Chemical Dependency Research Working Group

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Retention in Medical Maintenance

In this chapter the outcomes of medical maintenance treatment will be presented. This will include demographic data obtained at the time of intake and reviews of their records (Table 2). Also included will be a survival curve with data obtained from medical records concerning the duration of time in treatment, level of dose by employment at time of admission, a crude death rate and reasons for discharge (Figure 1 and Tables 3-5b). Follow-up on discharged patients will be reported.

In 1983 an initial 23 patients were selected for a pilot project from Beth Israel Medical Center's methadone program. An additional 93 patients were interviewed from 1985 to 1989, but only 77 patients were selected based on the criteria listed below. They were referred from Beth Israel and other programs.

The 16 patients who did not meet the above criteria were rejected for the following reasons:

The survival curve was calculated using the SPSS package. The observation period is 126 months for 100 admissions between 1983 and 1989 and continued to a final date of December 31, 1993. Dates of admission, treatment status and discharged date, reasons for termination and causes of death were obtained from physicians and medical records.

A crude death rate was calculated in patient years. Patient years in treatment was determined by combining the years in methadone treatment and medical maintenance. Thus, the denominator in the calculation represented the total time the patients were maintained on methadone.

Information concerning the adjustments of discharged patients who were returned to the methadone clinics of origin was obtained from the Acting Director of the methadone program at Beth Israel Medical Center. This researcher was not permitted to interview the patients who had failed in medical maintenance and who in treatment at Beth Israel. The Acting Director felt that the situation would be embarrassing and somewhat traumatic for these patients. Information about the adjustments of patients who left in good standing was obtained through interviews either, with former patients, a family member or interviews with the physician. The follow-up information was obtained from 12 to 66 months after withdrawing from methadone.

Table 2 presents demographic information on the first 100 patients admitted to medical maintenance from 1983 to 1989. This cohort has an observation period of 57 to 126 months (4.75 to 10.5 years) ending on December 31, 1993. This group is not typical of methadone maintenance patients in clinic system. Fifty-nine of the patients either attended college, graduated or went on to graduate or professional school. This education was obtained while they were enrolled in methadone maintenance. All of the patients in medical maintenance are employed or in college in comparison to methadone maintenance programs where only about 28 percent of the patients are employed or going to school (Randall, 1994). Also, the patients in medical maintenance are predominately white and male. The ethnic breakdown for methadone maintenance programs in New York City is about 65 percent black and Latino and about 30 percent female. The patients in medical maintenance have been in methadone treatment for about 15 years as opposed to the rapid turnover in clinics and short retention of about 2 to 3 years for patients in the clinic system. The majority of patients in medical maintenance are married.

Table 2

Demographic Data, Addiction and Treatment Histories
of 100 Methadone Patients at Entry into Medical Maintenance
Educational Level
Category			(SD)
Mean Age at Admission to Medical Maintenance		43	(9)
Gender
	Male	78
	Female	22
Ethnicity
	African American	9
	Latino/a	8
	White	83
Marital Status
	Married	61
	Single	16
	Separated/Divorced	13
	Widowed	5
	Common-law	3
	Engaged	2
	Less than High School	17
	High School	20
	Vocational	4
	Some College	38
	College Degree	14
	Graduate/Professional	7
Means of Support
	Full Time Employment	97
	Part Time Employment	1
	College Scholarship, Veteran's Benefits	2
Average Annual Income		$32,672	(18,450)
Average Age First Used Heroin		18	(4)
Average Age First Used Needles		19	(5)
Average Years Addicted to Heroin		8	(5)
Average Age First Arrested		20	(5)
Average Number of Arrests		6	(8)

Average Age Entered Methadone Maintenance		28	(7)
Average Years in Methadone Maintenance		15	(4)

Several medical maintenance patients have previously attempted withdrawal from methadone, only to relapse and reenter the program. Seventy patients have one continuous episode of treatment, twenty-six have two episodes, three have three episodes and one has four episodes. Other medical maintenance patients who are on low doses have attempted to withdraw but had to be restabilized because of physical discomfort.

Figure 1 (not available) is a life table showing retention in medical maintenance. For the 67 active patients there are five to ten years of observation depending on the year of entry into medical maintenance. Of the 33 terminations, twenty-nine (91%) occurred during the first five years of observation. Table 3 presents interval time in years for the life table, the number of patients entering during a particular year, the number being removed, the number discharged, the proportion remaining in treatment (surviving) and the cumulative proportion remaining (surviving) for each year. The median survival time is over 10 years (126 months).

Table 3

Retention in Treatment as of 12/31/93 for 100 Patients Admitted
to Medical Maintenance from 1983-1989
Year	Number Entered	Number Taken Out	Number At Risk	Number Discharged	Proportion Remaining In Treatment	Cumulative Proportion Remaining In Treatment
1	100	0	100.0	2	.98	.98
2	98	0	98.0	4	.96	.94
3	94	0	94.0	9	.90	.85
4	85	0	85.0	7	.92	.78
5	78	19	68.5	7	.90	.70
6	52	17	43.5	0	1.00	.70
7	35	18	26.0	0	1.00	.70
8	17	0	17.0	2	.88	.63
9	15	0	15.0	2	.87	.54
10	13	13	6.5	0	1.00	.54

Within the fifth year of observation, nineteen patients were removed from further observation because of lack of time in treatment. Subsequently, seventeen patients were removed in the sixth year, and eighteen were removed in the seventh year. The proportion of patients remaining in treatment for the first four years was 98, 94, 85 and 78 percent, respectively. Following the removing of patients in the fifth year because of lack of time, the cumulative proportion of patients remaining in medical maintenance was 70% for the fifth, sixth and seventh years of observation. The cumulative proportion of patients remaining in treatment decreases to 63% during the eighth year of observation, and to 54% in the ninth and tenth years of observation. This retention data compares favorably with a survival analysis of retention in methadone treatment in California of Anglo and Chicano men (45% and 57% retained respectively over a 20 month period) (Yih-Ing, Anglin and Yin, 1990-91). Gearing (1970a) showed in an analysis of retention using life tables that over 1530 men have an 86 percent probability of remaining in treatment for a year, and a 74 percent probability of remaining in treatment for 2 years. No statistical differences in retention was found for the three groups studied which included black, Hispanic and white. The retention in medical maintenance over a 24 month period is greater than the retention rate of patients in the general clinic population.

There were seven deaths. The causes of death included heart attack, meningitis, homicide, stroke, leukemia and lung cancer, and one patient with terminal AIDS was transferred to a hospice and subsequently died. According to medical records, three of the patients who died (e.g., heart attack, lung cancer, and stroke) were heavy smokers. None of the deaths, according to the physicians were related to the use of methadone. The one AIDS death in this group was related to sexual behavior and not to drug addiction. However, there is one patient who became HIV infected in the 1980s from use of a contaminated needle to inject cocaine. The low incidence of AIDS in this group was due to their longevity in methadone treatment and stable adjustment.

The 100 patients had accumulated a total of 2,053 patient-years on methadone -- 1,470 in the clinic system and 583 patient-years in medical maintenance. The crude death rate is 3.4 deaths per 1000 patient years. The mean age of death is 52.7 years (SD=6). This mortality rate is far below that for patients in methadone programs which was estimated at about 15 deaths per 1000 patient years prior to the AIDS epidemic (Joseph and Appel, 1985). In the Beth Israel Medical Center, AIDS is now the leading cause of death for patients in methadone maintenance. All patients who died were in good standing in medical maintenance. The physicians treating the medical maintenance patients were able to coordinate medical care and the prescribing of pain medication with continuing methadone treatment.

There were 15 unfavorable discharges from medical maintenance. These involved patients who were using cocaine/crack, were administratively unable to report as directed, and lost medication. These patients were returned to their clinic of origin. As noted in Table 4, this group had the highest percentage of patients who lost medication (71%) and all had problems with cocaine/crack. As of September 1994, six (43%) were still in treatment within the Beth Israel system and of these, three of the patients appeared to have resolved their cocaine problems and were employed. The other three had continuing problems with cocaine/crack and valium. Two patients (14%) were incarcerated. One (7%) patient withdrew by entering the Stuyvesant Square Program (Beth Israel Medical Center) and entered therapy, including a 12 step program. This patient who now appears to be doing well had 22 years of methadone treatment before attempting to withdraw. No information was available about the whereabouts of 5 (36%) of the unfavorably discharged patients.

Ten patients successfully withdrew from methadone. They had accumulated a mean of about 16.7 years (SD=4) of methadone treatment. The favorably discharged patients also appeared to have the best records for care of their medication and the lack of illicit drug use. Information was obtained on all ten favorable withdrawals (100%) through patient interviews (5 patients), or information relayed through a relative (2 patients), or from their former physicians (3 patients). It appears that the ten former patients are abstaining from use of heroin. Five consented to be interviewed: of which three are in therapy, one is in a 12 step program and one is functioning without therapy. One former patient in long term psychotherapy is also being prescribed antidepressants. However, one of the four, despite therapy, appears to be having some problems with drug craving: he had a dream about heroin within a two week period prior to the follow-up interview, has problems sleeping and has written a song about heroin. However, he has not relapsed to use of opiates.

Two of the former patients, a married couple with children, moved to a small town in a rural area. They were contacted by a sibling who is a patient in the medical maintenance program about participating in this study. The couple refused to participate or even be interviewed by phone. While on methadone, the husband completed college, professional graduate education and established a professional practice. The sibling advised this investigator that her brother would not cooperate because he feared a possible breach of confidentiality. Any suspicion of past addiction and methadone treatment could destroy his career. We were told that he and his wife are doing well and that there are no problems with drug use.

Information obtained from medical maintenance physicians on three cases indicated that the former patients moved to other locations and appeared to be doing well. One of the three, however, is an unemployed Vietnam veteran in receipt of disability benefits who is under psychiatric and medical care at a local Veterans Administration Hospital.

One patient decided to return to the clinic of origin because of confidentiality concerns. The patient used two names -- one as a methadone patient in the clinic system and the other as an employee. Nobody at the patients place of work about the patients enrollment in the methadone program. This patient subsequently died of cancer after returning to the clinic program. The extreme caution that this patient took to conceal enrollment in the methadone program reflects the stigmatized condition that methadone patients must contend with. It is a prime example of a discreditable person trying to conceal their stigmatized condition so as not to become a discredited person (Goffman, 1963).

Summary of Outcomes

Table 4

**Outcomes of 100 Patients in Medical Maintenance 4.8 to 10.5 Years**
Outcome	Number of Patients N (%)	Number of Patients With Incidents of Lost Medication N (%)	Number of Patients WithTransient Substance Abuse N (%)
Good Standing in Treatment	67 (100)	7 (10)	3 (4)
Unfavorable Discharge	15 (100)	10 (66)	15 (100)
Withdrawal in Good Standing	10 (100)	0 (0)	0 (0)
Deaths	7 (100)	1 (14)	0 (0)
Voluntary Return to Clinic	1 (100)	0 (0)	0 (0)

Table 4 summarizes the outcomes of the 100 patients. Aside from the outcomes discussed above, sixty seven remain active and in good standing in medical maintenance. The only patients who did not succeed in medical maintenance were the 15 who received unfavorable discharges.

Of the 67 active cases, 6 (9%) have retired and are living on pensions with their families. The remaining patients are still employed in a variety of jobs that span the labor market in the metropolitan area or they are successful owners of their own businesses. Over a ten year period there were seven patients that had lost medication on one occasion and 3 that had transient problems with alcohol or cocaine. However, these problems were resolved with referrals to therapy, and the patients continued in good standing in medical maintenance.

Table 5a summarize the dose levels by type of employment of the active patients at the time of their admissions to medical maintenance. For active patients 45% entered medical maintenance on doses of 50 to 100 mg/day. Patients on lower doses started treatment on higher doses but over the years, reduced their dose to levels that were comfortable, allowed them to function without withdrawal symptoms, drug craving or illicit drug use. For Table 5b similar employment categories can be noted in every category (active, favorable and unfavorable discharges and deaths) and at every level of dose.

Table 5a

Level of Dose by Type of Employment for Sixty Seven Active Cases
at Time of their Admissions to Medical Maintenance
Level of Dose mg/day	N (%)	Type of Work
05 - 20 mg/day	11 (16)	auto mechanic, bartender, 3 counselors, drafting, 2 maintenance men, owner of business, social worker , TV repairman
30 - 40 mg/day	18 (27)	agency administrator, computer operator, construction crane operator, 4 counselors, electronics salesman, elevator mechanic, musician, owns business, rental agent, secretary, skyscraper window cleaner, sports events coordinator, supervisor, teacher, warehouse manager
50 - 60 mg/day	11 (16)	bookkeeper/computer, 3 counselors, doorman, electrician, graduate student, musician, owns business, postal worker, sales
70 - 80 mg/day	14 (21)	bookkeeper, computer systems analyst, 2 counselors, electrician, fire department, 3 health workers, 2 owners of businesses patient advocate/benefits, quality assurance clerk, sales
90 - 100 mg/day	13 (19)	cab driver, clerk, computer software business, electrician/teacher, electrician, elevator operator, maintenance man, manager of store, office worker, 2 owners of businesses, paralegal, personnel manager

Table 5b

**Level of Dose by Type of Employment for Sixty Seven Active Cases at the Time of their Admissions to Medical Maintenance**
		Type of Discharge and Employment
Level of Dose N (%)	Deaths N = 7	Unfavorable Discharges N = 15	Favorable Discharges N = 11*
10 - 25 mg/day	rare book dealer	government worker	disabled Vietnam vet, systems analyst, owns business, temporary jobs, health care analyst
30 - 40 mg/day	2 counselors, carpenter, owner of business	attorney, businessman, maintenance, skilled worker, stenographer, counselor	counselor, owns business
50 - 60 mg/day		Investment broker	owns business, clerk,** professional
70 - 80 mg/day	painting contractor, counselor	cabinet maker, counselor, doorman, limo driver, musician, manager, programmer	office manager

* Favorable discharges include the ten patients who medically withdrew from methadone and the one patient** who voluntarily returned to the clinic system.

The medical maintenance patients in construction and electrical work are careful workers and report that methadone does not interfere with balance or coordination. They have accrued impressive safety records and have been employed in their jobs for up to 20 years without incident. Also, one patient obtained a pilot's license and another races boats as a hobby.

In summation, there is no association between level of dose, patient outcome, type of employment and ability to function. A physician who has treated about 60 medical maintenance patients reports that he would expect a variety of doses over time in methadone treatment. He compares it with the varied doses he prescribes to patients with diabetes and thyroid conditions. He indicated that from a clinical perspective, there are only appropriate doses and that these may vary for long term methadone patients as they do for patients with other chronic conditions. Those on higher doses are not "sicker" than those on lower doses. He considers dose to be a medical decision that permits patients to function optimally.

During the period 1985 though 1991, 28 patients received increases in their methadone above those prescribed at time of admission. The reasons were that patients were not feeling comfortable on the prescribed dose. They had tried to adjust to doses that were not adequate. The increases were in most cases minimal: four patients were increased by 5 mg/day, sixteen by 10 mg/day, five by 20 mg/day, one by 30 mg/day and two by 40 mg/day over an extended period of time. Two of those who were increased were subsequently sent back to their clinic of origin for cocaine use.

Tests of significance were carried out on certain variables to determine whether there were significant differences in outcomes between the following four groups of patients: 1) the sixty-seven who remained active, 2) the eleven who were favorably discharged (e.g., the ten who completed medical withdrawals and the one who voluntary return to the clinic), 3) the seven who died, and 4) the fifteen who received unfavorable discharges.

Analysis of variance was carried out on the following variables to determine whether significant differences existed between the groups of patients: age first used narcotics, years of addiction to heroin, number of arrests, annual income at time of admission, duration of methadone maintenance treatment prior to entering medical maintenance, age admitted to medical maintenance and dose. Chi square tests were carried out on the variables of gender, ethnicity and level of education to determine if there were differences between the groups of patients.

Of the above variables, the only one that showed a significant difference between the groups was the number of arrests. The F value is 5.1283 (p=.0025). However while the major finding is that the patients who died had the highest average number of arrests (15) prior to entering methadone treatment, the last arrests took place about 15 to 30 years prior to the deaths. Criminal behavior was not in evidence while the patients were enrolled in methadone treatment. They were compliant patients in good standing with good jobs. Except for one homicide (an accidental stray bullet on the street), the patients died from medical deaths unrelated to methadone treatment or their heroin addictions.

The trends in arrests for the other groupings show that those with favorable discharges had the lowest average number of arrests (2.3) prior to entering methadone treatment, followed by those who remained active (5.1), followed by those who were unfavorably discharged (7.7). These trends may reflect the extent of pretreatment deviant behavior that predict outcomes in medical maintenance. Further research with larger numbers of discharges is indicated to determine whether pretreatment arrests actually reflect outcomes in methadone treatment.

Position of American Society of Addiction Medicine (ASAM),
National Alliance of Methadone Advocates (NAMA), and the
American Methadone Treatment Association (AMTA)

Both ASAM and NAMA have approved of the concept of medical maintenance (National Alliance of Methadone Advocates, April 1994). ASAM is preparing a resolution for adoption by the American Medical Association to approve the development of methadone treatment in private medical practice (Payte, 1994). ASAM is interested in developing a training program for private physicians and their nurses who will be linked to and receive referrals from appropriate methadone maintenance programs. The concept of medical maintenance has also been accepted by NAMA (Novick, 1994) and AMTA (Parrino, 1995). Therefore, the three major organizations of physicians (ASAM), patients (NAMA) and the providers (AMTA) are in agreement that medical maintenance is an appropriate treatment for select methadone patients who are socially rehabilitated and no longer in need of counselling or services offered by the clinic system.

Medical maintenance has shown itself to be a highly effective form of methadone treatment for selected socially rehabilitated and employed methadone patients. These patients were originally treated in the conventional clinic system. While this system has advantages for patients with serious social and medical problems, the system and its controls mitigates against the further rehabilitation of employed patients who are medically and socially stable. The continuation in regular methadone programs with serious restrictions on travel and scheduling are counterproductive for patients who have family, jobs and careers that demand freedom.

The current study has shown that the majority of patients who entered medical maintenance have continued and improved their social adjustments by performing well on their jobs, establishing businesses, obtaining college, graduate and other training and improving their family and social lives. Those who were unable to adjust in this program were returned to their clinic of origin. Ten patients withdrew from methadone in good standing and on follow-up were still abstinent. In summation this pilot project has demonstrated that selected socially rehabilitated methadone patients can be treated successfully in private medical practice. The concept has the backing of major organizations of physicians (ASAM), patients (NAMA) and providers (AMTA).

Chemical Dependency Research Working Group

X Retention in Medical Maintenance

Table 2

Table 3

Table 4

Table 5a

Table 5b

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Retention in Medical Maintenance