Reguarding Methadone Treatment

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OVERVIEW

Over two million Americans have tried heroin, the most commonly abused opiate drug in the United States, and heroin use is on the increase. Statistics suggest that there are about 810,000 heroin addicts nationwide, with 250,000 in New York State, the majority of whom live in and around New York City.

Since introduced for the treatment of heroin addiction more than thirty-five years ago, methadone treatment has saved the lives of tens of thousands of persons throughout the world. Developed in 1964 by Drs. Vincent P. Dole and Marie Nyswander at Rockefeller University in New York City, methadone treatment is now used worldwide by over 30 countries. It is a significant therapy for diminishing opiate abuse and promoting a better quality of life for patients and their families.

For more than three decades, methadone treatment has been thoroughly evaluated and consistently found to be clinically safe as well as beneficial to individuals and communities. Methadone treatment, and other pharmacotherapies for opiate addiction offered through methadone treatment providers, play a pivotal role in:

stabilizing the lives of patients and dramatically diminishing heroin and non-narcotic drug use,
Markedly decreasing patient criminality, with greater decreases seen the longer the tenure in methadone treatment,
reducing behaviors associated with risk of exposure to and spread of HIV/AIDS and other infectious diseases,
improving patients' effective use of health services, overall health outlook, social productivity, and employability, and
offering cost-effective care to patients and communities. One large scale analysis found that for every dollar spent on methadone treatment, more than $4 are saved in social and health care costs.

Today, more than 179,000 persons receive substance abuse treatment and health-related services in methadone treatment facilities across the United States. Many thousands more are treated worldwide. In New York, methadone treatment is the State's most widely used therapy for heroin addiction, with 43,000 citizens in community-based methadone treatment programs throughout the State.

With a rich history and proven record, the value of methadone treatment continues to be affirmed. Regarding Methadone Treatment and Other Pharmacotherapies: A Review provides a unique overview of methadone treatment- its principles, scope, benefits and outcomes, describing how this important modality, and newly evolving pharmacotherapies for opiate addiction, can work positively in the lives of individuals and their communities.

(1) The language is confusing - drug abuse, drug dependence, drug addiction. What do they mean?

While the terms are often used interchangeably, distinctions are generally made among the terms drugabuse, drug dependence, and drug addiction.

Drug abuse refers to self administration of a substance without medical supervision or for purposes other than medicaly intended.
Drug dependence occurs when the body adapts to the presence of a drug. Tolerance requires an increaseing amount of the drug to acheive the same effect, and withdrawal occurs when the drug is abruptly removed. Drug dependence in itself is not necessaarily damaging, as many persons are medically treated on certain medications to address chronic illnesses or conditions.
Drug addiction referes to the overwhelming compulsion to continue taking a drug in the face of negative health, social, financial, and/or legal consequences.

(2) What causes people to abuse drugs?

The underlying causes of drug abuse involve biological, psychological, and social/environmental factors.

Study of the biological basis for addiction has revealed brain mechanisms and body chemistry changes involved in drug abuse. Basic medical research has now strongly established that adiction is a chronic, relapsing disease of the brain, with a range of physical, behavioral, social and public health manifestations.
The psychological factors associated with drug use are the most familiar to the public. Psychological theories suggest that people abuse drugs in an attempt to self-medicate to avoid unpleasant feelings or emotions, and to escape from the pressures and realities of living. It is generaly held that adicts are taking drugs to feel better/normal (self-medicating) or to feel good (sensation-seeking).
Social/environmental factors are also critical. Family and cultural beliefs about drugs and alcohol, family substance use, availability of drugs in the community, and acceptability of use within the social environment and peer group may contribute to drug use. Unemployment, poverty, poor housing, homelessness, and educational deficits also correlate with increased drug use.

(3) What are opiates? How are they used medically, how are they abused?

Opiates are derived from the opium poppy plant that are used throughout the world to treat pain and their medical conditions. Synthetic (man-made) opiates are often used as pre-operative anesthesia, or to treat pain associated with surgical procedures or cancer, to alleviate symptoms of opiate withdrawal, and in treating heroin addiction.

Opiate drugs may be taken orally, intranasally, intramuscularly, intravenously, transdermally, or in suppository form. In all forms and routes of use, they are highly addictive; dependence is both physical and psychological. Persons taking opiates as prescribed may experience a sense of tranquility, decreased anxiety, reduced anger, elevation of mood, and a lessening of depression. Opiate drugs are used illicitly to achieve a state of euphoria or "high", and/or as self-medication to relieve depression, anxiety, and stress.

Recent research involving brain imaging suggests that addiciton to opiatesmay be the result of neurochemical and molecular changes in the brain prompted by the prolonged effects of repeated drug use, or based in pre-existing neurochemical deficits. Medical research has established that for many persons with long histories of use, opiate addiction is often a chronic, relapsing, but treatable condition.

Included among the drugs classified as opiates are: opium, morphine, heroin, codeine, and the synthetic opiates methadone, Demerol®, and Dilaudi®. This review focusses primarily on heroin, the most commonly abused opiate.

(4) What are the characteristics of heroin addiction?

Heroin addiction involves a combination of physiological, psychological, and social/behavioral characteristics.

Physiological/Psychological Characteristics: The effects of heroin last four to six hours and during the initial period of use, are highly pleasurable (euphoria, pain relief, calming). To continue feeling these desired outcomes, however, increasing amounts of the drug must be used to achieve the same effect. This is known as "tolerance." The user may at first inhale ("sniff") heroin or inject it into skin or muscle, but as tolerance builds, direct injection into a vein (commonly known as "mainlining") often results.

As the addiction develops, the heroin addict requires shorter intervals between doses and increasing amounts of heroin to avoid withdrawal symptoms, which include muscular and abdominal pains, chills, nausea, diarrhea, yawning, runny nose, generalized weakness and insomnia. Even after the acute phase of the withdrawal syndrome is over (48 to 72 hours), individuals may experience prolonged symptoms, including irritability, insomnia and drug craving, for months after drug use has stopped.

Social/Behavioral Characteristics: As addiction develops, the user's life increasingly focuses on drug-related endeavors, with consequent inattention to daily responsibilities and needs. Basic changes in the user's activities, self-image and relationships usually emerge. Since the addicted person must, with rare exception, deal with a criminal market, a way of life evolves which commonly entails physical and emotional hazards, general deterioration of health and hygiene, and isolation from most non-addiction friends, associates, and family. The short-acting nature of heroin precludes stability in daily living.

"The Clinton Administration's decision to make methadone more accessible to heroin users is a long-needed change in national policy...Decades of experience have shown that methadone treatment is the most effective way to control heroin adiction. Methadone blunts the craving for the opiate, with substantial benefits to society."

The New York Times Editorial, October 3, 1998

(5) What are the physical, social, and economic consequences of heroin addiction?

The White House in its National Drug Control Strategy (February 1995), "The heavy toll drug use exacts on the United States is most easily measured by the criminal and medical costs imposed on and paid for by the Nation's taxpaying citizens. One estimate places the total cost of drug use at $67 billion [per year]. Almost 70% of this is attributable to the costs of crimes; the remainder reflects medical and death-related costs."

Physical Consequences:Heroin abusers often experience extreme deterioration of health. They are at high risk for infections, drug overdose, HIV/AIDS, Hepatitis B and C, sexually transmitted diseases, and tuberculosis.

Use of heroin by needle injection poses risk of improper injection or unsterile needles that can cause infections such as septicemia (blood poisoning), endocarditis (infection of the heart lining), skin abscesses, and tetanus, or accidental injection of air leading to rapid death.
Sharing of needles, syringes and other injecting equipment substantially increases the occurrence of hepatitis (inflammation of the liver), and risk of exposure to the Human Immunodeficiency Virus (HIV).
Heroin users have been observed to have abnormalities in cellular immunity, compromising overall immune system function.

Social/Economic Consequences: Regular users often have difficulty maintaining concentration and alertness.

With life pursuits focussed on drug procurement and related activities, family and friends unrelated to drug use may be disregarded. Sexual function and interest is often impaired and intimacy inevitably suffers. Family stability is threatened.
While some can manage jobs, the urgency involved in treating heroin addiction often results in lateness, absenteeism, performance deficits, and alienation at the workplace, if not ultimate job loss.
If financial resources are insufficient to support the addiction, family and housing stability are threatened, and criminal activity as a means of support may arise.

(6) Why do heroin addicts seek treatment?

The impetus to stop heroin use and seek treatment may derive from complete exhaustion and "burnout" from addiction's harsh and demanding lifestyle; or it may be fear of the dangers of street life, or more serious illness. The catalyst may be pressure from family, friends, employers, or the legal system. It can also be the result of repeated unsuccessful personal attempts to stop heroin use, or the reality of personal, family, or economic collapse. Users seek professional help to find support for change, to handle life stress, to break unhealthy connections with drug-related associates and places, to regain a sense of stability, and to repair health and social problems.

(7) What forms of treatment are available for heroin and other addictions?

There are many models of treatment available to persons addicted to heroin or other drugs.

Medical withdrawal from drug dependence in a hospital or outpatient setting.
Long-term or short-term residential treatment in a therapeutic community involving therapy in a highly structured residential environment.

Outpatient programs emphasizing a range of counseling and psychotherapy without the use of methadone or LAAM.

Self-help fellowships, such as Narcotics Anonymous, that utilize the "twelve step" approach to abstinence.

Pharmacotherapies such as methadone treatment or LAAM therapy which uses medically prescribed methadone, LAAM or other medications to rebalance body chemistry, block the effects of heroin, and reduce craving.

Methadone to abstinence treatment which provides methadone in decreasing doses to medically withdraw heroin addicted persons.

Use of opiate antagonists, non-addictive drugs which block the effects of opiate drugs, often used to prevent relapse to opiate use.

The largest number of heroin abusers are treated in methadone treatment programs.

"Mere numbers do not reveal the multitude of intractable addicts that had given up on themselves and believed that theu would never have a normal life. Their lives have been restored, family relations rebuilt, and because of methadone, they are now able to achieve their full potential and life goals that were once unthinkable."

President, National Alliance of Methadone Advocates, 1999

(8)What is methadone treatment for opiate addiction?

Methadone treatment provides the heroin addicted person with health, social and rehabilitational services, and medically prescribed methadone to relieve withdrawal symptoms, reduce opiate craving, and allow normalization of the body's function. Methadone treatment has been the most widely studied approach to opiate addiction and has been in use effectively for over thirty-five years.

Methadone treatment programs are staffed by professionals with extensive medical, clinical, and administrative expertise. Patients receive individually prescribed methadone medication from a licensed medical staff member (physician, registered physician's assistant, registered or licensed practical nurse, or pharmacist). Patients routinely meet with a primary counselor (social worker, caseworker, or certified substance abuse counselor), attend clinic groups, and access medical and social services.

(9) How was methadone treatment developed and established for the treatment of heroin addiction?

The use of methadone to treat opiate addiction was pioneered by Drs. Vincent P. Dole and Marie Nyswander in the early 1 960's at Rockefeller University in New York. At that time, New York City was estimated to have half of the active heroin addicts in the United States. Heroin-related mortality was the leading cause of death among 1 5 to 35 year olds, and a record number of heroin-related criminal arrests were being recorded. The only available treatment - detoxification - was resulting in ineffective outcomes, with 90% or more of opiate detoxification treatments ending in relapse.

Dr. Dole, a senior physician and metabolic disease researcher, and Dr. Nyswander, a practicing psychiatrist with extensive expertise in opiate addiction, recognized that opiate relapse, in most cases, was related to persistent or recurrent drug craving, and that any approach to treatment must first address the craving factor. They theorized that by controlling drug craving through medically supervised opiate replacement, rehabilitation of lifestyle might also be possible. Their work, and that of researchers over three decades, produced dramatic outcomes, showing that when methadone is taken daily at adequate dosages (doses individually based, which ensure constant methadone blood levels from at least 150-200ng/ml, to a peak of 4006OOng/ml):

Opiate euphoria is absent and opiate withdrawal symptoms are eliminated.
Craving for opiates is effectively diminished.
The ability to focus on daily life activities and goals is restored.
Methadone "blocks" the effects of heroin and other opiate drugs, rendering ineffective attempts to take them to achieve euphoria.
The medication's long period of action, oral effectiveness, and low cost per dose make it suitable for use in outpatient clinic settings.

(10) What is apropriate Methadone dosing?

Methadone is a medication, and like all medications, proper dosing is contingent upon the patient's individual needs. Taken oraly, methadone is rapidly absorbed from the gastrointestinal tract, appears in plasma 30 minutes after ingestion, and peaks one hour later. Methadone is also widely distributed to body tissues where it is stored and then released into the plasma. This combination of storage and release keeps the patient comfortable by preventing opiate withdrawl. As is the case for any other medications (such as insulin or antihypertensives), propermethadone dosing is determined through the doctor-patient relationship, taking into account the patients medical assessment, individual metabolic needs, and other medical conditions and treatments. Attitudes or opinions about methadone dosing that are based on rationale other than scientific evidence on effective dosing detract from the potential value of methadone treatment.

(11) Is methadone treatment medically safe?

Research and clinical study, particularly the ongoing work of Dr. Mary Jeanne Kreek of Rockefeller University, has demonstrated the unequivocal medical safety of long-term methadone treatment.

Absence of Serious Adverse Effects: When taken under medical supervision as prescribed, long-term administration of methadone causes no adverse effects to the heart, lungs, liver, kidneys, blood, bones, brain, or other vital body organs. Minor side effects associated with methadone treatment constipation, water retention, drowsiness, skin rash, excessive sweating, and reported changes in sexual libido - may occur during the initial stages oi treatment. These symptoms usually subside or disappear as methadone dosage is adjusted and stabilized, as tolerance develops, or as simple medical interventions are initiated. The myth that methadone is physically harmful has been shown scientifically to be unfounded.

Absence of Harmful Medication interactions: No harmful interactions have been noted between methadone and other medicines. Patients with conditions such as HIV/AIDS, hypertension, diabetes, pneumonia, cardiac conditions, cancers, psychiatric disorders, etc., may be treated effectively with prevailing regimens and medications. Coordination of methadone with certain other drugs is necessary. Dilantin® for epilepsy and rifampin for tuberculosis increase the body's metabolism of methadone and thus prompt the need for methadone dosage increase. Opiate agonist/antagonist drugs (such as Talwin® and buprenorphine) should not be prescribed for methadone treated patients, as they will produce opiate withdrawl illness.

Safe for Pregnant Women: With proper stabilization in methadone treatment, sexual function normalizes for both men and women in methadone treatment. Women can conceive and have normal pregnancies and deliveries. When properly prescribed for pregnant women, methadone provides a non-stressful, non-eventful environment in which the fetus develops. Because methadone crosses the placental barrier, babies born to female methadone patients are at first physically dependent on methadone, and must be weaned. Successful weaning using Paregoric® is well established and uncomplicated. These children show normal physical, emotional, and cognitive development, comparable to the children of any mother of the same background. The myth that methadone produces abnormalities in fetuses is unfounded.

"...current policy puts too much emphasis on protecting society from methadone, and not enough on protecting society from the epedemic of addiction, violence and infections that methadone can help reduce."

Institute of Medicine, 1995

(12) Does methadone treatment impair mental function?

Methadone treatment has no adverse effects on intelligence, mental capability, or employability. Methadone treated patients are comparable to non-patients in their sensitivity to the environment, in reaction time, in ability to learn, focus, and make complex judgements. Study of the long-term effects of methadone treatment on patients' intelligence revealed that after ten years of continuous methadone treatment, standard intelligence test scores were the same or slightly higher than at onset of treatment. Further, methadone treated patients do well in a wide array of vocational endeavors, including professional positions, service occupations, and skilled, technical and support jobs. Methadone patients are lawyers, engineers, secretaries, truck or taxi drivers, roofers, gardeners, teachers, salespersons, architects, computer programmers, etc.

(13) Is methadone treatment the best treatment for all heroin users?

Methadone treatment was developed for persons with significant histories of heroin addiction. It is not appropriate for individuals who use heroin occasionaly, but are not, or never were, physically dependant on heroin. Methadone never was intended to be a treatment for all drug abuse problems.

(14) What is LAAM therapy for opiate addiction?

In 1996, the New York State Office of Alcoholism and Substance Abuse Services announced approval for the use of Levo-Alpha Acetyl-Methadol (LAAM), a longer acting opioid agonist medication for use in the treatment of opiate addiction within licensed and approved methadone treatment programs. LAAM was approved by the United States Food and Drug Administration in 1993 after its safety and effectiveness were documented in clinical trials involving over 6,000 patients. Like methadone, LAAM blocks the euphoric effects of heroin and dramatically reduces the craving for narcotics. More importantly, patients now have a choice of treatment medications, giving them greater input into their treatment and rehabilitation. Each LAAM dose lasts between 48 to 72 hours, and for some patients as long as 96 hours. Its use allows patients to visit the treatment clinic less frequently, bringing more freedom to work, attend school and parent children. Until more information is available, LAAM is presently not recommended for pregnant or nursing women, persons under 18 years of age, or access to treatment for many persons whom daily pharmacotherapy served as a barrier to treatment.

(15) What other pharmacotherapies may be useful in the treatment of opiate addiction?

Naltrexone, a non-addicting long-acting narcotic antagonist, was approved by the FDA in 1985, for the treatment of opiate addiction. It is effective from 1 to 3 days depending on dosage level, and it blocks the euphoric effects of heroin and other opiates. Thus far, research has demonstrated that naltrexone may be most helpful in preventing opiate relapse once an abstinence state has been acheived.

Naloxone is also a narcotic antagonist, blocking the effects of opiate drugs, but has a relatively short duration of action. It is used as an 'antidote' in treating opiate overdose by rapidly reversing the effects of opiate drugs.

Buprenorphine, while not yet approved for the treatment of opiate addiction, is another medication being carefully studied. Early clinical findings suggest that buprenorphine, a partial opiate agonist, is safe and produces few side effects or withdrawl symptoms. The National Institute on Drug Abuse, where significant research on new pharmacotherapies for opiate addiction is currently based, is continuing its study of the usefulness of buprenorphine.

(16) As the most researched pharmacotherapy for opiate addiction, how effective is methadone treatment? Is the outcome worth the cost?

Methadone treatment has positive outcomes for the individual and for the community. It has been found to be highly cost-effective. The Institute of Medicine² has concluded that "methadone treatment pays for itself on the day it is delivered, and posttreatment effects are an economic bonus."

Reduction in Heroin Use: Studies of methadone treatment have found dramatic declines in heroin use after admission to methadone treatment³, and further declines as patients remain in treatment&sup4;. Variations in policies limiting methadone dosage in some areas of the United States adversely affect discontinuance of heroin use.

A landmark 1970's study of over 10,000 New York City methadone patients showed an 85% reduction in the number using heroin within the first year of treatment, 94% reduction among patients in treatment for three or more years&sup5;.
A 1986-1988 field study of 617 male methadone treatment patients in New York City, Philadelphia, and Baltimore, found abstinence from heroin for 92.4% of those in methadone treatment for more than 4.5 years; and 96.6% presented no use of other illicit opiates&sup6;.
1990 examination by the U.S. General Accounting Office of methadone treatment programs nationwide, found that for the New York programs reviewed, heroin use was eliminated for an average of 96% of patients in treatment for six months or longer&sup7;.
A major nationwide study of drug abuse treatment outcomes in the 1990's found that the number of patients reporting heroin use decreased 62% within two years of entering methadone treatment&sup8;.
Another investigation showed that 85% of 229 patients in methadone treatment for over ten years were free of illicit heroin use&sup9;.

Reduction in Criminality: Methadone treatment is associated with reduced criminal activity, and decreases in criminal behavior are greater the longer a person is in treatment.

In a nationwide investigation¹0;, 82% of methadone patients studied had been arrested at least once before treatment; by contrast, the arrest rate during treatment was only 19%.
Another national study¹1; of over 10,000 drug users entering drug treatment from 1979 to 1981 revealed that the percentage of methadone treatment patients who had committed one or more predatory crimes declined from almost 32% before entering methadone treatment to 9.8% during the first three months of treatment. Three to five years after leaving methadone treatment, these persons' arrests were still down 50% over pre-treatment rates.
A three-city field study of methadone treatment patients in New York City, Baltimore and Philadelphia¹2; found a marked reduction in criminality across fourteen types of crimes for patients integrated into methadone treatment, most categories declining over 80%.
Lifetime arrest rates of 151 male patients in Baltimore demonstrated a substantial reduction after admission to methadone treatment, an 85% decrease in the annual arrest rate from the addiction years¹3;.

Reduction in Risk of HIV/AIDS: The relation between intravenous (IV) drug use, needle sharing and HIV/AIDS exposure is well documented. Methadone treatment is its pivotal role in reducing the spread of HIV/AIDS.

One study¹4; demonstrated that methadone treatment is effective not only in decreasing intravenous drug use, but also in reducing needle sharing.
Data from the three-city field study of New York City, Baltimore and Philadelphia¹5; revealed that 71 % of 388 methadone patients in treatment for over a year had ceased IV drug use. Needle sharing behavior also markedly declined. In contrast, 82% of 105 patients who left treatment relapsed rapidly to IV use.
Studies from Sweden¹6; to the Bronx¹7; showed that persons in methadone treatment before 1983 were significantly less likely to test positive for HIV than those who entered treatment in later years (from 1984-86, and after 1987).
Another study¹8; revealed absence of HIV infection in all of 58 socially rehabilitated long-term methadone treated patients, who had been enrolled in methadone treatment for an average of 16.9 years.
In a comparison of patients in methadone treatment with IV using opiate addicts¹9;, methadone treatment patients were found to have lower initial HIV seropositivity rates and lower seropositive conversion rates during the eighteen month course of the study.

Methadone Treatment is Cost-Effectfve: By providing opportunities for patients to be free of heroin addiction, improve health and social productivity, and reduce criminality and risk of exposure to HIV/AIDS, methadone treatment effectively reduces economic and social burdens the community at large would otherwise bear.

Methadone treatment costs New York State about $5000-$6000 per year, per patient. Estimated costs to New York State for a heroin addict on the street have been projected to be over $50,000 per year ($35,000 in theft, $10,000 in subsistence and health assistance, and an average of over $5,500 in law enforcement costs per arrest). For supporting addicts in prison, incarceration costs range between $24,000 and $46,000 yearly²0;.
Methadone treatment is associated with reduced emergency room use and prevention of more serious medical disease. A major study of cost effectiveness of methadone treatment and other modalities²1; found a benefit to cost ratio of 4.4 to 1 - Still another analysis²2; showed significant cost benefits for Methadone treatment even in the year following methadone patient discharge, yielding a final benefit to cost ratio of 4 to 1. For every dollar spent on methadone treatment, over $4 are saved in health and social costs.
A California-based comprehensive study showed that for every $1 invested in treatment for drug and alcohol problems, taxpayers were saved over $7 in future costs²3;.

"Research provides strong evidence to support methadone treatment as the most effective therapy for heroin adiction."

United States General Accounting Office, 1998

(17) What services do methadone treatment programs offer?

Most methadone treatment providers offer an array of health, social, and human services, tailored to meet individual patient needs. Methadone treatment programs often function as a patients' "primary health care provider," where general health problems are diagnosed and treated on-site or by referral to specialty care facilities. While programs differ in the level and scope of services offered, today's methadone treatment programs offer medical and social approaches well beyond providing methadone medication. Many programs include a range of the following services:

Health Care:

Medical histories, annual physical examinations, and blood chemistry analyses.
Routine drug testing and medical treatment planning for abuse of alcohol and non-opiate drugs.
Diagnosis, treatment and referral for gynecological, pre-natal, and obstetrical matters.
Testing and treatment for TB and HIV/AIDS, and risk prevention regimens provided on-site or by referral.\
Health awareness, wellness, and nutrition education.

Social and Human Services:

Assessment and individual treatment planning to address overall Psychosocial, substance abuse, and life needs.
Crisis intervention, supportive counseling, group and family therapy, drug relapse prevention, cultural and gender sensitive support groups, and life skills training.
Assistance in accessing entitlements, legal advice, financial support, and stable housing.
Therapeutic community and twelve-step fellowship approaches in confronting alcoholism and abuse of non-opiate substances.

Mental Health Services:

Assessments to identify mental health problems.
Use of antipsychotic medications safely coordinated with methadone treatment.
Linkage with resources and colleagues in the mental health community.

Educational and Vocational Services:

Diagnostic skills testing, remedial education, high school equivalency classes, and assistance in college placement, on-site or by referral.
Help with job finding skills, resume preparation, and patient referrals to training and job placement programs.

Assistance for Children and Families:

Family counseling and parenting education.
Services to the children of patients through funding for 'children of substance abusers (COSA)' projects.
Enhancement of healthy pregnancy outcomes for methadone treated patients.

HIVIAIDS Casework:

HIV counseling, prevention, and risk-reduction education.
Support groups for persons who are HIV-positive or "worried well."
Liaison and advocacy with other agencies involved in delivering health, mental health, housing, and legal services to persons with HIV or AIDS.

Prison-Based Methadone Treatment.

The New York State Office of Alcoholism and Substance Abuse Services (OASAS) and New York City Department of Corrections have pioneered in the development of prison-based methadone treatment, methadone tapering, and methadone program referral. Known as the "Key Extended Entry Program (KEEP)" this initiative offers heroin addicts an oportunity to break the addiction-incarceration-addiction cycle. charged with misdemeanors to be stabilized on methadone medication during their incarceration. Opiate addicts charged with misdemeanors may be stabalized on methadone medication during their incarceration.
Upon release from prison, these patients are guaranteed a slot in a community-based treatment program for ongoing assessment and clinical intervention, and placement in short-term or long-term treatment.

Medical Treatment:

Successfully rehabilitated methadone patients who require methadone medication, but no longer need intensive counseling and support services, may enter "Medical Treatment," which provides methadone treatment in a physician's office setting, in a model similar to that used for other chronic diseases.
Medical Treatment patients are seen my physicians monthly and receive a supply of methadone for home use in the twenty-eight days between appointments.

(18) How is success in methadone and other pharmacotherapy treatments defined?

The primary goals are to help addicts cease heroin use and lead more stable, productive lives. But, as knowledge about heroin addiction and effective treatment practices has grown, so too have the objectives of most methadone treatment programs, which also aim to:

Decrease criminality and reduce the numbers of substance abusers entering the criminal justice system.
Assist patients in addressing multiple substance abuse (including crack/cocaine addiction and alcoholism).
Assure treatment for general health matters, especially those related to drug use, such as HIV/AlDS, tuberculosis, and hepatitis.
Promote patient employability and educational development.

Identify and assist in mental health issues and alleviate social problems such as homelessness, family substance abuse, and child and family dysfunction.

Reduction in illicit opiate use is the ultimate measure of methadone treatment's effectiveness. But "success" in methadone treatment is also observed by positive outcomes in the patients health and social functioning.

(19) Doeas methadone treatment and other pharmacotherapies for opiate addiction help with drugs of abuse??

Methadone is effective only in the treatment of opiate abuse. How then, do methadone treatment providers deal with other drugs of abuse such as alcohol, cocaine, anti-anxiety drugs, and antidepresants?

Participation in methadone treatment provides patients with greater access to treatment for non-opiate substance abuse. Multi-drug abuse treatment and support are provided on-site in methadone treatment clinics through one-to-one counseling, group support, involvement in twelve-step fellowships (Methadone Anonymous, Alcoholics Anonymous, Cocaine Anonymous, Methadone Is Recovery), acupuncture, or use of medically supervised chemotherapeutic approaches. Some research studies²4,25,26; have found that cocaine and other non-opiate drug use decreases over the course of methadone treatment, with the most substantial declines seen among patients in long-term continuous methadone treatment. Methadone treatment programs may also assist patients to overcome non-opiate drug abuse through referrals for in-hospital medical tapering.

(20) Can methadone and other pharmacotherapies be used to taper ('detoxify') persons adicted to heroin and other opiates?

Methadone can be used to taper opiate addicted persons, by providing methadone in decreasing amounts over a period of time, until the patient is medically withdrawn. Used in this way, methadone, in apropriate dosage, can entirely eliminate withdrawal symptoms in virtually all patients. Persons treated on LAAM can also be mediacally withdrawn. Other pharmacotherapies such as nnaloxone and naltrexone have been used in heroin/opiate tapering, although the procedure is more complex and requires more intensive medical supervision. In fact, the use of these medications requires a major intervention, including the use of general anesthesia, with its associated risks.

Unfortunately, return of opiate craving and relapse to opiate use frequently occurs in the vast majority of cases regardless of the type of tapering regimin used. The best opportunity for success in remaining opiate-free following tapering appears related to the individual's degree of overall rehabilitation, motivation toward abstinence, lifestyle change, strong social supports, and assimilation into the non-drug world.

(21) Who is eligible for methadone treatment?

In order to be admitted to methadone treatment, U.S. Food and Drug Administration standards require:

A minimum of one year of addiction to opiates as well as current evidence of opiate addiction. Special circumstances apply to opiate addicted pregnant women, who may be admitted without demonstration of the one year minimum.
Applicants must also be over 18 years of age.

If the applicant is under 18, (s)he must have parental consent and demonstrate at least two prior treatment events in either drug free treatment or short-term tapering.

Methadone treatment is voluntary and available to persons of any age, sex, ethnicity, and physical or mental condition, including pregnant women and mentally ill chemical abusers.

(22) What is the customary course of treatment for a methadone treatment patient?

Most methadone treatment facilities offer care in three phases - an initial stabilization period, followed by a period of intensive service delivery, culminating in a period of "aftercare."

Initial Phase: During the first ninety (90) days of treatment, patients receive their first physical examination and Psychosocial assessments. Emergency medical and social needs are addressed, and short-term and long-term treatment planning begins. Patients attend the program daily, meet with a primary counselor weekly, and are oriented to treatment goals, practices, expectations, and services. Methadone dosages are evaluated and adjusted periodically.

Intermediate Phase: Patients are assisted to achieve goals in health improvement, drug relapse prevention, reduction of drug and alcohol abuse, family concerns, and educational and vocational objectives. Provided established criteria are met, including demonstrated responsibility handling and safeguarding medication, patients may receive "take-home" methadone.

Advanced Phase: These patients are free of illicit substance use, involved in productive activity (such as family care, employment, or educational training), and do not require intensive counseling services or frequent clinic visits. The patient may continue to be treated on methadone as individually prescribed, or choose to continue without methadone. The patient attends the program, an extended aftercare program, or Medical Treatment program on a reduced schedule.

"Pharmacotherapies are essential for reducing the number of addicted Americans. Methadone therapy...is one of the longest-established, most thoroughly evaluated forms of drug treatment... Methadone therapy helps keep more than 100,000 addicts of heroin, off welfare, and on the tax rolls as law-abiding, productive citizens."

The National Drug Control Strategy, 1999

(23) How long should methadone or other pharmacotherapy treatments for opiate addiction last?

One answer to this question is succinctly suggested in the Federal Center for Substance Abuse Treatment (CSAT) State Methadone Treatment Guidelines to be, "as long as it needs to, or simply, long enough." The decision on the length of methadone treatment, LAAM therapy or other pharmacotherapy is a medical one, developed between the treatment physician and individual patient, with input from the entire interdisciplinary treatment team. To achieve rehabilitation, treatment duration is individually and clinically determined with each patient. Federal and New York State regulations require annual evaluations of all patients with regard to continuing the patient in methadone or LAAM therapy.

(24) How do methadone treatment programs benefit communities?

Methadone clinics are community health resources that provide vital substance abuse care primarily for people who live or work in the communities in which their clinics are located. Methadone programs provide opportunities for their patients to live productively in their communities, free of preoccupation with illegal drugs, and free of the physical and social hazards of addiction. Many programs offer extended services to the families of patients as well. At a relatively low cost per patient per year, methadone treatment reduces the economic and social burdens the community at large would otherwise bear in crime, criminal justice, social welfare, and emergency and other medical care for untreated addicts.

Despite these benefits, some community members are concerned about loitering and other undesirable behavior that may be associated with the presence of any large outpatient community facility. Methadone treatment programs are responsible for developing plans that effectively minimize any potential negative program impact on community life. Most methadone providers engage in comprehensive community relations involving liaison with community leaders and representatives, proactive community education and service, and procedures and actions to effectively address problems such as patient loitering. Methadone treatment programs are in the forefront of efforts advocating for resources which enhance communities and patient care through the improvement of drug treatment and related health care services.

Understanding and acceptance of a methadone treatment program by the community may be critical to the program's effectiveness in providing treatment to patients. To assure the provision of needed addiction services and to improve community health and well being, methadone treatment programs need the colaborative assistance of neighborhood residents, community leaders, merchant and business groups, elected officials, colleagues in health, social and human services agencies, religious and spiritual leaders, and police and law enforcement officials.

(25) How are methadone treatment programs monitored?

Methadone treatment is the most monitored and regulated medical treatment in the United States. Federal and state regulatory agencies monitor methadone treatment programs through on-site program reviews. At the Federal level, regulatory oversight is being moved in a multi-year initiative from the Food and Drug Administration (FDA) to tje Center for Substance Abuse Treatment (CSAT), using an accreditation model. Programs are also licensed by the United States Drug Enforcement Administration (DEA). Some providers are certified through the Joint Council on Accreditation of Health organizations (JCAHO). In New York State, methadone treatment programs are licensed and approved by the New York State Office of Alcoholism and Substance Abuse Services (OASAS) and the New York State Department of Health (DOH).

"While the public would never suggest that heart patients should go without medication or that diabetics be denied needed insulin, this same public has not absorbed the science of addiction and the changes in the brain that substances like heroin produce ... We have medications -- methadone and LAAM -- and we need to use them in the same way the medical profession uses other pharmoceuticals to treat disease..."

Director, Center of Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration, 1999

THE FUTURE

The United States Drug Enforcement Administration (DEA) reports that heroin has become increasingly available at purer levels throughout the nation, and the National Institutes on Drug Abuse (NIDA) cites alarming increases in the number of young people using heroin. In the three decades since the pioneering of methadone treatment, an enormous body of research has proven its benefits in alleveviating heroin addiction, reducing crime, improving individual and public health, and saving lives - all accomplished through services that are cost-saving and cost-effective for communities.

Into the new millenium, The Committee of Methadone Program Administrators (COMPA) and its provider organizations are committed to assuring that quality addiction treatment and comprehensive health care for addicted persons, their families, and addiction-affected communities are available to the people of New York State, with methadone treatment as an integral part of this continuum of care. To achieve optimum outcomes and to maximize the beneficial impact of methadone treatment, COMPA supports the following initiatives:

Expansion and enhancement of New York Sate's methadone treatment system to accommodate into treatment New York's untreated opiate addicts wanting treatment. thedre are an estimated 200,000 untreated addicts throughout the State.
Establishment of physician office-based methadone/pharmacotherapy treatment services, that would enable qualified physicians to treat opiate addiction within their general medical practice, thus placing methadone treatment in the mainstream of medical service delivery.
Replication of the highly successful New york City prison-based Key Extended Entry Program (KEEP) throughout the State's correctional system, providing a treatment regimen of methadone for incarcerated opiate addicts and referral to community-based methadone treatment.
Creation of Satellite treatment assessment units within the criminal court, family court, welfare-to-work and child/family service systems, to assist these systems in evaluation and adjudication of drug-related cases, identification of addiction-related issues, and facilitaded treatment referrals of opiate-addicted persons and families.
The licensing and financial support of multi-service models for treating opiate addiction that offer the full continuum of addiction and primary health care services to opiate-addicted persons and their families.
Dissemination of information about the nature of heroin addiction as a chronic, relapsing disease of the brain, and the beneficial outcomes of methadone treatment.

"From a clinical perspective, few practitioners experience the satisfaction of participating in a process that restores and enhances quality of life to the extent seen in methadone treatment. After more than thirty years, I marvel at the corrective properties of methadone on the human brain as seen in the wonderful changes that occur."

Co-Chair, committee on Opioid Agonist Treatment
American society of Addiction Medicine, 1999

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