The COMPA Bulletin
Volume II, Issue 2 March 4, 2002
ACCREDITATION DEADLINE ARRIVES
March 4th was the deadline for opioid treatment programs to apply for survey by one of the four approved accrediting bodies (JCAHO, CARF, the Council on Accreditation for Children and Family Services, and the State of Washington). A separate application had to be completed for each methadone and detoxification program unit, including those methadone programs accredited as part of the CSAT demonstration project. Programs that participated in the demonstration project can now submit a request to CSAT asking to be moved from transitional to certified status. A copy of the final report and accreditation certificate must be submitted with such requests. Under the new CSAT regulations, accreditation surveys must now be completed by May 19, 2003, although it is our understanding that CSAT is willing to grant extensions to the end of 2003 if requested. CSAT has also entered into contract with JBS for technical assistance and has provided funds to each accrediting entity in order to reduce the costs of the initial round of surveys, with discounts expected in the vicinity of $3,000.
ACCESS TO TREATMENT FAILS TO KEEP UP WITH DEMAND
According to figures made available by the NYS Office of Alcoholism and Substance Abuse Services, admission of opiate users into New York State alcohol and substance abuse programs increased considerably between 1996 and 2000. The largest increases were reported in Jefferson County, which experienced a 448.8% increase; Delaware County, which experienced a 268.9% increase; and Saratoga County, which experienced a 251.1% increase. Downstate, Rockland County experienced a 117.4% increase, Suffolk 82.9%, Orange 34.6%, Westchester 31.9%, and Nassau 24%. In New York City, Richmond County experienced an increase of 73.9%, Kings 37.6%, Manhattan 29.6%, Bronx 23.3% and Queens 18.2%. These increases are consistent with national patterns which indicate that opiate abuse is no longer simply an inner city problem but is increasingly affecting suburban and rural areas as well.
In spite of these upward trends, however, treatment remains difficult to obtain in many areas of New York State. Of 125 programs statewide, 95 are located downstate. Upstate, methadone treatment programs are located in Albany, Syracuse, Rochester, Buffalo, Binghamton, and in the Hudson Valley, leaving broad swaths of the state with no treatment and forcing patients to drive well over 30 miles to reach the nearest clinic. In Rochester, where 200 treatment slots were added only two years ago, over 250 applicants remain on waiting lists. Large waiting lists also exist elsewhere in the state, including in Albany and on Long Island. At the same time, treatment slots are being lost in New York City as a result of Beth Israel’s closure of their Queens Hospital program last year and the pending closure of their Coney Island program.
Quickly opening new programs remains problematic and is compounded by a shortage of funds, stigma and a lack of political will. OASAS is pursuing a number of solutions, including seeking new providers interested in adding methadone treatment to their continuum of care, looking at the possibility of co-locating methadone treatment with other existing services, licensing the state’s ATCs to provide methadone treatment, and beginning a mobile treatment program in the Adirondacks.
MEDICAL MAINTENANCE IN NYS
By Herman Joseph, NYS Office of Alcoholism & Substance Abuse Services
Methadone Medical Maintenance (MMM) offers an advanced level of care to socially rehabilitated patients who want to continue being treated with methadone but who do not need the services of a traditional clinic. Patients who have been stabilized and who have achieved a significant level of success in their recovery are treated outside the traditional clinic system in offices of private physicians, primary care centers or other venues where physicians practice medicine. Eventually patients report once per month to a physician and patients receive a month’s supply of medication in the form of dry diskettes in one or two vials instead of daily bottled liquid preparations. The traditional clinic serves as the hub or anchor program for MMM, and the office of the MMM physician is a satellite of the anchor clinic.
The MMM physician becomes the central medical professional in the patient’s life and must deal with a variety of medical, social and personnel issues that affect the patient ‘s adjustment. At the very least, the physician must understand the patient’s need for an adequate dose of methadone and be aware of drug interactions that may require changes if the patient is prescribed other medications. Also, physicians with specialties (e.g., internal medicine, diabetes, pulmonary medicine, and infectious diseases) may also offer the patient primary care in addition to MMM. If a referral for treatment is made to other health professionals, the MMM physician acts as a medical ombudsman by educating the other professionals about the patient’s need for continued methadone treatment, drug interactions with methadone, pain management, and professional biases against methadone maintenance treatment that may exist within the health care professions.
MMM patients are acutely aware of the stigma directed towards methadone treatment. Therefore, it is most important, that the MMM physician protect the patient’s confidentiality and offer support to resolve stigma issues that impact negatively on the patient ‘s adjustment. Physicians should be flexible about appointments since patients may be asked on short notice by their employers who usually do not know that the patient is enrolled in the program to make business trips or work overtime.
MMM offers the following advantages for patients:
If patients should again need clinic services, they can be returned to the anchor or traditional clinic. Hospital-based and commercial pharmacies can be considered for dispensing the methadone to MMM patients. MMM programs have to be approved by CSAT, the DEA and OASAS.
The following criteria for admission to MMM and quality assurance have been developed:
New York State continues to place considerable focus on this emerging form of methadone treatment and has now developed six MMM models which offer office based-prescribing. Five are currently operating around the state and the sixth will be starting in a matter of months.
A life table analysis of the five programs in operation shows a retention rate of about 95% for a two-year period. Relapse to drug use, especially cocaine or serious alcoholism, were the major reasons for unfavorable terminations. The patients were sent back to the anchor programs which serve as a safety net for the MMM program. A few patients who were doing well died from the effects of Hepatitis C and smoking. Over an 18 year period, about 12 (4%of 300 admissions) patients successfully withdrew from methadone after an average of about 18 years in treatment.
Planning an MMM program
Physicians and administrators of existing programs now feel that MMM is essential for the continued development of their socially rehabilitated patients. Patients also value the program for the advantages that permit them to live freer, less restrictive lives enabling them to accomplish more in their business and social endeavors.
To establish an MMM program, administrators should plan with OASAS taking into account the patient population, financing of the program, available medical and other personnel, and, facilities and resources in their hospitals, primary care centers and communities. The program is established by obtaining approvals for exemptions as set forth by CSAT and OASAS. In addition DEA approval is necessary. When established the MMM receives a PRU number so statistics are readily available from the OASAS Management Information System.
OASAS established the original MMM office based prescribing program in the country with the Rockefeller University and has assisted programs establish the current programs. It is one of the successful innovations that we are especially proud of and would like to work with programs to expand the state MMM model.
AATOD RELEASES FACT SHEET FOR DRUG COURT PRACTIONERS
The following fact sheet for drug court practitioners was prepared by Mark W. Parrino, MPA, President, of the American Association for the Treatment of Opioid Dependence, utilizing material from the resources listed at the end of the document. Laura McNicholas, MD, PhD, Director of CESATE, Philadelphia Veterans Administration Medical Center, prepared the sections on Buprenorphine and LAAM.
Programs are encouraged to utilize this fact sheet as an educational tool when meeting with judges and other representatives of the criminal justice system. Copies may be obtained from AATOD whose contact information is listed at the end.
DRUG COURT PRACTITIONER FACT SHEET
Methadone Maintenance and Other Pharmacotherapeutic Interventions in the Treatment of Opioid Dependence
Drug Courts are being confronted with increasing numbers of opiate dependent offenders. This Fact Sheet is intended to dispel misperceptions and educate practitioners about the efficacy of medication assisted treatment. Opioid dependence is a devastating reality and a treatable disease.
According to the Office of National Drug Control Policy, there were over 977,000 heroin dependent individuals in the United States in the year 2000. The Substance Abuse and Mental Health Services Administration’s 2000 National Household Survey on Drug Abuse indicated that an estimated 104,000 persons used heroin for the first time in 1999.
There has been an increasing trend in new heroin use since 1991. A significant proportion of these recent new users were smoking, snorting or sniffing heroin. Most of these new users are under the age of 26 (SAMHSA/U.S. Department of Health and Human Services). According to SAMHSA’s 2000 National Household Survey on Drug Abuse, the average age of first heroin use has steadily declined since 1989, from 24 to 19 years of age in 1999. The "Monitoring the Future" study indicated that approximately 1.4% of our nation’s 10th grade students used heroin in 1998.
According to the DEA’s Domestic Monitoring Program data, the national average for heroin purity has remained relatively stable (above 35% per pure milligram) since 1992. An analysis of these same data also indicate a steady decline in the average price per milligram for heroin since 1992 at both the retail and dealer level. According to 1999 FBI Uniform Crime Reports, arrests for drug abuse violations have steadily increased since 1991. There were 1.56 million drug-related arrests in 1998.
The Substance Abuse and Mental Health Services Administration’s (SAMHSA) 2000 Emergency Department Data from the Drug Abuse Warning Network (DAWN) identified an increase in heroin/morphine mentions between 1999 and 2000 in eight of the 21 metropolitan areas in the reporting network.
SAMHSA’s Center for Substance Abuse Treatment (CSAT) has also reported the increasing use of oxycontin and the fact that methadone maintenance treatment is also an effective pharmacotherapeutic intervention if oxycontin dependent individuals meet existing federal admission criteria. A significant number of oxycontin dependent individuals have been admitted to methadone treatment programs during 2001 and have improved with a stable medication treatment regimen, in addition to getting access to counseling and other medical services.
Methadone Maintenance Treatment
Methadone is the most widely studied medication and treatment for any disease in the world. Opioid treatment programs provide the dependent individual with an array of rehabilitative services. Therapeutically prescribed doses of methadone and LAAM relieve withdrawal symptoms, eliminate opiate craving and allow normal functioning. The efficacy of these medications increases significantly with counseling and on-site medical and other supportive treatment services. Medical personnel supervise treatment and nurses administer the medication to patients, most typically on a daily regimen until the individual is stabilized. Patients also provide toxicology samples, which are tested for the presence of methadone and drugs of abuse.
Methadone has been used to treat opioid dependence for thirty-five years and like all medications, therapeutic dosing is contingent upon individual patient needs. The therapeutic dosage range is generally between 80 – 120 mg. Methadone is taken orally and is rapidly absorbed from the gastrointestinal tract, appearing in plasma within thirty minutes of being ingested. 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, free from craving, and feeling stable.
The General Accounting Office reported in 1990 that "The National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, the federal government’s two primary agencies for researching drug and alcohol abuse issues, respectively, have concluded that methadone is the most effective method available for treating heroin addiction."
The Center for Substance Abuse Treatment has found, as of October, 2001, that more than 205,000 individuals are being treated in methadone treatment programs. The National Institutes of Health Consensus Development Conference on "Effective Medical Treatment of Opiate Addiction" (November 1997) concluded that it is necessary to increase access to methadone treatment services throughout the United States and to increase funding for methadone treatment, including providing benefits to methadone patients as part of public and private health insurance programs.
The Pharmacology of Methadone Treatment
Some critics of methadone treatment believe that it represents substituting one drug for another. Such critics see no distinction between heroin as an illicit drug and methadone as a medication, which is used in conjunction with other treatment services. Research has proven the drug substituting assertion to be false. Heroin and methadone have completely different pharmacologic properties.
Heroin has an immediate onset of action with a four to six hour duration. The route of administration is typically through injection, snorting or smoking several times each day. Very few individuals can achieve any kind of neurochemical stability through such a short-acting opiate.
Methadone is taken once per day and has a duration of action of between 24 and 36 hours. It is orally ingested and is released into the body over the course of time through the liver. This is why methadone maintenance does not cause euphoric effects in the stabilized patient.
Other critics of methadone treatment include people in recovery from other drugs of abuse, including alcohol. They claim that since they are able to be abstinent without pharmacotherapy that methadone maintenance does not represent a "true" state of recovery. Once again, science does not support this view. The National Institute on Drug Abuse has found through years of research that there are profound changes in the chemistry of the brain as a result of chronic use of exogenous opiates such as heroin. The biology of the brain changes and may never revert back to its pre-heroin use state for a number of heroin-dependent individuals. While this may not apply to all heroin-dependent persons, it has been found that more than 80% of methadone maintained patients will relapse to heroin use when methadone maintenance is withdrawn within the first 12 months of treatment being terminated.
Methadone and Pregnancy
Women can conceive and have normal pregnancies and deliveries when maintained on methadone. When the methadone dosage is therapeutically prescribed for pregnant women, methadone treatment provides a non-stressful environment for the developing fetus. Because methadone crosses the placental barrier, some babies born to female methadone patients may be physically dependent on methadone at first and need to be weaned. It is also true that methadone maintained women give birth to babies who do not experience any withdrawal. The myth that methadone produces abnormality in fetuses has no basis in fact. Additionally, children born to methadone maintained women have been studied longitudinally and develop normally in good post natal environments. Accordingly, it is medically contraindicated to withdraw pregnant methadone maintained patients.
Federal Oversight of Methadone Treatment
The Center for Substance Abuse Treatment within SAMHSA manages the new accreditation system for methadone treatment programs. Implemented on May 18, 2001, this system will ensure that every methadone maintenance treatment program in the country is accredited over the course of the next three years, providing better program accountability and improving treatment quality throughout the nation’s 950 registered methadone treatment programs. All treatment programs, regardless of the source of their funding (private or nonprofit) will be subject to these quality-driven accreditation standards.
Impact of Methadone Treatment in Reducing HIV Infection, Treating Hepatitis C and Psychiatric Comorbidity
Studies of methadone treatment have consistently found dramatic declines in heroin use after admission to methadone treatment and further declines as the patient remains in treatment. The value of treatment retention cannot be overstated.
The relationship between intravenous drug use, needle sharing and HIV/AIDS exposure is also well documented. Methadone treatment has played a pivotal role in reducing the spread of HIV/AIDS, according to NIDA-funded studies.
We also know that more than 70% of methadone maintained patients across the country are HCV-positive. Accordingly, methadone treatment programs are providing support services to these patients, ensuring that they are followed for HCV in addition to other comorbidities.
There is also significant psychiatric comorbidity in the methadone treated population, cited in the Ball & Ross study "The Effectiveness of Methadone Maintenance Treatment", published in 1991. The study found a lifetime prevalence of serious depression and anxiety disorders in 48% of the patients in the study. Methadone treatment programs are able to treat such psychiatric comorbidity either through the methadone treatment program or by referral to psychiatric services.
Impact of Methadone Treatment in Reducing Crime/Cost Effectiveness
Methadone treatment is also associated with reducing crime in the patient population as patients enter and remain in treatment. It has been repeatedly demonstrated that 80% of the patients will reduce or eliminate crime as they remain in methadone treatment programs.
The cost savings to taxpayers are also well documented. A comprehensive examination of the economic benefits and cost of methadone treatment reveals the benefits to cost ratio at 4:1; $4.00 in economic benefits for every $1.00 spent.
The Institute of Medicine concluded that "methadone maintenance pays for itself on the day it is delivered, and post treatment effects are an economic bonus." The average cost of outpatient methadone treatment is approximately $5,000.00 per year and involves the use of medication in addition to medical care and counseling.
Methadone treatment programs are staffed by professionals with extensive medical, clinical and administrative expertise. Patients routinely meet with a primary counselor, attend clinic groups and access medical and social services within the program setting.
Methadone Treatment in Correctional Settings
According to NIDA’s October 1999 "Principles of Drug Addiction Treatment": "Research is demonstrating that treatment for drug addicted offenders during and after incarceration can have a significant beneficial effect upon future drug use, criminal behavior and social functioning. The case for integrating drug addiction treatment approaches within the Criminal Justice system is compelling. Combining prison and community-based treatment for drug addicted offenders reduces the risk of both recidivism to drug-related criminal behavior and relapse to drug use."
At present, Rikers Island in New York City is the only correctional system in the United States that treats heroin dependent inmates with methadone, referring them to treatment programs upon release. The intervention is called the Key Extended Entry Program (KEEP) and has been a part of the Rikers Island Health Services since 1987. The service combines pharmacotherapy and comprehensive therapeutic treatment.
The Rikers Island program treated 3,985 inmates with methadone in 2000. Approximately 70% of these inmates were men and 10% of the women in the program were pregnant. All inmates have been diagnosed as opiate dependent by medical staff and were charged with either a misdemeanor or low grade felony, serving a misdemeanor sentence in order to qualify for the program. 76% of all inmate patients reported to their assigned programs for continued substance abuse treatment following their release from jail.
The average KEEP patient’s length of stay was 35 days at Rikers Island in 2000. The program has demonstrated statistically significant differences in decreased criminal recidivism. It makes sense to expand access to this kind of service for people under legal supervision, especially since Drug Courts and other courts sanction untreated, drug dependent individuals to correctional facilities. Consideration might be given to reframing the Rikers Island KEEP program as a "reentry" program so that heroin dependent individuals can gain access to methadone treatment services upon release from incarceration.
A number of correctional facilities have indicated an interest in using pharmacotherapeutic interventions in treating chronic opiate dependence, based on the success of the Rikers Island model. Additionally, such correctional facilities have been using Naltrexone and are likely to consider using Buprenorphine, when it is approved. The Rikers Island experience indicates that providing access to such medication assisted treatment in correctional facilities is an extremely effective method of reducing recidivism and ensuring that people get access to outpatient services when they are released from jail.
Buprenorphine is a partial agonist of the mu-opioid receptor that is currently in development for the treatment of opioid dependence. When available, it will be marketed as sublingual (SL) tablets. Two forms of buprenorphine will be available – buprenorphine alone in 2 and 8 mg tablets and a combination of buprenorphine and naloxone as sublingual tablets containing 2mg of buprenorphine and 0.5 mg of naloxone or 8 mg of buprenorphine and 2 mg of naloxone.
As a partial agonist, rather than a full agonist such as methadone or morphine, buprenorphine has pharmacological properties that are similar to but different from those of methadone. It has a ceiling effect for most of the effects produced by opioid drugs, such as analgesia and respiratory depression. This makes buprenorphine safer, in terms of respiratory depression in case of an overdose, but also may limit its efficacy for some patients. From a variety of studies in opioid-dependent patients, it has been shown that buprenorphine, 4 – 8 mg SL, is as effective as 30 mg of methadone in supressing opioid withdrawal signs and symptoms for approximately 24 hours.
For maintenance therapy, approximately 16 mg of buprenorphine SL is equal to approximately 65 mg of methadone. Further, buprenorphine is thought to occupy the opioid receptor for much longer than other agonists, such as methadone, and is very firmly bound to the receptor, making it difficult for other opiates to displace it. For these reasons, buprenorphine works very well for some or most patients who need agonist maintenance therapy. However, patients who require high agonist doses for stabilization may not be adequately treated with buprenorphine.
Further, for patients who are currently maintained on methadone or LAAM, it will not be appropriate or, often, possible to switch patients to buprenorphine. Because of the partial agonist qualities of buprenorphine, patients cannot simply be switched over from methadone to buprenorphine; the patient must first be stabilized on a daily dose of methadone of no more than 30 mg, then switched to buprenorphine. It must be remembered that many patients on higher doses of methadone have a great deal of difficulty decreasing the daily methadone dose while maintaining stability in treatment.
When available, buprenorphine will be marketed as both the mono form and in combination with naloxone. The reason for the combination is that when buprenorphine has become available and distributed in the mono form, it has been abused. While buprenorphine, as a partial agonist, has a lower abuse potential than full agonists, it does have opioid effects and can be abused. In places where the medication has been abused, it has been by the injection, not the sublingual, route of administration. Naloxone is not readily available when taken by the sublingual route, but is readily available when injected. It is thought that adding the naloxone to the sublingual tablet will decrease diversion and abuse by the injection route. Studies have shown that the combination tablet is as effective in clinical trials as the mono form of SL buprenorphine.
LAAM, levomethadyl acetate, is a long-acting mu-opioid agonist. It acts much like methadone in the treatment of opioid dependence, but offers some advantages for some patients. Because LAAM undergoes extensive metabolism to active and long-lasting metabolites in the liver, it can be dosed less than daily. Most patients will receive LAAM only on a thrice-weekly schedule, allowing better functioning in the workplace or in the family situation. While LAAM offers some advantages for some patients in terms of dosing frequency, it has recently been associated with cardiac side effects. It has been shown that LAAM may prolong the Q-T interval in some patients and, in order to prevent medical complications, patients must be monitored with ECGs before and during their treatment with LAAM.
Methadone medication is not a substitute for heroin and does not affect the individual in any similar way. Methadone treatment has been rigorously studied for more than 35 years and the results are found to be uniformly positive.
Accreditation oversight will enhance the consistency and quality of treatment services throughout the nation’s methadone treatment programs. It is expected to end the debate about the quality of care offered in publicly funded vs. privately financed treatment programs since all programs, public and private, will be accredited through CSAT’s approved accrediting organizations.
While a number of people will continue to be critical of methadone treatment because the medication, as a pharmacotherapeutic agonist, has its own dependence producing qualities, the reality is that we do not have anything at the present time (including Buprenorphine), following years of exhaustive research by NIDA, that will be able to perform as methadone maintenance treatment does in normalizing brain function without having some dependency-producing characteristics.
Just as psychiatrists are not expected to withdraw depressed patients from their antidepressant medication and, as physicians do not withdraw their patients from cardiovascular or other life sustaining medications that stabilize the patient and enable him/her to lead a normal life without struggling through the debilitating effects of an illness, methadone patients should not be required to withdraw from a medication that improves their quality of life.
Heroin dependence is a form of addictive disease, and methadone maintenance is a well-researched therapeutic medication. The empirical evidence consistently supports its safety and efficacy. Methadone and alternative pharmacotherapeutic agents alone are not sufficient; they must be combined with other therapeutic services to be of value to the individual. It is important that the criminal justice system strengthen its commitment to evidence-based treatment and work to address ideological biases through continuing education.
State Methadone Treatment Guidelines, DHHS Publication No. (SMA) 93-1991, 1993.
Regarding Methadone Treatment and Other Pharmacotherapies: A Review, Committee of Methadone Program Administrators of New York State (COMPA) 1999.
Methadone Community Education Kit, Center for Substance Abuse Treatment/SAMHSA, 2000
Principles of Effective Treatment, NIH Publication No. 99-4180, 1999.
American Association for the Treatment of Opioid Dependence
217 Broadway, Suite 304
New York, NY 10007
COCAINE ACCELERATES HIV INFECTION
February 15, 2002, UCLA, Contact: Elaine Schmidt (email@example.com)
For the first time, UCLA AIDS Institute scientists have demonstrated in an animal model that cocaine use dramatically accelerates the spread of HIV infection. Offering a useful tool for examining other HIV-related risk factors, their findings were reported Feb. 14 in the online edition of the Journal of Infectious Diseases. "Cocaine not only influences risky behaviors," said Dr. Gayle C. Baldwin, associate professor of hematology-oncology and a member of the UCLA AIDS Institute. "It also has a direct and profound effect on the AIDS virus."
Using mice specially bred without immune systems, Baldwin's team inoculated the animals with human cells, then infected the cells with HIV. Four days following infection, the researchers gave half of the mice daily injections of liquid cocaine. The rest of the mice received a saline placebo. After 10 days, the UCLA team harvested the human cells from the animals and counted
the HIV-infected cells. They made three distinct discoveries that surprised them.
"We saw a 200-fold increase in AIDS viral load in the blood of the animals injected with cocaine compared to those that received the placebo," Baldwin said. "In only two weeks, the drug radically stimulated the production and spread of HIV." Secondly, the mice exposed to cocaine possessed more than double the number of HIV-infected cells than the mice injected with saline. Finally, Baldwin's team saw a significant nine-fold drop in CD4 T-cells — the immune cells that HIV targets to destroy the immune system — in the cocaine-exposed mice.
"The cocaine increased HIV's efficiency so dramatically that it nearly wiped out the CD4 T-cells," Baldwin said. "We found nine times fewer CD4 T-cells in the cocaine-treated mice than in the animals that received the placebo." "This means that the cocaine produced a spectacular double outcome," she said. "Not only did the drug double the number of HIV-infected cells — it produced a nine-fold plunge in the number of T-cells that fight off the virus."
Baldwin proposes that the mouse model provides a practical method for examining other factors that may influence how the AIDS virus affects the body, such as diet, alcohol and other drugs. "Cocaine doesn't work in a vacuum," Baldwin said. "We need a living host to examine its absorption rate in cells and tissue. Studying cells in a test tube won't allow us to do this." The National Institute of Drug Abuse, UCLA AIDS Institute's Center for AIDS Research and UCLA's Jonsson Comprehensive Cancer Center provided financial and facility support for the study. Co-authors included Michael Roth, Donald Tashkin, Beth Jamieson, Jerome Zack and Ruth Choi.
FEDERAL PLAN FOCUSES ON ENFORCEMENT AND TREATMENT
From the New York Times, February 13, 2002, By Christopher Marquis
President Bush today unveiled a $19 billion national anti-drug strategy that gives renewed impetus to law enforcement at home and abroad and calls for "compassionate coercion" to get addicts into treatment. Asserting that illegal drugs kill as many as 20,000 Americans a year and cost the health care system almost $15 billion, Mr. Bush set a goal of reducing drug use nationally by 25 percent over the next five years.
"Drugs attack everything that is best about this country, and I intend to do something about them," Mr. Bush said in a White House ceremony that was attended by a handful of lawmakers and the drug policy chief, John P. Walters. The sharpest increase in the budget over last year was a 10 percent rise in financing for interdiction. That effort to stop drugs at their source, or while they are in transit, includes hundreds of millions for eradication efforts and police work in South America as well as more money for the Coast Guard and
The $2.3 billion interdiction budget bore the imprint of Mr. Walters, who has long advocated stronger enforcement. Mr. Walters, a top antinarcotics official in the administration of the president's father, quit in protest in 1993 when President Bill Clinton announced a shift away from law enforcement toward coping with addiction. Mr. Bush linked the fight against drugs to the battle against terrorism, saying groups like the Taliban in Afghanistan financed their attacks in part through narcotics trafficking. "You know I'm asked all the time, `How can I help fight against terror? And what can I do, what can I as a citizen do to defend America?' " Mr. Bush said. "Well, one thing you can do is not purchase illegal drugs."
As if to underscore the enforcement drive, officials have notified Congress that they intend to resume American counter narcotics flights over Colombia and Peru. Those flights were suspended last year after a Peruvian fighter jet, alerted by a Central Intelligence Agency aircraft, shot down a plane carrying American missionaries, killing two. A Senate panel sharply criticized the C.I.A. for lax oversight and demanded new safeguards, which the administration says it is putting in place. Control of the surveillance flights will be transferred from the C.I.A. to another government agency, officials said.
The national strategy calls for a 6 percent increase in spending on treatment, allocating $1.6 billion over the next five years. Money will be targeted for the most vulnerable populations, including pregnant women, the homeless, people with H.I.V. and teenagers, the president said. Some critics said the administration should be vastly increasing spending for treatment, noting a 7-to- 1 disparity in favor of law enforcement. "Unless the president commits to funding treatment and controlling demand at the same level as supply reduction," said Rachel King, a lawyer with the American Civil Liberties Union in Washington, "the administration will inevitably fail in its goal of cutting drug use by a full quarter by 2007."
The president's strategy calls for the creation of a "new climate of compassionate coercion" to persuade drug users to seek treatment. It seeks to enlist the help of family members, friends and employers, as well as the police and groups tied to religion, to break through addicts' denial. Mr. Bush acknowledged that the best way to affect supply is to reduce demand. His budget calls for spending $644 million on school and community programs and $180 million on a media campaign intended to reach the young. "If we want to usher in a period of personal responsibility, if we want a new culture that changes from `If it feels good, do it' to one that says we're responsible for our decisions, it begins with moms and dads being responsible parents, by telling their children they love them, on a daily basis," he said. "And if you love somebody, you'll also tell them not to use drugs."
Some advocates of a new drug policy expressed impatience with such remarks, given the pervasiveness of the problem. A recent University of Michigan study found that fully half of students reaching 12th grade had tried an illegal drug. Ethan Nadelmann, the executive director of the Drug Policy Alliance, which favors a strategy based more on treatment, noted that the president's own daughters and a niece had recent brushes with the law involving alcohol and prescription drugs. "When it comes to drug policy, you should treat other people's children the way you'd want your own treated," Mr. Nadelmann he said. "That's a policy that's missing" from the administration's approach, he added.
FARMERS IN PERU ARE TURNING AGAIN TO COCA CROP
From the New York Times, February 14, 2002, By Juan Forero
His farm filled with money-losing crops, Francisco Torres had begun to despair that he could ever make ends meet in this green river valley in northern Peru. Then tens of thousands of acres of coca were eradicated in neighboring Colombia in a vast American-backed campaign of aerial fumigation. The tightening supply has pushed the price of coca to new highs in recent months, drug market analysts say, making legitimate crops even less appealing while opening fresh opportunities for Mr. Torres and his neighbors. Now they are making more room for coca, a crop that Peru had made great strides in eradicating in the 1990's. "We live off coca," said Mr. Torres, 58. "We pay for our harvest with coca money. Without coca, there is no life."
In at least two river valleys in Peru, for the first time in years, coca, cocaine's main ingredient, is making a comeback, say Peruvian and United Nations antidrug officials. The trend does not mean that antinarcotics efforts in the Andes are failing, said analysts who track American antidrug programs. But it does underscore how fleeting victories can be in a drug war where national boundaries mean nothing to traffickers who can shift their crop across remote and poorly policed regions.
While the reasons for the increase in Peru are complex, most experts attribute it largely to what they call the "balloon effect," in which eradication in one place simply pushes coca growing to another, given the continuing demand for cocaine, principally in the United States. Once-successful eradication efforts in Peru had already shifted much production to Colombia, where a $1.3 billion American-financed antidrug effort, called Plan Colombia, has now helped nudge coca growing back here again. "The drug mafia knows Plan Colombia would be hard, so they began to automatically move," said Ricardo Vega Llona, Peru's newly named drug czar. "And how do they give incentives to get people to plant? By paying higher prices."
Even in Colombia, which had more than 400,000 acres dedicated to coca in 2000, new growth has offset eradication efforts, leaving the size of the coca crop steady last year, according to new United Nations estimates. In Bolivia, where the government declared coca nearly wiped out a year ago, farmers in the Chapare region have continued planting the leaf, with drug traffickers increasingly shipping to Brazil. Ecuador has also become an important corridor for coca paste shipped from Colombia, as well as a port for cocaine bound for the United States via Pacific sea routes, said Klaus Nyholm, director for the United Nations Drug Control Program in Colombia and Ecuador. "This is a footloose industry, and by footloose I mean it always goes to the path of least resistance," said Eduardo Gamarra, director of the Latin American and Caribbean Center at Florida International University in Miami.
In Peru, satellite maps, aerial surveillance and ground assessment work by the United Nations Drug Control Program show that the coca crop has slightly expanded to cover about 125,000 acres in 2001, from 107,000 in 2000. Several Peruvian government officials, including Mr. Vega Llona, say those preliminary figures are accurate. The shift to Peru comes after years in which the coca crop here was cut by 75 percent — falling to 84,474 acres in 2000 from 318,000 in 1992, according to American figures — with a decade long American-supported program in which the Peruvian forces pulled up coca bushes and intercepted and even shot down drug flights and coca farmers were offered alternative crops. The strategy succeeded in collapsing coca prices, destroying coca labs, and disrupting transportation routes. But coca did not disappear. One high-ranking State Department official who works on drug issues said coca cultivation was now up 10 to 12 percent in two traditional growing regions of Peru, the Upper Huallaga and Apurimac valleys.
Other American officials here and in Washington took issue with the United Nations findings on Peru, saying American data for 2001 now being analyzed shows that eradication efforts in Peru have simply slowed. The American figures also point to a smaller overall coca crop in Peru than the United Nations figures, putting the total crop at 84,000 acres in 2001, a reduction of 500 acres from the previous year. Still, American officials are concerned about the new growth in Peru and the rising price for coca leaf, which has shot up to over $4 a kilogram in this region from less than $2 two years ago, increasing its appeal over alternative legal crops.
"That's really high," said James Williard, director of antinarcotics affairs at the American Embassy. "For it to be competitive with coffee or cacao, it needs to be around $1." American and Peruvian officials blame a range of factors for the new growth, including the political turmoil in Peru after President Alberto K. Fujimori's government collapsed in November 2000. The suspension last April of a policy that allowed Peruvian Air Force planes to shoot down drug flights has also permitted trafficking to pick up, Peruvian officials say. The suspension came after a Peruvian fighter plane shot down a private plane carrying American missionaries, killing a woman and her baby. American officials, though, remain optimistic about eradication efforts here, noting that antidrug aid to Peru is tripling to about $150 million this year to pay for the renovation of antidrug aircraft and to finance alternative development programs for farmers. More money is likely in the coming years for a sustained, long- range program here and elsewhere in the Andes. "It's not a one-year effort," said the State Department official. "It won't work in one year, and I think Congress agrees."
Peru's government has increased the police presence in coca-growing regions, signed a new eradication plan with the American government and declared narcotics a national security issue. American officials in Washington also say that the suspension of the aerial interdiction program may be lifted later this year. "I anticipate the possibility of making great headway here in the next few years," said John Hamilton, the American ambassador in Lima. Still, coca and opium poppies, which are also on the rise in Peru, will be particularly hard to uproot fully because the recent collapse of coffee prices and stubbornly low prices for other legal crops have given farmers few options, said Patricio Vandenberghe, director of the United Nations Drug Control Program in Peru.
For now, here in the Monzón valley planting more coca simply makes economic sense, since prices have reached nearly $50 for 25-pound bales of leaves, the highest in Peru because of the quality of the plant. But the crop has also brought violence and other social ills. Beyond leading to renewed signs of drug trafficking, the increased coca plantings here and elsewhere have led to a reappearance of Shining Path guerrillas, who benefit from the coca trade. The group was nearly wiped out in recent years. In fact, across Peru the police are discovering that traffickers are increasingly operating labs that process coca paste into cocaine, a change from years past when labs were solely for producing paste that was then shipped to refineries in Colombia, said Juan Zárate, director general of intelligence at the Interior Ministry. New trafficking routes, many of them headed into Brazil or to Peruvian ports, have also been found. Just last month, six tons of coca paste was discovered in a truck in southern Peru, an indication of how ambitious traffickers had become. "This was a signal that the cocaine industry is reactivating," Mr. Zárate said. "It put us on the alert."
CONFERENCE AND TRAINING OPPORTUNITIES
Blending Clinical Practice & Research
Sponsored by NIDA, this conference will be held on March 14 – 15, 2002 at the Grand Hyatt Hotel in New York City. Teams of nationally recognized clinicians and researchers will conduct plenary presentations and workshops on topics such as: Drugs, Brain and Behavior; Innnovations in Behavioral Therapies; Co-Occurring Drug Abuse and Mental Illness; Gender Issues in Addiction; PTSD and Drug Abuse; Drug Treatment in the Criminal Justice System; and Craving and Relapse. The cost of the conference is $30 and lodging is available by calling the Grand Hyatt at 212-883-1234. On-line registration and conference information is available at www.mac1988.com/blendingnyc or by calling Melinda Gray at 301-468-3364.
The Committee of Methadone Program Administrators of New York State is a not-for-profit coalition representing New York State’s methadone treatment system which serves over 46,000 individuals suffering from opioid addiction and other substance abuse disorders.
Opioid addiction is a chronic, relapsing medical disorder, with serious consequences related to public health and safety. Methadone treatment has proven to be the most effective means of treating this disorder.
COMPA’s mission is to further the treatment of opioid addiction and other substance abuse disorders in order to address the medical, social and psychological consequences of use, prevent the spread of HIV and other infectious diseases, reduce criminal behavior, promote employment and self-sufficiency, and support the return to a healthy and productive lifestyle.
In order to support this mission, COMPA and its member organizations are committed to the promotion and expansion of methadone treatment through education of elected officials, providers, consumers, and the public at large. COMPA advocates for expanded models of service delivery, co-located services and consumer empowerment to provide increased access to treatment. COMPA supports enhanced services, a comprehensive continuum of care, the provision of high quality treatment and ongoing professional staff development. COMPA encourages the involvement of membership in the development of public policy, standards of care, and regulatory oversight.
COMPA Board of Directors
Peter Coleman, NYC Health and Hospitals Corporation, President
Ira Marion, AECOM-Montefiore, Vice President
Johanne Morne, Whitney Young MMTP, Secretary
Richard Woytek, Long Island Jewish MMTP, Treasurer
Herbert Barish, Lower Eastside Service Center
Willard Campbell, Suffolk County Division of Alcohol and Substance Abuse Services
Robert Krauss, Long Beach Hospital MMTP
Robert Sage, A.R.T.C.
Sheila Tierney, Crouse Hospital
Ira Wolfe, St. Luke’s Hospital
COMPA Executive Director
COMPA has established this newsletter to ensure that New York State providers of opioid treatment services have an effective mechanism of communication which facilitates the dissemination of information, encourages dialogue and the adaptation of best practices, promotes staff development and retention, and assists in the effort to reduce stigma. The COMPA Bulletin includes information regarding best practices, research, demonstration projects, accreditation, training opportunities, conferences, and other items of interest to the field and will be distributed via email on a monthly basis.
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