Commnique Archive — Communique — Documents — Home

Methadone Maintenance in the 1990s

—Guest Editor Mark Parrino, M.P.A., President, American Methadone Treatment Association, Inc. (formerly the Northeast Regional Methadone Treatment Coalition, Inc.)

Methadone maintenance was initially designed as an inexpensive outpatient treatment for chronic heroin addicts. Years of destructive narcotic abuse could be treated with a proper daily methadone dose and limited counseling in a therapeutic environment. To the addict, the methadone program was far more hospitable than septic shooting galleries and crowded prison cells.

A historical perspective

Early support for methadone maintenance was rooted in the powerful correlation between untreated heroin addiction and criminal behavior. Methadone treatment demonstrated impressive results when measured against the yardsticks of reduced heroin use in more than 85 percent of maintained patients and a reduction of criminal activities in 80 percent of the patients who remained in treatment for 1 year. Methadone maintenance represented a neatly packaged, low-cost "silver bullet" that could successfully treat a pernicious addiction.

Heroin addiction was widespread in the 1960s and a ripe topic for tabloid journalism. Emergency room heroin overdoses were frequent and the criminal justice system was overwhelmed. The incidence of contagious serum hepatitis was increasing. Crisis intervention was required to quell an increasingly shrill public alarm.

The Food and Drug Administration (FDA) promulgated its standards for methadone programs in 1974 and the States soon followed with their own stringent requirements. However, the silver bullet was tarnished by such problems as patient loitering. The increasing public opposition to methadone maintenance prevented new clinics from opening in community-based settings. The crowded treatment system was acceptable only so long as the population of untreated heroin users remained static and no other serious problems emerged. But the status quo changed in the mid-1980s.

Addressing the current realities

Today, methadone treatment programs are experiencing great turbulence, driven by dramatically changing patient characteristics. Two major problems have surfaced during the last several years: a high incidence of HIV infection among intravenous drug users and an increase in multiple drug abuse.

The existing methadone treatment system must improve if it is to treat heroin addiction within the context of these new realities. The following are needed.

• More comprehensive on-site medical and counseling services are essential to respond to the needs of the present patient population.
• Program managers and staff require enhanced professional training to reshape the treatment environment.
• The public must be better educated about the value of methadone maintenance in the new treatment environment.

Finally, methadone treatment programs will require greater financial support to meet these objectives, which will be especially difficult in the present era of cost containment by third party payers.

Responding to HIV infection and alcohol/cocaine abuse

The characteristics of people entering methadone treatment have changed dramatically over the past 5 years. From the 1960s until recently, most addicts used heroin as their primary drug of abuse. At present, patients enter treatment with multiple addictions, particularly to alcohol and cocaine. Patient morbidity has also increased with the incidence of HIV infection and AIDS. Patients at risk for tuberculosis, pneumonia, and a host of other debilitating diseases require more intense medical attention at the program site.

The staff complement of existing programs is not adequate to respond to these needs. Treatment programs must become more staff-intensive, especially in the counseling and medical departments. Statewide training initiatives, drawing new personnel into the treatment system, should be established in conjunction with provider associations, State and Federal agencies, and other specialized parties.

Reducing caseloads

Caseloads must be significantly reduced so counselors can provide HIV counseling and intensive clinical support for alcohol and cocaine abusers, in addition to tracking the patient's progress. The present patient population requires increased access to group counseling services, in tandem with individual counseling. Patient peer support groups should also be developed along the 12-Step model that has been so successful in treating alcoholism and other addictions.

Expansion and marketing of the methadone treatment system

The American Methadone Treatment Association, Inc. (formerly known as the Northeast Regional Methadone Treatment Coalition, Inc.), an organization of methadone treatment providers, supports the need to open new, full-service methadone treatment programs to serve all heroin addicts in need of medical care. However, if methadone treatment is to become more readily available, sufficient resources—including increased funding, better trained personnel, and a major public education campaign—must be allocated to develop comprehensive programs.

Need for public education

Public support for methadone treatment is essentially nonexistent. Most people perceive drug abusers to be frightening, sociopathic, and generally incurable. The methadone treatment process is shrouded in mystery.

A national public relations campaign is required to educate the public about the value of methadone treatment. Treatment should be portrayed as a concrete intervention in which the heroin addict is progressively challenged by a team of experienced professionals through incremental steps in the rehabilitation process. By means of radio interviews, posters, and films, the public should be exposed to patients who are successfully maintained. Methadone treatment should be characterized as improving the quality of life for the individual patient, for his or her family, and for the community through the reduction of criminal behavior and the enhancement of socially productive lifestyles. Methadone treatment reduces general health care expenditures, contains the spread of AIDS and other infectious diseases, and frees the criminal justice system to deal with other crimes.

Methadone maintenance is an extremely valuable treatment and has saved thousands of lives. Public policy officials must work cooperatively with treatment providers to ensure that heroin addicts have continued access to methadone treatment and to preserve the benefits that existing patients derive from their ongoing care.

Last Updated