April 16, 1999

When New York City Mayor Rudolph Giuliani announced last July that he was planning to phase out all city methadone programs, the reaction of the addiction treatment community was in some cases unprintable.

But through a combination of highly public criticism and quiet diplomacy, New York's outspoken mayor was persuaded that he was wrong, and this January he announced that he had changed his mind. The addiction treatment community and methadone addicts who had come to rely on the drug to function normally breathed a collective sigh of relief.

The story, unfortunately, does not have an entirely happy ending, as U.S. Sen. John McCain rushed into the breach this February with federal legislation that would, if approved, drastically curtail access to methadone treatment. So far the legislation has gone nowhere, but it has methadone advocates worried.

"What is most encouraging about Mayor Giuliani's actions is that he did respond to input from experts in the field and rescinded his previously announced policy of essentially eliminating long-term methadone treatment in the New York City health care system," Richard Suchinsky, M.D., vice chair of APA's Council on Addiction Psychiatry, commented. "One would hope that his enlightened approach would be emulated in other settings."

McCain's recent legislation is misguided, observed Suchinsky. "I think the senator has been misinformed," Suchinsky said. "In well-run methadone programs the use of methadone and related compounds like LAAM (levo-alpha-acetyl-methadol) have proved to be effective in helping opiate-dependent individuals deal with their illnesses." Eliminating these compounds from addiction psychiatry's "treatment armamentarium would be a tragic mistake," he concluded.

McCain's bill, S. 423, the Addiction-Free Treatment Act of 1999, would: limit Medicaid payments for methadone and LAAM to a maximum of six months; require frequent random urine testing; and terminate methadone/LAAM treatment immediately for any patient whose urine tests positive for an illicit drug. Programs funded by the federal Substance Abuse and Mental Health Services Administration (SAMHSA) would be subject to the same restrictions.

Psychiatrist Donald Vereen Jr., M.D., deputy director of the Office of National Drug Control Policy (ONDCP) and a corresponding member of APA's Council on Addiction Psychiatry, discussed the methadone developments with Psychiatric News.

"You take the time to digest the evidence and then the conclusion you can draw is pretty clear: that methadone has a role in the treatment of opiate addiction," said Vereen.

Regarding McCain's recent foray into anti-methadone legislation, Vereen said that the ONDCP also has "concerns about methadone treatment in this country" and has therefore worked with the Department of Health and Human Services for the last two years to move oversight for methadone programs from the Food and Drug Administration to the Center for Substance Abuse Treatment. This would change oversight of methadone treatment "from a regulatory-based oversight to an oversight based on clinical standards and outcomes," he explained. This would improve the likelihood that methadone treatment would occur within the context of an integrated program addressing biological, psychological, and social issues.

He expressed optimism that more well-rounded programs would permit more people to ultimately kick methadone and remain abstinent.

The provision of McCain's draft legislation that would terminate methadone treatment immediately if an addict in treatment had a dirty urine, that is, showed evidence of illegal drug use, has particularly worried methadone advocates.

"Methadone is a tool-it's not a cure-but anyone who knows anything about methadone treatment knows you are going to have relapses," Vereen pointed out. "The critical issue is how you deal with those relapses. We also know that people on methadone do less drugs, commit fewer crimes, get back to work, and interact with their families better. The dirty urine issue has to be looked at within the reality of what addiction is and what the recovery process is."

While some politicians would like to tighten the circumstances in which methadone or other addictive drugs could be dispensed to opiate addicts, the mainstream addiction treatment community appears to be moving in the opposite direction.

The idea that "at some point in the future addiction could be treated like any other disease, meaning that someone stabilized in treatment could be treated in the outpatient office of [his or her] physician, would be doable if we develop a clear set of clinical standards and clinical goals in compliance with the regimen," said Vereen. "That's further down the road; we're not there yet."

The idea of less restrictive dispensing of methadone or similar drugs is consistent with the notion that addiction should be treated like any other clinical problem, Vereen continued. "Why is it if you're an opiate addict and you're a [treating] doctor, you have to go to the one place that gives methadone every day and is only open from 10 a.m. to 2 p.m.?" Vereen commented.

Some addicts "may have to be on methadone indefinitely," Vereen said. Medicine doesn't yet know enough about who is best suited to achieve abstinence and who is most likely to need methadone indefinitely. The current system doesn't encourage physicians to make that distinction, Vereen observed, but there is speculation that about a third of addicts would be good candidates for drug-free treatment.

"Perhaps a third of methadone treatment patients could come off at some point, about a third probably never could come off, and then there's a group in between that we just don't know enough about," said Vereen.

In a related development, Johns Hopkins University researcher Eric Strain, M.D., and colleagues published a study in the March 17 Journal of the American Medical Association reinforcing evidence that many addicts would do better on higher doses of methadone than those commonly dispensed by methadone programs. Federal law discourages dispensing of more than 100 mg methadone daily per addict, and many programs dispense doses much lower than that, generally in the 30 mg to 60 mg range daily. The JAMA study found, however, that addicts receiving 80 mg to 100 mg daily did much better on a variety of measures than those getting lower doses. Strain speculated that some addicts may need doses higher than 100 mg for optimal benefit.

"There are some states that say you can't give more than a certain amount of methadone," Vereen noted. "What if someone needs more than that for it to be effective? Since when did the states get a medical license? We tend to undertreat with opiate drugs, because we doctors fear addiction."

While methadone continues to stir controversy, steps are under way to permit physicians to prescribe a much weaker opiate drug, buprenorphine, as a maintenance drug. Unlike methadone, buprenorphine is a mixed agonist-antagonist.

"The important issue here is it still has abuse potential, but less than methadone," said Vereen. "It could, thus, fit more easily into the realm of outpatient use."

He expressed optimism that bupre-norphine, unlike methadone and the related, longer-acting drug LAAM, will progress quickly to use as an addiction maintenance treatment without getting "hung up in the regulatory matrix. Let's get it out there for the medical profession to use" but at the same time "make sure doctors are trained properly to use the stuff."

As with methadone, psychiatric, social, and employment issues should be addressed. "Unless you do the biopsycho-social approach to addiction, you will lose the battle," Vereen said. -R.B.K.