Methadone medical maintenance in primary care

BACKGROUND: Methadone is effective treatment for opioid addiction, but regulations restrict its use. Methadone medical maintenance treats stabilized methadone patients in a medical setting, but only experimental programs have been studied. OBJECTIVE: To evaluate the implementation of the first methadone medical maintenance program established outside a research setting. DESIGN: One-year program evaluation. SETTING: A public hospital and a community opioid treatment program. PARTICIPANTS: Methadone patients with >1 year of clinical stability. Eleven generalist physicians and 4 hospital pharmacists. INTERVENTIONS: Regulatory exemptions were requested. Physicians and pharmacists were trained. Patients were transferred to the medical setting and permitted 1-month supplies of methadone. MEASUREMENTS: Patient eligibility and willingness to enroll, treatment retention, urine toxicology results, change in addiction severity and functional status, medical services provided, patient and physician satisfaction, and physician attitudes toward methadone maintenance. RESULTS: Regulatory exemptions were obtained after a 14-month process, and the program was cited in federal policy as acceptable for widespread implementation. Forty-nine of 684 patients (7.2%) met stability criteria, and 30 enrolled. Twenty-eight were retained for 1 year, and 2 transferred to other programs. Two patients had opioid-positive urine tests and were managed in the medical setting. Previously unmet medical needs were addressed, and the Addiction Severity Index (ASI) medical composite score improved over time (P=.02). Patient and physician satisfaction were high, and physician attitudes toward methadone maintenance treatment became more positive (P=.007). CONCLUSIONS: Methadone medical maintenance is complex to arrange but feasible outside a research setting, and can result in good clinical outcomes.     

The cost-effectiveness of methadone maintenance as a health care intervention

Aims. Cost-effectiveness analysis using life-years of survival as the measure of treatment benefit is widely used in the economic evaluation of health care interventions but has not been applied to substance abuse treatment. The cost-effectiveness of methadone maintenance was evaluated to demonstrate the feasibility of applying this method to substance abuse treatment. Design. A literature review was undertaken to determine the effect of methadone treatment on the rate of mortality associated with opiate addiction. Information was also obtained on the average cost and duration of treatment. A two-state Markov model was used to estimate the incremental effect of methadone on the life span and treatment cost of a cohort of 25-year-old heroin users. Findings. Providing opiate addicts with access to methadone maintenance has an incremental cost-effectiveness ratio of $5915 per life-year gained (that is, for every year of life that is saved by providing methadone to opiate addicts, an additional $5915 in treatment costs are incurred). One-way sensitivity analysis determined that the ratio was less than $10 000 per-life year over a wide range of modeling assumptions. Conclusions. The ratio determined for methadone is lower than that of many common medical therapies, and well within the $50 000 threshold for judging cost-effectiveness. Even if decision makers do not wish use the same ratio that is applied to the general population, this method allows substance abuse treatment enhancements to be compared to improvements in health services offered to individuals with substance abuse disorders. Future work will require information on the impact of methadone treatment on the cost of health care and public programs, the indirect costs incurred by patients, and adjustments to reflect quality of life.     

Methadone Regulations and Public Policy: The New York Experience

Methadone treatment of opiate addiction is a controversial yet beneficial medical activity [1,2]. Strictly regulated at the local, state, and federal level, methadone treatment to be effective requires a close relationship between health care providers and the government [3,4]. Based on recent experiences in New York State, this article describes the government-health care partnership by taking note of both positive and problematic outcomes in the methadone field.     

Treating opioid dependence. Growing implications for primary care

Almost 3 million Americans have abused heroin. The most effective treatment for this concerning epidemic is opioid replacement therapy. Although, from a historical perspective, acceptance of this therapy has been slow, growing evidence supports its efficacy. There are 3 approved medications for opioid maintenance therapy: methadone hydrochloride, levomethadyl acetate, and buprenorphine hydrochloride. Each has unique characteristics that determine its suitability for an individual patient. Cardiac arrhythmias have been reported with methadone and levomethadyl, but not with buprenorphine. Due to concerns about cardiac risk, levomethadyl use has declined and the product may ultimately be discontinued. These recent safety concerns, specifics about opioid detoxification and maintenance, and new federal initiatives were studied. Opioid detoxification has a role in both preventing acute withdrawal and maintaining long-term abstinence. Although only a minority of eligible patients are engaged in treatment, opioid maintenance therapy appears to offer the greatest public health benefits. There is growing interest in expanding treatment into primary care, allowing opioid addiction to be managed like other chronic illnesses. This model has gained wide acceptance in Europe and is now being implemented in the United States. The recent Drug Addiction Treatment Act enables qualified physicians to treat opioid-dependent patients with buprenorphine in an office-based setting. Mainstreaming opioid addiction treatment has many advantages; its success will depend on resolution of ethical and delivery system issues as well as improved and expanded training of physicians in addiction medicine.     

海洛因成瘾者对美沙酮维持治疗的态度及相关因素

美沙酮维持治疗虽已有接近50年的历史,但是医疗机构与海洛因成瘾者双方依然存在对于美沙酮维持治疗态度的差异,主要表现在对于美沙酮治疗方式、美沙酮性质、不良反应、治疗效果等方面的不同认识。美沙酮这种多年来逐渐被医疗机构认为需终生维持的药物,海洛因成瘾者看来更应该作为短期内通过剂量递减方式实现戒断海洛因目的的药物,海洛因成瘾者同时认为美沙酮存在较强的不良反应和戒断症状。海洛因成瘾者形成此种态度的现状,则主要受到医生对于维持治疗方式的支持程度、本人是否参加过美沙酮维持治疗以及其他海洛因成瘾者参加治疗失败的经历的影响。     

Evidence-based treatment for opiate-dependent clients: availability, variation, and organizational correlates

The majority of opiate-dependent clients entering substance abuse treatment are referred to "drug-free" (non-methadone) modalities. Given the known challenges of treating these clients in drug-free settings relative to the documented effectiveness of methadone maintenance, these analyses investigate the availability of various clinical and wraparound services for this population among a US sample of addiction treatment programs with and without methadone maintenance services (N = 763). Face-to-face interviews conducted in 2002-2003 gathered data on the number of opiate-dependent clients treated; organizational characteristics, including size, ownership, accreditation, and staffing; treatment practices, including methadone availability, use of other pharmacotherapies, and levels of care; and services offered, including vouchers, transportation, and other wraparound services. Facilities treating proportionately more opiate-dependent clients were significantly more likely to offer a variety of evidence-based services, regardless of methadone availability. Implications for referral linkages and quality of care are discussed.     

Evidence-Based Treatment for Opiate-Dependent Clients: Availability,Variation, and Organizational Correlates

The majority of opiate-dependent clients entering substance abuse treatment are referred to “drug-free” (non-methadone) modalities. Given the known challenges of treating these clients in drug-free settings relative to the documented effectiveness of methadone maintenance, these analyses investigate the availability of various clinical and wraparound services for this population among a US sample of addiction treatment programs with and without methadone maintenance services (N = 763). Face-to-face interviews conducted in 2002–2003 gathered data on the number of opiate-dependent clients treated; organizational characteristics, including size, ownership, accreditation, and staffing; treatment practices, including methadone availability, use of other pharmacotherapies, and levels of care; and services offered, including vouchers, transportation, and other wraparound services. Facilities treating proportionately more opiate-dependent clients were significantly more likely to offer a variety of evidence-based services, regardless of methadone availability. Implications for referral linkages and quality of care are discussed.     

Fiscal strain and access to opiate substitution therapy at Department of Veterans Affairs Medical Centers

This study examines the relationship between institutional fiscal strain and the availability of opiate substitution therapy (eg, methadone maintenance), an effective but relatively expensive treatment for heroin addiction. An observational design was used to examine the association of changes in funding and changes in provision for treating opiate addiction at 29 VA Medical Centers (VAMCs). We hypothesized that VAMCs experiencing greater fiscal strain would show reduced availability of opiate substitution treatment. Administrative records from each of 29 VAMCs that provided opiate substitution therapy in both Fiscal Year (FY) 1995 and FY 1999 were used to measure changes in the availability of this service, ie, the percent change in total patients treated, annual visits per patient, and total services delivered. Institutional fiscal strain was measured by the percent decline in per capita funding at four levels at each VAMC: the entire medical center, all mental health programs, all substance abuse programs (inpatient and outpatient), and outpatient substance abuse programs alone. The total number of patients receiving opiate substitution increased from 5,549 in FY 1995 to 6,884 in FY 1999 (24%), annual visits per patient decreased by 16%, and the total number of units of services increased by 4%. There were no significant relationships between changes in the delivery of opiate substitution services and changes in per capita funding at any of the four institutional levels. No new programs were started during these years. Although no new programs were started, the availability of opiate substitution therapy at VA facilities with existing programs was maintained over a five-year period regardless of local funding changes, although at somewhat reduced intensity.     

Towards a rehabilitation of methadone maintenance: integration of relapse prevention and aftercare

Methadone maintenance was originally proposed as a long-term treatment modality for opiate addiction. However, most clients leave methadone maintenance rather than take methadone indefinitely and subsequently relapse to opiate use. In this article, the author examines relapse to opiate use by clients during and after methadone maintenance treatment in the United States. He reviews models of relapse prevention and aftercare which may be applicable to clients in methadone treatment. There now exist structured and psychotherapeutic relapse prevention methods which may be integrated into methadone maintenance treatment and could serve, in addition, to revitalize methadone maintenance treatment.     

French field experience with buprenorphine

In most European countries, methadone treatment is provided to only 20-30% of opiate abusers who need treatment due to regulations and concerns about safety. To address this need in France, all registered medical doctors since 1995 have been allowed to prescribe buprenorphine (BUP) without any special education or licensing. This led to treating approximately 65,000 patients per year with BUP, about ten times more than with more restrictive methadone policies. French physician compensation mechanisms, pharmacy services, and medical insurance funding all minimized barriers to BUP treatment. About 20% of all physicians in France are using BUP to treat about half of the estimated 150,000 problem heroin users. Daily supervised dosing by a pharmacist for the first six months resulted in significantly better treatment retention (80% vs 46%) and lower heroin use. Intravenous diversion of BUP may occur in up to 20% of BUP patients and has led to various infections and relatively rare overdoses in combination with sedatives. Opiate overdose deaths have declined substantially (by 79%) since BUP was introduced in 1995. Newborn opiate withdrawal in mothers treated with buprenorphine compared to methadone was reported to be less frequent, less severe, and of shorter duration. Although some of the public health benefits seen during the time of buprenorphine expansion in France might be contingent upon characteristics of the French health and social services system, the French model raises questions about the value of tight regulations on prescribing BUP imposed by many countries throughout the world.     

Barriers and facilitators to primary care or human immunodeficiency virus clinics providing methadone or buprenorphine for the management of opioid dependence

BACKGROUND: Federal initiatives aim to increase office-based treatment of opioid dependence, but, to our knowledge, factors associated with willingness to deliver this care have not been defined. The objective of this study was to describe clinics' willingness to provide methadone hydrochloride or buprenorphine hydrochloride for opioid dependence. METHODS: The design of the study was a survey conducted in New York State. Two hundred sixty-one directors of primary care and/or human immunodeficiency virus specialty clinics (response rate, 61.1%) that serve Medicaid enrollees were questioned. Outcomes were willingness to provide methadone and buprenorphine. Predictors included clinic characteristics, attitudes about drug users and their treatment, and reported barriers and facilitators to treatment. RESULTS: Clinics were more willing to provide buprenorphine than methadone treatment (59.8% vs 32.6%; P < .001). Clinics offering human immunodeficiency virus specialty care (adjusted odds ratio [AOR], 2.16; 95% confidence interval [CI], 1.18-3.95) or a safe location to store narcotics (AOR, 2.99; 95% CI, 1.57-5.70) were more willing to prescribe buprenorphine and more willing to provide methadone. Willingness was positively associated with continuing medical education credits for training, but negatively associated with greater concern about medication abuse. Immediate telephone access to an addiction expert was associated with willingness to provide buprenorphine (AOR, 2.08; 95% CI, 1.15-3.76). Greater willingness to provide methadone was associated with a belief that methadone-treated patients should be seen along with other patients (AOR, 6.20; 95% CI, 1.78-21.64), methadone program affiliation (AOR, 4.76; 95% CI, 1.64-13.82), and having more patients with chronic pain in the clinic (AOR, 2.80; 95% CI, 1.44-5.44). CONCLUSIONS: These clinics serving Medicaid enrollees were more receptive to buprenorphine than methadone treatment. Willingness to provide this care was greater in clinics offering human immunodeficiency virus services, treating more chronic pain, or affiliated with methadone programs. Accessible addiction experts and continuing medical education for training may facilitate adoption of this care.     

Evaluation methodology

The results of several large methadone maintenance programs are reviewed and the outcome measures used are analyzed. Criteria measures were often vague and sometimes not defined. Many studies base their findings on unverified patient self-reports because costs for more reliable and systematic data collection are prohibitive. Available data does not allow for resolution of the pro- or antimethadone maintenance views for treatment of heroin addiction.     

Evaluating outcome criteria used in methadone maintenance programs.

This report reviews the results of several large methadone maintenance programs and analyzes the outcome measures used. Criteria measures were often vague and sometimes not defined. Many studies base their findings on unverified patient self-report because costs for more reliable and systematic data collection are prohibitive. Available data does not allow for resolution of the pro- or antimethadone maintenance views for treatment of heroin addiction.     

Evaluation of the 21-day outpatient heroin detoxification

There is a paucity of studies in the literature documenting failure rates of outpatient detoxification from heroin. This study reports on the results of the 21-day ambulatory treatment program at the Miami Veterans Administration Hospital. Heroin users with less than a 2-year history of opiate use must complete the detoxification process within 21 days according to federal regulations. The results of this study indicate 100% "unsuccessful drug rehabilitation" utilizing the 21-day outpatient detoxification treatment modality, a finding similar to studies conducted to evaluate results of inpatient methadone treatment programs.     

Alcohol use by heroin addicts: evidence for an inverse relationship. A study of methadone maintenance and drug-free treatment samples

This study examines the relationship between the patterns of use of alcohol and heroin by narcotics addicts, and evaluates the hypothesis--frequently reported during methadone maintenance--that this form of treatment can be causally implicated in an increased consumption of alcohol. Data were obtained on lifetime patterns of alcohol and heroin use of 375 Anglo and Chicano male addicts sampled from two treatment sources: the nonmethadone (drug-free) California Civil Addict Program (CAP) and several Southern California Methadone Maintenance (MM) programs. Repeated-measures MANOVAs revealed that alcohol and heroin consumption were inversely related throughout the addicts' careers. This pattern was evident in the addiction, treatment, and postdischarge stages of Anglo and Chicano addict careers, in both the CAP and MM samples. Consequently, the authors reject the hypothesis that increased alcohol consumption is caused solely by addicts' participation in methadone maintenance treatment. Rather, the findings suggest that addicts' alcohol use during methadone treatment reflects a lifetime pattern of increased alcohol use following any decline in heroin intake.     

A National Study of the Retention of Irish Opiate Users in Methadone Substitution Treatment

Background: Retention in treatment is a key indicator of methadone treatment success. The study aims to identify factors that are associated with retention. Objectives: To determine retention in treatment at 12 months for Irish opiate users in methadone substitution treatment and to indicate factors that increase the likelihood of retention. Methods: National cohort study of randomly selected opiate users commencing methadone treatment in 1999, 2001, and 2003 (n = 1269). Results: Sixty-one percent of patients attending methadone treatment remained in continuous treatment for more than 1 year. Retention in treatment at 12 months was associated with age, gender, facility type, and methadone dose. Age and gender were no longer significant when adjusted for other variables in the model. Those who attended a specialist site were twice as likely to leave methadone treatment within 12 months compared with those who attended a primary care physician. The most important predictor of retention in treatment was methadone dose. Those who received <60 mg of methadone were three times more likely to leave treatment. Conclusion: Retention in methadone treatment is high in Ireland in a variety of settings. The main factors influencing retention in methadone treatment was an adequate methadone dose and access to a range of treatment settings including from primary care physicians. Scientific Significance: Providing an adequate dose of methadone during treatment will increase the likelihood of treatment retention. Methadone treatment by the primary care physician is a successful method of retaining opioid users in treatment.     

The perceptions of program directors and clients regarding the efficacy of methadone treatment.

A statewide sample of regional coordinators, program directors, and clients associated with opiate addiction treatment programs revealed their biases and expectations regarding the efficacy of methadone as a form of treatment. Methadone and drug-free program directors held consistent beliefs about treatment except the efficacy of methadone. Prior methadone clients currently in drug-free programs were skeptical of the methadone treatment, unlike clients currently in methadone treatment. The data reveal differences of opinions across the levels of the treatment system represented in the survey. In policy decisions, the need to consider empirical evidence in addition to personal opinions is emphasized, if consensus is ever to be realized.     

Treatment collaboration of methadone maintenance programs and therapeutic communities

Although they developed from different backgrounds, therapeutic communities and methadone maintenance programs became major treatments of heroin abuse in the 1970s. Research published in the last 5 years demonstrates that therapeutic communities are associated with long-lasting improvements in functioning for the few drug abusers who stay in treatment at least 3 months. A principal limitation of this modality is that few patients remain in treatment long enough to acquire the changed values that produce long-lasting effects. Research on methadone maintenance continues to show that this treatment produces immediate decreases in criminality and drug abuse; however, patients who taper off of maintenance are prone to relapse. The aspects of treatment that appear to prevent relapse include minimizing withdrawal symptoms during tapering and providing support during and after completing maintenance. The strengths of these two treatment modalities can be combined to enable narcotic addicts to taper off of methadone maintenance in a therapeutic community and remain drug-free. Several other clinical, administrative, and research collaborations could be beneficial, pooling the medical/technical expertise of maintenance programs with the intensity of therapeutic community treatment.     

Heroin anticraving medications: A systematic review

Background: Heroin craving is a trigger for relapse and dropping out of treatment. Methadone has been the standard medication for the management of heroin craving. Objectives: We explored the medication options other than methadone which may have heroin anticraving properties. Methods: To be selected for the review, articles had to include outcome measures of the effect of the studied medication on subjective and/or objective opiate craving and be of the following two types: () randomized, controlled, and/or double-blind clinical trials (RCTs) examining the relationship between the studied medication and heroin craving; () nonrandomized and observational studies (NRSs) examining the relationship between the studied medication and heroin craving. Thirty-three articles were initially included in the review. Twenty-one were excluded because they did not meet the inclusion criteria. We present the results of 12 articles that met all the inclusion criteria. Results: Some new medications have been under investigation and seem promising for the treatment of opiate craving. Buprenorphine is the second most studied medication after methadone for its effect on opiate craving. At doses above 8 mg daily, it seems very promising and practical for managing opiate craving in patients receiving long-term opioid maintenance treatment. Conclusions and Scientific Significance: In doses higher than 8 mg daily, buprenorphine is an appropriate treatment for opiate craving. More research with rigorous methodology is needed to study the effect of buprenorphine on heroin craving. Also more studies are needed to directly compare buprenorphine and methadone with regard to their effects on heroin craving.