A.T.F.
Volume V, #1. Winter, 1996
In our last edition of A.T.F. [Vol IV, #3, Fall 1995,
"Graying" of Methadone?]
we raised the question of an aging methadone maintenance treatment (MMT)
patient population and what their special needs might be. As always, we
invited readers to participate with their responses.
Dr. Elizabeth Ameson of the Southland Counseling Center in Lansing, Michigan
noted that, at their clinic, they have professional staff who've served
the needs of elderly patients in the past, plus many staff with experience
in dealing with their own aging parents. Consequently, they've been able
to provide considerable support to their older or very ill patients, as
well as those patients with elderly parents. [We didn't think of this
in our article, but dealing with the increasing needs of their elderly
parents could pose an added strain on some older, age 50+, methadone patients
that might influence their successes in MMT].
Dr. Ameson notes that, in their relatively small patient population, they've
experienced eight elderly methadone patients with serious or advanced
medical conditions requiring hospitalization [and, continued methadone
treatment outside their clinic]. She also lists several need areas that
might be associated with older methadone maintenance patients:
- 1. Transportation to the MMTP, or delivery of
methadone to their homes or other care facilities where they reside.
- 2. Internists and other specialists understanding
of addiction treatment and "willing" to care for such patients.
- 3. Relatives, friends or other caregivers to
provide assistance during at-home illnesses or during post-hospital
recovery periods.
- 4. For the "younger elderly" who still
have living parents, assistance may be needed in securing care for
their parents.
- 5. As MMT patients age, they may need special
counseling in dealing with the psychological, spiritual and everyday
activity aspects of their changing lives; such as, mental confusion,
social isolation, physical pain, and the eventual prospect of death.
- 6. MMTP staff need training in drug interactions
and in the management of methadone in "crisis situations."
Many readers also sent-in notes on the response cards.
Here are some typical comments that we received:
"Over age 50 patients have generally cleaned-up their acts so they
shouldn't have to continue being humiliated for the remainder of their
lives. They should be prescribed methadone by [primary care] physicians
on a quarterly basis just like any other patients on continuous medications.
Pharmacies I've spoken with are 100% willing." - Anonymous
"Patients who've been in the program for years know more than the
counselors that are `treating' them. We older folks need a medical maintenance
approach; give us our prescriptions and let us be! We can always get outside
counseling for special needs." - Olympia, WA
"MMTP patients that are age 50+ and who are socially and economically
rehabilitated should be admitted to medical maintenance care." -
Milwaukee, WI
"I'm an age 45 MMTP patient with a successful 20+ year MMTP history.
I feel very strongly that I could best be served by a private physician
or a specialized MMTP for older patients." - Alexandria, VA
"It's my opinion that older patients tend to do better in recovery
and stay on the program longer; they follow program rules better. "
- Rochester, NY
"High blood pressure and mobility restrictions are common with older
patients. [MMTP] programs should take these into account." - Seattle,
WA
"[Older] patients need more financial and employment help, nutrition
and diet counseling, fewer visits to clinics, better coordination between
clinics and their [primary health care providers]. Such patients also
need help with transportation to/from clinics." - LaMarque, TX
"I agree with Dr. Khuri that there is a need for mature counselors;
rather than younger ones who may be good but not able to relate or empathize
with much older patients. I dread the possibility that the time may come
when I'm in too much physical pain to visit the clinic easily." -
Brooklyn, NY
"Special support groups are needed for patients age 50 or older to
address their problems." - Indianapolis, IN
"Average age of patients [at our MMTP] is much higher than in the
past. P.S., our nurses are getting older too!" - Timonium, MD
Most reader comments suggested the need for a medical maintenance model
to deal with the needs of "graying" patients, wherein they would
be treated and prescribed methadone - just like any other medication -
by primary care physicians. Unfortunately, we did not hear from any clinics
that have addressed this issue by establishing special programs for their
older patients either within their own clinics or with outside physicians.
If there are any out there, we'd like to report on what you are doing.
Let us hear from you.
TRIPS is Gone: Where to Get Methadone
Where to Get Methadone On the Road
The TRIPS project that assisted methadone patients in finding alternate
dosing sites while traveling has closed. While it is far better if patients
can take their methadone along with them during travel, this is not always
possible.
There is a reference book available - Narcotic Treatment Programs Directory
- that patients and/or their program administrators can use to locate
potential dosing clinics in other cities. It is available from the Regulatory
Management Branch (HFD-342); Division of Scientific Investigations; Food
& Drug Administration; 7520 Standish Place; Rockville, MD 20855: Phone
301-594-1029.
Arrangements must always be made in advance with the alternate sites.
Be aware, however, that programs and clinics around the country vary widely
regarding their policies and cooperation in treating visiting patients
on a temporary basis.
The National Alliance of Methadone Advocates (NAMA) will also try to assist
patients in finding suitable alternate sites during travel. They can be
reached at 212-595-NAMA.
NIDA Focuses on Drug Use-HIV/AIDS Links
The link between illicit drug use and HIV/AIDS is certainly
of great concern. Injection drug use was the second leading cause of new
AIDS cases through mid-1994, accounting for 31.8% of all cases. More than
half of the 40,388 new HIV infections in 1994 were drug related.
According to NIDA Director Dr. Alan Leshner, "The fastest growing
subgroup of patients with AIDS over the last several years has been heterosexual
men and women, most of whom are linked sexually to drug users.
NIDA's research findings have shown that "comprehensive drug abuse
treatment programs can be effective in reducing high-risk HIV behaviors."
A 1993 study found that IVDU addicts not receiving methadone treatment
had a conversion rate to HIV-positive status that was six times higher
than rates among in-treatment IVDUs who were regularly exposed to risk-reduction
education, counseling and other strategies.
NIDA has produced a 17-minute videotape for drug abuse counselors titled,
"Drug Abuse and HIV: Reaching Those at Risk ." It features an
innovative outreach and HIV/AIDS risk-reduction intervention model. To
order this program call the National Clearinghouse for Alcohol and Drug
Information at 800-729-6686 and refer to NIDA Videotape Series, April-May
1995, NCADI Stock #VHS-74.
Continued Heroin Use: Why?
Many past reports and research studies have suggested
that methadone doses of 70 mg/day and above are the most effective and
adequate for eliminating continued heroin use. Based upon this data, Ira
J. Marion, M.A., Acting Executive Director, Division of Substance Abuse,
Albert Einstein College of Medicine (AECOM), Bronx, NY, comments that
several years ago their program reviewed their dosing practices and policies.
AECOM serves 3,500 MMT patients through nine clinics and is the second
largest program in the country.
Their review of records discovered that their average doses were even
below the 60 mg/day minimum threshold suggested by NIDA. So, AECOM developed
a new policy promoting the initial stabilization of all patients at a
minimum methadone dose of 70 mg/day. Once patients achieved that dose
level, further adjustments would be made based upon patients' clinical
reactions and reported physical comfort. Exceptions were allowed, since
some patients achieve adequate doses at much lower levels. On the other
hand, many patients needed (and received) far more than 70 mg/day of methadone
to achieve the desired narcotic blockade effect and abatement of drug
craving.
The new policy was instituted over a period of 18 months. Slightly over
a year ago, however, they were surprised to find there was still a group
of about 150 patients who were continuing
heroin use; despite apparently adequate methadone doses according to all
clinical measures (and well in excess of 70 mg/day). To help understand
possible reasons for this, in-depth interviews were conducted among a
sampling of 50 of those patients. The surveys discovered at least three
significant areas for concern:
·A large number of patients were using heroin in conjunction with
continued cocaine abuse, or as a way of managing the undesirable withdrawal
symptoms following a cocaine abuse episode.
·A number of the patients reported frequent, though poorly defined,
feelings of physical and/or psychic pain for which they tried to self-medicate
themselves with heroin.
·Social context also played a major role for many of the patients
when they found themselves among friends who were using heroin and succumbed
to peer pressure.
The study suggested that there are patients for whom psychiatric intervention
would be equally essential along with methadone treatment. Marion also
concluded that there was more education needed for professional staff
regarding the concept of "adequate" methadone dose, the pharmacology
of addiction, the methadone treatment process, etc. However, this education
process was complicated by a frequent turnover of staff, and the negative
attitudes toward methadone maintenance therapy among some professionals.
The AECOM experience suggests that achieving an adequate methadone dose
can be problematic, requiring aggressive clinic policies, staff cooperation
and training, and program flexibility. Marion notes, that they are not
at all opposed in their program to requesting exemptions to federal or
state regulations which will allow higher dosages for patients who can
benefit from them.
This case study serves as a reminder that, even when an "adequate"
dose is achieved (consistent with the research), and with methadone performing
the expected pharmacologic functions, there can be a host of lifestyle
issues, psychological forces, negative myths and attitudes, and other
factors which may come into play to influence continued heroin use among
patients. For a great many opiate-addicted patients, methadone is a most
vital component of an ongoing addiction treatment program; yet it alone
may not be a complete and total solution for every addict's needs.
Where to Get Info
"TAP" Into CSAT
Here are two books as part of the Technical Assistance Publication (TAP)
Series from CSAT that may interest readers. Each can be ordered at no
charge from the National Clearinghouse for Alcohol and Drug Information
at 800-729-6686 (use the Order # indicated).
Treatment of Opiate Addiction with Methadone: A Counselor Manual (Order
#BKD-151) is a good primer, especially for beginning counselors. Besides
an overview of all aspects of counseling methadone patients, there are
a variety of useful worksheets, questionnaires and forms dealing with
treatment planning.
Approval and Monitoring of Narcotic Treatment Programs: A Guide on the
Roles of Federal and State Agencies (Order #PHD -666) is an invaluable
reference for anyone thinking about starting an addiction treatment program.
It discusses the approval
and monitoring process, relevant
regulations, and provides essential FDA and DEA forms and information.
MMTP Explained
A new booklet from COMPA (The New York State Committee of Methadone Program
Administrators) could be just what you were looking for to give government
and public policy makers. "Regarding Metha-done Treatment: A Review"
provides a clear and concise overview of methadone treatment - its principles,
scope, benefits and outcomes, describing how this modality can work positively
in the lives of individuals and
their communities.
Interested readers should contact:
Sy Demsky or Tina Griffin; Mt. Sinai Medical Center NRC; Box 1106; 17
E. 102nd St.; New York, NY 10029. Phone: 212-241-6646.
Medical Modalities
Dealing With Acute Pain in Methadone Patients
Since methadone has been both approved by the FDA for
the treatment of pain (since 1947) and regulated in the treatment of opiate
addiction (since 1972) this has led to many misunderstandings and some
confusion regarding the management of acute pain in methadone patients.
In essence, patients maintained on methadone can and should be treated
just like any other patients in acute pain. Note, however, that pain control
in hospitalized patients and the long-term management of pain in addicted
persons suffering from chronic or terminal disorders is a separate issue
and may require the greater expertise found among medical specialists
and/or clinics which focus on pain control.
Joyce Lowinson, M.D., Professor of Psychiatry, Albert Einstein College
of Medicine, Bronx, NY, notes, "A major problem in the field of medicine
in general is the undertreatment of pain. While pain is a problem for
any patient, it is especially problematical for persons with a history
of substance abuse."
According to the 1995 Institute Of Medicine report Federal Regulation
of Methadone Treatment, "Methadone maintained patients who are being
treated for conditions associated with acute moderate-to-severe pain are
often denied treatment for pain. This denial is usually based on two misconceptions:
first, that any patient taking a daily dose of methadone should derive
adequate analgesia from the maintenance dose, and second that prescribing
an additional amount of an opiate agonist would lead to relapse and/or
compromise the treatment of the addiction."
An excellent paper on this subject by J. Thomas Payte, M.D. and others
["Methadone Patients and the Treatment of Pain"], describes
the unwarranted fear of prescribing opioid analgesics for addicts as "addictophobia."
They claim, "the education of physicians in the pharmacology of opiods
and their ability to relieve pain, along with training in the basics of
addiction, will help eliminate these attitudes." The paper also stresses
that the behaviors associated with compulsive drug taking are quite different
from the behaviors of a patient with a history of illicit drug use who
requests medication to relieve acute pain.
Lowinson stresses that, due to advances in medical knowledge, there is
no pain that needs to go unsuccessfully treated. However, there is a fear
of addicting patients to the pain medication. She believes that even if
dependency does develop it can be dealt with by later tapering the patient
off the pain medication. This is especially true of patients on methadone,
because they have a protective base - a blocking of the euphoric effects
of short-acting opioids - which allows them to use short-acting opiods
without becoming "readdicted." In brief, there is unlikely to
be a problem in prescribing opiod analgesics with methadone patients.
As the Payte paper notes, patients maintained on adequate doses of methadone
have developed a tolerance or resistance to the narcotic, analgesic and
tranquilizing properties of methadone. Hence, they feel pain to the same
degree as anyone else and need adequate doses of typical analgesics, including
narcotics, that will relieve their pain.
In most cases, the usual regimen used to provide pain relief for the non-opiate
tolerant patient can be used to treat those maintained on methadone, according
to the Payte paper. Methadone patients on proper maintenance doses will
not feel any euphoric effect from short-acting narcotics. And, since methadone
maintained patients are, in essence, protected from respiratory depression
as a potential side effect of narcotic analgesics, the physician's primary
concern should be to achieve satisfactory analgesia.
The IOM report suggests that MMTP staff must provide guidance to physicians,
dentists and other practitioners to ensure humane treatment of methadone
maintained patients being treated for acute pain. The report outlines
three simple principles to keep in mind:
1. Continue methadone therapy without interruption.
2. Provide adequate doses of appropriate short acting opiate agonist drugs
for pain. Due to cross tolerance, however, higher than normal and more
frequent doses of short-acting opiate agonists may be required for pain
relief.
3. Antagonist and mixed agonist-antagonist opiate drugs [such as, Talwin,
Stadol or Nubain] should not be given to methadone maintained patients
since they may produce a serious withdrawal reaction in opiate-tolerant
persons.
As an aid to MMTP clinic staff, a "Sample Letter to Physicians and
Dentists Treating Patients on Methadone Maintenance" may be found
in CSAT TAP #7, Treatment of Opiod Addiction with Methadone, p. 28. [See
"Where to Get Info" section in this issue of A.T.F.] It provides
an excellent overview of the function and benefits of methadone maintenance
as well as sound advice regarding acute pain control in methadone patients.
Clinics and patients should find this letter, or their own edited versions,
very helpful in communicating with medical professionals.
A very important aspect of pain management is the attitudes of health
care practitioners, Lowinson notes. Many physicians and nurses have a
fear of producing drug dependency in patients, however, this is largely
due to ignorance. Physicians are also concerned about possible sanctions
by regulatory agencies regarding perceived overuse of addictive pain medications,
especially when patients with histories of drug abuse are involved.
When treating patients in pain, it is important to take a thorough history
and accept the patient's self-report of symptoms. "It is preferable
to be duped rather than to undertreat pain," says Lowinson. However,
realistic goals should be set. The main goals are relief of pain and recovery
from illness. Following the World Health Organization's analgesic ladder
is recommended by Lowinson. Start out with NSAIDs and proceed to weak
opiods like Percodan or codeine. Lowinson prefers to avoid combination
drugs such as Tylenol with codeine, or Empirin with codeine; it is better
to separate the drugs to achieve more accurate titration.
Stronger opioids should be considered only after other analgesics have
failed, according to Lowinson. But, that doesn't mean there should be
any delay in prescribing opiods if the patient is not getting adequate
pain relief. Using the right opioid, in the best dosage and scheduling
can be important. Dosing should be on a regular prescribed basis, rather
than PRN, to prevent the breakthrough of pain.
According to Herman Joseph, Ph.D., research scientist with OASAS (New
York Office of Alcoholism and Substance Abuse Services) and chairman of
the Chemical Dependency Research Working Group (CDRWG), "We have
realized that pain management among methadone patients is a major problem,
mostly due to the ignorance of medical professionals. They're not taught
much about this in medical school. No matter where you look, methadone
patients are denied adequate pain medication because of ignorance and
stigmatization."
Sponsored by the CDRWG of OASIS, this is a first-of-its-king conference
to deal with pain mangement among methadone patients. Joseph is serving
as Executive Chair to help organ ize the event. Even more broadly, however,
it will deal with a host of pain management and chemical dependency issues.
Dr. Russell Portenoy, M.D. of Sloan Kettering will serve as Medical Chair.
The conference will be international in scope, examining complicated issues
relating to both acute and chronic pain control, and how public policies,
federal regulations and medical practices have to be defined and brought
into harmony. A broad spectrum of addictions - including, opiates, cocaine,
alcohol, etc. - will be addressed relating to the topic.
"I think that this whole issue has to be aired and understood,"
he says. "The term addiction really has to be defined and there is
a tendency for people to regard methadone in maintenance treatment as
a long acting heroin. Nothing could be farther from the truth; in maintenance
treatment it functions as a medication to normalize certain processes."
Here are details on the conference: Pain Management in Chemical Dependency:
Evolving Perspectives November 21-23, 1996, Crown Plaza Hotel, New York
City [Interested readers should call Herman Joseph at 212/961-8491 or
Joyce Woods at NAMA at 212/595-NAMA.]
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