ICAAT: Methadone: Office-based Practices

Integrating Opiate Addiction Treatment into Community Based Medical Practice

Abstract: Mainstreaming methadone maintenance treatment: the role of the family physician; by Mark Latowsky MD and Evelyn Kallen Ph.D- Canadian Physicians

Data from international studies conducted in New South Wales, Australia, Scotland and elsewhere, strongly suggest that methadone maintenance treatment is a very effective and practical way for community-based physicians to integrate the medical care of opioid addicted patients into primary practice. More than 85% of methadone maintained patients in some countries are cared for by primary care physicians, and are able to fill their methadone prescriptions at pharmacies in their communities. This system of care is supported by public money and treatment of addicted patients often is provided in collaboration with clinics that offer continuing education, training and other support to providers. This system of community-based integrated primary medical care produces positive treatment outcomes, and opioid addicted patients who receive this type of personalized primary care are reported to experience increased personal dignity and self respect. They have more opportunities to expand their social, educational and employment horizons, and greater privacy protection of their medical condition and their treatment.

The authors conclude that:

Methadone maintenance treatment produces very successful health outcomes for opioid dependent patients.
Incorporation of the human rights approach into the primary care setting is necessary to extend the medical model and reduce the stigmatization of methadone maintained patients.
Family physicians with specialized education and training in drug addiction and dependence are needed to integrate this system of medical treatment into the mainstream of traditional primary practice in America, where methadone treatment is still heavily regulated by stringent government policies.

For Specific Country Information on General Practitioner & Opiate Addiction Treatment:

Reference

Latowsky, Mark, & Kallen, Evelyn (1997) Mainstreaming methadone maintenance treatment: the role of family physician, Canadian Medical Association Journal, Vol. 157(4), pp. 395-398.

Census of Patients Receiving Methadone Treatment in a General Practice

References: Byrne, A, and Wodak, A (1996) Census of Patients Receiving Methadone Treatment in a General Practice, Addiction Research Vol. 3(4), 341-349.

I. Introduction

Byrne and Wodak (1996) describe the demographic characteristics, drug use patterns, and treatment outcomes of a sample of 121 patients receiving methadone treatment at an inner city general practice facility in Sydney, Australia. Patients selected for participation in this investigation were recruited from other medical practitioners and local hospitals and were assessed without appointment by the physicians and nurses who staffed the practice. The majority of patients accepted had previous involvement with other types of drug treatment that had yielded less than satisfactory outcomes. All were treated in the same setting and under the same medical conditions as other patients in the practice.

II. Assessment Procedures

Before being considered for the office based drug treatment program all applicants in this investigation received an initial assessment that included an in depth physical examination and urine drug screening test. Patients accepted by the program were started the same day on a dose of 30 to 40mgs of methadone. Methadone dose was gradually increased by the medical staff, and urine specimens were collected on a weekly basis during the initial phase of therapy, and less often as treatment progressed.

III. Dosing Arrangements

Patients were given some degree of control over their prescribed dose of methadone. In the absence of evidence of heroin use, patients were permitted take home doses of methadone syrup for four days each week. Almost all methadone patients in the study used the primary care facilities of the practice at least once during the six month period, and about half told investigators that they had no other family physician.

IV. Data Collection Procedures

Data for this investigation were collected using a cross sectional questionnaire administered to all patients during a twenty-minute interview conducted in November, 1993. Information gathered included demographic characteristics, drug use patterns, and social and medical history. All self reported drug-use data were compared to urine test results and other medical information found in the medical records whenever possible. Informed consent was obtained from each patient before entering the study.

V. Findings

Of the 121 patients in the study receiving methadone treatment at the time the questionnaire was administered,
1) Eighty-two percent were male;
2) Fifty-four percent reported that they had a spouse or other relative that was opioid dependent;
3) Thirty-nine percent reported that they had served at least one month in jail for a drug abuse related offense prior to treatment;
4) The average age of first heroin use reported was 20.1 years and the average total duration of use was 66 months;
5) fifty-six percent of the patients reported no heroin use in the previous six months during enrollment in the program;
6) of 1009 random, monitored urine samples collected during the same six-month period, 7.4 percent were positive for the heroin metabolite, morphine;
7) the employment rate of patients rose from 28% before treatment to 56% after admission;
8) the average daily dose of methadone was 68mgs and the duration of treatment at the time of the study was 28 to 42 months;
9) twenty-nine percent reported having in-treatment problems with drugs other than opioids;
10) blood tests were performed on all but one of the subjects in the study. Fifty-six percent had abnormal liver function, 96% were Hepatitis C positive and 1.7% were HIV positive.

VI. Conclusions

The investigators conclude that general practice based methadone treatment appears to be a satisfactory alternative to specialized clinics. General practice settings for addiction treatment also provide patients with much needed primary health care services that they might not otherwise receive.

Methadone Medical Maintenance: Treating Chronic Opioid Dependence in Private Medical Practice

A Summary Report (1983-1998) by Edwin A Salsitz MD, Herman Joseph Ph.D, Blanche Frank Ph.D, John Perez MS, Beverly L. Richman, MD, Nadim Salomon MD, and Marcia F Kalin MD, and David M Novick MD

Introduction

Salsitz et al (2000) present a longitudinal evaluation of a methadone medical maintenance treatment program at New York’s Beth Israel Medical Center.

The program is intended to enable socially rehabilitated methadone patients to receive treatment for their addiction in private physicians’ offices rather than in a "clinic" setting. Data for the multi year evaluation were collected over a fifteen-year period, from 1983 to 1998.

Description of the Patient Population and Admission Criteria

A total of 158 methadone patients were recruited from standard methadone clinics (see below). Eligibility requirements included:

Methadone treatment for at least four years
No illicit drug or excessive alcohol use or involvement in criminal activity for at least three years
Evidence of employment
No diagnosed psychiatric illness
A statement from the referring clinic that methadone medical maintenance was anticipated to yield improvements in the patient’s overall quality of life

Patient Recruitment Procedures

Patient recruitment was accomplished through letters sent to New York City area clinic directors telling them about the program and its criteria. Participating medical maintenance physicians reviewed applications and sought approval on an individual basis from the New York State Office of Alcoholism and Substance Abuse Services.

The Program

Initially, patients were given physician appointments every two weeks. After the first month, patients were placed on a monthly schedule. At each visit one dose of methadone was ingested under direct observation and a urine specimen for toxicology was obtained. Each patient received an annual physical examination to check for possible medical problems. Unlike the clinic system (where all dispensed methadone must be in dissolved form), each patient in the medical maintenance program was given one month’s take-home supply of diskettes, ordered from the hospital pharmacy and stored in the physician’s office prior to each scheduled appointment.

Results

In order to evaluate the efficacy of the private office based medical maintenance treatment program, investigators conducted patient interviews and collected data on patient demographics, addiction and criminal history, length of treatment retention, compliance, discharge criteria and outcome. Results included the following:

Of the 158 patients who entered treatment, 132 (83.5%) were compliant with program regulations throughout; and the remaining 26 patients (16.5%) were referred back to the clinics for continued care in a more comprehensive treatment setting or were discharged from the program.
Patients reported that the simplified appointment schedules and reduced restrictions of office based treatment better enabled them to meet their employment responsibilities, participate in educational programs, and enhance the overall quality of their lives.
Eight percent of patients withdrew from methadone after an average total of almost 18 years of treatment, at their initiative and with the support of the physician.
The mortality rate was 13% mortality over the course of this study. Causes included hepatitis C, AIDS, cancer, homicide, complications of morbid obesity and meningitis. The most common causes of death were related to cigarette smoking (40%). None of the patient deaths was attributed to methadone treatment.
One of the main causes of methadone medical maintenance treatment failure was crack/cocaine use.
Stigma associated with enrollment in medical maintenance was a major social issue, with the most negative impact perceived by the more stable, successful, socially integrated patients. Many patients refuse to reveal to families, friends, co-workers, employers and others (including medical professionals) that they were receiving prescribed methadone.

Conclusions

The investigators conclude that methadone medical maintenance in the private offices of primary care physicians provides socially rehabilitated methadone patients with an effective alternative to the traditional clinic system. They believe, however, that state and federal regulations related to the use of methadone in primary care practice must be modified to encourage the development of medical maintenance treatment along the lines of other medical care. Finally, they advocate better training and education to foster unbiased professional attitudes toward the disease of addiction and those who require treatment to deal with it.

References

Salsitz, Edwin A, Joseph, Herman, Frank, Blanche, Perez, John, Richman, Beverly L., Salomon, Nadim, Kalin, Marcia F., & Novick, David M. (2000) Methadone Medical Maintenance: Treating Chronic Opioid Dependence in Private Medical Practice — A Summary Report (1983-1998), Mount Sinai Journal of Medicine, Vol. 67 (5 & 6) 388-397.