- AMTA on Leading Edge
- “Graying” of Methadone?
- Straight Talk From the Editor
- No Medicaid for Methadone
- IOM Report Review
- Clinic as a Family System
- TB Crisis Spurs Action
- Where to Get Info
AMTA on Leading Edge
As a prelude to the November 1995 AMTA Conference in Phoenix [see notice on page 4 in this issue], A.T. Forum spoke with Mark Parrino, MPA. He is president of the American Methadone Treatment Association, Inc. which is sponsoring the conference.
A.T. FORUM: What is the most critical issue AMTA is working on right now?
MARK PARRINO: AMTA is working with federal and state agencies to develop a consistent methadone policy, in responding to the issues of managed care and shifting responsibilities from federal to state authorities. There is a flurry of activity at the federal level in the aftermath of The Institute of Medicine report on methadone regulations, Federal Regulation of Methadone Treatment. [See, our review of that report in A.T. Forum, Vol. IV, #2, p. 6 – ed.]
The Federal Inter-agency Methadone Policy Review Board has forwarded correspondence to the Assistant Secretary of Health in HHS to provide greater methadone oversight at the state level, with less involvement from the federal authorities. Treatment/ practice guidelines in addition to increased credentialing standards could be used to replace current federal operating requirements.
The Drug Enforcement Administra-tion is also restating its concerns about methadone diversion as a result of the IOM report. An IOM chapter, which evaluated the role of methadone diversion to be minimal in nature, the but DEA is saying that the report misstated the problem of methadone diversion. As a result, the DEA released a twenty page report describing methadone diversion incidents in considerable detail.
A.T.F.: Essentially, what did the DEA say?
PARRINO: The report provided anecdotal references and referenced DAWN data, indicating that there was one reported heroin death for every eight methadone related overdose deaths. This represents inaccurate reporting.
AMTA has been discussing this matter with federal agency officials in Washington, requesting that the FDA in conjunction with the CDC (Center for Disease Control) and CSAT and NIDA coalesce to bring forensic experts together to develop an accurate case definition for a methadone toxicity overdose. The current data are flawed and the DEA is arriving at improper conclusions.
A.T.F.: What other issues are at the forefront right now?
PARRINO: We have asked NIDA to conduct a multi-site study evaluating the comparative effectiveness of private (profit oriented) methadone programs vs. publicly funded methadone programs. We have asked NIDA to determine if there is any significant difference in the quality of care that is rendered to patients in such facilities or in patient outcome. It is hoped that these results will remove the issue of public vs. private from our policy debate.
A.T.F.: AMTA, then, serves as a catalyst for change?
PARRINO: We are encouraging federal and state methadone regulatory bodies, researchers and methadone treatment providers to work together to develop a sound methadone-related policy to improve our treatment system. There appears to be interest on the part of both federal and state authorities to do just this. We plan to convene a number of policy making forums in Phoenix to further open such communications and share information in order to craft a more meaningful and consolidated strategic plan to improve methadone treatment in the era of managed care and the anticipated changes in federal law. We have asked the Office of National Drug Control Policy to be involved in this Conference and they have agreed to do so.
A.T.F.: Are there critical changes brewing due to the Republican Congress elected in 1994?
PARRINO: Yes, and the changes could be devastating! For one thing, I suspect that SSI benefits are going to be eliminated completely for patients who have alcohol and drug abuse problems. Last year in Congress the SSI benefit was reduced from being open-ended to a limit of 36 months. Now, the Senate Finance Committee has pressed for total elimination.
A.T.F.: What about Medicaid?
PARRINO: The problem there is twofold: first, at the federal level, it looks like Congress is going to implement a Medicaid block grant to shift the program to the states; second, you will then have the states getting a Medicaid block grant which will presumably give them more flexibility in setting up their own Medicaid reimbursement program.
Essentially, you will have the states establishing their own managed care programs. So, you get a state alcohol/drug abuse treatment system, which is only a part of each state’s healthcare system, having to compete with all other programs for those Medicaid dollars. The states will have to work within a newly established cap while they are also creating managed care programs through waiver applications to HCFA. The state’s alco-hol/drug abuse treatment system will have to compete with other healthcare dollars and mental health dollars in an era of shrinking resources. It represents another waive of instability in the structure of substance abuse treatment programs. [See also, “MMTP Issues” in this edition of A.T.F. – ed.]
A.T.F.: Where’s your “battlefield,” so to speak; at the federal or state level?
PARRINO: The real battles are in the states. The pattern is often an angry reaction by the states – that drug treatment is not a good investment. They ask, “Why do we still need this program in our state?” Often, we have to convince state governments that they DO have a real opiate addiction problem and that methadone treatment is a good investment.
I optimistically believe more states will begin developing methadone treatment services. And the pressure for that is probably going to come from an influx of private programs. For example, in one state, an administrator asked me, “Why do you think, Mr. Parrino, that private programs have so aggressively pressed to get methadone services opened here?”
And I said, “Because, you’re not funding public programs by using federal block grant moneys and available Medicaid funds to develop methadone treatment services. There is a demonstrated need in your community for such services, and if you don’t do it, others will .”
For more information, readers should contact AMTA.
217 Broadway, Suite 304
New York, NY 10007
“Graying” of Methadone?
We have an aging population in the United States, so in addition to the many other benefits of methadone treatment, it may have created a whole generation of older, gray-haired patients in recovery. If this is true, what special needs might these older patients have?
At one time, it was generally believed that opiate addicts did not survive into old age; they either died or were incarcerated. In fact, according to Herman Joseph, Ph.D. – research scientist with the New York Office of Alcoholism and Substance Abuse Services – during the early days of methadone research in the 1960s there was an upward age limit of forty for methadone patients. At the time, there was a theory that addicts tended to mature out of addiction and that past age 40 there weren’t very many needing treatment. That age restriction, however, was wisely rescinded in the early 1970s.
According to the Substance Abuse and Mental Health Services Administration, in 1994 slightly over 11% of all methadone patients were 45 or older. However, some leaders in the field, such as Elizabeth Khuri, M.D. at Cornell Medical Center, believe the percentage is actually much higher.
At Beth Israel Medical Center, with the largest methadone treatment program in the United States – they have over 8,000 MMTP patients – a 59% majority are 40 years of age or older. Sixteen percent of all their patients are 50 years of age or older according to Patricia Friedman, M.S., Research Associate. Friedman also observed from her most current data that older patients, have on average been in treatment longer than younger patients; 48% of those aged 50 or older were in treatment 10 years or more, versus only 16% of those under age 50.
Charles Eaton, Acting Director of the Office for Drug Abuse Intervention, New York City Department of Health, observes that almost all of the research relating to older people and drug use and abuse has focused on prescription drug misuse and/or alcoholism. During the 1970s and `80s the existence of a population of opiate dependent elderly was essentially ignored and that trend continues today .
However, during the 1980s, Dr. Joseph was surprised to find a cluster of quite elderly methadone patients in New York City, dispelling the myth that addicts didn’t survive into old age. In fact, six of those he studied were born in the 1890s and a good number were born before 1915. Joseph’s findings were reported in a book coauthored by Courtwright and Des Jarlais, called Addicts Who Survived (University of Tennessee Press, Knoxville, TN, 1989).
Those interviewed for this article agreed that older MMTP patients experience many of the same medical and social problems as anyone else their age. These may include the need to take medications for heart, blood pressure, gastrointestinal, mental, and other disorders. Dr. Joseph emphasizes that elderly patients do very well on methadone, “[it] is a very safe medication with no known toxicity and no interaction with other drugs.” However, as pharmacist John St. Peter noted in our last edition of A.T. Forum [Vol IV, #2, p. 4], “There are age-related changes in drug metabolism. Some of those changes relating specifically to methadone haven’t been well defined….” Also, as newer classes of drugs are developed for geriatric disorders, there may be a need to monitor their possible interaction with methadone.
Some of our interviewees expressed concerns that the psychosocial needs of older MMTP patients may not be adequately met. Eaton points out, the problems experienced by many of these older patients are unrelated to prescribed or illicit drugs; they have difficulty maintaining a steady income, problems with transportation, physical limitations or medical problems that are worsened by age, and the like. Many need the sort of services provided by social service agencies: legal aid, help finding shelter and food, etc.
Regarding MMTP clinic counseling, Eaton believes, “The counselors and staff generally have large case loads and lack the time or expertise to work with the special problems of older patients.” Dr. Khuri concurs that there is a need for mature counselors who can understand the life changes of the older patient; younger counselors may be at a disadvantage in this regard. She feels there possibly should be specialized programs for older MMTP patients. Those patients who have been in an MMTP for some time may not need ongoing counseling and could best be served by private physicians who can also deal with their medical problems.
At this time, there seem to be more questions than answers regarding the older patient and methadone. Certainly, this is an area worthy of further research and discussion among addiction treatment professionals. Provide us your opinions on the feedback card inserted in this edition of A.T.F. or write to us. A follow-up report will appear in our next edition. (See Follow-Up: Graying of Methadone)
Straight Talk From the Editor
Four Years Old & Growing
This edition of A.T. Forum marks the beginning of our fourth year of publication, since our premier edition was launched in the summer of 1992. We’ve been encouraged by your many positive responses to this publication. A.T.F. readers may be found in all of the United States as well as a great many other countries worldwide.
We’d also like to acknowledge and thank the sponsors of this independently researched and produced publication: Mallinckrodt Chemical, Inc., St. Louis, MO. They provide ongoing funding for this project under an educational grant.
Also, Mallinckrodt deserves mention for the other support they’ve provided over the past several years to the addiction treatment community. The list of their specific commitments is long but, to be brief, they broadly include: demonstration grants, support for patient advocacy groups, assistance in fundraising efforts for individual programs, nationwide educational symposiums for professionals, and new product research and development. Their dedication to making the difference in furthering the cause of addiction treatment programs for opiate addicts seems exemplary.
Is Change Brewing on the Horizon?
Over the past few years, we’ve seen few dramatic changes in the addiction treatment field and, in particular, methadone maintenance. With the publication of two new reports from the Institute of Medicine, as reviewed in this edition and our previous edition of A.T . Forum, discussion of many critical issues may heat-up. Certainly, the agenda for the upcoming AMTA Methadone Conference is filled with opportunities to address such concerns and change may become the order of the day. But, will it be changed for the better?
We’d like your comments regarding a new issue raised in this edition – older methadone patients. Please respond to our question: What are the special needs of MMTP patients who are age 50 or older? Use the attached feedback card to list a few needs that come to mind.
As always, your other comments about our publication are most welcome and appreciated. Write or fax us at: A.T. Forum
1750 East Golf Rd., Suite 320
Schaumburg, IL 60173
Stewart B. Leavitt, Ph.D., Editor