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Volume VI, #5. Winter 1998
GPs
& Methadone Achievable Dream...Or...?
Events to NoteFor additional postings & information, see: www.atforum.com
February 1998
March 1998
Bringing together world-renowned professionals and consultants in the field of addiction with a common interest in abstinence-based treatment. Contact: Rob Zubin [Aus] 61.3. 5954.7424; FAX: 61.3.5954.7001
April 1998
[To post your event announcement in A.T. Forum and/or our Web site, fax the information to: 847/413-0526 or submit it via e-mail from http://www.atforum.com]
Case Challenge ResponseDealing with difficult MMT patients In our last edition [Fall 1997] we presented a question from a clinic Medical Director regarding how to deal with the "difficult patient," those who view methadone as only a short-term cure and refuse to accept education allowing them to participate effectively in decisions regarding their care. Such patients have very negative views of methadone, continue to abuse opioids while in treatment, and generally fail to respond to MMT. An instructive response was received from a west coast MMT patient who first started using heroin 27 years ago and has successfully been on methadone for the past two years. He admits that during previous experiences with MMT he never really wanted to cease using illicit opiates altogether. "I wanted to use methadone merely to limit my use of narcotics, mainly for financial reasons, and stop being sick," he writes. "I got sick of my dependence on the people a junky must depend on, and the constant concern over whether I could stay well from one day to the next. I was terribly depressed. I doubt that I said any of that to any counselor, since most addicts are good at telling clinic staff what they want to hear." "I know many addicts who hold prejudices against methadone, just as does the general public," he continues. "The only thing clinic staff can do is educate those patients as much as possible, which can be difficult. It's also important to make certain that staff members, themselves, do not have negative attitudes that actually promote the stigma surrounding methadone treatment. This can especially be a problem among non-medical staff." "The staff must be honest with every patient. Many clinics try to control patient behavior by blaming regulations for their restrictive policies and using a one-size-fits-all treatment plan. Patients should be provided with copies of official rules and regulations, as well as written clinic policies specifying the reasons for any deviations from federal or state regulations. When patients are dealt with honestly, they feel respected and are much more willing to stick with treatment. This makes for a 'patient-friendly' environment." Sometimes, the best that can be done is to wait and hope that, in time, problem patients will be ready to accept MMT in a way that will benefit them in the long run. Remember also that the treatment experience does do those patients some good if only for a short period of time. "You can lead a horse to water but you can't make him drink," he comments. "Although with hope he'll figure it out before he dies of thirst."
Methadone by Docs not Politics
Last September 1997, General Barry McCaffrey, Director of the U.S. Office of National Drug Control Policy (ONDCP), asserted that doctors everywhere should be allowed to prescribe methadone to help fight heroin addiction more widely. He criticized current methadone programs that require addicts to go to special centers to get their treatment. "If we do this thing correctly, if we allow the dose rates to be prescribed by doctors and not by policy, if we allow it to be decentralized so that physicians who are trained and monitored are allowed to dispense the drug instead of necessarily having it only in some centralized locations ... we're going to make a big difference," he told a conference sponsored by the National Institute on Drug Abuse. McCaffrey predicted a third of the estimated 600,000 heroin addicts in the U.S. might be helped if methadone programs were broadened. [This represents a 66% increase in patients compared to the 120,000 patients currently in methadone treatment programs in 42 states. Ed.]
Liberate Physicians, NIH More recently, last November, a Consensus Development Conference convened by the National Institutes of Health concluded that, "heroin addiction is a medical problem that can be effectively treated if doctors are freed from heavy-handed restrictions on the use of methadone." The Committee Chairman went so far as to assert, "We know of no other area of medicine where the federal government intrudes so deeply and coercively into the practice of medicine. If extra levels of regulation were eliminated, many more physicians and pharmacies could prescribe and dispense methadone and make treatment more readily available." The Consensus Statement acknowledged, however, that the shortage of physicians and other healthcare professionals prepared to care for opiate addiction was a significant barrier. "All primary care medical specialties... should be taught the principles of diagnosing and treating patients with opiate addiction.... The greater the number of trained physicians and other health care professionals, the greater the supply not only of professionals who can competently treat the opiate addicted but also of members of the community who are equipped to provide leadership and public education on these issues." [The complete Consensus Statement is available online at http://odp.od.nih.gov/consensus/statements/cdc/108/108_stmt.htm. - Ed.]
Physician Responsibilities Of interest, the NIH Statement followed a Public Policy Statement issued by ASAM (American Society of Addiction Medicine) last summer addressing screening for addiction in primary care settings. That report estimated that over two-thirds of persons with addiction see a primary care or emergency care physician every six months, so those physicians are ideally situated as the first-line defense in recognizing, diagnosing and intervening in those cases. It recommended that, "Proper training in detection and intervention techniques, and proper motivation on the part of physicians to utilize these techniques, are necessary for these techniques to be widely employed." [The ASAM Policy Statement is available online at: www.asam.org/ppol/screen.htm. - Ed.] Even earlier, last March, a national panel convened by the New York-based Josiah T. Macy Jr. Foundation warned that physicians diagnose "only a fraction" of their patients with alcoholism and substance abuse problems. The panel called upon physicians to "...learn as much about alcohol and drug abuse as they know about typical medical problems such as hypertension, cholesterol reduction and diabetes."
Bull By The Horns Unfortunately, none of the reports or statements mentioned above provided specific blueprints for action to achieve their goals, nor did they specify just where funding for such activities might be derived. One state, however, has grabbed the proverbial bull by the horns. The comprehensive drug policy bill (Public Act 97-248) passed by the Connecticut General Assembly in 1997 requires establishing a pilot program in one region of the state to study the prescription of methadone by private physicians. Other federally approved opiate-substitution therapies might also be used, presumably including LAAM or buprenorphine. The bill specifies that the participating private physicians must be "skilled in addiction medicine" and associated with an existing MMT clinic. It is believed that those physicians initially selected will be certified by ASAM in addiction medicine but, if the pilot is successful, training might be provided to other interested physicians in the community. CSAT is providing technical assistance for the research program.
Diverging Views In October 1997, the American Methadone Treatment Association issued more specific criteria for implementing physician-based methadone practices, essentially "methadone maintenance." Mark Parrino, President, estimated that about five to seven percent of existing methadone maintained patients would qualify for such services. As one point of interest, qualifications for "physician involvement" include: "Certification in Addiction Psychiatry, Addiction Medicine, or 3 years experience or a minimum of 1500 hours working in a licensed 'Narcotic Treatment Program.'" [Such requirements would seem to exclude most primary care physicians. - Ed.] Two other viewpoints have been noted: While the merits of these two viewpoints are debatable, they serve as reminders that more accessible methadone maintenance treatment is far from a straight-forward solution in the hearts and minds of American health professionals and the lay public.
Sites Worth SeeingAddiction Resource Guide http://www.hubplace.com/addictions/ This site provides easy-to-use, detailed profiles of international, national, state and local treatment facilities, plus a great deal of other useful information for helping persons addicted to alcohol or other drugs. There are abundant links to other sites of interest.
Don't Leave Home Without This http://home.muenster.net/~indro/ On-line guide, "Travel Regulations for Methadone Patients," provides important information on over 150 countries. It examines the possibilities of maintaining treatment abroad, including contact addresses, and alerts travelers to restrictions regarding the transport of medications across international borders. Report assembled by Dr. Ralf Gerlach of INDRO, a non-profit, independent advocacy organization.
The Recovery Network http://www.recoverynetwork.com/ This organization provides educational, supportive and preventive programs for a wide range of behavioral and mental health issues. It also produces Recovery Talk Radio, a national discussion show and Web site providing extensive information on addiction and recovery. The Network also has a toll-free helpline 1-800-400-RNET for people in need of immediate information and guidance in their local communities.
Accreditation Model CSAT continues to work with various agencies FDA, DEA, ONDCP, NIDA, HHS regarding a transition of responsibility to CSAT for the future accreditation and regulation of MMT programs. "We're concerned that our discussions reach a conclusion very soon," Mactas says. "There are some considerations from a funding perspective for CSAT, and we've been discussing the resources we need for the transition and also the maintenance of any new system." Mactas submitted a proposed budget, organizational structure and timelines. "We believe progress is being made," he continues, "but there is still the need for identification of resources in this regard." CSAT has been establishing a "working laboratory" approach that will allow testing of an accreditation model at over 100 sites. This model will be evaluated from perspectives of methadone program operations and the clinical progress of the clientele. Contracts for these activities were awarded last September and work has begun.
Medical Maintenance Since ultimate responsibilities for accreditation of both programs and practitioners are still not determined, any possible medical maintenance initiatives such as primary care physicians treating methadone patients have been on hold at CSAT. These regulatory and accreditation initiatives were under the direction of Joyce Johnson, DO, who left the agency when she was promoted to Director of Health & Safety for the U.S. Coast Guard. "It's clear that [General Barry] McCaffrey, head of ONDCP, is interested in taking a look at this," Mactas notes. "Certainly, we agree with him in this concern for closing the gap between the need for services for chronic substance abusers and the capacity to deliver those services. ONDCP wants to maximize both present and future systems, and medical maintenance is a logical modality for exploration." Are there any specific moves in that direction to report? Mactas points toward Connecticut, which plans to start an "office-based practice" initiative on a test basis. However, while CSAT is providing technical assistance for that project, it is strictly a state initiative.
Pharmacy Dispensing Another CSAT project, examining the utility of medical maintenance, was a concern of Jerome Jaffe, MD, who recently retired. "While no such initiative is in place," Mactas observes, "potential models of a pharmacy dispensing program have been reviewed by CSAT and we continue to pursue further discussions regarding the approach." There could be significant barriers rational and irrational to pharmacy dispensing programs spreading across the country, Mactas acknowledges, with the potential for diversion being a prime fear. Yet, he believes, "we in the field are not sure that diversion of methadone is a great problem, especially for stable, long-term patients. And, when weighed against the down-side of tethering everybody to clinics, I think we need to demonstrate the efficacy of moving some people out [of those clinics]."
Harm Reduction What about harm reduction efforts, such as needle exchange programs? HHS has been evaluating such programs and there's been some controversy regarding the funding of them. "We've been involved in those discussions in an advisory role," according to Mactas, "and it seems quite brave of HHS, especially with this Congress, to pursue such efforts. CSAT's concern is that, if those programs are executed by government, there should be a significant component for treatment referral, patient placement and outcome research." As for experiments like those in Switzerland that distributed free heroin to addicts, Mactas adroitly remarks, "The spirit in Washington is not toward permissiveness."
Slow Going Sometimes it seems the wheels of government spin rather slowly; what are the obstacles? Mactas responds: "We've been engaged in methadone activities and technical assistance for a long time, but we just can't go off on our own to get things done. Expediting government can be a challenge and sometimes things just take their course, but there are often reasons for delays." Still, he agrees, the pace of forward progress might appear from the outside at least to be "rather cautious."situations."
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