- GPs & Methadone Achievable Dream…Or…?
- Dual Diagonsis & MMT A Chicken-Egg Enigma
- From the Editor
- Events to Note
- Case ChallengeResponse
- Methadone by Docs Not Politics
- Sites Worth Seeing
- CSAT Update
GPs & Methadone Achievable Dream… Or…?
Recently, there has been some powerful discourse promoting more widespread availability of methadone treatment for opiate addiction, especially care that might be provided by community-based GPs (general practitioners or primary care physicians).
However, despite many calls for change in the past, the status quo in MMT (methadone maintenance treatment) has persisted in the U.S. According to J. Thomas Payte, MD, Director of Drug Dependence Associates, San Antonio, TX and Chairman of ASAM’s committee on methadone treatment, “We have basically the same number of patients in treatment today as we did about ten years ago. And, I think the reason it’s not expanding is that there’s no money, there’s the stigma, and there’s resistance around every corner.”
The boxed text [Methadone by Docs Not Politics, see page 3] accompanying this article provides background on the recent drive to more extensively involve the medical community at large in methadone treatment.
After reviewing those recently published position statements and the perspectives of leaders in the field, there remain some important questions:
A.T. Forum consulted some distinguished representatives of the addiction treatment community for their opinions.
A Party Without Guests
Inviting the medical community to become more involved in treating addiction could be like throwing a party and having nobody show up. Might this happen?
Tom Payte believes that most primary care physicians would not be interested. Yet, a small number would gravitate to addiction treatment in their offices if they were provided training in that discipline.
However, according to Henry Blansfield, MD, most physicians are “addictophobic, sharing with the general public an irrational fear and loathing for addicts. This phobia has been fostered by the narcotics authorities who have limited comprehension of the medical nature of chemical dependency.” Blansfield, a former surgeon and GP, is active in addressing the social and political issues surrounding addiction treatment, especially in his home state of Connecticut.
David Smith, MD Founder & Medical Director, Haight Ashbury Free Clinic, San Francisco, and immediate past President of ASAM (American Society of Addiction Medicine) says, “The government agencies fear that untrained physicians will become ‘scrip doctors’ or mere dispensaries for medications without adequate treatment. There needs to be some way of certifying who is qualified to prescribe these drugs. We want to see the ‘medicalization’ of addiction treatment, we want more treatment capacity available, more referrals to treatment, and expanded involvement by the overall medical community.”
Our panel generally agrees that the recent call by General Barry McCaffrey, Director of ONDCP, for doctors everywhere to be allowed to prescribe methadone [see page 3] needs to be taken in a broad context. Smith believes McCaffrey was supporting increased medicalization of the field through more widespread medical and scientific involvement in addiction treatment.
“An important question becomes, ‘What is the price of admission for a physician who is going to participate in a program like this?’ Especially, considering that this is not an area of great competence within the general medical profession,” notes David Mactas, Director of CSAT
“Clearly, to make this successful and widespread, physicians outside of MMT clinics must be engaged in treatment,” he continues. “The dilemma then becomes, where will those community-based primary care physicians who are adequately trained in addiction treatment come from?”
An ASAM Policy Statement of last July [see page 3] addressed the importance of primary care physicians recognizing addiction in patients and then working with medical specialists in treating the disease, according to G. Douglas Talbott, MD, Medical Director, Talbott Recovery Campus and President of ASAM.
Talbott stresses, “We’re trying to get them to identify the disease and intervene by sending patients to specialists or appropriate centers for treatment.”
Smith agrees: “We’re not saying that general practitioners should be barred from treating addiction, a physician can become knowledgeable by studying addiction medicine, becoming ASAM certified, taking the ASAM-sponsored Medical Review Officer Course there are many ways.” He further believes that it would not be burdensome for a physician to acquire adequate knowledge of the field.
According to Mactas, there are also eleven Addiction Technology Transfer Centers serving 24 states that do curriculum development, physician training, and continuing education seminars on a local basis. These are principally university-based CSAT initiatives.
Payte notes, “the mechanics of just methadone prescribing isn’t rocket science, it can be learned in a day or so. The nuances of treating a chronic, progressive, relapsing disease comes over a longer period of time.” ASAM’s methadone treatment committee has organized a training “Course for Clinicians” that might eventually become available in a self-instructional format.
Payte proposes a first approach might involve the model being followed in Connecticut [see page 3] using existing methadone programs as hubs where patients would be stabilized and then referred-out to qualified community-based physicians. However, he believes that the extensive qualifications for these community physicians proposed by the American Methadone Treatment Association [see page 3] are somewhat unrealistic and may discourage GPs from participating.
Resistance From Specialists
Blansfield is concerned that resistance from established MMT programs and specialists could be a major stumbling block to the prescribing of methadone by GPs. “There is apprehension that this approach might result in adverse economic and employment consequences to existing MMT clinics,” he says.Payte agrees that there may be a sense of “protecting one’s turf.”
However, Payte and Blansfield also concur that, in view of the large numbers of untreated addicts, many needing desperate assistance, the role for the “program” as we know it will continue and probably be increased. The programs might even gain the added tasks of admitting and evaluating patients for appropriate levels of care, one being referrals to community-based physicians, and monitoring ongoing patient performance.
“With general practitioners on board, it can increase the percentage of the total addict population that’s in treatment,” Payte suggests. “There can be a great deal of synergism and I don’t think the programs or addiction treatment specialists need to feel threatened in any way.”
Blansfield adds, “The present treatment community would reap the rewards economically as their services grew in demand. Plus, the funding necessary for expansion would be offset by a significant savings to taxpayers as a result of decreased expenses for healthcare for drug-related illness and for marked reductions in criminal activity by addicts.”
So, where will that funding for broader addiction treatment come from? And, would GPs find their participation in the field economically worth their while? Talbott concedes that a problem today is many of the HMOs and PPOs don’t cover addiction treatment. In Smith’s experience, however, reimbursement organizations do respond to qualified addiction medicine practitioners. Knowledgeable physicians serve to legitimize the field and encourage reimbursement for their services.
“Treatment providers need to gain the trust of regulatory agencies and reimbursement organizations,” Smith proposes. “At some point, there may be an authorized provider list of those physicians who’ve demonstrated the competency to be reimbursed for their addiction treatment services.”
Blansfield says Connecticut has insisted on a parity of addiction illness with other chronic diseases and a guarantee that there will be insurance coverage for it. “Other states must insist that similar coverage be maintained over the long term.”
Still, if there’s a financial incentive for GPs, might there also be the danger of methadone “dispensing mills” popping up as they once did? “I think with accreditation and dispensing controls that won’t happen again,” Payte contends. “We’ve matured enough as a field to avoid those kinds of abuses. As one possibility, however, there might a limit on the number of methadone patients that participating GPs can have in their practices.”
Although the widespread availability of methadone treatment, provided on demand and by qualified general practitioners who are adequately compensated for their services, seems like wishful daydreaming, Smith prefers the term “visionary” “it’s not here today, but progress is being made in the right direction.”
Payte says, “What this comes down to is that, with 600,000 heroin addicts, we have 480,000 persons with untreated heroin addiction in the U.S. I predict there will be lower thresholds of entry into treatment and alternatives to ‘programs.'”
“What we’re now seeing in programs is the sickest of addicts,” he observes. “Other prospective patients will not put up with the disruption of their lives, the rigid routine, and stigma found in so many treatment programs if they can see their personal physicians.”
Of course, the whole vision hinges on a nationwide corps of private practice physicians who are ready, willing and trained to more effectively treat addiction, especially when it comes to methadone maintainence. And, it would also require secure and convenient community-based outlets (e.g., pharmacies) for dispensing the methadone, which has not been discussed here and seems far from implementation. Otherwise, this dream will never become a reality.
Dual Diagnosis & MMT A Chicken-Egg Enigma
The combination of emotional disturbances and drug abuse is commonplace, yet it can be puzzling. Often, there is the question of which came first the addiction or the mental disorder; the chicken or the egg and does it really matter?
According to Theodore G. Williams, MD Chief of Psychiatry Services, St. Joseph Hospital, Tustin, CA until recently, the mental illness and chemical dependency fields have rarely crossed paths. “Gradually, there has been a coming together of the fields, both recognizing that many emotionally disturbed persons may be suffering from both a psychiatric disorder and an alcohol and/or drug abuse or dependency problem. Hence the term ‘Dual Diagnosis,'” he wrote.
Recognizing the importance of dual diagnosis issues, the latest revision (DSM-IV) of the American Psychiatric Association’s diagnostic manual published in 1994 listed a new category of mental disorders called “substance-induced mood disorders.” This refers to depression and/or mania resulting from drug intoxication or withdrawal. But, in many cases, the connection is complex and difficult to understand from the perspective of which came first.
The Harvard Mental Health Letter observed that both types of disorders drug addiction and mood disturbances are the result of complex biological, psychological, and social influences. Drug abusers, including alcoholics, have quite high rates of depression, but it is usually unclear whether they are trying to medicate themselves for pre-existing mood disturbances or whether they are depressed because of the personal and social problems resulting from addiction.
Charles O’brien, MD, has noted that quite a variety of psychiatric disturbances typically coexist with addiction, including anxiety, psychotic and affective disorders. One possibility is that “chronic drug-taking could produce changes in the brain and in social interactions that predispose an individual to the development of psychiatric disorders.” 
Psychiatric Comorbidity Common
Speaking at the 9th Annual U.S. Psychiatric & Mental Health Congress, Kathleen Brady, MD, PhD associate professor of psychiatry at the Medical University of South Carolina observed that substance abuse occurs in 30% to 60% of patients with bipolar (e.g., manic-depressive) disorders. Further, ongoing alcohol and other drug abuse may contribute significantly to psychiatric treatment resistance and poor outcomes.
Other studies have found that 41% of persons with bipolar disorder had abused or were dependent on opiates, cocaine,
or other drugs of abuse; 46% were dependent on or abusers of alcohol. It has been noted that there is considerable overlap between drug abusers and persons with manic-depressive illness, with substance abuse masking manic and/or depressive symptoms.
A fairly recent study by Brooner and colleagues of 716 opioid abusers seeking methadone maintenance treatment (MMT) found psychiatric comorbidity in 47% of the sample (47% of women and 48% of men). Antisocial personality disorder (25.1%) and major depression (15.8%) were the most common diagnoses. The subjects were also likely to abuse other drugs besides opioids, with cocaine, reported by 43.6%, the most prevalent.
Yet another report claimed between 48% and 90% of opioid-dependent patients in treatment will have a comorbid psychiatric disorder. Among HIV-seropositive addicts, including opioid addicts in MMT, the incidence is probably higher. Depression is the most common disturbance with 80% of HIV-infected patients needing treatment for depressive symptoms while in MMT. Etiologies become complex when considering which of the three disorders might have come first addiction, HIV, or depression.
Prompt Treatment Recommended
While Williams conceded there have often been disagreements over whether the drug abuse or psychiatric disorder came first, the most enlightened approach recognizes that both must be cooperatively addressed or there will be no progress in treating either. A further complication is that alcohol and/or drug intoxication or withdrawal symptoms may mimic a psychiatric disorder (such as the appearance of psychosis in an alcoholic patient suffering delirium tremens). Williams noted that, at his facility, psychiatric consultations are standard for all patients admitted for drug or alcohol treatment.
Brady suggested that substance abuse often serves to unmask mood disorders, sometimes revealing an inherent vulnerability to depression or mania. She recommended that when manic or depressive symptoms persist for as little as 14 days beyond the resolution of an acute alcohol episode or other drug detoxification, there is often value in beginning pharmacotherapy for mania or depression.
It doesn’t seem to matter which came first: “In essence, whenever affective symptoms endure beyond the period of acute withdrawal, regardless of onset of mania or depression and substance abuse, independent treatment for a mood disorder may be indicated,” she said.
Brady’s position, based on supportive research, challenged old maxims under which clinicians often hesitated to diagnose or treat mood disorders until concurrent substance abuse was in stable remission. She stressed that the outcome for substance abuse may improve if mood disorders are more quickly diagnosed and treated in dual diagnosed patients.
Is Methadone Detox Necessary?
One question left unresolved by Williams and Brady is whether heroin addicts maintained on methadone must first be detoxed for effective psychotherapeutic treatment of coexisting mood disorders. A preliminary answer seems to be “no,” as suggested by Australian physicians writing in the January 15, 1991, The Lancet.
The authors seemingly posed another chicken-egg riddle. Alcoholics and drug abusers must receive treatment in addition to detoxification or they will relapse, they observed. However, detoxification itself discourages addicts from seeking help because they fear the physical pain and mental anguish of withdrawal. So, which should come first, detoxification or treatment; and, in the case of methadone, is detoxification really necessary?
Methadone might provide a solution in stabilizing the patient’s life and making him/her more receptive to adjunctive therapies. One of the authors, Richard Mattick, a professor at the National Drug and Alcohol Research Center at the University of New South Wales, specifically noted that opiate addicts need not be taken off methadone before undergoing other therapies.
Brooner’s group recommended that specialized therapeutic interventions are necessary in treating dual diagnosed substance abusers. “In particular, specialized psychotherapies and pharmacotherapies may be useful for depressed opioid abusers and for those with antisocial personality disorder (ASP).” The treatment of ASP, however, is most challenging and the authors suggested that methadone treatment might be an effective adjunct since it does decrease the antisocial behavior of opioid abusers.
Still, there do not seem to be any controlled clinical studies comparing the outcomes for dual diagnosed methadone patients undergoing psychiatric therapy with or without prior methadone detoxification. This seems a worthy area for future investigation.
 Williams TG. Dual diagnosis: The time has come. [Community Service Information Center, Monthly Feature Article, November 1996]. Available at: http://www.csic.com/article.html. Accessed October 1, 1997.
 Update on mood disorders-Part I. The Harvard Mental Health Letter. Reprint MTL-RP:3. [Primary reference is made to Harvard Mental Health Letter, August/September 1991.]
 O’Brien CP. A range of research-based pharmacotherapies for addiction. Science. 3 October 1997; 278:66-69.
 Goldberg J. [Reporter]. Substance abuse and bipolar disorder. Medscape. Available at: www.medscape.com/clinical/. Accessed September 12, 1997.
 Bowden CL. Update on bipolar disorder: Epidemiology, etiology, diagnosis, and prognosis. Medscape Mental Health. 1997; 2(6). Available at http://www.medscape.com. Accessed June 17, 1997.
 Brooner RK, et al. Psychiatric and substance use comorbidity among treatment-seeking opioid abusers. Arch Gen Psychiatry. 1997; 54:71-80.
 Ferrando SJ. Substance use disorders and HIV illness. The Aids Reader. 1997; 7(2):57-64.
 Detoxification doesn’t cure addicts, doctors say. The Chicago Tribune. January 16, 1997.
From the Editor
Read All About It
There was certainly much excitement late last November as a distinguished panel of scientists assembled by the National Institutes of Health concluded that heroin addiction is a medical problem that can be effectively treated if physicians are freed from restriction on the use of methadone.
Stirred by apparent winds of change, newspaper headlines around the country proclaimed sentiments such as: “Panel Urges Treatment of More Addicts” [Newsday]; “Health Panel Assails Curbs on Methadone”[Chicago Tribune]; “Heroin Addiction Called Curable: ‘Onerous’ Methadone Rules Make Doctors Leery of Treating It”[The Washington Times].
Although we were skeptical of the word “curable” used in association with an addiction, the purveyors of public opinion seemed to have their hearts in the right place, and we wondered if this invigorating outcry would actually change healthcare policy.
Of special note, the NIH panel, as had other sources earlier, pointed in the direction of primary care/general practitioners (GPs) as a likely national resource for treating addiction. To explore the feasibility of this, we consulted several experts around the country [see “GPs & Methadone” in this issue].
Double Bind of Dual Diagnosis
Examining the issues further, we found that a large percentage of addicts also present with psychological disorders that can be difficult to diagnose and challenging to treat [see “Dual Diagnosis & MMT”]. This would put GPs in the double bind of being both psychiatrists and addictionologists, and there are nagging questions about the practicality of and extent of their involvement especially in this era of managed care.
The official statements and media stories sounded a hopeful chord that maybe, finally, the U.S. would awake to the potential benefits of methadone maintenance treatment (MMT). But, when the dust had settled, we and others were wondering where the action plans were for implementing the sweeping recommendations.
In search of possible answers, we spoke with David Mactas of the Center for Substance Abuse Treatment [see “CSAT Update”]. We were impressed by his candor, as always, but disappointed with the sluggishness of government in addressing the issues.
It appears that, on all fronts, concrete action plans in response to the NIH Panel recommendations are still somewhere in the future. For many reasons, procrastination still prevails.
Methadone Survey – Round II
Optimistically assuming some forward direction is in the offing for MMT, this seems a good time to update our survey of nearly five years ago concerning methadone dosing practices of clinics around the U.S., and hopefully also include international data. If methadone is to be more widely prescribed, certainly it will be important to understand currently accepted dosage practices.
That first A.T. Forum survey, reported by us in spring/summer 1993, was very well received and an eye-opener for many patients and clinicians. So, let’s do it again.
But, WE NEED YOUR HELP. Here are the questions about your clinic’s operation:
1. The Highest typical daily methadone dose is _____ mg/d.
2. The Lowest typical daily methadone dose is _____ mg/d.
3. The Average typical daily methadone dose is _____ mg/d.
4. We operate on a __ for profit __ nonprofit basis (check one)
Be certain to include the city/state and country of your clinic.
Please provide your responses and written comments on the postage-free feedback card in this issue, OR write or fax us, OR visit our Web site to respond via e-mail. As always, your written comments will be very important for helping us explain your checked responses.
Addiction Treatment Forum
1750 East Golf Rd., Suite 320
Schaumburg, IL 60173
Stewart B. Leavitt, PhD, Editor