Medication-Assisted Treatment: Merging with Mainstream Medicine (Part 1)
By Barbara Shine
Imagine you have a chronic condition such as hypertension and have
been taking daily medication under medical care for several years.
How would you feel if you had to obtain a limited dose of your medication
from an inconveniently located treatment program during restricted
hours rather than purchasing a 30-day supply from your pharmacy
to take every day at home?
These are the kinds of obstacles that patients in treatment for
addiction to heroin and other opiates face every day. Unlike the
millions of Americans who have some choice in their doctors and
hospitals for treatment of chronic diseases such as heart disease
or diabetes, people who suffer from the chronic disease of addiction
to heroin or other opiates have had to seek care through specialized,
federally regulated treatment programs.
Observed urine testingin which the patient is watched while
providing the sampleis yet another hurdle for opioid treatment
program patients who've become medically stable in their recovery
However, since May 2001, treatment providers and patients nationwide
have been witnessing a sea change in opioid addiction treatment.
The U.S. Department of Health and Human Services repealed the Food
and Drug Administration (FDA)-enforced regulations for methadone
treatment, in place for 30 years, and instituted a SAMHSA-directed
system that relies on accreditation of treatment programs. Opioid
treatment programs now apply to be accredited by one of four accreditation
organizations designated by SAMHSA, and they have greater discretion
for individualized patient treatment within the parameters of the
Because accreditation is standard practice for health care providers
in nearly all fields of health care, its use for opioid treatment
programs should help addiction treatment begin to look more like
other areas of health care and reduce widespread prejudice against
patients in addiction treatment.
Mark W. Parrino, M.P.A., president of the American Association
for the Treatment of Opioid Dependence, explains some of the misconceptions
behind this prejudice. "Some critics of methadone treatment
believe that it represents substituting one drug for another. Such
critics see no distinction between heroin as an illicit drug and
methadone as a medication that is used in conjunction with other
Other critics, he says, "include people in recovery from
other drugs of abuse, including alcohol. They claim that since they
are able to be abstinent without pharmacotherapy, methadone maintenance
does not represent a ‘true' state of recovery."
In fact, Mr. Parrino says, "methadone treatment has been
rigorously studied for more than 35 years and the results are found
to be uniformly positive." He adds, "The changes we're
seeing under the new accreditation guidelines from SAMHSA may seem
small, but they are nothing short of a revolution."
"The new SAMHSA rule puts the patient first. It gets the
Federal Government away from directing medical practice in addiction
medicine," says Robert Lubran, M.S., M.P.A., Director of the
Division of Pharmacologic Therapies within SAMHSA's Center
for Substance Abuse Treatment (CSAT). "Rather than dictating
how opiate-addicted patients are to be treated, the regulations
have made it clear that medical and clinical treatment professionals
should be encouraged to apply their training and expertise in making
patient care determinations without undue concern about burdensome
Federal restrictionsmore like mainstream medical care."
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Standards, Not Controls
Under the former system of FDA regulation, methadone maintenance
treatment programs were monitored by Federal inspectors to ensure
their adherence to rules limiting the amount of methadone given
to each patient in a daily dose and rules for detailed record-keeping
practices. Monitoring the distribution of a controlled substance—methadone—appeared
to be the primary objective.
The new SAMHSA rules, by contrast, shift the direction of Federal
oversight to ensuring that more than 1,100 opioid treatment programs
across the country are applying the best clinical practices as described
in the CSAT accreditation guidelines. The guidelines are based on
recommendations from the 1997 National Institutes of Health Consensus
Statement on Effective Medical Treatment of Opiate Addiction,
the 1995 Institute of Medicine report, Federal Regulation of
Methadone Treatment, and the deliberations of a panel of field
experts. The accreditation bodies have all adopted new standards
for the treatment of opiate addiction that emphasize improving the
quality of care through individualized treatment planning, greater
medical supervision, and assessment of patient outcomes.
CSAT's accreditation guidelines for optimal care in addiction
treatment programs have been translated into measurable standards
by accrediting organizations. The standards of care are designed
to ensure, for example, that patient care is tailored to individual
needs. Arbitrary restrictionssuch as ceilings on methadone
doses and observation of urine testshave been removed. And,
in the Nation's health care system, patients with the disease
of addiction are treated with the same respect afforded patients
with other chronic diseases.
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