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Chemical Dependency Research Working Group |
This chapter will describe the steps that transform a street heroin addict into a methadone patient. This is a major transformation that involves the efforts of staff counselors, nurses and physicians cooperating with suspicious and apprehensive newly admitted patients. To assume the patient role, the patient must first relinquish control over the administration of narcotics from him or herself to a professional medical staff. The second consideration is that the patient must be compliant with the rules of the clinic by reporting as directed, taking his or her dose as directed and accepting the rules of the program. This includes compliance with physical examinations, the periodic collection of urine samples and cooperating with social service and medical personnel in the treatment of addiction as opposed to participating in the networks of the streets when the patient was addicted to illegal narcotics.
Thus, there should also be a transformation in the acceptance of networks the medical, social service network that will provide methadone, other medical regimens, counselling, vocational and educational guidance and referrals for additional services to community agencies when appropriate. However, this transformation implies that patients modify or relinquish networks developed in the streets including old friendships. Transformations in relation to street networks may happen immediately or take years. The transformations could be complete no contact with former associates or modified. The modification of relationships to street networks and the consequences of modifying relationships may reflect the role that patients assumed in the street while using heroin. For example, when this writer administered a clinic, a patient tried to remove herself from the control of a pimp and was subsequently found murdered.
Also, transformations may reflect the patient's perception of the program's philosophy towards patients (trust vs. mistrust, concern vs. indifference, excessive control vs. flexibility), the patient's understanding of the methadone, the patient's own agenda for treatment. Does the program trust or mistrust patients? The major component in becoming a compliant patient is the confidence in the medication and the understanding of the properties of methadone (D'Annuno and Vaughn, 1992).
Phases of Methadone Maintenance Treatment
The methadone maintenance treatment program is subdivided into three basic phases:
This is the initial intake and stabilization period which lasts for about three months. The patients are built up to an appropriate doses of methadone, receive various physical and pychological examinations, are introduced to the regulations of the program and are assigned a counselor. Patients also adjust to the medication, becoming tolerant or resistant to its narcotic, analgesic (pain killing) and tranquilizing effects. Patients during this period make a transition from street addict to patient. They begin to relinquish the use of illegal drugs, primarily heroin and entrust the administration of methadone which they might have used illegally in the streets to the medical administration within the clinic. During this period patients may report six or seven days per week drinking their dose of methadone in the presence of a nurse at a specially designed dispensing station. At most, they receive one take home dose of medication for Sunday. Urine tests are taken two or three times per week during Phase 1. In some clinics the patient is observed while urinating to ensure that the specimen is correct.
This phase can last indefinitely and is the basic period of methadone maintenance. Patients begin to plan for their futures. Those with job skills seek employment while others without needed skills can apply for vocational assessment, counseling, job training and placement if such services are available either within the clinic or the community. Through counselling, families can reunite. The patient's life begins to normalize during this phase of treatment.
However, clinics are highly regulated. Some programs serve substantial populations of sick and highly dysfunctional patients with AIDS, tuberculosis, homelessness, chronic unemployment, excessive use of cocaine/crack, alcoholism and a variety of other problems. Methadone is dispensed in bottles each containing one daily dose. Employed and stable patients who report one day a week are given six bottles of medication, which for compliant patients may be difficult to conceal. This clinic system while effective for many patients, especially those with serious problems may work against the continued social adjustment of compliant, stable, and employed patients.
This phase is called aftercare. Patients in good standing report to a clinic once every two weeks, give a urine specimen, drink a dose of methadone in front of the nurse and receive a two week supply of methadone (13 bottles). However, these patients are still in the clinic system, report to an identified methadone program and are subject to the same regulations if they must go on extended business trips or vacations for more than two weeks. The patients are still medically segregated in a special methadone clinic.
This phase is medical maintenance and is considered an investigational status. The federal government is currently deciding whether medical maintenance should be continued. Stable and employed patients are assigned to a physician with a hospital-based medical practice and thereby placed in general medical practice. The reporting schedule is determined by the physician and patient. At the beginning of medical maintenance, patients report once every two weeks. When patients are comfortable with a two weeks supply of medication, their schedules are changed to once per month. They are treated in a private doctor's office, submit a urine sample and drink a dose of methadone before the physician to show that tolerance to methadone has been maintained. They pay for the medication, and the services of the physician who may treat other problems that the patient may present (e.g., arthritis, diabetes, cardiac, and in rare cases, AIDS ). Methadone maintenance treatment is theefore just one aspect of the patient's health status. The methadone patient is integrated into general medical practice away from the segregated clinic system.
Procedures With Patients in Methadone Maintenance Clinics
About 115,000 patients are currently enrolled in methadone maintenance treatment in the United States. Of this number, about 40,000 (25%) are enrolled in programs in New York State (COMPA, 1993). Patients from different socioeconomic classes and with varying social and psychological problems are serviced in public and private clinics. The administration of the medication is quite formal and regulated (Watters and Price, 1985). Patients begin by standing in line to await their turn at the clinic's medication counter. Methadone is dispensed at a counter by a nurse. Patients are required to drink a daily dose of methadone in front of the nurse to demonstrate a continued tolerance to the medication. Some programs dictate that patients must talk to the nurse after taking their medication so that medication is not secretly spit out into a container and diverted for black market sales in the streets. Urine screening is random and patients must be ready to produce a urine sample if selected to do so. Urine samples are used to determine whether patients have taken their medication on the days they do not report to the clinic and to determine if they are using other drugs. In some clinics, patients may be required to urinate observed by a member of staff. Toilets used by patients to produce urine samples are sometimes difficult to keep clean and sanitary because of the constant use. This results in complaints from the patients because the conditions compromise their dignity.
Patients report from one to seven days per week to a clinic depending on the amount of time they were in treatment and their productively (e.g., employed, student, homemaker). Patients are assigned counselors to assist them to overcome problems and to make relevant referrals. However, in most clinics the counselling is not adequate, considering the many social and medical problems that patients present.
If patients do well they report less frequently within a given week and are allowed to take home up to six doses of their daily medication. This take home process is highly regulated by federal, state and local regulations. If patients have to go on distant business or personal trips, they must ask permission sometimes several weeks in advance to receive additional medication which must be approved at the proper level of governmental authority. An alternative plan is to assign patients on vacation or business trips to local clinics that may be more restrictive than the clinic of origin. Patients are therefore in a highly controlled process that can intrude on their business and personal lives. The primary function of the governmental regulations is to control diversion of methadone the selling of methadone by non-compliant patients to street addicts who are not in treatment. These patients are in the minority, but, unfortunately, their noncompliance impacts on all patients.
The Origin of Medical Maintenance
In the 1980s, Dr. Nyswander realized that the imposed regularity of the reporting schedules hindered the progress of patients who were employed and appeared to be socially and medically stable. Also, from the inception of methadone maintenance, Nyswander and Dole felt that a group of socially stable patients could be treated in medical practice. With the help of this writer, a medical maintenance protocol and criteria were established that allowed selected patients to receive their methadone as a prescribed drug within private medical practice. It was planned that patients would report at least once per month and therefore be able to go on needed personal and business trips and take extended vacations without the interference of rigid controls, denigrating regulations and weekly reporting schedules. Furthermore, patients would pay the physician a monthly fee (about $75.00) for the visit, annual physical exam, monthly urinalysis test and a month's supply of medication. Permission was obtained from the federal government to implement the program as a study or investigation of a new drug. Patients would be removed from a rigid clinical reporting system that compromised their confidentiality. Most importantly, their status as methadone patients would be more concealed since they were removed from identifiable clinics, and the treatment process itself would be concealed within private medical practice (Novick and Joseph, 1991). Another alternative would be to withdraw successful patients from methadone. Several studies over the past two decades show high rates of relapse to heroin after patients leave the program irrespective of their adjustments while in treatment. However, patients who leave in good standing appear to relapse at slower rates than those who leave against medical advice (Ball and Ross, 1991; Dole and Joseph, 1978). Neuroscience research has shown that there may be a physical explanation for relapse, namely a dysfunction within the opiate receptor system which methadone normalizes as long as the patient takes the medication (Dole, 1988; Kreek, 1988). Many successful patients, therefore, prefer to remain in treatment since they are cognizant of the reality of relapse to heroin not only from the results of studies but, more importantly, from their own experiences and those of their friends. Patients in good standing have withdrawn but there have been high rates of relapse among this group. Nevertheless, there are patients who have succeeded in leaving methadone treatment and have lived comfortably without medication or relapse to heroin. The reason that some patients can live in comfort after withdrawing from methadone and others are unable to, is a research question that is now undergoing study and has yet not been answered.
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Last Update: March 15, 2001 |
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