- Dosage Survey
- Naltrexone Nexus – Part 2
- From the Editor
- Events to Note
- Where to Get Info
- IBR Illuminates the “Black Box” of Treatment
- Clinical Concepts
Dosage Survey ’98
Changes for the Better
…that’s how the results of our latest survey on methadone dose might be characterized. Looking at a ten-year trend, increases in dose levels have been dramatic.
This past spring and summer we solicited input from readers via a response card and at our Web site regarding the methadone dosage practices at their MMTP clinics. Our 1998 survey replicated one that we conducted in spring/summer 1993.
Three questions were asked:
1. The HIGHEST typical daily methadone dose?
2. The AVERAGE typical daily dose?
3. The LOWEST typical daily dose?
We also requested the geographic locale of the clinic, so responses could be divided into regions, and whether the clinic operated on a for-profit or non-profit/public basis.
Why Focus on Dose?
At the risk of lapsing into what one reader called “number worship,” there has been long-standing concern within the MMT community regarding the dimensions of an “adequate” or “optimal” dose:
- In the 1960s, Dole and Nyswander, developers of MMT, recommended daily maintenance doses of 80 mg to 100 mg.
- More recent research by Caplehorn and Bell found that patients taking 80 mg/d or more were twice as likely to remain in treatment, compared to those taking 60 – 79 mg/d. And, those in the latter group were more than twice as likely to stay in treatment as those receiving less than 60 mg/d.
- Caplehorn, Bell and others also reported that patients maintained on only 40 mg/d were over twice as likely to use heroin as those receiving 80 mg/d. Within certain limits, there was a 2% decrease in the odds of a person using heroin for every 1 mg/d increase in daily maintenance dose.
- CSAT’s State Methadone Maintenance Treatment Guidelines, published in 1992, suggested an optimum dose for most patients would be 80 mg/d ± 20 mg.
- Data collected from MMT clinics across the U.S. by D’Aunno and Vaughn (D&V; see chart) in 1988 indicated that maintenance doses averaged only 45 mg/d and the average highest dose limit was 79 mg/d.
Hence, there have long been published recommendations and guidelines for optimum dose levels, although most clinics seemed to have strayed significantly away from them.
The purpose of our current survey was to explore the ten-year trend, comparing D&V 1988 results to our own 1993 and 1998 surveys.
Results & Observations
In 1998, there were 251 total respondents to our survey, a 24% increase over 1993 (203), although not all responded to every question. From available information, it appears nearly all respondents were clinic staff with access to accurate data, or at least in a position to report educated estimates.
There were several limitations of our surveys (see discussion in box), but some remarkable trends nonetheless (see chart below):
Methadone Dosage – 10 Year Trend
|1988 D&V1||1993 ATF||1998 ATF|
|(N; SD)||(N; SD)||(N; SD)|
|(172; 20.0)||(201; 19.6)||(247; 92.4)|
|(172; 10)||(196; 13.0)||(237; 26.2)|
* = p < 0.05 (Simple t-tests of summary data. This is the most conservative estimate, actual p values were much smaller.)
MEAN = average score (mg/d); N = Number of respondents; SD = Standard Deviation (mg/d)
1. D’Aunno T, Vaughn TE. Variations in methadone treatment practices: Results from a national study. JAMA. 1992;267(2):253-258. (Aggregated data were collected in fall 1988 from 172 randomly selected outpatient treatment units. The means reported above are averaged results combining “pure” units and “mixed” units – those with only methadone patients and those also including other treatment modalities.)
HIGHEST TYPICAL DOSE – There was a large, significant rise from 89 mg/d in 1993 to 123 mg/d in 1998. There had also been an increase from D&V 1988 (79 mg/d) to our 1993 findings, but it was not statistically significant.
AVERAGE DOSE – Over the ten years, there was a statistically significant, upward trend in average daily doses from one survey to the next, reaching 69 mg/d in 1998.
LOWEST TYPICAL DOSE – (not on chart) Of our three survey questions, this was the most confusing to readers, and D&V did not assess this question at all in their research. Our 1998 findings (27.6 mg/d) increased significantly from 1993 (21.8 mg/d). However, 1998 scores ranged from less than 5 mg/d to over 100 mg/d. For most clinics, the very lowest doses are given to patients undergoing detoxification and, since such doses are continuously changing, it seems impractical to define what is “typical.” Therefore, these data elude valid interpretation.
The ten-year 54% increase of “average dose” is encouraging. It may mean that MMT clinics are generally moving more toward optimum dose levels recommended by past research and guidelines. Subsequently, this could lead to greater patient retention rates with reduced abuses of heroin during treatment.
The problem with averages, however, is that some clinics will be much above our reported 69 mg/d and many will be below. Nearly a third of respondents in 1998 indicated a typical average dose of 80 mg/d or more. Yet close to 25% indicated average doses less than the 60 mg/d CSAT-recommended minimum optimum dose.
The 56% ten-year upward shift of “highest dose” to 123 mg/d suggests that more clinics are assessing patients’ true needs, possibly testing blood serum concentrations, and are willing to provide whatever methadone dosages are best for those particular patients. Still, there was a high degree of variability in responses to this question, especially in 1998, with reports ranging up to 900 mg/d.
The median (midpoint) was 102.0 mg/d, so the reported mean highest dose was skewed upward by some clinics reporting extremely high doses, which may not have been “typical” of a great many patients. Yet this represents forward progress, since so many clinics in the past have totally resisted such optimally high doses.
As in 1993, the 1998 results still portray broad overlaps in what various clinics consider as high versus average dose. That is, the highest typical dose at one clinic might be considered only average at another; the average doses at some clinics may be viewed as too high by others.
Although our findings suggest optimistic trends, much variation in MMT dosing practices still abounds. There are further opportunities for improvement ahead.
Coming up in the next A.T. Forum – surprising, but positive, shifts in dosage practices by region and clinic operation (for profit vs. non-profit/public), including results from outside the U.S.
Dosage Survey Limitations
A.T. Forum surveys are useful for sensing trends, but they are not promoted as being scientifically rigorous. There are several caveats for this present research:
Randomization – All A.T.F. readers were invited to respond to our survey; there was no attempt to select a random, representative sample of MMT clinics. The D’Aunno and Vaughn research did survey a random sampling of the U.S. clinic population.
Interpretation of Questions -The meanings of “typical,” “highest,” “average,” and “lowest” were not defined and may have been unclear to some respondents. This problem was detected in our 1993 survey, but, for consistency, the questions were not modified in 1998. The D’Aunno and Vaughn study overcame this limitation via telephone interviews with clinic directors and supervisors.
Data Censorship – 1998 data was not censored in any way, such as deleting extreme scores that might be considered “outliers.” This could help account for higher response variances, as depicted by larger standard deviations in 1998.
Significance – Simple t-tests were performed on summary data to detect significance levels of p < 0.05, meaning there was less than a 5% probability that the differences found from year to year were due purely to chance or random error. Actually, the significance findings were much more powerful; e.g., p < 0.0001, but we could not be certain that the probabilities were reliable at those levels.
Despite the limitations, it seems reasonable to speculate that there were similar, consistent sampling and response errors in both the 1993 and 1998 surveys. Hence, though the precision of the numbers might be questioned, the trends between our two surveys, and over the entire ten years including the D&V study, are most likely valid and reliable.
It is curious that, to our knowledge, the well-designed D&V study has not been replicated in more recent years. Certainly, such an endeavor might serve to corroborate or modify our findings.
Naltrexone Nexus – Part 2
The first part of this article introduced naltrexone, a mu opioid receptor antagonist, as a relapse prevention aid for recovering opioid addicts. This second link in the nexus considers how naltrexone and chemically-related naloxone are being used for the detoxification of narcotic-dependent persons. Hopeful optimism, along with some concerns and controversies, has surrounded this quicker way of “kicking” a narcotic habit, achieved in hours rather than days or weeks.
Speeding Withdrawal – RD
The physical and/or psychological discomforts of withdrawal have posed challenges for opioid addicts and clinicians alike. In an excellent review of the subject, Colin Brewer, MD notes that distressing symptoms often account for 25% of patients failing to complete inpatient opiate withdrawal programs, and up to 80% failing outpatient detox attempts. “Detoxification fear” deters up to a third of those wishing to become opioid-free from even trying.
Brewer observes, “In the past, heavy sedation was sometimes used to cover abrupt opiate withdrawal, but it had to be maintained for at least 3 or 4 days until the withdrawal symptoms were well past their peak.” Such extended sedation was particularly perilous during early attempts prior to the advent of intensive care techniques.
Thus, there has long been interest in making the detoxification process much faster and less unpleasant for addicts. The first reports of rapid detox attempts date back to late 19th century Hong Kong, when toxic bromide sedatives were used, unsuccessfully, to help mitigate withdrawal.
The development of naloxone and naltrexone in the early 1960s opened the door for rapid antagonist-mediated opiate detoxification (RD) techniques. These medicaments precipitate an intense, but not life-threatening, withdrawal syndrome as they displace heroin, other narcotics or methadone from the patient’s opiate receptors.[1,3]
Naloxone was used first, along with benzodiazepine sedatives and, later, the alpha-2 adrenergic agonist clonidine to ease withdrawal symptoms. In the early 1980s, researchers used longer-acting naltrexone instead of, or along with, naloxone to precipitate rapid withdrawal.
According to Herbert Kleber, MD – Professor of Psychiatry and Director, Division of Substance Abuse, Columbia University College of Physicians & Surgeons – who participated in early research developing RD techniques, the process took up to three days. Hence, a great many patients still found the approach unappealing.
Adding Anesthesia – URD
“Anesthesia takes this detox technique the next step,” Kleber notes, “because larger doses of the antagonist can be delivered more rapidly. The patient won’t feel the discomfort, and various medications to deal with side effects can be used while the person is unconscious.” Due to the rapid establishment of a complete opiate receptor blockade, patients can be continued on naltrexone immediately following the procedure as part of long-term relapse prevention therapy.
The pioneering work in this ultra-rapid antagonist-mediated opiate detox under anesthesia (URD) is credited to Loimer and associates at the University of Vienna’s Department of Psychiatry. Since 1986, when Loimer began his research, numerous refinements in URD technique have been published, largely modifications in anesthesia protocols and the pharmaceutical regimen used to control side effects.
During the first 24 to 48 hours, several adverse effects may be of concern: diarrhea, vomiting, seizures, anxiety and other psychiatric symptoms, and pain. To counter these, various combinations of clonidine, ondansetron, somatostatin, and other drugs have been used. Symptoms may persist longer, but their durations and severities have not been systematically studied.
To date, at least 10,000 opiate-dependent persons worldwide have undergone URD. Besides anecdotes of patients suffering severe side effects of URD, concerns have centered on reported deaths following the procedure, often due to overdoses of illicit opioids. However, few deaths or morbidities have been directly attributed to URD itself.[1,6,7]
Some critics have claimed that, since mortality due to uncomplicated opiate withdrawal via other means is unheard of, introducing the potential hazards of anesthesia is unjustified, and could be especially precarious for persons concurrently addicted to alcohol or benzodiazepines, or those with liver disease.[8,9] A report two years ago commissioned by the National Institute on Drug Abuse (NIDA) said URD posed an “unacceptable” risk of death and that “[the approach] is currently without ethical, medical, scientific, or financial justification.”[10,11]
However, Brewer recently claimed that mortality associated with prolonged general anesthesia affects overall 1 in 200,000 [0.0005%] patients and, although deaths associated with URD have been reported, “I think none would have occurred had patients been monitored (as is our practice) by experienced intensive care staff for 24 hours…” He further noted: “The justification for using anesthesia in detoxification is the same as for any other procedure whose unpleasantness raises barriers to treatment or causes unacceptable suffering.”
Cost is another concern. URD treatment is promoted as taking one day, with patients under anesthesia for 4 to 7 hours, and ranging in cost from $2,500  to $10,000. The higher fee usually includes daily naltrexone and a period of counseling following the procedure. Costs are currently not covered by private or public insurance, so critics assert URD is accessible only to a select group of highly motivated and financially endowed patients.
A number of commercial enterprises have ventured into the URD arena – NEURAAD, Nutmeg Intensive Rehabilitation, and CITA, to name a few. CITA (Center for Research & Treatment of Addiction) is the largest, being international in scope and also operating at six U.S. medical centers.
A number of programs have sought patent protection for their alleged proprietary URD protocols, followed by some lawsuits against rivals. This has raised the ire of many in the
addiction treatment community, as Kleber comments: “The foundation for [URD] has been laid for years by Loimer, Brewer, and others. The fact that it might now be patented in some fashion for commercial purposes seems obscene, and it’s not even clear that they’ve made any major contributions worthy of patenting.”
Where’s the Research?
Last winter, Alan Leshner, PhD, head of NIDA, stated: “I don’t know of any scientific evidence as yet establishing [URD’s] value, and NIDA is not sponsoring research on this….”
An overview article, published last January in JAMA, surveyed 31 years of RD/URD research and uncovered only 21 studies worthy of analysis. All used widely varying treatment protocols, and only one study each in the RD and URD categories fulfilled research validity requirements of having a control group, randomization, and any sort of blinding. Neither study had follow-up periods of more than eight days, and the one valid URD study had only 16 subjects.
Obviously, a qualitative meta-analysis of the 21 studies could not be performed. The authors concluded that further research was needed using more rigorous research methods, longer-term outcomes, and comparisons with other treatment methods.
Last June, CITA announced the “first long-term clinical study” of URD, claiming that 55% of 120 patients remained relapse-free after six months. NEURAAD’s Oregon-based clinic (one of seven throughout the U.S.) has promoted six-month opiate-abstinence rates of 70%, and 53% after one year.
CITA and NEURAAD, like other commercial ventures, do not publicly acknowledge drug dosages or other protocols used during their detox processes. And little is known about their therapeutic milieus following detox. So, there is no way of independently verifying the reliability or external validity of results.
Kleber believes that the lack of full disclosure, and patenting of protocols in some cases, interferes with the evaluation and advancement of URD techniques. He’s interested in doing scientifically valid research using random assignment of subjects to different detox modalities, followed by random assignment to several types of post-detox therapies. To avoid selection bias, there would be no charge to the patients.
“Addicts are unlikely to become normal, healthy persons overnight – URD is not a ‘magic bullet,'” he emphasizes. “If we say that detox is only the first step in treatment, and not treatment per se, then we need to know how to do a better job of getting people to take the second step.” Certain types of detox may make it easier, for certain patients, to take the crucial next step on the road to recovery, but research-based recommendations are lacking.
Multiple Choices in Canada
In early 1997, Toronto-based family care physicians Mark Greenberg, MD and Peter Garber, MD opened a separate office – Addiction Treatment Centers (ATC) of Canada – offering methadone maintenance treatment for some of the area’s 3,500 heroin addicts. About ten months later, they became the first in Canada to also provide URD.
“We find it a valid complement to our practice by being able to offer patients multiple options for getting off illicit opiates,” notes Greenberg. “We provide methadone maintenance, outpatient medical detox over 7 to 10 days, or rapid detox under anesthesia. [URD] is but one therapeutic modality that supplements what we are already doing – our goal is to offer the best therapy for the particular person.”
Detox isn’t for everyone, he stresses. The person best suited for detox in any form has some stability in his/her life – a place to live, a job, steady social relationships. “Some persons are first more suited for methadone maintenance to get their lives sorted out before detox. It would be unethical for me to detoxify patients, at great cost, unless I believe it will be worthwhile for them.”
ATC charges about $3,000 (USD) for the URD procedure, which is supervised in a special intensive care suite in their offices by a board-certified anesthesiologist, along with a critical care nurse. Regarding the cost, Greenberg explains, “nobody seems concerned about people getting expensive elective plastic surgery for which they pay personally. Feeding a drug habit is tremendously expensive, plus there are often large costs incurred by families of addicts for legal expenses, paying back debts and other indemnity. The cost of [URD] is a small price to pay if it will help end the cycle of ongoing financial calamity that addiction can incur.”
All patients undergoing URD are prescribed naltrexone for up to twelve months following, with caregivers enlisted to help monitor daily compliance. Greenberg believes the possibility of a long-acting, implantable naltrexone formulation offers much future promise, but it’s especially important that patients also receive long-term support via counseling, recovery groups, or other means.
How does Greenberg assess treatment success? “There is a question as to what end point or outcome should be measured,” he emphasizes. “The number actually completing any detox process is one measure, but not the most important. Unassisted, ‘cold turkey,’ detox has only a 15 – 20% completion rate; whereas all [URD] patients complete the procedure since they’re anesthetized.”
Length of opiate abstinence is an important measure, as well as retention in treatment and compliance with the naltrexone regimen. “But, there’s no end to addiction,” he concludes, “since the person might relapse at any future time no matter how far out from detox.”
As the first two articles in this series have underscored, naltrexone plays important roles in narcotic detoxification and relapse prevention. A third link – how naltrexone has become an accepted therapeutic tool for the treatment of alcohol abuse and dependency – will be discussed in the next installment of “Naltrexone Nexus.”
1. Brewer C. Ultra-rapid, antagonist-precipitated opiate detoxification under general anaesthesia or sedation. Addiction Biol. 1997; 2:291-302.
2. MacLeod, N. Morphine habit of long standing cured by bromide poisoning. BMJ. 1897;i:76-77 and MacLeod N. Cure of morphine, chloral and cocaine habits by sodium bromide. BMJ. 1899;i:896-898.
3. Experts debate merits of 1-day opiate detoxification under anesthesia. JAMA. 1997; 277(5):363.
4. Loimer N, Schmid R, Presslich O, Lenz K. Continuous naloxone administration suppresses opiate withdrawal symptoms in human opiate addicts during detoxification treatment. J Psychiatric Res. 1988;23:81-86.
5. Brewer C. Opiate detoxification under anaesthesia: Enthusiasm must be tempered with caution and scientific scrutiny. BMJ. 1997;315:1249-1250. Editorial.
6. Personal communication, Andrew Byrne, MD, Redfern, NSW, Australia; June 20, 1998.
7. Miotto K, McCann MJ, Rawson RA, Ling W. Overdose, suicide attempts and death among a cohort of naltrexone-treated opioid addicts. Drug & Alcohol Dependence. 1997;45:131-134.
8. Farrell M. Opiate withdrawal. Addiction. 1994;89:1471-1475.
9. Strang J, Bearn J, Gossop M. Anesthesia assisted detox questioned. BMJ. 1997;7118(315). Editorial.
10. Janoff L. How good is ER’s Rx? Time. 1998(1 June);151(21):74.
11. Clary M. Is there really a painless way to get off heroin? Los Angeles Times – Orange County Edition. July 3, 1997.
12. Brewer C. Opiate detoxification under anaesthesia. BMJ. 1998;316:1983. Letter.
13. Study shows good six-month results for rapid opiate detox. Alcoholism & Drug Abuse Weekly. 1998 (June 15);10(24).
14. Scott G. Controversial heroin detox under attack. The Star-Ledger (Newark, NJ). January 12, 1997:25.
15. Managing heroin addiction: a look at the options. Behav Health Management. 1998; (January/February):44.
16. O’Connor PG, Kosten TR. Rapid and ultrarapid opioid detoxification techniques. JAMA. 1998;279:229-234.
17. Neuraad Rapid Heroin Detox in Tampa. PR Newswire report, March 20, 1998.
From the Editor
Drunken Flies, Cheap Dates & Addiction Research
This edition features several articles pleading the case for more and better research on addiction. Yet, as Albert Einstein is rumored to have said: “Not everything that counts can be counted; and not everything that can be counted counts.”
Investigators in California seeking insights into the genetics of human alcoholism have found a gene, which they nicknamed “cheap date,” that makes it easier for fruit flies to get drunk.
As reported in the June 1998 edition of the scientific journal Cell, the cheap date bugs stumble and stagger around erratically and eventually pass out when exposed to alcohol vapor. Tests showed the pests could attain an alcohol level as high as 0.2%, twice the legal limit for driving in most countries.
The lead researcher, Ulrike Heberlein, conceded this basic laboratory research may sound frivolous, but she claimed fruit flies and humans have similar reactions to alcohol. So, maybe a comparable gene affects people’s sensitivities to booze.
At the more applied end of the research spectrum, D. Dwayne Simpson, PhD [interviewed in this edition] argues that when it comes to the sometimes enigmatic “black box” of addiction treatment, many very practical developments have been accounted for. Now, if decision-makers will only attend to the positive results.
“We’re still a step away from everything the public and the politicians want to hear,” Simpson told us, “but what we have measured is enough to establish the credibility of addiction treatment.”
Indeed, as Thomas McLellan, PhD and associates reported at a forum of the newly formed Physician Leadership on National Drug Policy (PLNDP), research shows that drug dependence meets all the criteria for a treatable, chronic medical condition and is as consistently diagnosable as other illnesses. The genetic influences for addiction are comparable to those of chronic hypertension, diabetes, and asthma.
Furthermore, addiction treatment has patient compliance rates and outcome successes as good as for those other chronic conditions. But, surprisingly, needs for added treatment within a year are actually lower following addiction treatment than for the other disorders.
Still, there is much uncharted territory in the addiction field. One procedure sorely needing further investigation is ultra-rapid opioid detoxification under anesthesia [discussed in this issue]. Although it is being selectively used in clinics worldwide, there is today a lack of solid research validating its safety and efficacy. If ever anything needed counting – that is, better scientific assessment – this is it.
Reader Survey – Where’s theResearch?
Certainly, there are many addiction treatment challenges worthy of further investigation, although there are always limited funds for research. Where do YOU think more research funds should be spent?
Here are some selections to get you started, but feel free to list your own preference under “other.” Make only one choice:
- Defining hereditary influences.
- Evaluating better detox methods.
- Improving counseling techniques.
- Expanding uses of maintenance drugs (besides methadone and LAAM).
- Other: (specify) _________________.
There are several ways for you to reply: A. Provide your answers on the postage-free feedback card in this issue; B. Write or fax us [see info below]; or C. Visit our Web site to respond online. As always, your written comments will help us better discuss the results in our next issue.
- Stewart B. Leavitt, PhD, Editor
- Addiction Treatment Forum
- 1750 East Golf Rd., Suite 320
- Schaumburg, IL 60173
- FAX: 847-413-0526
- Internet: http://www.atforum.com
Events to Note
- For additional postings & information, see: www.atforum.com
- OCTOBER 1998
- 12th Annual National Meeting on Alcohol, Other Drug & Violence Prevention in Higher Education
- October 15-18, 1998
- Washington, DC
- Sponsor: US Department of Education
- Contact: 800-676-1730
- Web Site: www.edc.org/hec/natl/1998
- Review Course in Addiction Medicine
- October 22-24
- Chicago, IL
- Sponsor: ASAM
- Contact: 301-656-3920
- Web Site: www.asam.org
- United States Conference on AIDS
- October 29 – November 1
- Dallas, TX
- Contact: 202-483-6622 x317
- E-mail: email@example.com
- NOVEMBER 1998
- Association for Medical Education & Research in Substance Abuse
- (AMERSA) Conference
- November 5-7
- Washington, DC
- Contact: 401-785-8263
- E-mail: AMERSA@caas.caas.biomed.brown.edu
- American Public Health Assn. 126th Annual Mtg. & Expo.
- November 15-18
- Washington, DC
- Contact: 202-789-5660
- Second Annual National Managed Health Care Congress
- November 16-19
- Los Angeles, CA
- Contact: 888-882-2500
- E-mail: firstname.lastname@example.org
- DECEMBER 1998
- National Leadership Forum VIII
- December 2-5
- Washington, DC
- Sponsor: Community Anti-Drug Coalitions of America
- Contact: 703-706-0560 x231
- E-mail: Ronald_Dixon@msn.com
- [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]
Where to Get Info
Wandering The Web
- If you could only bookmark one Web site to help find everything you ever wanted to know about addiction, this would be it: www.danya.com/metaview.htm.
- Here you’ll find links to over 300 sites, featuring addiction information ranging from community coalitions to workplace issues; 18 different broad subject categories in all. Plus, there are fact sheets and a handy connection to master search engines, such as AltaVista, for finding any other particular topic of interest on the Web.
- This site was assembled by Danya International, Inc., of Silver Spring, MD. The firm was founded over 18 months ago by Jeffrey Hoffman, PhD to manage human services programs, conduct social research and evaluation, and develop innovative products in the healthcare field.
- Among other projects, Danya manages OATIP (Opioid Addiction Treatment Improvement Project), funded by CSAT, and under a NIDA grant has produced “Living in Balance” – a
- substance abuse treatment and relapse prevention manual and videos for cocaine and other drug abuse. Busy folks. To learn more, call them at 301/565-2142 or visit www.danya.com.
- Plug Into Payte
- Finally, you can visit J. Thomas Payte, MD at his new Web site: http://home.swbell.net/jtpayte.
- Get the latest scoop on the Journal of Maintenance in the Addictions, which he edits. Plus, there’s a collection of useful forms and letters that Payte has developed during his 30-plus years of addiction medicine practice.
- A “To whom it may concern…” letter is intended for family or other interested parties, explaining the benefits of methadone treatment. Another missive responds to a threat that a patient must “detox” or be involuntarily withdrawn from methadone. Finally, there is his classic “Dear Doctor” letter that patients can take to their healthcare providers, explaining what MMT is about and how the patient should be fairly treated.
- This site is still a work in progress, so we’re also looking forward to future treats Payte is stirring up in his computer.
IBR Illuminates the “Black Box” of Treatment
When the Institute for Behavioral Research (IBR) was founded 35 years ago by psychologist Saul (S.B.) Sells at Texas Christian University, Fort Worth, TX, the notion of having community-based addiction treatment clinics, possibly staffed with recovering addicts, was a new and questionable concept.
How well might that modality, which we take for granted today, work? What would happen during treatment to make it work?
Studies Cover 30 Years
Spanning from the late 1960s to the present, IBR has been involved in three consecutive, but overlapping, nationwide, government-funded research studies seeking to measure addiction treatment processes and outcomes. They are known by the acronyms DARP (Drug Abuse Reporting Program), TOPS (Treatment Outcome Prospective Study), and DATOS (Drug Abuse Treatment Outcome Study). Another project, DATAR (Drug Abuse Treatment Assessment and Research), has focused on opioid addicts entering outpatient methadone programs since 1989.
Initially, addiction treatment centers were like “black boxes.” Patients would go in, and they’d come out usually better than before. But just what happened inside those boxes to make a difference was largely a mystery.
With a staff of 30, “IBR’s strategy has been to evaluate treatment as delivered in the real world,” says D. Dwayne Simpson, PhD, who joined the team in 1970 and became Director in 1982. “We then seek to use those findings to help make the case that treatment works.”
There were 150 research publications coming out of the DARP study alone, convincing opinion leaders and legislators that treatment does work. And Simpson believes that IBR’s research over the years has been instrumental in keeping supportive funding coming into the field.
Unfortunately, every new generation of policy-makers has needed reminding that treatment works. So, Simpson observes, “every ten years we’ve had to launch another large-scale, flagship study reiterating what is happening in the real world of addiction treatment.”
IBR’s studies have revealed important treatment concepts that many in the field take for granted today:
- “Length of stay in treatment has been one of the most consistent predictors of treatment success,” according to Simpson. “For example, patients who stay in outpatient methadone treatment for at least a year are five times more likely to have favorable outcomes in terms of drug use and criminality.”
- A major factor affecting retention is higher program participation as measured by counseling session attendance, which is facilitated by positive therapeutic relationships with the staff.
- One technique found to work well is “contingency management” – essentially, offering patients small, tangible rewards for such performance as counseling attendance or drug-free urine screens. They need not be costly and can be as simple as stars on a chart posted prominently in the clinic. Simpson acknowledges, however, that an extremely small percentage of clinics use such techniques.
Many of IBR’s findings may not seem new, since they’ve been practiced by better clinics and counselors for some time. “But discovering just what goes on in that ‘black box’ and demonstrating these effects empirically, establishing their scientific credibility, is an important part of what we do,” Simpson notes.
Methadone Just Medicine
IBR’s findings support the advisability, and help justify the costs, of patients staying in methadone treatment for a longer period of time. “Most methadone maintenance treatment programs say that patients should stay in treatment for at least two years. The problem is that many patients don’t do that,” Simpson claims. “Some programs have as few as 16% of patients staying a year or longer.”
His studies indicate that for most drug addictions, if patients aren’t in therapeutic treatment for at least three months, it’s as if they were never in treatment at all. For methadone patients, a minimum of one year is needed. In any case, the first few months are critical for establishing compliance with treatment recommendations.
He further emphasizes that methadone is just a medication, it isn’t therapy. And once methadone doses reach an adequate level for each patient, the dose itself ceases to be a predictor of treatment success.
Benefits to the Field
IBR has an extensive Web site at <www.ibr.tcu.edu> as a resource for practitioners. Researchers will be most interested in study abstracts and a selection of patient assessment instruments.
For counselors, proven treatment interventions have been assembled into a series of manuals. These include separate focuses on men’s and women’s issues, HIV/AIDS education, a new manual addressing cocaine, and a monopoly-type board game for entering patients called “downward spiral.”
The manuals are listed at the IBR Web site and are available for purchase from Lighthouse Productions (<www.chestnut.org/pub.html>; phone: 309/827-6026). Prices range from $15 to $19, plus shipping and handling.
“I’ve always had a great appreciation for counselors who do front-line work in the field,” Simpson says. “We want to continue to do whatever we can to simplify their jobs and help improve the effectiveness of what they do.”
The plan is for IBR to continue to do process evaluation research that demonstrates treatment effectiveness, and to communicate interventions that work to counselors.
The Challenge of Funding Value-Added Programs
Three years ago, the El Rincon Community Clinic – a 25-year-old Methadone Maintenance Treatment Program serving Chicago’s inner-city Westown neighborhood – was overcoming an outbreak of multi-drug resistant tuberculosis among patients and staff [see A.T. Forum Vol. IV, #3, Fall 1995]. Today, with TB controlled by better patient screening and medical treatment, along with facility improvements, the mostly Hispanic clinic population has increased by two-thirds to 450 patients.
However, with nearly all being injection drug users, over a quarter of patients are already documented as having HIV, with another 20% to 40% expected to testseropositive. So, adding further treatment enhancements is a priority.
At the start of 1998, El Rincon emerged from a five-year strategic plan to purchase their facility – an old warehouse building that was difficult to maintain – and completely refurbish it. “We learned long ago that patients behave differently if you treat them with respect,” note Directors Paul Buchholz, ACSW, and Rafael Rios, “and one way of doing that is to provide a clean, safe environment in which they receive treatment.”
But a major question was how to further develop and add value to El Rincon programs without sufficient funding?
Partnering for Service
The answer was in El Rincon’s model of organizational development, based on the bicultural partnership of the Directors and their combined strengths. Plus alliances with other organizations that have their own funding to serve the needs of the community.
“We provide them needy patients, office space and whatever support possible at our facility,” Buchholz explains. “They include our patient population in their grants, and provide services at no charge to us.” El Rincon has this arrangement with up to six organizations, depending on the time of year.
For example, a local family health services group and an AIDS foundation provide primary and secondary health care and HIV/AIDS case management and education.
“It’s an everybody wins situation,” Rios believes. “El Rincon patients receive a broader range of services in already familiar surroundings, without the need to travel to other clinics. Meanwhile, the partnering organizations gain access to patients for fulfilling their service missions.”
One downside, Buchholz concedes, is that his clinic doesn’t receive an administration fee for many services provided by outside groups. “So, it’s been necessary to invest, at no charge, some of our staff time in order to facilitate those partnerships. On the other hand, our services to patients are considerably enhanced, so we gladly do it.”
Another partnership for El Rincon is with a local university research project seeking to locate Hispanic women at high risk of HIV. Patients are paid a small fee to be tested, and it helps the community by detecting and treating new HIV cases. A pharmaceutical company is also researching a new patient education program and treatment modality with those patients, thus bringing some added funding and enhanced services to El Rincon.
Meanwhile, Buchholz is still busy submitting grant applications for funding to develop more extensive internal programs of their own. The clinic is also recruiting volunteer
services of a fund-raiser to help garner support from private charities and corporations.
He notes that El Rincon survived its first 25 years essentially on a single grant from the state Department of Alcohol and Substance Abuse. “In the long run, however, that doesn’t build a viable organization. It’s a matter of year-to-year survival.”
“Flexible endowments, going beyond dedicated-purpose grants or per-patient allowances, may permit us to grow programs in ways that public funding sources are reluctant to support,” Rios explains. “For example, providing improved benefits for our staff. It’s all part of a diversification strategy to become a value-added, comprehensive treatment service.”
Buchholz prefers to call the organization a “Narcotic Treatment Program (NTP),” rather than MMT, because he believes the day is near when methadone will be but one of many addiction treatment medications that could be offered. “We need to think of ourselves as potentially much more than just methadone dispensing facilities.”
Ongoing community involvement is another important issue, and the clinic is very active in local health fairs and festivals. Greater outreach hasn’t been possible in the past, due to insufficient resources and limited patient capacity.
“El Rincon has been the community gatekeeper here for a quarter century; it’s a place of opportunity when it comes to narcotic treatment matters,” Rios says. “Now, our mission also includes HIV because of risky lifestyles, and those won’t improve in our community if people aren’t sober enough to do anything about them.”
“Our future goal is to be even more integrated into the community, with a full menu of core on-site services to meet any needs that are injection drug abuse related,” Rio continues. “And we will continue to enhance outpatient services and aftercare for alcohol and cocaine abuse.”
The existing clinic will be at full capacity within five years. “Then we’ll be taking a close look at community needs and design our strategy around those needs. We want to bring drug treatment solutions as close to the problems as possible,” Buchholz comments.
He concludes that there are multiple client constituencies served by a community NTP clinic: “As a Director, my client is the organization, whereas the counselor’s client is the individual. But the organizational client is the whole community, and we need to be flexible in meeting all of the different needs as they apply to the local culture and subcultures.”