.
According to Anita Marton, senior staff attorney at the Legal Action Center, New York, there was once discussion about block grants for Medicaid that would let each state decide how to best use the funds. That legislation never was passed, so each state must presently work with HCFA in getting permission to use public aid funds for proposed
programs.
Normally, states may not require that persons eligible for Medicaid receive services from a specific managed care provider. So, for many years, public aid recipients have been able to voluntarily sign-up for a variety of private managed care plans. In some areas, there has been fierce competition - including some unscrupulous practices - among those plans to sign-up patients.
In order to deny an individual "freedom of choice," and force the patient into a state-authorized managed care program funded by Medicaid, the state must obtain a "section 1115 waiver" from HCFA. According to Jack Knowlton, executive vice president of the Center for Health Policy Studies Consulting, Albany, NY, HCFA has currently approved waivers for about 17 states and New York has applied for such a waiver. Knowlton's firm is working with the New York State Committee of Methadone Program Administrators (COMPA) to help determine a course of action in the event MMT programs fall under managed care.
Knowlton says 75-80 percent of methadone patients in New York state are eligible for Medicaid [and a similar proportion might be expected in other states]. In New York, MMT programs are entirely separate or "carved out" from the state's managed care benefit package and they still operate on a fee-for-service basis. Program services are directly billed to Medicaid according to a weekly payment formula. Yet, Knowlton believes, it is not known how long this approach will be continued before MMT will come under more of a managed care approach.
Another example is Illinois, which was very recently (July 1996) granted a federal waiver for its "MediPlan Plus" program. All Medicaid recipients will be required to sign-up for a state-approved health maintenance plan some time next year. However, certain programs - such as behavioral health services (including, MMT) - will continue to be paid under traditional fee-for-service agreements. According to a newspaper report (R. Pearson and C. Parsons. "Edgar's HMO Plan For Poor Approved." Chicago Tribune, July 13, 1996, front page), there were questions as to whether such a plan would genuinely result in cost savings, and one might speculate that such "carved out" programs might soon come under the scrutiny of the managed care system.
In other states, MMT programs are also separate ("carved out") from any state managed care plan for general health care when it comes to funding. But, in essence, those programs operate
rather than fee-for-service. This often creates confusion because an individual MMT patient on Medicaid must work through two completely separate managed care systems to receive comprehensive medical and drug treatment
services.

MMT "Carve Outs" Can Be Troublesome

Parrino notes that problems can arise when "carved out" MMT programs must work through the referral systems of private or state-run managed care plans in obtaining laboratory tests,
hospital services and other medical care for patients. Knowlton agrees that there can be many "gatekeepers" through whom even a simple request for patient treatment must pass. "There's a potential here for harm to the programs," he says, "because [referring to New York] we don't know yet what the rules of the game are going to be."
Another fear under managed care is a limitation on payments and duration of care. Certainly, MMT can be a life-long treatment modality. Under managed care, there may be a greater emphasis on detoxifying patients from methadone at a certain point. This, despite the current evidence showing that over a patient's lifetime, indefinite continuation on methadone can reduce overall health care costs. "I believe that there is very little knowledge or experience on the part of managed care organizations regarding this issue," Knowlton says. "It's a big enough leap for most of them to deal with the general Medicaid population and we've only just begun to communicate with them about methadone patients."
Marton concurs that there is not only unfamiliarity among managed care plans with methadone treatment, but an ignorance of the complex federal, state and local laws regarding dispensing of the drug. An executive with a major plan once told her, "I'm very glad we don't have to provide methadone services, because we don't believe in it!" Hence, there may also be an ingrained prejudice against the whole methadone treatment modality.
According to Marton, one client - not on Medicaid but under a private managed care plan - was pressured into going through detox from methadone. The patient was personally paying for his own methadone treatment, but the plan still insisted he go through detox in an apparent effort to curtail their long-term health care costs. Worse yet, another impact of managed care, she observes, seems to be a reduction in the time allowed for medical detox whether on an in-patient or out-patient basis.
Parrino is concerned that the "carve outs" keeping MMT programs separate from other state managed or endorsed general health care delivery systems may result in the programs becoming isolated. They could then become "sitting ducks," subject to the future pot-shots of health care managers looking to cut little understood or poorly justified programs. Yet, he notes, some methadone providers prefer to preserve the status quo as long as they can, since they retain the security of knowing what fees they will continue to receive under the old system. "It's as if they're waiting for the storm to come and blow-over, and then all will be well again," he says. "But, the landscape and climate all around them is changing; things will never be quite the same."
Knowlton has a similar outlook: "Everybody needs to understand that life as they've known it in the past might not be right for the future. Being adaptable may be the key." He believes that, in the future, managed care plans will be most interested in working with MMT programs that also offer primary medical care services on site or are closely allied with community health care facilities. Those are the sort of programs that managed care administrators can most easily understand and appreciate.
Parrino stresses that managed care organizations also prefer to work with networks of MMT programs as opposed to individual clinics on a one-by-one basis. "This is a significant advantage of forming state-wide methadone provider associations and also working with state-wide alcohol and drug abuse provider organizations to address common concerns," he claims.
As yet, there don't seem to be any comforting answers to the basic, underlying question: "What's really the best managed care approach for MMT patients in their recovery and long-term success?" The only certainty seems that the winds of change are rapidly brewing, and the final storm - of unknown dimensions - is still forming over the horizon.

Where to Get Info

Methadone and Managed-Care
For a copy of CSAT's TIE Communique´ publication entitled: "Managed Care: Meeting the Challenge of Substance Abuse Treatment" (Spring 1995) contact the National Clearinghouse for Alcohol and Drug Information (NCADI) at 800-729-6686. Email address is info@prevline.health.org.
[While this free, 50-page, document may be somewhat dated, it will provide interested program administrators with a broad background on the issues surrounding MMT in a managed care environment.]
The American Methadone Treatment Association (AMTA) may be reached at 212-566-5555 (FAX: 212-349-1073). President Mark Parrino produces an extremely topical and insightful newsletter called "AMTA News Report" that should be required reading for all key MMT executives.
The Legal Action Center may be contacted in New York City at 212-243-1313 (FAX 212-675-0286). They can help MMT patients and clinic staff deal with difficult issues such as: access to services under managed-care plans, discrimination in housing or employment, confidentiality, and other concerns.
The Center for Health Policy Studies Consulting (CHPS Consulting) may be reached in Albany, NY at 518-426-4315. Executive vice president Jack Knowlton and his organization assist a variety of organizations, including MMT providers, address the many challenges presented by managed care environments.