Methadone medical maintenance (MMM): treating chronic opioid dependence in private medical practice--a summary report (1983-1998)

BACKGROUND

Methadone Medical Maintenance (MMM) was implemented in 1983 to enable socially rehabilitated methadone patients to be treated in the offices of private physicians rather than in the traditional clinic system. Over a period of 15 years, 158 methadone patients who fulfilled specific criteria within the clinic system entered this program in New York City. Participating patients reported to their physician once a month and received a one-month supply of methadone tablets rather than a one-day liquid dose in a bottle.

METHOD

Of the 158 patients who entered this program, 132 (83.5%) were compliant with the regulations and proved to be treatable within the hospital-based private practices of internists participating in the program. Compliant MMM patients found it easier to improve their employment status and business situations, finish their educations, and normalize their lives in MMM as opposed to the traditional clinic system because they had simplified reporting schedules and fewer clinical restrictions. Twelve (8%) compliant patients were able to successfully withdraw from methadone after an average of 17.7 years of treatment in both the traditional clinics and MMM. Twenty compliant patients (13%) died from a variety of causes, 40% of which were related to cigarette smoking. None of the deaths were attributable to long-term methadone treatment. Other causes of death included hepatitis C, AIDS, cancer, homicide, complications of morbid obesity and meningitis.

RESULTS

The 26 noncompliant patients (16.5%) were referred back to their clinics for continued treatment or were discharged for failure to report as directed. A major cause of failure in MMM was abuse of crack/cocaine.

CONCLUSIONS

Stigma concerning enrollment in methadone treatment was a major social issue that patients faced. Many refused to inform employers, members of their families, friends, and other physicians who treated them for a various of conditions that they were methadone patients. The methadone medical maintenance physician, therefore, functions as a medical ombudsman for the patient, educating other physicians who treat the patient about methadone maintenance and its applicability to the patient. Our results can serve as a model for the expansion of office-based MMM treatment.

Outcomes of treatment of socially rehabilitated methadone maintenance patients in physicians' offices (medical maintenance): follow-up at three and a half to nine and a fourth years

OBJECTIVE

To determine whether selected socially rehabilitated former heroin addicts maintained on methadone can continue successful rehabilitation while maintained on methadone by primary care physicians rather than licensed clinics. This procedure has been termed "medical maintenance."

DESIGN

Cohort study with 42-111 months of follow-up.

SETTING

Offices of hospital staff physicians (internists or family practitioners).

PATIENTS

The 100 patients met extensive entry criteria, including five or more years in conventional methadone maintenance treatment; stable employment or other productive activity; verifiable financial support; and no criminal involvement, use of illegal drugs, or excessive alcohol use within three or more years.

MEASUREMENTS AND MAIN RESULTS

Outcome measures used were retention in treatment, discharge for one of several reasons, lost medication incidents, and substance abuse. At one, two, and three years of treatment, 98, 95, and 85 patients, respectively, remained in medical maintenance. Cumulative proportional survival in treatment was 0.735 +/- 0.048 at five years and 0.562 +/- 0.084 at nine years. After 42-111 months, 72 patients remained in good standing; 15 patients had unfavorable discharges (11 for cocaine use, three for misuse of medication, and one for administrative violations); seven voluntarily withdrew from methadone in good standing (after receiving it for 9.1-24.4 years); four died; one transferred to a chronic care facility; and one voluntarily left the program.

CONCLUSIONS

Carefully selected methadone maintenance patients in medical maintenance have a high retention rate and a low incidence of substance abuse and lost medication. Voluntary withdrawal from methadone maintenance after one or two decades is possible. The authors believe that medical maintenance should be made available to appropriate patients in other localities.

Absence of antibody to human immunodeficiency virus in long-term, socially rehabilitated methadone maintenance patients

Human immunodeficiency virus (HIV) infection has become widespread among parenteral drug abusers. We measured antibody to HIV and hepatitis B virus markers in 58 long-term, socially rehabilitated methadone-maintained former heroin addicts. None of the 58 had antibody to HIV, but one or more markers of hepatitis B virus infection were seen in 53 (91%). The duration of methadone maintenance was 16.9 +/- 0.5 years, and the median dose of methadone was 60 mg (range, 5 to 100 mg). Before methadone treatment, the patients had abused heroin parenterally for 10.3 +/- 1.7 years, and they had engaged in additional high-risk practices for HIV infection. We conclude that successful outcomes during methadone maintenance treatment are associated with sparing of parenteral drug abusers from HIV infection.

Methadone maintenance patients in general medical practice. A preliminary report

Medical maintenance is the treatment by primary care physicians of rehabilitated methadone maintenance patients who are stable, employed, not abusing drugs, and not in need of supportive services. In this research project, physicians with experience in drug abuse treatment provided both the pharmacologic treatment of addiction as well as therapy for other medical problems, as needed. Decisions regarding treatment were based on the individual needs of the patient and on currently accepted medical practice rather than on explicit regulations. We studied the first 40 former heroin addicts who were transferred to this program from more conventional methadone clinics. At a follow-up visit at 12 to 55 months, 33 (82.5%) of 40 patients had remained in treatment; five (12.5%) had been discharged because of cocaine abuse and two (5%) had been voluntarily discharged. Personal benefits of medical maintenance include the dignity of a standard professional atmosphere and a more flexible reporting schedule. This program has the potential for improving treatment of selected methadone maintenance patients.