From the Publisher

Methadone Diversion: Do You Know Your Responsibilities?

One of our feature articles in this issue, Ensuring the Safety of Take-Home Doses, and Preventing Diversion, reviews Opioid Treatment Program (OTP) responsibilities related to take-home doses, including educating staff and patients about the unique pharmacology of methadone. We discuss reasons patients sell or share their take-home doses, and suggest ways OTPs may address these issues. We also review patient responsibilities, including the importance of safely storing methadone take-home doses at home, or while traveling.

If you or your OTP are doing something unique to address methadone diversion, we would like to hear from you. You can respond by e-mail, fax, or mail (see below).

Also in This Issue

How do today’s OTPs differ from those in previous years? We take a look at OTP expansion, shifts in ownership, methadone dosing trends, and barriers to clinic expansion. OTPs: Past, Current, Future - Part III is the third in our four-part series on Medication-Assisted Treatment (MAT) in OTPs.

Reader Responds: From the Other Side of the Window of Opportunity

In response to Ben Guerrero’s column in our Spring 2008 issue: Window of Opportunity: Clinic Staff Member Hopes He Made a Difference, a reader wrote:

“As I type these words, my vision is clouded with tears. Mr. Guerrero's piece deeply affected me. I am one of those on the other side of the window, at the methadone clinic.

I was so touched by Mr. Guerrero’s words. He brings into the light just how closely we human beings are connected. Regardless of where we come from, where we are headed, we are all of the same tree of life.

I visit my methadone clinic two days a week, now that I’ve climbed the ladder for take-out doses. I show my I.D. to the nurse, and we say a few words. In our few moments together, the nurses behind the glass window have always been wonderful. I empathize with them in a new way now . . . because of reading Ben Guerrero's touching letter.

Thank you, Mr. Guerrero, for reaching out, through the window.”

Sue Emerson Publisher
ATForum@ATForum.com

 

Spring 2008 - OTP Part II Clarification
In the Spring 2008 issue of AT Forum, on page 4 in the article on OTPs: Past, Current, Future - Part II, Figure 1 is titled Patient Admissions to OTPs (1968-2006). The data in the graph actually reflect patient census data.

 

OTPs: Past, Current, Future – Part III

Publisher’s note: This is the third in a series of four articles exploring changes in Opioid Treatment Programs (OTPs) since the inception of Medication-Assisted Treatment (MAT) in the 1960s. In this issue we focus on how the characteristics of OTPs have changed over the years and adapted to meet the needs of today’s OTP patients.

Changing Characteristics of OTPs

OTP Expansion Decelerates in the 2000s

The number of OTPs in the U.S. doubled during the 1990s, from about 600 to 1,200. The number declined by about 10 percent from 1999 to 2005, but returned to 1999 levels in 2006, with again about 1,200 clinics in operation (see Figure 1). An important factor in the slowdown in OTP expansion was state-imposed moratoriums on opening new facilities.

 

Ownership Shifts to Private, For-Profit

In the early years of MAT, most OTPs were publicly owned, nonprofit operations. In the 1980s, cutbacks in federal, state, and local budgets reduced public funding for OTPs, and more clinics became privately owned, for-profit enterprises. About 10 years ago the programs were equally divided between nonprofit and for-profit. Since then, almost all OTP expansion has been in the private sector, with about 100,000 treatment slots added nationwide. Today, for-profit programs are growing more rapidly than nonprofits, and virtually all OTP growth is in the private sector.

OTP Chains Emerge in the 1990s

In the mid-1990s, corporate chains of OTPs began buying out single clinics and smaller chains, and opening new facilities. The 10 largest OTP chains have about 220 locations.

The new chains have made MAT available in previously unserved cities and states. Many chains use standardized operating procedures and evidence-based approaches, and have the potential to improve treatment standards and provide better outcomes.

Accreditation Improves OTP Standards of Care

In 2001, the Substance Abuse and Mental Health Services Administration (SAMHSA) established an accreditation requirement to help OTPs improve the quality of patient care. The requirement emphasizes person-focused care, integrated and individualized approaches to OTP services and outcomes, increased patient-satisfaction, improved recruitment of staff, and enhanced community confidence and outcomes. SAMHSA approves accreditation agencies and sets standards to which opioid treatment programs must adhere. Accreditation agencies set their own additional standards for organization, administration, and level of care.

By 2006, the Commission on Accreditation of Rehabilitation Facilities (CARF) had accredited 56 percent of OTPs; the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) had accredited 37 percent. CARF and JCAHO are the two major accrediting bodies. Washington State and Missouri are approved accreditation agencies for programs in their own states.

The Center for Substance Abuse Treatment (CSAT) of SAMHSA periodically reviews and revises OTP accreditation standards. The latest standards are available on the SAMHSA website, at http://www.dpt.samhsa.gov/regulations/accreditation.aspx

Medication Choices Are Now Available

Methadone Remains the Standard Medication

In MAT, the current principle of individualized treatment contrasts sharply with past practices. Adequate individualized methadone dosages are now considered the single most important factor in patient retention. In 1965 Dr. Vincent Dole published data in The Journal of the American Medical Association showing that a daily methadone dose of 80 mg to 120 mg was the most effective for suppressing the craving that leads to opioid abuse, while causing minimal side effects. According to the National Institute on Drug Abuse (NIDA), most patients need a daily methadone dose of at least 60 mg for optimum therapeutic effects. Yet because of misguided policies, such as “less is better,” or lack of understanding of the underlying science, or both, the average daily methadone dose in the late 1980s, more than twenty years after Dr. Dole’s published findings, was only 45 mg—far less than his recommendation.

The average daily dose gradually increased in the 1990s, reaching 69 mg in 1998 and 85 mg in 2003. This marked increase is attributed to two key government reports issued in the 1990s (Institute of Medicine: Treating Drug Problems; U.S. GAO: Methadone Maintenance.

As discussed in the Spring 2008 Issue of AT Forum, these reports noted that artificial caps on the daily methadone dose were often so low that patients were undertreated, and consequently continued to use intravenous heroin. The reports cited research on the effectiveness of adequate, individualized doses, and recommended basing doses on patient need. Since 2003, the average daily dose has been slightly less than 90 mg (see Figure 2), indicating that OTPs are now attentive to the role of adequate doses in quality treatment.

Important progress in dosing has occurred during the last two decades, but more can be done. In 1988, only six percent of patients received at least 80 mg of methadone daily, compared to almost one-half (44 percent) in 2005. Yet, in 2005, one-third of patients received less than 60 mg per day; 17 percent, less than 40 mg per day (see Figure 3).

 

Buprenorphine Introduced in 2002

Buprenorphine became available to OTPs in 2002, as an alternative to methadone in MAT, and has gradually been adopted by some programs. In 2006, approximately 10 percent of OTPs provided buprenorphine therapy to about 2,040 patients.

Demand for Comprehensive Services Increases

As emphasized in our Spring issue, today’s OTP patients have more complex treatment-needs than those in previous years. Today’s challenges include poly-drug abuse, prescription-drug abuse, and co-occurring mental health and medical disorders that were previously undetected, or treated elsewhere.

Research has shown that methadone programs offering comprehensive mental and physical health services yield much better patient outcomes. Some clinics have adopted the “one-stop shopping” model, providing all services on-site. Although the principles of comprehensive care are widely accepted, many smaller OTPs lack the resources to implement this type of care. These OTPs refer patients to other facilities, and encourage them to follow up—then hope that they do.

OTPs Face Barriers to MAT Expansion

Barriers to expansion limit the number of patients who can access MAT. These barriers may also contribute to a lower retention rate, by overburdening the staff and limiting patient access to comprehensive services.

Convenient Access to Treatment May be Limited

In the early years of MAT, OTPs were located primarily in urban and metropolitan areas of larger cities, and usually treated heroin-dependent patients. Today, many people seek MAT because of prescription-opioid abuse.

OTP availability has not kept pace with the geographic dispersion, changing demographics, and increased numbers of people who need MAT. Patients in many states need to travel long distances to access OTP services. Four states currently have no OTPs: Montana, North Dakota, South Dakota, and Wyoming. Twenty states have fewer than 10 clinics.

In Maryland, New Jersey, Vermont, and Washington State, mobile methadone programs deliver treatment to patients who lack convenient OTP access. Mobile programs have been successful in rural areas, and wherever community opposition has prevented OTP expansion.

Alternatives to MAT in OTPs

For patients who must travel long distances, a major barrier is the federal requirement of OTP attendance for at least 90 days. An option to MAT is office-based opioid treatment (OBOT), but OBOT programs with methadone have been approved only for stable patients in long-term therapy. OBOT with methadone is commonly used in European public health systems, but has not been widely adopted in the U.S.

Office-based treatment using buprenorphine is another option, especially in rural and remote areas, but is not widely available. Only about 160,000 patients have had access to buprenorphine in physicians’ offices since its approval in 2002 for treating opioid dependence.

Treatment is Unaffordable for Many

Lack of funding and insurance reimbursement prevent many people from receiving MAT. In 2003, patients paid about 40 percent of MAT expenses out-of-pocket. With the cost of weekly treatment in 2002 averaging $82, and sometimes reaching twice that, many people must find a way to finance their treatment, or do without. Treatment for the working poor and uninsured is particularly problematic.

Making treatment more affordable is a top priority. Private nonprofit clinics are more likely than others to use a sliding fee scale and to accept various types of health insurance, including Medicaid and Medicare. Medicaid benefits cover MAT in 20 states. Medicare does not cover MAT, but may cover some medical services delivered in comprehensive MAT clinics. According to recent figures from SAMHSA, Medicaid and other public funds pay for about 50% of outpatient methadone treatment. Patients pay about 40% out-of-pocket.

Stigma/NIMBY Are Still Going Strong

The stigma of MAT continues to affect the attitudes of health care professionals, social service agencies, workers, and the public. Stigma influences criminal justice policies, creates political division, and limits OTP funding and space availability. NIMBY—an acronym for “Not in My Backyard”—has plagued OTPs almost since the beginning of MAT.

Some people have attributed the recent rise in methadone-associated deaths to OTPs—but the rise is mainly due to increased methadone prescribing for chronic pain by practitioners who do not understand methadone’s unique pharmacokinetics (New York Times. August 17, 2008). The higher death rate has created community concerns and prevented new clinics from opening. In the meantime, positive news about MAT typically goes unreported.

Knowledge Gained Over the Years

More than four decades of clinical experience and research have equipped OTP clinicians with awareness, tools, and skills. Evidence-based practices are now available to help deliver more-effective patient care. OTPs can adapt their treatment plans to cover a wide range of co-occurring physical and mental health conditions, family and social circumstances, and recovery expectations. But despite impressive progress, much work remains before MAT is fully integrated into mainstream medicine and viewed as an acceptable pathway to recovery. Better communication between OTPs and their communities and supporters remains a top priority.

In our next issue we will explore the final topic in this series, Part IV: The Future of MAT in Opioid Dependence.

Sources

Bishai D, Sindelar J, Ricketts EP, et al. Willingness to pay for drug rehabilitation: Implications for cost recovery [published online ahead of print December 5, 2007]. Health Econ. 2008 (Jul);27(4):959-972.

Center for Substance Abuse Treatment (CSAT). Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 06-4214. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005, reprinted 2006. Available at:
http://download.ncadi.samhsa.gov/Prevline/pdfs/bkd524.pdf. Accessed October 1, 2008.

Centers for Disease Control and Prevention (CDC). Methadone Maintenance Treatment. IDU HIV Prevention. Atlanta, GA: U.S. Department of Health and Human Services, CDC. February 2002. Available at: http://www.cdc.gov/IDU/facts/MethadoneFin.pdf. Accessed October 1, 2008.

Dole VP, Nyswander M. A medical treatment for diacetylmorphine (heroin) addiction. A clinical trial with methadone hydrochloride. JAMA 1965(Aug 23;(193):646-650.

Institute of Medicine. Treating Drug Problems: A Study of the Evolution, Effectiveness, and Financing of Public and Private Drug Treatment Systems. Washington, DC: National Academy Press, 1990.

Leavitt SB. A Community-Centered Solution for Opioid Addiction. AT Forum [special report]. 2004 (May). Available at:
http://atforum.com/pdf/com_ctrd_mmt.pdf. Accessed October 1, 2008.

Marion IJ. Methadone treatment at forty. Science & Practice Perspectives. 2005(Dec);3(1):25-33.

Pollack HA, D’Aunno T. Dosage patterns in methadone treatment: Results from a national survey, 1988–2005. Health Serv Res 2008; Jun 3 2008. Available at: http://www.blackwell-synergy.com/doi/abs/10.1111/j.1475-6773.2008.00870.x.
Accessed October 1, 2008.

Substance Abuse and Mental Health Services Administration (SAMHSA). National Drug and Alcoholism Treatment Unit (NDATUS) and Uniform Facility Data Set (UFDS) surveys: 1990-1993,1995-1997. Rockville, MD. Office of Applied Studies, SAMHSA. Available at: http://wwwdasis.samhsa.gov/97ufds/ufds1997report.pdf. Accessed October 1, 2008.

Substance Abuse and Mental Health Services Administration (SAMHSA). National Survey of Substance Abuse Treatment Services (N-SSATS): 2003-2006. Rockville, MD. Office of Applied Studies, SAMHSA. Available at: http://oas.samhsa.gov/dasis.htm#nssats2. Accessed October 1, 2008.

U.S. General Accounting Office. Methadone Maintenance: Some Treatment Programs are Not Effective. Greater Federal Oversight Needed. Publication No. GAO/HRD-90-104. Washington, D.C., U.S, Government Printing Office. Washington D.C.; 1990. Available at: http://archive.gao.gov/d24t8/141087.pdf. Accessed October 1, 2008.

Wechsberg WM, Kasten JJ. Methadone Maintenance Treatment in the U.S.: A Practical Question and Answer Guide. New York, NY: Springer Publishing Co; 2007.

 

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Ensuring the Safety of Take-Home Doses, and Preventing Diversion

Methadone diversion* of take-home doses by patients is an ongoing concern to opioid treatment programs (OTPs), the Drug Enforcement Administration (DEA), accreditation agencies, and neighborhoods where OTPs are located. Organized groups of family members and friends of individuals who have died from methadone-related overdoses are urging the government to curtail or eliminate methadone take-home doses.

*When methadone is not taken by the intended patient, but instead is sold or shared.

While there is consensus that most diversion arises from the illegal sale or sharing of prescription methadone channeled through hospitals, pharmacies, or medical practices, diversion of methadone take-home doses from OTPs does occur. To what extent is not known.

Diversion Control Plan (DCP)

To the extent possible, OTPs are responsible for protecting the health and safety of their patients, their patients’ families, and the neighborhood. Federal standards require OTPs to develop and maintain a DCP as part of their quality assurance program, and to integrate the plan into patient and staff orientations. Diversion plans may include random drug testing, take-home call-backs (requiring the patient to return all unused take-home medication to the clinic when called), neighborhood rounds to observe the impact of local patient flow and to assess community concerns, and patient education about safely using and storing take-home methadone.

OTP Take-Home Responsibilities

It is imperative that OTP program providers maintain a balance between implementing or sustaining their control measures, in order to minimize methadone diversion, and providing opioid-dependent patients ease of access to MMT treatment, fostering a therapeutic milieu for treatment and patient progress.

In the Spring 2008 issue of AT Forum, we reviewed the eight federal criteria that OTP staff need to evaluate when considering granting take-home privileges. The OTP Medical Director and OTP staff members are responsible for reviewing and periodically reassessing methadone take-home requests, based on progress in treatment. They should be prepared to adjust treatment plans, evaluate changes in the level of care, and determine if indications exist for reducing or terminating take-home privileges.

All staff members are responsible for educating patients about the unique pharmacology of methadone. Patients should be encouraged to discuss any side effects, so dosages can be individualized.

While staff input is important, federal rules state that the Medical Director is responsible for setting dosage levels and approving take-home doses of methadone. Medical Directors must take this responsibility seriously, and must weigh the benefits and risks of providing take-home medication, including the possibility of diversion.

Why Some Patients Divert Take-Home Doses

As part of the take-home evaluation, all OTP staff members need to understand the reasons some patients divert take-home doses, and, when possible, take proactive steps.

• Assessing Patient Resources: Some patients sell take-home doses to make money. OTPs can help minimize this risk. They can provide patients with vocational help, or, if patients are funding some or all of their treatment, OTPs can work with them in seeking financial assistance or applying for entitlements.
• Reviewing Dosages: Some patients buy methadone to augment inadequate doses given at the OTP. This situation could be prevented by educating staff about the need for adequate doses, and by periodically assessing patients to be sure they are comfortable on their current dose.
• Talking With Patients About Family and Friends: Some individuals share or buy additional methadone to “help” relatives or friends who are dependent on opioids. Should this be a problem, staff members can help with access to appropriate treatment for these individuals.

OTPs should make sure that their policies and procedures provide appropriate ways to address any forms of diversion (see Sidebar below). Most important: Usually, patients who divert medication are having difficulties, and may need a higher level of care.

OTPs also need to continuously network with their local law enforcement and community agencies, who may be aware of patient patterns of street sales and purchases. This can help OTP staff members understand the impact of the program in the community.

Are OTP Take-Home Policies Strict Enough?

 

The Importance of Ongoing Staff and Patient Education

Staff members must be well-informed so they can provide ongoing patient education, an essential part of a clinic’s risk-management program. OTPs need to spell out standards of behavior and responsibilities for patients, including proper use of take-home doses.

• When speaking with patients, OTPs need to continually reinforce the message that methadone is a highly potent drug that cannot be shared. Methadone is classified by the DEA as a Schedule II drug. This means methadone has a high potential for abuse, which may lead to severe psychological or physical dependence.
• Patients also need to thoroughly understand that methadone’s unique pharmacologic properties make it appropriate for addiction treatment. Methadone has a slow onset of action and long half life. This allows patients to be monitored as the drug takes effect. Methadone’s long duration of action means that a single daily dose is effective. But when methadone is taken by people who are non-tolerant to opioids, its pharmacologic properties can lead to overdose or death.
• Patients need to fully understand the dangers of poly-drug abuse, and the potential for interactions between other drugs and methadone. Taking methadone with drugs of abuse, particularly benzodiazepines, and with alcohol or other sedative drugs, is dangerous. Giving methadone to non-tolerant family members or friends puts them at risk of overdose or death, especially if they use other drugs of abuse.
• Patients need to be reminded that methadone take-homes are a privilege, not a right. Patients work very hard to earn take-home privileges, and must demonstrate progress in treatment in order to receive take-home doses. Patients who divert their take-homes increase the stigma of methadone therapy in OTPs, and fuel “Not in My Backyard” (NIMBY) movements. These consequences contribute to community opposition to local OTP expansion. Diversion occurring near a clinic results in adverse reports in the media, and increases the public outcry to close clinics or eliminate all take-homes.

Patient Take-Home Responsibilities

Patients who have earned the privilege of take-homes need to have a clear understanding of their responsibilities.

• Of prime importance: Patients have the responsibility to safely store methadone take-home doses at home or while traveling. Methadone should always be kept in its original, labeled, child-proof containers, and stored in a safe place. A locked, sturdy cabinet or metal box is best. Methadone medication must always be kept out of children’s reach. Methadone take-home doses do not have to be refrigerated, and do not spoil if taken as directed.
• Patients need to educate their family members and friends about the potency of methadone, and the potential dangers when people non-tolerant to opioids ingest methadone.
• If family members and friends who are opioid-dependent ask to share take-home doses, patients should encourage them to enter medication-assisted treatment (MAT) instead. Getting treatment will help ensure that these people receive a safe and effective methadone dose, and will enable them to benefit from the comprehensive services OTPs offer.
• Patients need to fully understand the serious legal consequences of sharing or selling their methadone take-homes. It is illegal to share or sell controlled substances. In cases where diversion has resulted in overdoses or death, patients have been prosecuted to the fullest extent of the law. Recent examples include:
  
  
  • An Indiana mother accused of giving a lethal dose of methadone to her 17-month old son is charged with neglect of a dependent - a Class A felony. If convicted, she faces up to 50 years in prison. (11/07)
  • New Jersey school-bus aide pleads guilty to giving liquid methadone to a 15-year-old student. The aide will serve at least five years in a state prison before becoming eligible for release on parole. (The student recovered physically from the incident.) (7/08)

The Maine Community Awareness Diversion Campaign

The Maine Office of Substance Abuse, with federal technical assistance, developed a community-awareness project in the summer of 2003. The goal was to emphasize that methadone maintenance is safe and effective when patients take a responsible role in their recovery.

Posters, radio commercials, and telephone calling-cards helped spread the message. The Substance Abuse and Mental Health Services Administration (SAMHSA) provided the funds for all promotional materials.

• Four-color display posters were distributed to OTPs (see Figure 1).
• Two recovery-oriented radio commercials (see links below) were aired for three months. The state paid an advertising agency to develop a radio plan and to purchase commercials on rock-oriented stations. The state also received free public service announcements (PSAs) (see links below).
• Paper napkins and telephone calling cards (see Figure 2) were distributed at OTP dosing windows and at homeless shelters.

OTPs responded enthusiastically to the campaign.

For more information on the Maine Community Awareness Diversion Campaign visit http://www.state.me.us/dhhs/osa/treatment/opioid.htm

Radio Spot #1 (mp3 format)
Radio Spot #2 (mp3 format)

 

 

 

Sources:

Center for Substance Abuse Treatment (CSAT). Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 06-4214. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005, reprinted 2006. Available at:
http://download.ncadi.samhsa.gov/Prevline/pdfs/bkd524.pdf. Access checked October 1, 2008.

Joseph H, Stancliff S, Langrod J. Methadone maintenance treatment (MMT): A review of historical and clinical issues. Mt Sinai J Med. 2000(Oct/Nov);67(5-6):347-364. Available at:
http://www.mssm.edu/msjournal/67/page347_364.pdf. Access checked October 1, 2008.

Maine Office of Substance Abuse. http://www.state.me.us/dhhs/osa/treatment/opioid.htm. Access checked October 1, 2008.

U.S. Department of Justice, National Drug Intelligence Center. Methadone Diversion, Abuse, and Misuse: Deaths Increasing at an Alarming Rate. Document ID 2007-Q0317-001. Rockville, MD: November 16, 2007. Available at: http://www.usdoj.gov/ndic/pubs25/25930/index.htm. Access checked October 1, 2008.

Wechsberg WM, Kasten JJ. Methadone Maintenance Treatment in the U.S.: A Practical Question and Answer Guide. New York, NY: Springer Publishing Co; 2007.

 

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Survey Results: Impact of OTP Characteristics on Methadone Dosing Levels

A recent study published by Pollack and D’Aunno addressed two questions related to standards of care in Opioid Treatment Programs (OTPs).

• To what extent are U.S. OTPs meeting empirically established standards of care for methadone dose levels?
• What characteristics of OTPs are associated with variations in their methadone dose prescribing?

Our feature article on OTPs: Past, Current, Future – Part III (see above) addressed the first question: Over the past two decades, marked progress has been made in providing therapeutic levels of methadone dosing.

To address the second question, Pollack and D’Aunno extended their earlier research studies by analyzing data for 2005 obtained by the National Drug Abuse Treatment System Survey (NDATSS). They found that variation in methadone dose levels by OTPs is related to 1) OTP patient and staff characteristics; 2) OTP ownership, payment (ie, managed care arrangements), and accreditation; and 3) managerial attitudes and beliefs about addiction treatment and HIV prevention.

The following summarizes key findings of their study, based on data for 2005, in which they examined OTP characteristics related to methadone dosing.

OTP Managed Care and Accreditation

Pollack and D’Aunno examined the impact on dose levels of preauthorization of treatment services required by managed care organizations. They found that OTPs operating under preauthorization restrictions are significantly less likely to provide daily doses of methadone above 60 mg. The authors suggested that OTP staff “may be reluctant to provide high methadone doses to patients covered by managed care contracts simply because such a higher-dose course of treatment requires more time, and managed care [organizations often] shorten treatment duration.”

OTP accreditation, mandated in 2001, has led to higher dose levels of methadone. Previously, OTPs that sought accreditation had a higher average methadone dose level than OTPs that were not accredited. This suggests that accredited OTPs were more motivated to improve their quality of care, and were relatively resource-rich (eg, in funds, staff, and training). Thus, they were more likely to respond to the evidence documenting the benefits of higher methadone doses.

Staff Attitudes and Beliefs

Pollack and D’Aunno also found that attitudes and beliefs of an OTP’s management and staff strongly influence OTP outcomes. Managers who favor abstinence or oppose harm reduction efforts (HIV prevention and syringe exchange), or both, are more likely to be affiliated with clinics that provide low methadone doses. Many individuals who hold the view that methadone treatment “substitutes one addiction for another” also tend to promote the idea that if methadone is to be used in treatment, it should be used briefly and in as low a dosage as possible. Evidence gained in many studies, however, shows that inadequate methadone doses lead to relapse to heroin usage.

Source

Pollack HA, D’Aunno T. Dosage patterns in methadone treatment: Results from a national survey, 1988–2005. Health Serv Res. 2008 Jun 3 2008. Available online at: http://www.blackwell-synergy.com/doi/abs/10.1111/j.1475-6773.2008.00870.x

 

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Survey Results: Reasons for Patient Discharges from OTPs

Medication-Assisted Treatment (MAT) for treating opioid dependence in opioid treatment programs (OTPs) is an ongoing process. It involves phases of treatment in which interventions are matched to levels of patient progress and intended outcomes.

Length of therapy is a critical factor in addiction recovery. Studies have found that patients in MAT for less than three months generally show little or no improvement. Reductions in illicit opioid use of up to 80 percent may occur after several months, with the greatest reductions appearing after more than a year of therapy. For many patients, MAT may be a lifelong treatment, as happens with any chronic medical condition. A few patients may taper off and discontinue medication (complete MAT), but with the exception of a small percentage of patients who taper successfully, virtually all who abandon MAT and fail to pursue some type of further treatment eventually relapse.

Following are survey results from the Treatment Episode Data Set (TEDS) for 2005. The survey compiled data on length of stay in MAT, and reasons for discharge. Discharge from OTPs usually is a negative outcome. Except for the few who taper; people progressing toward recovery remain in treatment for long periods.

About 49,000 admission and discharge records from 28 states show that about 11 percent of patients successfully completed MAT. Almost half, 45 percent, dropped out of treatment (see chart below).

The median (the midpoint in a series of numbers arranged in order of their value) length of stay, by group, was as follows: completed treatment, 180 days; transferred for further treatment, 125 days; dropped out of treatment, 95 days; treatment terminated by the facility, 195 days; and failed to complete treatment for other reasons, 166 days. Patients with no previous treatment episodes were the most likely to complete MAT or to transfer to further treatment (31 percent).

About one-fourth of patients discharged from outpatient OTPs had no previous treatment; almost one-fifth had been in treatment five or more times. About three-fourths were self-referrals or individual referrals. Patients most likely to complete MAT or to transfer to further treatment—about one-third of all patients—were referrals from health care providers, alcohol or drug abuse providers, or the criminal justice system.

A U.S. Department of Health and Human Services (DHHS) Consensus Panel recommends encouraging patients in MAT to remain in some type of therapy, and to re-enroll in MAT if relapse occurs, or seems likely. The Consensus Panel also recommends informing all patients at entry that many patients remain in MAT for long periods, or later reenter therapy. OTP staff members can play an important role by placing the focus on recovery rather than tapering, encouraging patients to return to therapy if relapse occurs, and minimizing obstacles to reentry.

Sources

Addiction Treatment Forum – FAQ - How long does a patient need to stay in MMT? November 2004
http://atforum.com/faqs/mmt.php#q7. Accessed October 1, 2008.

Center for Substance Abuse Treatment (CSAT). Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 06-4214. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005, reprinted 2006. Available at: http://download.ncadi.samhsa.gov/Prevline/pdfs/bkd524.pdf.      Accessed October 1, 2008.

Substance Abuse and Mental Health Services Administration (SAMHSA). Treatment Episode Data Set (TEDS): February 2005. Discharges from Substance Abuse Treatment Services, DASIS Series S-17. DHHS Publication No. (SMA) 08-4314. Rockville, MD: Office of Applied Studies, SAMHSA, 2008. Available at: http://wwwdasis.samhsa.gov/teds05/TEDSD2k5TOC.htm. Accessed October 1, 2008.

 

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How Much Would OTP Patients be Willing to Pay for Treatment?

A businessperson, flying to a meeting, sits next to a teenager going to visit a friend. The two seats are identical, but the businessperson’s ticket costs several times more than the teenager’s. Because of their different needs, the business traveler is far less sensitive than the teenager to price. The airline optimized its revenue by setting different prices for different needs.

If the same principle would hold for Opioid Treatment Programs (OTPs), they could increase their revenue by offering patients a selection of services. New patients could select options for which they would pay all or part of the treatment cost. Would patients be willing to do this?

A group of government economists, working with OTPs in Baltimore, Maryland, investigated this question. If a more-tailored approach would bring more revenue to OTPs, the additional revenue could fund more slots. OTPs could treat more patients.

The investigators used an economics concept known as the price elasticity of demand. This is simply a measure of how much buyers are willing to pay for a specific product or service. High elasticity means that the product or service is very dependent on price; when the price increases, fewer people buy. Low elasticity means that the product or service is important enough that people will buy it almost regardless of price.

To measure price elasticity as it applies to OTPs, the economists questioned 241 heroin users who were referred for treatment, but not yet enrolled. They asked how much the heroin users would be willing to pay for a hypothetical program offering three months of freedom from heroin. Next, they asked what they would pay for programs offering up to 24 months drug-free. Another question was how much the participants would be willing to pay in addition if case-management services were an option.

The investigators determined the median fee the participants were willing to pay. (The median is the middle number in a group of fees, ranked from lowest to highest.) For three months of heroin-free time, the median the participants would pay was $7.30 per week. For programs offering 24 months of heroin-free time, the median acceptable amount rose to $17.11 per week. For case-management services as an add-on, the participants would be willing to pay an additional $5.64 per week. (These amounts reflect the prices at the time of the study, which was during the year starting in January 2002.) The investigators speculated that some other enhancements might bring in higher fees for some clinics, but did not test for these. Enhancements included a more accessible location, more convenient dosing hours to accommodate patients’ work, travel, and social needs, and a higher level of services for those patients who are willing to pay more. Some clinics might cater to a specific group of patients.

The authors summarized their findings: “This study shows that drug addicts’ demand for methadone treatment depends on price, service amenities and perceived treatment outcomes.” They pointed out in their conclusion that the fee the patient would be willing to pay falls short of estimated program costs, which are $82 per week. Given this finding, it might seem that many fee-for-service programs charge more than patients can afford to pay. They concluded that combining user fees with subsidization could be the optimal financing strategy for the drug-treatment system.

Source:

Bishai D, Sindelar J, Ricketts EP, et al. Willingness to pay for drug rehabilitation: Implications for cost recovery [published online ahead of print December 5, 2007]. J Health Econ. 2008 (Jul);27(4):959-972.

 

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