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Improving the Nation's Methadone Maintenance Treatment System
Challenges and Directions for the 1990s

— Beny J. Primm, M.D., Associate Administrator, Office for Treatment Improvement

I am delighted to introduce this issue of the TIE Communiqué, which focuses on current challenges and directions for improving the Nation's methadone maintenance treatment system. This Communiqué addresses many topics of current interest and concern to the field. In light of the present challenge, I am pleased to describe Office for Treatment Improvement (OTI) initiatives that will benefit the methadone treatment system, including technical assistance, development of new policy guidelines, and other activities.

The social and health consequences of the opiate epidemic continue to represent one of the most serious domestic issues facing our Nation. For the past 22 years, as both a practicing physician and a program administrator at the Addiction Research and Treatment Corporation in Brooklyn, New York, I faced the devastation caused by this epidemic daily. Unfortunately, those of us in the addiction field know too well that efforts to address these problems at both the treatment system and clinic levels are only just beginning. The challenge of changing this reality is daunting but not without hope.

Status of our current treatment system

For more than 25 years, the research community has been providing a wealth of excellent information demonstrating the efficacy of methadone maintenance treatment. Yet the reality in 1992—27 years after the publication of pioneering research by Drs. Dole and Nyswander—is that our Nation's treatment system for narcotic addiction remains far from adequate. Let me characterize what I mean by inadequate.

• The March 1990 General Accounting Office report found substantial variation in the range of services that programs provide; none of the programs studied "systematically evaluated their effectiveness in treating patients."
• Not enough providers are tailoring their service mix to the changing characteristics and to the health and psychosocial needs of patients entering treatment—especially women, minorities, and multiple substance abusers.
• Communicable diseases—particularly sexually transmitted diseases, tuberculosis, and HIV—are increasing at alarming rates even among patients in treatment for narcotic addiction, and this problem is not unique to urban settings.
• Economic pressures on State governments are leading to cutbacks in already limited treatment resources; reductions in treatment access, availability, or intensity will only exacerbate the myriad problems that flow from addiction.
• Diversion of methadone for illicit purposes is occurring all too often because of inappropriate treatment practices at some programs.
• Many methadone maintenance units are using treatment practices—such as inadequate dose levels—that current research indicates put patients at increased risk for failure.
• Many influential leaders among our alcohol and drug abuse prevention and treatment industry, health care purchasers, those in criminal justice systems, and the public at large still do not understand that addiction is a chronic, relapsing disorder.
• Regulators continue to focus on evaluating the effectiveness of methadone programs in terms of compliance with procedural requirements, rather than on the quality and appropriateness of the care process or the outcomes of treatment.

In fact, we already know a great deal about which treatment practices work in methadone maintenance programs, as well as which practices are ineffective or inappropriate. I hope that you will take the time to read the recent studies by John C. Ball and Alan Ross and Thomas McLellan, et al., summarized in this edition of the TIE Communiqué. In many ways, the findings of these and other studies supported by the National Institute on Drug Abuse (NIDA) can act as guides to where the field must go. This research is the cornerstone for OTI's State technical assistance projects and for our categorical grant, program-based management improvement initiatives.

OTI technical assistance initiatives

The Office for Treatment Improvement is not a regulatory agency, but rather seeks to improve addiction treatment through service demonstrations, training, and technical assistance. At OTI, technical assistance means the developing, publishing, and disseminating of protocols and guidelines that reflect state-of-the-art scientific and clinical knowledge on effective treatment practices; the convening of experts to address specific systems-level treatment issues; and the providing of on-site consultation to define and help resolve unique problems at a program or State level.

OTI recently awarded a multi-year contract to establish a new technical assistance effort—the Methadone Treatment Improvement Project (MTIP). Through this project, we will provide technical assistance to help States and local treatment programs enhance the effectiveness of the existing methadone maintenance treatment system.

To identify the most critical needs and to frame and set priorities under MTIP, OTI brought together treatment experts, researchers, and State agency officials from throughout the country as a planning committee. This committee, which was chaired by Robert Garner, Director of the Santa Clara County Bureau of Alcohol and Drug Problems, San Jose, California, provided OTI with a set of priority topics to which technical assistance efforts might be targeted.

For example, guidelines for State alcohol and drug abuse agencies on state-of-the-art practices in methadone maintenance treatment are well underway. To help develop the guidelines, OTI brought together a group of nationally known experts in methadone maintenance treatment and State officials involved in licensing and evaluating of methadone treatment programs. This meeting of experts, held under the auspices of the American Methadone Treatment Association, enabled OTI to cover a broad range of critical issues. The guidelines will be widely distributed in the field for review before being published in their final form.

Other technical assistance activities now under consideration, also based on the planning panel's input, include the development of:

• A Treatment Improvement Protocol on screening, assessment, and treatment planning for codependency on narcotics and other substances, especially stimulants such as cocaine
• Techniques and methodologies for performing effective monitoring and evaluation of program performance
• Standards for automating methadone maintenance clinical management and administrative information and records

OTI's practical guidance will be based on the best available research. We are fortunate in having colleagues at NIDA working in collaboration with us to transfer the most relevant research findings in these areas into practical applications.

Finally, we all should be encouraged by the priority that NIDA is giving to research on developing new medications. We look forward to the day when clinicians will have a multitude of pharmacotherapies, in addition to methadone, with which to treat narcotic addiction.

My thanks go out to all of you who are working so hard to improve the quality of treatment available to narcotics addicts and who are helping to make OTI an effective organization. I also thank all those whose expertise is reflected in their contributions to this special edition of the TIE Communiqué. Working together, I am confident that we will be able to meet the challenges of addiction treatment in the 1990s.

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