- Changing Roles for MMT Clinics
- Clinical Concepts
- From the Editor
- Events to Note
- Where to Get Info
- Hepatitus C- Health Crisis of the Century
- Readers Survey – Docs Rxing Methadone
Changing Roles for MMT Clinics
Change is inevitable. Progress can seem painfully slow.
“Patients with good treatment compliance records, no illicit drug use, and steady employment should be able to receive methadone from private physicians.” That’s essentially what over 83% of those responding to an A.T. Forum survey in Fall 1996 (Vol.V, #3) said about “medical methadone maintenance.” Pilot programs previously testing the concept had good success, but the approach was never expanded.
The concept of private practice doctors prescribing methadone was raised again on these pages over a year ago (Winter 1998, Vol.VII, #1). It was noted that the number of patients in methadone treatment had long been stagnant up to that time, and there was resistance to growth from many directions, especially due to stigma and lack of funding.
Meanwhile, MMT patients with many years of successful abstinence from street drugs have voiced concerns about a treatment system that still seems poorly designed to meet their needs. (See feedback briefs on page 3.)
Broadening the Field
As if responding to those patients’ pleas, in September 1997, General Barry McCaffrey, Director of the U.S. Office of National Drug Control Policy (ONDCP), asserted that doctors everywhere should be allowed to prescribe methadone to help fight heroin addiction more widely. He criticized existing policies that allowed treatment only at special clinics.
Exactly a year later at the American Methadone Treatment Association Conference in September 1998, as noted in the last edition of A.T. Forum (Winter 1999; Vol.VIII, #1), McCaffrey issued a similar edict: “treatment must be provided in all settings in which drug abuse occurs – at inner-city clinics and in suburban doctors’ offices alike.”
Despite such well-intended interest in broadening methadone treatment, progress in that direction has been cautious. And there is still the question of what might happen to traditional MMT program clinics when changes are made.
The Connecticut Connection
A model of what the future may hold could be slowly taking shape in Connecticut.
The Connecticut General Assembly passed a comprehensive drug policy bill in 1997 authorizing a pilot program to study methadone maintenance delivered in private physicians’ offices – called “physician’s office-based methadone maintenance” or POM.
By February 1999, an Advisory Committee – composed of critical state agency, private physician, patient, provider, and federal representatives – completed extensive preliminary work and the POM study was getting underway, according to Thomas A. Kirk, Jr., PhD, Deputy Commissioner, and Sam Segal, LPC, LADC, Senior Clinical Policy Advisor, Office of the Commissioner, Connecticut Department of Mental Health and Addiction Services (DMHAS).
DMHAS is funding the service aspect of the initiative, while the federal Center for Substance Abuse Treatment (CSAT) supports the evaluation and physician training components. Kirk stresses that CSAT has been very helpful and he expects the agency’s future policy decisions may be influenced by the findings.
The POM study involves two groups of 30 patients each from the Waterbury, CT facility of Connecticut Counseling Centers, Inc. (CCCI), a private, not-for-profit behavioral health agency, including an MMT clinic. Patients who volunteered were randomly assigned to either a control group receiving clinic treatment as usual or an experimental group receiving treatment at one of seven participating office-based physicians.
Patients report to either the clinic or doctor’s office weekly for methadone. The clinic delivers the necessary methadone to the doctors’ offices.
Segal notes the selected patients had at least a year in treatment, free of illicit drugs, and were already receiving some level of take-home methadone doses. Those with significant histories of unstable psychiatric or medical conditions were excluded.
Outcome measures will include: any illicit drug use; patient satisfaction; provider satisfaction; and retention in treatment. This research study, expected to last six months, is being administered by the departments of Internal Medicine and Psychiatry of the Yale University School of Medicine.
The Connecticut POM study took a long time to develop. But, Kirk stresses that to have the study fail due to some unexplained technical difficulties would undeservedly scuttle the whole project. He expects to submit preliminary results to the state legislature by this June and hopes there will be scientifically valid, favorable results so it can be extended and eventually expanded.
Clinic’s Perspective
According to Kirk, “We all agreed that we don’t see this approach as a replacement for methadone clinics. It’s for those patients that are truly stabilized and a way to ease some of the pressure on clinics.”
In Connecticut, which has eighteen MMT programs, it was estimated that up to 25% of patients might eventually qualify for POM programs. Segal estimates, however, that there are plenty of prospective patients who could come into treatment, more than filling the gap.
Michael Freeman, MS, LADC, Program Director at CCCI, Waterbury (which is participating in the study) agrees that such programs would probably not reduce their case loads. Growth has been exceptional at the clinic, going from 150 to 650 patients in but a few years, with plans to exceed 750.
However, Freeman emphasizes that their resource utilization management and levels of care approaches can deal with a changeable patient census. “We can staff according to patient needs [and] will continue to provide methadone treatment on demand.”
CCCI offers an outstanding range of comprehensive services, including family counseling, relapse prevention, pregnant addict care, and major programs dealing with HIV/AIDS, TB, and hepatitis. Freeman observes, “We have the expertise and the services that patients need, especially during early stages of recovery. A private physician couldn’t provide all of those.”
Richard (Rico) Bilangi, MS, President and Executive Director of CCCI, acknowledges that patients who’ve been successful in MMT for a number of years and have been achieving treatment plan goals could benefit from being removed from the traditional clinic environment. Essentially, he believes, the Connecticut POM model is a form of medication management, allowing patients to legally access methadone in a controlled setting outside the clinic.
However, Bilangi continues, such settings could be satellites of the MMT clinic, much like a private doctor’s office, but focusing exclusively on advanced patients. “I don’t think patients necessarily have to be treated by physicians outside of the addiction treatment system.”
Furthermore, he cautions, “One of the worst things that could happen is private physicians becoming involved in this having negative attitudes perpetuating the stigma of methadone or, worse yet, have a philosophy of detoxing patients as soon as possible.”
Physician’s Perspective
Kirk notes it was felt that patients should be integrated into the physicians’ regular practices. There was also a sensitivity to the needs and rights of patients: they should have choices in the physicians delivering their care, and be able to change doctors or return to the clinic if desired.
The POM model requires that participating physicians be affiliated with the core clinic, and the patient remaining registered at that clinic. Kirk does not expect any future movement toward either the patients or physicians being entirely separated from a methadone clinic.
He says physicians were very interested in the approach and in participating in the POM study. A mix of doctors with and without prior addiction treatment experience was selected, and they attended two four-hour training sessions.
Peter O. Rostenberg, MD, FASAM, a primary care physician, is one of those participating. He believes a great many doctors would be interested in methadone treatment. “Doctors like to take care of patients,” he says, “and opioid medications, including methadone, aren’t that complicated.”
He doesn’t see the POM approach entirely taking the place of MMT clinics, but patients should receive the level of care that they need. “Generally, it is most intense at the beginning of methadone treatment; then, at later stages, lower-cost step-down treatment should be available.”
Rostenberg, who is the New England Regional Director of ASAM, believes too much of the Connecticut state budget is being spent on the medical, legal, and social consequences of too little substance abuse treatment. “Our efforts have been directed toward providing more treatment and especially more efficient substance abuse treatment. The POM study grew out of those endeavors.”
“MMT clinics are like ‘intensive care units’ and patients should have the hope of step-down treatment that doesn’t exist today at many clinics,” he says. The clinics are cost-efficient when patients are sick and need a lot of services, but many patients do get better and no longer need the clinic structure and wrap-around services.
Rostenberg doesn’t view treating methadone patients as a way to expand his income. Rather, he insists, “I see this as a personally gratifying, but not financially enriching, part of my practice.”
He also downplays the amount of training a private physician might need, at least under the POM type of program. “These are stable patients, ‘good citizens’ whose behavior has been closely scrutinized, plus doctors will have back-up support from the clinics if and as necessary.” So, the expertise of the clinic staff could play an ongoing vital role, but he says, “We have to learn what the ongoing relationship between the primary care doctor and the MMT clinic needs to be.”
Scaled Reimbursement
For the Connecticut study, the providers – clinic (CCCI) and physicians – were guaranteed that they would be compensated for any lost revenues. Kirk doesn’t anticipate there will be any significant charge-backs. However, there may be some future changes in how addiction treatment providers are compensated.
According to Kirk, Connecticut currently pays MMT clinics the same for patients at any stage of treatment, whether entry level or more advanced. He hopes to review that policy with an eye toward paying more when the patient needs intensive and comprehensive care and services, and less at later stages of ongoing maintenance.
If that happens, it would greatly encourage clinics to release their stable patients to outside care providers. He realizes this is a sensitive issue, but it seems that development of the POM approach could make it practical and to the benefits of both clinics and patients.
Rostenberg agrees that payments for services should be stepped down in accordance with less care needed by patients. “There are plenty of new patients who could come into methadone treatment,” he asserts, “but some clinics may not appreciate that fact.”
Bilangi says it is understandable that a clinic would receive less reimbursement for offering a lower level of services. “For me this is not a money issue, or one of not having enough patients. We treat over 800 patients at our two clinics.” However, he recognizes there are many smaller, private programs around the country that might feel financially pinched by a scaled reimbursement approach.
Nationwide Roll-out?
For a long time there has been interest in ways to expand methadone treatment, including medical maintenance experiments in New York City and Maryland. Last January, there were news reports that, due to a spate of heroin-related problems, Washington State was considering legislation allowing doctors to provide methadone treatment. Other states are also considering their options.
Kirk says his office has received a number of inquiries about the POM program, and his office has been cooperating in providing information. Although the program seems simple in concept, there was a long, tortuous path to its inception. “We had to consider all of the ‘If this happens, what will be done?’ kinds of questions,” he recalls.
Kirk also notes that the Connecticut legislature specifically did not restrict the POM approach to methadone, but emphasized opiate substitution therapy. This could open the door for other “medication-assisted drug treatment.” He says, “My opinion is that the emphasis on methadone, and only methadone, is not in the best interests of the field and only tends to reinforce the stigma.”
Rostenberg believes that if the Connecticut approach works it could quickly spread around the country. “It is both more humane and less costly,” he affirms.
The final result may be MMT clinics doing more of what they do best today, doing it better and more cost-efficiently, using a variety of medications, and sharing responsibilities with outside medical practitioners. Time will tell.
Patients Want Better Options
Alternative System Needed
“I am a four-year methadone patient with experience in 3 different clinics. I’ve been waiting for the day when there is an alternative to the current ‘clinic system’ of treatment.”
“The priority of minimizing so-called ‘diversion’ has imposed hardships on staff and patients alike. . It’s sad that after nearly 30 years this incredibly effective treatment option reaches less than 20% of the people in need. What’s even sadder is the number of ex-methadone patients opting for a drugging lifestyle because they can’t tolerate the callous, degrading ‘treatment’ provided under the present system.”
Medical Maintenance Misgivings
“I have been on methadone for 20 years with no setbacks or slipups. For those of us that have been on Medical Maintenance programs (28-day take-homes) there is still the feeling of ‘punishment’ attached to being on methadone. We are still forced to travel to a doctor who could be a distance from where we live or work, sometimes losing a half-day’s pay to pick up our medication. When will this ever change?”
“If I want to relocate, or merely spend winter months away in a warm climate, it is impractical to return every 28 days for medication. I would end up back at a clinic.”
“We should be able to pick up our medication at a pharmacy just as a person with diabetes picks up insulin. And at any pharmacy in the country.”
Forced to Detox
“After 13 years on methadone maintenance and two blessed years on medical maintenance, I was forced to decide to detox from methadone. I needed to move from New York City to an area lacking medical maintenance services and I refused to return to a clinic. I have experienced 9 different methadone programs in 3 states. Despite their public or private status, each delivered the same doses of humiliation along with the methadone.”
“Many individuals such as myself find themselves ‘out in the cold.’ What kind of special training is needed to prescribe methadone? If physicians are competent to prescribe opiates at all, they are competent to add methadone to the list of their prescriptions.”
Drug Use a Medical Problem
“I have been on a methadone maintenance treatment program for a number of years and I have only good things to say about this treatment. If it wasn’t for methadone I would either be in prison or dead.”
“[However] the government and states have been a dismal failure everything they do is geared toward punishment of the user. It’s time that they realize that drug use is a medical problem and start allowing the doctors and other medical professionals to handle this problem. There has to be a better way.”
Clinical Concepts
Methadone Induction; A Safety First Approach
There have been concerns over the years about reported patient deaths during the first few days to two weeks after starting methadone treatment. This is the induction phase, a start-up period designed to bring the dose of methadone to an adequate level, eliminating or greatly reducing drug craving and preventing the onset of withdrawal sickness (abstinence syndrome) for more than 24 hours.
The goal is to accomplish induction quickly, but safely.
Patient Responsibility
According to J. Thomas Payte, MD – Medical Director, Drug Dependence Associates, San Antonio, Texas and Chairman of ASAM’s Committee on Methadone Maintenance – about 80% of deaths in some reports were due to mixed drug overdose, not solely attributed to methadone. But, that still leaves 20% of deaths possibly due to methadone intoxication.
In one reported case, Payte recalls, there was a relatively modest methadone induction schedule of 35 to 40 mg/day, with patient death occurring on about the fifth day. The postmortem methadone blood level was 1800 ng/ml, over four times greater than a normal full maintenance level, and incredibly high given the conservative induction doses. All of the facts are not known, but Payte surmises the person most likely supplemented the clinic dose with methadone from other sources.
This raises a basic question: What responsibility rests with the patient versus the clinic?
Patients sometimes misrepresent or distort their medical histories to obtain higher doses, thinking that is what they need to feel better. At Payte’s clinic, staff use a checklist of signs and symptoms of methadone over- and under-medication. Admittedly, however, this can be less meaningful when patients are determined to deceive the observers.
In Payte’s experience, patients have even found ways to project false physical signs of abstinence syndrome. For example, ophthalmic solutions can be used to keep pupils dilated. The unwary examining physician may believe the patient has more opioid tolerance than is actually the case.
Clinic Accountability
Payte does concede, however, that there have been egregious instances of methadone being misprescribed. For example, there was a patient who died after receiving 80 mg of methadone during each of the first three days. The patient had no history of opioid tolerance or objective signs of withdrawal noted on his medical records. “Fortunately, such occurrences are rare, but they shouldn’t happen at all,” he says.
Payte cautions that, unless the patient’s history is well-known, it is somewhat easy to be misled. There is a strong need to document objective evidence of existing opioid dependence. He mentions there is increased interest in using the naloxone (Narcan) challenge test whenever there may be doubts about such dependence. The patient is injected with small amounts of the opioid antagonist and monitored for signs and symptoms of abstinence syndrome.
A key is to spend the time to carefully examine the patient with a defensive outlook, so the physician is not misled. If the induction dose is too conservative, the patient will feel quite ill, with drug cravings, and may continue to use illicit drugs. Being overly liberal at first runs the risk of hazardous methadone build-up in the first few days, leading to possible overdose. It is more practical and safe to increase the dose gradually with careful observation of patients for persistent signs of withdrawal.
Slow, Steady Stabilization
Understanding the pharmacokinetics of methadone is important for safe induction. Some physicians falsely believe it takes only an hour for a dose of methadone to take full effect, Payte says. However, it actually takes about three hours for methadone to reach a peak blood level, so giving add-on doses earlier than that to treat abstinence symptoms could lead to dangerously high initial levels.
Most pharmacology texts indicate it takes 4-5 half-lives of any medication to achieve a steady state, which should take about 5 days for methadone (with a long half-life of 24-36 hrs). But Payte observes, “We’re finding that it takes 8 to 10 days, with the greater part of the accumulation beginning about the third day.”
Even after the dose is stabilized and held constant, blood levels of methadone will continue to rise for several days before achieving a steady state, he cautions.
Payte suggests that rapid induction procedures, seeking to accelerate the attainment of steady state levels, could be hazardous. And it must be considered that certain physical conditions and medications may impact methadone metabolism. For example, phenytoin, rifampin, or carbamazepine may lower plasma levels and decrease methadone effects, while others – cimetidine, fluvoxamine, ketoconazole – could increase plasma levels and methadone effects. (See A.T. Forum Vol. VII, #2 – Spring 1997 for a list of interacting medications.)
Phases of Induction
There are several phases of methadone induction leading up to the full maintenance dose. Similar to other guidelines (such as CSAT’s State Methadone Maintenance Treatment Guidelines, 1992), Payte recommends a conservative approach with an initial safe methadone dose of 30 mg or less. An additional 5-10 mg could be prescribed after a few hours, but no more than 40 mg total the first day. A patient might be given 5mg increases based on subjective symptom reports, but for 10mg there should be more objective physical signs. [See chart.]
Payte believes it is important to see patients 2 to 4 hours after observed dosing to gauge their responses during the first several days. The concern is that a patient may get too much methadone, go home and nod out for most of the day, then seem okay by the next morning.
Yet, the patient might still complain about not being able to sleep and other symptoms, so the dose is increased. Over time, this could lead to overdose.
Payte stresses that the severity of the person’s withdrawal is not a good indicator of tolerance, nor are prior dose levels of opioids (including methadone). A person can be very sick withdrawing from a relatively small daily dosing habit of heroin or another opioid.
Patient Education Important
At Drug Dependence Associates, a handout for patients and their “significant others” provides a thorough explanation of the methadone induction process. Patients are also required to complete an assessment form describing symptoms during the first 8 days, and this becomes part of their medical records.
A portion of the handout warns of overdose signs and advises what to do. Patients and significant others are cautioned that any degree of drowsiness or lethargy could be a serious sign of over-medication and the patient should never just sleep it off.
Another part, written for patients in no-nonsense language, is called “Death penalty for lying or, how to die in less than a week.” It strongly warns patients about the potentially dire consequences of misrepresenting the extent of their opioid habits and withdrawal symptoms, or taking supplemental drugs.
Phases of Methadone Dosing
| Phase | Objective | Range in mg (comments) |
| Initial Does | Relieve withdrawal (abstinence)symptoms | 15-30 mg |
| Early Reduction | Reach tolerance level | ± 5-10 mg every 3-48 hours |
| Late Reduction | Establish adequate dose (physical / emotional well-bring) | ± 5-10 mg every 5-10 days |
| Maintenance | Maintain desired effects (steady state occupation of opoiod receptors) | Ideally 60-120 mg / day (may be more than 120 or less than 60) |
Source: J. Thomas Payte, MD, 3/06/98
From the Editor
Putting Science Before Ideology
Measure Benefits and Harms
In the Fall 1998 edition of Issues in Science and Technology, Mark Kleiman editor of the “Drug Policy Analysis Bulletin” and a professor at UCLA writes that the drug policy debate continues to be polarized between the advocates of stringent controls and those favoring more liberalization.
He observes that current policy reflects the stance of the drug warriors, stressing stricter controls, increased enforcement, harsher punishments, and mass media campaigns to stigmatize the use of illegal drugs. Treatment is secondary.
Critics of those policies focus on making drug use less harmful, such as with needle-exchange programs, he says. Proponents of “harm reduction” believe that eliminating penalties for drug use would lower associated crime and violence.
The element missing from current policies is scientifically measuring policy effectiveness both in terms of benefits produced and harms avoided, he concludes.
McCaffrey Wants Suggestions
General Barry McCaffrey, Director of the ONDCP, responds to Kleiman’s article in the Winter 1998-99 edition of the same publication by expressing disappointment that the research community continues to criticize the government’s anti-drug efforts. He invites critics to put aside their rhetoric and join the government in its push to establish new policies.
McCaffrey challenges the research community to help the government bring policies in line with the most current scientific findings. He points out that his job is not to establish policies unilaterally but to facilitate a dialogue between all concerned parties.
As part of the National Drug Control Strategy, there are 93 performance targets being evaluated, including more and easier access to drug treatment. McCaffrey urges researchers to review the current plans and offer suggestions.
Indeed, McCaffrey seems willing to ask the important questions and listen to informed answers. The real challenge now before the addiction treatment community is to speak up for what works best in terms of good science. And the Connecticut experiment described in this edition of A.T. Forum seems one step in that direction.
Reader Survey – Challenges Facing MMT Clinics?
On the subject of challenges, with all the talk of change in the air, we wonder how MMT clinics would rate the most critical obstacles and opportunities facing them – those areas in which they need the most assistance.
What do you think is the single most critical challenge facing MMT clinics? [Select only one]:
Recruiting new patients.
Retaining patients in treatment.
Funding for ongoing or expanding operations.
Developing proposals for research grants.
Hiring and training good staff.
Dealing with local community politics.
Complying with state and/or federal regulations.
Controlling methadone diversion.
Other: _____________________
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
- stew202@aol.com
- 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
APRIL 1999
- American Orthopsychiatric Association 76th Annual Meeting
- April 9-11, 1999
- Washington, DC
- Contact: 212-564-5930
- ASAM 30th Annual Medical-Scientific Conference
- April 29 – May 2, 1999
- Marriott Marquis; New York, NY
- Contact: 301-656-3920; e-mail@asam.org or www.asam.org
MAY 1999
- 60th Annual Convention of the Canadian Psychological Association
- May 19-22, 1999
- Halifax, Nova Scotia
- Contact: 613-237-2144 or 1-888-472-0657; www.cpa.ca
- NAADAC-23rd Annual Conference on Addiction Treatment
- May 26-28, 1999
- Philadelphia, PA
- Contact: 703-741-7686
- Tools for a Healthy Future
- National Rural Health Association
- May 27-30, 1999
- San Diego, CA
- Contact: 816-756-3140; www.NRHArural.org/conf99
JUNE 1999
- NADCP 5th Annual Training Conference
- Natl. Assn. of Drug Court Professionals
- June 3-5, 1999
- Miami, FL
- Contact: Dean Schultheiss 703-706-0576; www.nadcpi@aol.com
JULY 1999
- ASAM: Forensic Issues in Addiction Medicine
- July 15, 1999
- Washington, DC
- Contact: 301-656-3920;
- e-mail@asam.org or www.asam.org
- ASAM: MRO Training Course
- July 16-18, 1999
- Washington, DC
- Contact: 301-656-3920;
- e-mail@asam.org or www.asam.org
[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
Everything You Wanted to Know About Hepatitis
The C. Everett Koop Institute at Dartmouth College has developed a very extensive Internet site and also provides information via phone on all types of hepatitis. The offerings range from the highly scientific to easy-to-digest explanations covering all aspects of the diseases. Dr. Koop, a former Surgeon General of the U.S., obviously takes the HCV threat very seriously.
See www.epidemic.org or call 1-800-HEP-9674.
Drug Information from ONDCP
Interested in knowing what the government has in store for addiction treatment? The White House Office of National Drug Control Policy (ONDCP) has an informative Internet site offering the latest scoop on what the government is doing to fight drug abuse. There also are plenty of important facts and figures, plus the latest updates of General Barry McCaffrey’s policy plans. Special sections offer tips for parents and even a page just for kids.
See www.whitehousedrugpolicy.gov.
Earn CEUs Online at ATTCs
The Center for Substance Abuse Treatment (CSAT) has funded a network of Addiction Technology Transfer Centers (ATTCs) around the country to help increase the knowledge and skills of treatment professionals by facilitating access to current research and education. To learn of their locations and services, the national office in Kansas City, MO can be accessed online at: www.nattc.org or call 816/482-1135.
The New England ATTC sponsors a number of reasonably priced online educational courses for professionals throughout the year. Titles include: Relapse Prevention, Motivational Interviewing, Advanced Pharmacology, Understanding 12 Step Programs, and many others. Courses, which fill up fast, are coordinated through Brown University’s Center for Alcohol and Addiction Studies, and allow participants to earn Continuing Education Units (CEU’s) over the Internet.
For a course schedule and to register, go to: www.caas.brown.edu /CED/coursecal.html, or e-mail: Monte_Bryant@brown.edu.
Hepatitus C – Health Crisis of the Century
Silent Epidemic
According to medical experts, hepatitis C (HCV) is an epidemic lurking like a massive iceberg with only its tip exposed to public view. First discovered in 1989, an estimated 4 million Americans are now infected with HCV. Yet most people know nothing about this common virus, how it spreads, or just how silently dangerous it can be – 95% of those infected don’t even know they have it.
When first infected, only one in five persons exhibit acute symptoms – fatigue, jaundice, appetite loss, abdominal pain, nausea and vomiting – which may be easily mistaken for the flu. About 75% go on to develop chronic disease, but many won’t have symptoms until there is serious liver failure.
HCV can cause cirrhosis from scarring of the liver; it is the number-one cause of liver cancer; and it is responsible for over a third of all liver transplants. Such complications can take 20 or 30 years to develop, and occur in about 20% of those infected with the virus.
It is a deadly disease, claiming 10,000 lives each year and rising. While HIV/AIDS gets all the headlines and fund-raising endorsements from celebrities, HCV has quietly infected four times as many Americans. Deaths from HCV are expected to be more than double those from AIDS within 20 years.
HCV Plagues Addicts
Since HCV is a blood-borne disease and highly infectious, drug abusers are of great concern. A person involved in intravenous drug use and needle sharing – even once – is at tremendous risk; sharing needles accounts for 60% of cases. HCV also can be transmitted via shared straws used to sniff cocaine, unprotected sex, and other means. It is a particularly damaging disease in addicts because they often suffer repeated exposures to the virus.
Four years ago, A.T. Forum (Vol IV. #1; Winter 1995) rang a warning bell for methadone maintenance treatment (MMT) programs, noting that addicts are highly prone to contracting the various types of hepatitis. HCV now seems to pose the greatest threat and is the most deadly.
Recently, speaking at the American Methadone Treatment Association conference last September, Mary Jeanne Kreek, MD stated that HCV could be the number- one public health problem going into the next century. Kreek, who is a professor and researcher at Rockefeller University, New York City, observed that while 10% to 60% of heroin addicts have HIV, between 60% and 90% have HCV.
At the same conference, John (Jack) McCarthy, MD – Director, Bi-Valley Medical Clinic, Sacramento, CA – observed that up to 96% of patients at his clinic tested positive for HCV, while there was a very low incidence of hepatitis B (only 5 cases). Patients were affected regardless of age or length of time addicted, and were infected prior to coming into MMT.
Less than 10% of those infected with HCV will clear the virus without treatment, Kreek suggested. Twenty percent develop cirrhosis and 20% of those develop carcinoma. Hepatitis A and/or B on top of HCV can create a more fulminant liver disease. It is also important to note that moderate to heavy alcohol use worsens the prognosis for HCV.
MMTs Must Test & Treat
Kreek emphasized that MMT patients must be tested and treated for HCV, and not be denied treatment for any reason. She acknowledged, however, that in many places getting reimbursement for hepatitis testing can be challenging.
McCarthy agreed that public policies can be obstructive. Only 10% of the patients at his clinic in managed care programs were tested for HCV because the test had to be requested by a primary care physician.
He also observed that elimination of SSI benefits caused problems with funding treatment delivery. And laws preventing clean needle distribution contributed to infection spread among heroin addicts.
McCarthy recommended screening all patients for hepatitis and cirrhosis (eg, elevated bilirubin). Patients with cirrhosis may need their methadone dose monitored more closely, since the liver doesn’t store methadone as well. Patients not infected with hepatitis A or B should be vaccinated against those viruses.
Kreek noted that there is no vaccine or cure for HCV; infected persons will carry it for life and can pass it on to others. And, being an RNA virus, it readily mutates into different strains.
Early, aggressive treatment can help prevent drug-resistant mutations from developing and includes interferon-alpha, to which 35% to 50% of patients will respond in six months. However, response falls off following treatment.
If interferon fails, the new approach is to combine interferon with ribavirin. This combination can reduce HCV to undetectable levels in 36% of patients without previous treatment.
Treatment side effects – including possible depression or flulike symptoms – and high costs for medication can be barriers. However, Kreek stressed that the costs of not treating are far more burdensome and she encouraged MMT programs to work hard in finding ways to fund proper care.
The message is clear: prevention, early intervention/screening, and treatment are the watchwords for stemming this growing crisis among MMT patients and the population at large.
Readers Survey – Docs Rxing Methadone
Our last edition of A.T. Forum (Winter 1999) asked readers several questions that tied in nicely with the “Changing Roles for MMT Clinics?” article in this current edition (starting on page 1). There were 225 responses to our survey, either mailed in or at our Web site, although not everyone answered all questions. Here are the results:
Is methadone treatment in private doctors’ offices a good idea?
A majority, 60%, said “yes”; 35% “no”; and 5% “don’t know.” Although favorable toward the concept, this is a rather surprising result. When we asked a similar question several years ago, during Summer 1996, over 80% said it was a good idea. Other than the responding groups being different for the two surveys, we have no explanation for the significant downturn.
Will private physicians have an interest in treating opioid addiction?
Responses were fairly evenly divided between “yes” (45%) and “no” (38%); 17% replied “don’t know.” Yet, for our “Changing Roles” article, Dr. Peter Rostenberg believed that most physicians would indeed be interested, and for humanitarian rather than financial reasons.
How much specialized training should those physicians have?
The majority (40%) felt that this was an area for addiction specialists only. About 29% felt MMT clinic experience was necessary and only 11% believed a 1-2 day course would be sufficient.
There were a number of write-in suggestions, such as: ongoing in-service training, specialized courses offering CEUs, and a certification program. One counselor, with 20+ years on methadone, responded that physicians should consult successful MMT patients as mentors.
“A 1 or 2 day course is a waste of time,” responded the counselor, “as it is not possible to learn everything about methadone and patients’ needs in that short a time. Perhaps the most important thing to learn is that all substance abusers are different and require individualized care and treatment plans.”
Another reader offered that a 40-hour course, including a full day’s visit to an MMT clinic, might be sufficient.
Finally, a reader warns: “The potential ‘willy-nilly’ distribution [of methadone] by less than adequate physicians (we all know they exist) has the potential of leading to scathing headlines about methadone overdoses.”
Indeed, as the article on “Methadone Induction” in this issue (starting on page 1) notes, there certainly could be justifiable concerns about the potentially dire consequences of poorly trained or experienced physicians starting new patients on methadone. In this regard, the best and safest solution would seem to be having patients started on methadone at well-established clinics prior to maintenance treatment by community physicians.
How long should patients attend clinic programs before referrals to doctors’ offices?
Responses to this were mixed. The largest proportion (28%) suggested 3+ years of clinic attendance; 17% checked 2 years; 22% indicated 1 year; 13% said 6 months. A fairly large contingent 20% believed that no clinic attendance at all was necessary.
For past experimental programs providing MMT in physicians offices, the clinic attendance requirement varied from one, to three, to ten years. During interviews for our “Changing Roles” article, Rostenberg and Kirk agreed that it should probably depend on the individual patient’s progress. Bilangi suggested that at least 1 year would be needed.
Unasked Questions
There were several questions we didn’t ask in our survey. For example, how often should MMT patients be seen by private physicians?
For the Connecticut study, weekly visits are required. “[That’s] an arbitrary time period,” Rostenberg contended. “Medical practice should be guided by patients’ progress, and patients should be motivated by benefits that can be derived from that progress.”
Where should methadone be available to patients for pickup?
Bilangi said that the Connecticut model, with his clinic delivering methadone to physicians’ offices, will not work nationwide. “Doctors will need the ability to write methadone prescriptions for filling at local pharmacies,” he told us. Yet, pharmacy dispensing of methadone is a separate program unto itself, one which CSAT explored in the past (see A.T. Forum, Winter 1997), and one that has yet to become realized.