A.T.F.
Volume V, #2. Spring/Summer, 1996, Page 2
Pain Conference Info
The response to the article in our last edition
[Vol. V, #1; Winter 1996] "Dealing With Acute Pain in Methadone
Patients" - was the all-time winner in terms of reader interest
and responses. At the end of the article, we mentioned an upcoming conference
discussing the issues and here are further details:
- November 21-23, 1996
- PAIN MANAGEMENT &
- CHEMICAL DEPENDENCY
- Evolving Perspectives
- Crowne Plaza Manhattan Hotel
- New York City
- FOR INFORMATION, CONTACT...
- IMEDEX USA: 770-751-7332;
- FAX 770-751-7334
The conference program is designed for health care
professionals, policy makers, and allied health practitioners involved
with the treatment and management of pain and chemical dependency. Many
programs will address the particular needs of drug addicted (including
methadone) patients. A featured speaker will be Dr. Alan Leschner of
NIDA, plus 32 distinguished faculty representing the best-known research
centers in the field will make program presentations. The Executive
Chair for this conference is Herman Joseph (featured in this edition
of A.T.F.), and among the sponsoring firms providing unrestricted educational
grants to help support the event is Mallinckrodt Chemical.
Special discounts for registration, hotel and travel fees are available
for early registrants. Up to 18 hours of professional continuing education
credits are available for nurses, alcohol and substance abuse counselors
and physicians.
Give People What They Want
Opinion from the Journals
In the Winter 1996 issue of State Substance Abuse Quarterly Tom McLellan,
scientific director of Philadelphia's Treatment Research Institute suggests
that too many drug abuse treatment programs view "sobriety"
(total abstinence from all potentially addictive medications) as the
end-all and be-all of outcomes. He is quoted as saying, "What society
really wants out of substance abuse treatment is not necessarily abstinence.
People want less family violence, less unemployment, fewer people on
welfare, less over-utilization of health services, and reduced crime.
The Congress and taxpayers demand and need fewer drug-related problems."
McLellan asserts that if you merely stop someone from taking drugs,
and the other problems don't end, the person will relapse again into
addiction. Along with this, he believes (according to the article) that
treatment programs which look at abstinence as the sole indicator of
success could be doing themselves a disservice. "While substance
abuse programs are not great at producing (total drug) abstinence, the
best things they do accomplish are some of the same measures that society
is interested in," he says.
The article notes that a patient who has returned to occasional drug
use but has a job and has stopped abusing his/her children (or other
deviant behavior) probably would not be considered a failure by society,
and should not be labeled a failure by the drug treatment field. As
we've noted over the past four years in Addiction Treatment Forum, many
in the addiction treatment field are still leery of methadone maintenance
as a legitimate option since the patient is not considered technically
"drug-free." For this, the patients and even their treatment
providers have been stigmatized in various ways as this current issue
discusses. Yet, perhaps, this is a time to re-examine the true goals
of addiction treatment and just what society really wants and expects.
Disaster Planning Revisited
More Info Available A Case Example
As a follow-up to our article "Disaster Preparedness - Are You
Ready?" [Vol. IV, #2; Spring 1995], Ruby Gordon, M.S.S.W., manager
of the MORE Center in Louisville, Kentucky and Carol McPherson, manager
of the Southern Indiana Treatment Center, agreed to share their experiences
with our readers. Starting in June 1994, the publicly funded MORE (Methadone/Opiate
Rehabilitation & Education) Center and the private, for profit Southern
Indiana Treatment Center (SITC) in Jeffersonville, Indiana about ten
miles away began developing a Reciprocal Dosing Agreement. Over a 17-month
period four regulatory agencies were involved for input, consultation
and approval, and the plan was finally implemented in September 1995.
The impetus for such a plan came in January 1993 when the MORE Center
area had a 15 inch snow storm which totally crippled the community for
five days. The National Guard transported essential staff daily to the
methadone clinic, and patients somehow got to the clinic through their
own ingenuity and need for methadone. It was recognized, however, that
there was a strong need for emergency planning in case the clinic could
not be opened at all due to a major catastrophe.
Hence, representatives of MORE and SITC met to consider a Reciprocal
Dosing Agreement to be used in the event of fire, tornado, flood, chemical
leak, or other disaster. All realized that any arrangement would need
approval by the FDA, DEA, and state methadone authorities in Indiana
and Kentucky.
The development process was somewhat time consuming and arduous, but
all agencies cooperated to arrive at mutually agreeable written recommendations.
Prime concerns included proper identification of patients and their
dosage levels, and the potential for patients misrepresenting their
take-home privileges so they could avoid the inconvenience of traveling
away from their "home" clinic. The availability of emergency
methadone supplies during the crisis and fee reimbursements also needed
addressing.
As a future step, Gordon suggests that, since the two cooperating clinics
are only ten miles apart, they need a plan for a catastrophe that might
totally close both clinics at once. Formal agreements for this have
not yet been worked-out, but she believes that as a result of their
past experiences in developing such plans less preparation time will
be needed.
As Gordon notes, "Hopefully this Agreement for emergency dosing
will never be needed. Yet, it is comforting to know that it exists."
She hopes that other clinics may be able to benefit from the example
they can provide in establishing such a program.
For more detailed information, Gordon may be contacted at: 502-574-6414;
FAX 502-574-6503. See Unpublished Articles for complete Reciprocal
Dosing Agreement.
( See original article Disaster
Preparedness, or Disaster
Planning Guides)
Research Perspectives
Interim Methadone Treatment Does Not Hinder Retention
Time in treatment has long been considered an important predictor of
good outcomes for drug abuse treatment and methadone maintenance in
particular. In the past, patient retention has been viewed of special
concern for low-service types of treatment.
As an example, interim methadone maintenance was developed as an alternative
to waiting lists and as a method of providing HIV risk-reduction services
to heroin addicts waiting for treatment. It is low-service in that it
does not include the regular counseling required in comprehensive methadone
treatment.
The Chemical Dependency Institute of Beth Israel Medical Center, New
York City did an analysis to compare the retention of patients first
admitted to an interim methadone clinic and latter entering full-service
modalities versus the retention of patients admitted directly to a comprehensive
clinic. The two groups were identical with respect to demographics.
The three-, six-, and 12-month retention rates of patients first admitted
to the interim clinic were 78%, 69%, and 62% respectively. In comparison,
the three-, six-, and 12-month retention rates for patients admitted
directly into a traditional methadone clinic were 84%, 76%, and 68%
respectively. While the percentages do seem better for the second group
(those admitted directly into a full-service modality), the authors
of the study found there were no statistically significant differences.
Interim treatment does not appear to adversely affect overall retention
in treatment. Furthermore, three-, and six-month retention rates of
interim clinic patients fall within the six-month nationwide retention
rates reported by the GAO.
SOURCE: Friedman P., et al. "Retention of patients who entered
methadone maintenance via an interim methadone clinic."J. Psychoactive
Drugs 1994: V25(2); 217-21.
Streamlined Admissions to MMT Attracts Addicts
Increasing the availability of methadone treatment and streamlining
the admissions process for entry into programs have consistently been
the focus of national initiatives to address the HIV/AIDS epidemic.
Under a waiting list reduction demonstration grant, the Center for Social
Research and Policy Analysis, Research Triangle Institute, North Carolina
was able to significantly increase both the number of people requesting
MMT program intake appointments (from 35 to 100 per month) and the percentage
of people keeping those appointments (from 33% to 54%).
An additional 100 slots (an entire year's waiting list) were filled
in fewer than three months and actually resulted in a net increase in
the length of the waiting list. Relative to the preceding two years,
new patients during the grant period were significantly likely to be
age 41 or older, African-American, unemployed, daily opioid users, daily
cocaine users, and dependent on public assistance to finance treatment.
There were no significant changes in retention rates among those admitted
to treatment under the grant program. The program's static client capacity
rose from 310 patients prior to the grant to a peak of 449 during the
grant, and leveled off at 410 after the grant period.
The authors conclude that since it is clearly more humane and less expensive
to treat addicts who want treatment and when they want it, rather than
waiting for them to commit a crime and be arrested or even executed,
there is certainly the need to make more treatment available on demand.
The study also showed that there is a pent-up hunger for treatment among
a core of opioid addicts who can benefit greatly from more ready access
to methadone programs.
SOURCE: Dennis ML, et. al. "Effectiveness of streamlined admissions
to methadone treatment: a simplified timeseries analysis." J. Psychoactive
Drugs 1994: V26(2); 207-16.
Patient Confidentiality
Patient Confidentiality A Clarification
We received a letter from Frank J. Gold, Ph.D., executive director of
the Fairbanks Substance Abuse Center in Alaska. He was concerned about
regulations proposed several years ago requiring the reporting of drug
addicts entering methadone treatment who are suspected of child abuse
and neglect. "Almost by definition," he wrote, " those
using opiates are neglecting their children. For example, if they 'nod
off' for hours at a time, they can't be considered attentive parents."
Dr. Gold says when the regulations were first proposed, he expected
the Legal Action Center (LAC) would protest the matter. Instead the
LAC provided treatment programs with direction to adhere to the new
rules. "Our protest to the Center was ignored, and the law now
requires that I report to the appropriate authorities my opiate addicted
clients who happen to also be parents. This I cannot do."
For a clarification, we contacted Paul Samuels, director of the Legal
Action Center, with offices in New York City and Washington, DC. The
LAC, funded by government and foundation grants, is a law and policy
organization specializing in alcohol and drug treatment, HIV/AIDS, and
patient discrimination issues.
Samuels states the LAC has always supported the notion that someone
with an addiction problem and who also cares for children should not
automatically be reported to child abuse authorities when they enter
a treatment program. Obviously, this would be detrimental to the drug
treatment system and also flood the child protection system with unfounded
notifications where there was no actual evidence of abuse or neglect.
Congress agreed with this rationale and, in 1986, amended the legislation
to require reporting only when there is specific evidence to indicate
the actual or imminent harm to or abuse of a child. The mere fact that
a patient entering treatment has a drug problem and also has children
in his/her care or custody does not mandate reporting the patient.
Samuels agrees that, over the past ten years, this issue may have become
confused and the confidentiality laws protecting patients can be complex.
Plus, Congress did leave a loophole of sorts by requiring that alcohol
and drug abuse programs must still comply with the provisions of mandatory
reporting laws within their respective states. According to Samuels,
however, the LAC is not familiar with any state regulations which contradict
the intent of the federal legislation in this case. If there are any,
they would certainly like to know about them so appropriate inquiries
could be made.
Samuels emphasizes that the LAC can assist methadone patients with their
confidentiality questions and, especially, if there is suspected discrimination
in equal access to employment, housing or medical care. A growing area
of concern is the denial of reimbursement for methadone treatment or
refusal to authorize treatment because the patient falls under a managed
health care program.
The Legal Action Center may be contacted at: 212-243-1313; FAX 212-675-0266.
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