November 20, 1998

White House Office of National Drug Control Policy (ONDCP) Director Barry McCaffrey presented in New York City this September plans to expand methadone and antiheroin programs across the country. The announcement, which McCaffrey made at a methadone treatment center and at the national convention of methadone treatment providers, came two months after New York Mayor Rudolph Giuliani said that he would gradually close down the city's methadone programs (Psychiatric News, September 18).

In a speech at the American Methadone Treatment Association, McCaffrey outlined plans that would result in far more people being able to receive treatment for heroin addiction in a greater variety of programs. "Our challenge is to expand treatment opportunities for the four million Americans who are chronic users of illegal drugs," said McCaffrey. Only 50 percent of those who need treatment now get it, he noted, but the 1998 National Drug Control Strategy has established the goal of reducing this treatment gap by 20 percent by 2002 and 50 percent by 2007.

He said methadone availability is too limited and that government regulations determining who can enter a methadone program and what doses they can receive are too stringent.

"We need your help to make the case to Congress and legislatures all across this country that investing in treatment is good fiscal policy. We also need your help to gain parity in health coverage treatment," he said.

McCaffrey also discussed a reform effort on which ONDCP is working with the Department of Health and Human Services (HHS) and Drug Enforcement Administration (DEA) and asked for feedback, discussion, and support from the audience of substance abuse clinicians and providers.

McCaffrey presented ONDCP's new "Consultation Document on Opioid Agonist Treatment." In addition to expanding treatment capacity, the document calls for development of a standardized accreditation system for methadone treatment programs with transfer of regulator oversight for methadone from the Food and Drug Administration to the Substance Abuse and Mental Health Services Administration (SAMHSA) and elimination of regulatory barriers to allow individual physicians to administer methadone.

ONDCP's new policy on treatment also involves HHS oversight of efforts by SAMHSA, the Center for Substance Abuse Treatment (CSAT), National Institute on Drug Addiction (NIDA), FDA, and DEA to develop new procedures for developing methadone programs and accrediting providers. Recent grants to CSAT will be used to study existing treatment programs and create new ones. Sixty to 300 programs will be surveyed, and new standards will be developed and applied to programs and site visits. The Commission on Accreditation of Rehabilitation Facilities and the Joint Commission on the Accreditation of Healthcare Organizations will be responsible for accrediting providers.

McCaffrey said that ONDCP is working on a notice of proposed rule making and accreditation surveys that may be available this winter. ONDCP will release the 1999 National Drug Control Strategy and 2000 budget with increases in treatment funding in February 1999. Accreditation testing is scheduled for March through October 1999, and a final rule for January 2000. It is not clear when individual physicians will be able to administer methadone.

Richard Frances, M.D., chair of the Public Policy Committee of the American Academy of Addiction Psychiatry (AAAP), said the AAAP is in favor of McCaffrey's move to have methadone maintenance regulated by the Center for Substance Abuse Treatment as opposed to the DEA.

"We support the move from a legal to a medical stance-methadone is a medication like other medications," said Frances. "Addiction is a deep brain disease that requires treatment. [Treatment] is effective. It reduces crime, gets people back to work, and reduces the spread of HIV and other infections."

The AAAP also encourages the effort to have primary care physicians and addiction psychiatrists be able to administer methadone in office-based practices, he said. "There have not been enough treatment slots for heroin addicts," said Frances. "Approximately one in eight addicts is in a treatment program for methadone, and we would like to see a higher percentage in treatment."

AAAP members are concerned, however, that there be adequate controls put in place to reduce the possibility of diversion, said Frances. "Methadone is an abusable drug, and our recommendation is that only addiction psychiatrists and American Society of Addiction Medicine (ASAM) members be allowed to do this and only after they have been trained."

Much of the impetus for the new ONDCP policy originates from recent research and reports demonstrating the effectiveness of treatment for substance abuse. In his speech, McCaffrey noted that the Institute of Medicine of the National Academy of Sciences studies completed in 1995 showed that a reduction in existing regulations could be accomplished without negative impact on health or safety standards. He also reported that a consensus development conference convened by the National Institutes of Health in 1997 strongly recommended broader access to methadone treatment programs for people who are addicted to heroin or other opiate drugs. Attendees of the conference proposed the elimination of federal and state regulations and other barriers that impede access.

McCaffrey listed research that provides evidence to support methadone maintenance as the most effective treatment for heroin addiction, including a 1998 Government Accounting Office report and the NIDA Drug Abuse Treatment Outcome Study that found that methadone treatment reduced participants' heroin use by 70 percent and their criminal activity by 57 percent while increasing full-time employment by 24 percent.

"We estimate that illegal drugs cost our society more than $100 billion a year," said McCaffrey. Nationally, only about 115,000 opiate-addicted individuals out of an estimated 810,000 are participating in methadone maintenance programs. In New York City 36,000 out of a total of 200,000 heroin addicts are enrolled in monitored methadone programs, but the city's methadone treatment system is operating at only about 90 percent of its capacity.

"Giuliani was flying against all of science in saying he wanted to get rid of methadone programs," said Frances. "He threw down the gauntlet. McCaffrey has picked it up."