Federal Regulation of Methadone Treatment (1995) / Chapter Skim
Currently Skimming:
Treatment Standards and Optimal Treatment
Treatment Standards and Optimal Treatment
Pages 185-216
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 185... ...
Throughout, we distinguish between methadone as a medicine and methadone maintenance treatment as a program of comprehensive services that enhance the effectiveness of the pharmacological treatment. The detailed discussion in this chapter of treatment in relation to the federal methadone regulations stems from the view of the committee that regulations have an appropriate place, but that they can be improved in a number of ways.
|
From page 186... ...
An example is the therapeutic use of naltrexone to block the effects of heroin or other opiate agonist drugs. The two primary clinical applications of opiate agonist pharmacotherapy to treat opiate addiction are the limited-term withdrawal of an addict from opiate use with the objective of achieving abstinence from illicit opiates and other psychoactive substances (known as detoxification treatment)
|
From page 187... ...
For example, because patients admitted for "detoxification" represent a shortterm obligation of treatment programs, by definition, they often receive fewer services than patients admitted for maintenance, without respect to clinical need. Not surprisingly, the results of detoxification treatment have been generally disappointing.
|
From page 188... ...
~2~) of the regulations and be defined as follows: "Sustained administration of an approved opiate agonist drug, at relatively stable doses, for the treatment of opiate addiction." In addition, the committee proposes that the following language changes be made in the regulations and incorporated in any practice guidelines that are developed later: Replace all references to the treatment of "narcotic addicts" with references to the treatment of "opiate addiction"; replace all references to "narcotic dependence" with "opiate addiction"; and replace all references to "opiate addict" with the definition of "opiate addiction." "Opiate" defines the class of drug in question; "narcotic" refers to any stupor-inducing drug, and is a legal term that includes cocaine (see chapter 5~.
|
From page 189... ...
, should be based on a comprehensive evaluation and a clear clinical diagnosis of physical opiate dependence and chronic opiate addiction, defined to include the psycho-social-behavioral characteristics described as "drugseeking behavior." A comprehensive evaluation should establish patient eligibility for methadone pharmacotherapy on the basis of the following: current physical opiate dependence and addiction; objective findings and subjective reports of the patient that support the need for pharmacotherapy; a judgment that the patient is capable of understanding and participating in a treatment program; and an expressed willingness of the patient to enter treatment after the nature of that treatment has been carefully explained to him or her. Once a primary diagnosis of opiate addiction has been made, an assessment of its duration and severity should determine the most appropriate treatment for the patient.
|
From page 190... ...
Admission to Maintenance Pharmacotherapy Admission to methadone maintenance treatment was originally limited to the 'hard-core heroin addict," defined as a person with a year or more of daily self-administration of heroin. Current regulations still draw the line at an
|
From page 191... ...
Some members of the committee are concerned that distinctions between opiate addiction and opiate physical dependence may not be adequate to prevent inappropriate admissions to long-term MPT. For example, chronic pain patients who become physically dependent on opiates and then experience withdrawal symptoms when opiates are reduced or discontinued are sometimes referred, inappropriately, to methadone treatment programs which treat opiate addiction.
|
From page 192... ...
First, the assessment of opiate addiction should be based on clinical diagnostic criteria and should not be determined by formulas set forth in regulations. Second, the diagnostic criteria for MPT should be set forth in clinical practice guidelines, such as the CSAT State Methadone Treatment Guidelines (see, e.g., Center for Substance Abuse Treatment, 1992)
|
From page 193... ...
Therefore, additional small doses of methadone (5-20 ma) may be needed three to twelve hours after the initial dose, for up to one week, to prevent signs and symptoms of opiate withdrawal (Dole et al., 1966; Kreek, l991c; Payte and Khuri, 1992~.
|
From page 194... ...
After initial stabilization, daily doses of methadone are then gradually increased, by 5 or 10 mg each week, until a full treatment dose of 60 to 120 mg is reached by the end of an induction period of four to eight weeks.
|
From page 195... ...
Other dosing restrictions should be removed from the regulations, including the language that "the administering physician shall ensure that a daily dose greater than 100 mg is justified in the patient record"; patient take-home medication and other clinic privileges should not be contingent on dose levels, and clinical practice guidelines should be developed to assist clinicians regarding adequate dosing and take-home practices. Comprehensive Treatment Services Methadone as a medication is but one element of a comprehensive treatment program offering a full range of services, which include methadone administration, counseling, and other medical care (Hubbard et al., 1989; McLellan et al., 1993; TOPS 1979-1981~.
|
From page 196... ...
Thus, while methadone maintenance can be seen as a service to or even a privilege for the affected individual because it reduces his/her withdrawal symptoms and cravings for opiates, to the extent that it is effective in reducing the social harm caused by these associated problems, methadone maintenance treatment may be seen as a public health benefit to society, similar to education and vaccination programs. It must be emphasized that the potential benefits to the public derive from reductions in the associated problems of crime, loss of productivity, and disproportionate use of medical and social services for those in methadone treatment- and not from reductions in the use of opiates per se.
|
From page 197... ...
Several studies document the efficacy of this form of treatment service for the "average" methadone maintained patient. At the same time, this mainstay of methadone maintenance treatment is frequently in short supply due to large patient caseloads (current regulations allow for caseloads of 50 patients per counselor)
|
From page 198... ...
In summary, this work indicates that counseling and especially professional interventions should be added to standard methadone treatment and these interventions can produce significant improvements in drug use, employment, legal status, and health services utilization in individuals with multiple problems. Three conclusions flow from existing research on the rehabilitative goals of methadone maintenance treatment.
|
From page 199... ...
There is little evidence that, at least at the initiation of methadone treatment, the provision of methadone by itself can lead to reductions in other important problem areas of nonopiate drug use, alcohol dependence, unemployment, psychiatric problems, and disproportionate use of health care services. Data from the past ten years have shown that counseling and particularly professional health care and social services can significantly augment the direct effects of methadone in achieving reductions in opiate use and are essential to achieving the important goals of social rehabilitation for opiate-dependent patients.
|
From page 200... ...
State authorities and individual treatment programs sometimes impose stricter urine testing requirements than these. Urine testing is a helpful clinical tool, useful as a way to determine patient progress and compliance with treatment protocols.
|
From page 201... ...
Perform a comprehensive evaluation of the full range of medical, employment, alcohol, criminal, and psychological problems of all patients admitted to methadone maintenance and medically supervised withdrawal. As indicated above, it is in the public interest for methadone maintenance programs to address the "addiction related" problems of unemployment, crime,and infectious diseases.
|
From page 202... ...
These diseases are disproportionately represented in the opiate-abusing population and represent a risk to all society as well as to the individuals directly affected. Typically, few medical screening services are available to these patients outside the methadone maintenance programs and it is in the interests of the patient, and of society, to see that these diseases are recognized and treated.
|
From page 203... ...
Opiate Addiction in Pregnant Women The use of methadone to treat pregnant opiate addicts has, for years, been controversial. Although the benefits of methadone pharmacotherapy in pregnancy, in contrast to continued illicit drug use, have been clearly demonstrated, some issues remain unresolved.
|
From page 204... ...
allow providers to give maintenance pharmacotherapy outside of a licensed narcotic treatment program. Alternatives to treatment programs might include hospital, pharmacy, clinic, and individual practitioner's office acting as MPT programs for the purpose of prescribing methadone to pregnant opiate addicts who are awaiting admission into a licensed program, or for the duration of the pregnancy for patients in geographic areas where there are no licensed programs.
|
From page 205... ...
The principles of long-term medically supervised MSW include the following: 1. Any patient being considered for MSW must be physically dependent upon opiates and therefore have an established opiate tolerance level, which is determined by the amount of methadone required to suppress the signs and symptoms of withdrawal.
|
From page 206... ...
The decision lo terminate methadone maintenance treatment has profound implications for a patient and should not be implemented until the conclusion of a hearing and appeal. In cases of involuntary MSW, it is particularly important that the pace of the withdrawal be accomplished safely (according to standards set forth in this report)
|
From page 207... ...
The federal regulations governing methadone treatment also affect opiate-addicted individuals in the inpatient setting: methadone maintenance patients who are hospitalized for medical or surgical reasons; and opiate addicted individuals not in treatment programs who are admitted for .
|
From page 208... ...
Guidelines, in the judgment of the committee, should reflect the following general principles: 1. On admission of a methadone maintenance patient as a hospital inpatient, the hospital staff should notify the patient's treatment program and confirm the individual's enrollment in the treatment program, methadone dose, and time and date of last dose.
|
From page 209... ...
The committee recommends that the following change be made in the regulations to accommodate the needs of hospitalized opiate addicted patients: Patients who meet the criteria for opiate addiction during any inpatient hospital admission may be treated, when appropriate, with methadone to relieve opiate withdrawal. Patients may then be discharged to methadone treatment programs for their continued treatment.
|
From page 210... ...
Although not asked to deal specifically with issues of pain and its clinical management, the committee has concluded that the intersection of the two uses of methadone for treating opiate addiction and for pain treatment is of sufficient importance to warrant this discussion. We identify two issues: first, the problems of the non-opiate addicted pain patient; and second, those of the methadone maintenance patient and the "recovering" opiate-dependent patient who also needs pain treatment.
|
From page 211... ...
Joranson, of the University of Wisconsin Pain Clinic, wrote to the committee (letter, October 25, 1993~: "A person who needs a morphinelike drug only for the medical treatment of intractable pain and to prevent withdrawal associated with the treatment of intractable pain is not a narcotic addict and is not eligible for admission to a narcotic treatment program. A practitioner may prescribe, administer, or dispense narcotic drugs including methadone in the course of professional practice to such a person for the treatment of intractable pain." It is appropriate that pain experienced by opiate-addicted individuals, along with other medical and psychiatric conditions, be treated in the context of a comprehensive methadone treatment program.
|
From page 212... ...
This denial is usually based on two misconceptions: first, that any patient taking a daily dose of methadone should derive adequate analgesia from the maintenance dose, and second, that prescribing an additional amount of an opiate agonist would lead to relapse and/or compromise the treatment of the addiction. Opiate addiction treatment program medical staff must provide guidance to physicians, dentists, and other practitioners to ensure humane treatment of methadone maintained patients being treated for acute pain.
|
From page 213... ...
The corollary of reducing governmental discretion over treatment programs is to recommend that increased reliance be placed on clinical practice guidelines, as they are developed, for clinicians and treatment programs. This shift of responsibility from government officials to clinicians, is already under way in some measure and should be extended, as the committee has recommended.
|
From page 214... ...
In: Center for Substance Abuse Treatment. State Methadone Treatment Guidelines Treatment Improvement Protocol (TIP)
|
From page 215... ...
In: Center for Substance Abuse Treatment (1992) State Methadone Treatment Guidelines.
|
From page 216... ...
1990. Methadone maintenance in the treatment of opioid dependence: A current perspective.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.