Methadone Treatment in Narcotic Addiction. Chapter 13

Introduction

The character of an out-patient detoxification program is determined primarily by its admission criteria and procedures, and by the medical guidelines which govern treatment, especially dosage limitations and the duration of the detoxification regimen. The orientation of the New York City Ambulatory Detoxification Program (NYC ADP) with respect to these issues is discussed in this chapter.

Admission Criteria

The criteria for admission to the NYC ADP are the following.

1. Only voluntary applicants are eligible for admission. As in the case of the NYC MMTP, "voluntary treatment" is defined pragmatically as a therapeutic relationship in which the program is under no implicit or explicit obligation to report to any outside individual or agency regarding the patient's admission, progress in treatment, or termination.
2. The applicant must have a primary physical dependence on narcotics. In applying this criterion, major reliance is placed on the history of drug usage given by the applicant. If there is an obvious inconsistency in the history (e.g., if a daily heroin consumption of only one or two "bags" is reported by someone allegedly addicted for a considerable period of time), or if suspicion is aroused during the medical examination (e.g., by the absence of "track marks" in an individual claiming many years of intravenous heroin use), the applicant is generally referred to an in-patient facility, where it is possible to provide continuous observation before and after the administration of medication (lxxv).

   The weight given self-reported drug history reflects the assumption that there is very little incentive for nonaddicts to seek admission: the relatively low dosage of methadone initially prescribed is rapidly reduced, and discontinued altogether within one or two weeks; diversion of prescribed methadone is impossible since all medication is administered and consumed in the clinic under the direct observation of the nursing staff; nonaddicted "experimenters" are unlikely to be tempted by the small amount of methadone provided by the Program, since a preliminary intake interview, complete physical examination, and extensive laboratory tests always precede the administration of medication. Despite the safeguards inherent in the protocol, however, the possibility that a nonaddict might apply to the NYC ADP obviously can not be ruled out entirely.

   Rather than employ sophisticated, time-consuming, and expensive techniques in an effort to identify the occasional applicant who should be excluded, the NYC ADP has focused its energies and resources on implementing admission procedures which will permit prompt treatment of those who want and need care. A major factor in determining this policy has been the realization that, to date, no screening methods exist which are both reliable and consistent with Program goals:

   Insisting upon routine preadmission urinalysis results which are positive for opiates entails a delay of at least one or two days, and involves considerable expense. Furthermore, urine testing only suggests that a drug has recently been taken; it sheds no light on the frequency or duration of use, or the extent to which dependence and tolerance have developed. The nonaddict who is determined to be admitted would simply be encouraged to use heroin once or twice in order to "pass" the urine screening test.

   Requiring confirmation of prior addiction treatment would conflict with the stated aim of the NYC ADP to attract the previously "unreachable" addict; it would also compromise confidentiality, and necessitate delays in the admission process.

   Withholding treatment until physical signs of the abstinence syndrome appear (lxxvi) would be paradoxical for a program whose aim is to prevent the discomfort associated with withdrawal.

   At best, an elaborate screening process might serve to protect the Program from adverse criticism, but it would do so at the expense of those the Program is intended to serve. In this regard, there has been a constant fear that a news reporter would make a spurious application to the NYC ADP in order to document the "laxity" of the admission procedure. This actually occurred on one occasion, and in that instance the reporter gave up the attempt before the preadmission physical examination had been carried out.

3. The applicant may not be simultaneously enrolled in any other clinic which administers methadone or any other narcotic or narcotic antagonist. Prior to admission, the NYC ADP routinely checks against its own patient listing to ensure that the applicant is not currently enrolled (lxxvii). The instances of attempted multiple enrollment in more than one Program clinic have been exceedingly rare. This is to be expected in view of the low dosages of methadone used in withdrawal treatment, the short duration of detoxification, and the nature of the admission procedures of the NYC ADP. It is also clear that the only completely reliable means of thwarting an applicant who is determined to receive medication in two facilities simultaneously is through the use of a fingerprint (or footprint) registry in which all chemotherapeutic programs in the metropolitan area would participate; even if legally and technically feasible, there would be an almost universal refusal of programs to be included in such a system.
4. If an applicant has previously been treated at any detoxification clinic, admission is not permitted within 28 days of last medication. This requirement is enforced only with respect to the component clinics of the NYC ADP, since no mechanism is available to identify individuals who may have been detoxified recently in other programs.

   The initial rationale for insisting on a 28-day interval between admissions was based on the limited intake capacity of each clinic (100 new patients weekly), and the Program's objective of providing detoxification to as many addicts as possible. It was not the intent of the NYC ADP to supplement the capacity of long-term treatment programs, but rather to provide a different, more limited service to addicts who did not seek long-term care. Accordingly, it was necessary to limit the duration of the detoxification regimen, and at the same time prevent the spurious "termination" and "readmission" of patients from one day to the next. Otherwise, the NYC ADP could have become, de facto, a low-dose methadone maintenance program.

   The length of the "waiting period" between admissions was the subject of considerable debate, with many staff members favoring a reduction to three or even two weeks. An analysis of Program readmissions, however, found that fewer than 10% of former patients who reapplied did so during the first four weeks following the 28-day interval; it was therefore concluded that there was little need to reduce further the minimum time period between treatment episodes.

5. Applicants under 18 years of age must have written consent of a parent or guardian, except in the case of "emancipated minors." This requirement has been retained primarily on the advice of the Department of Health General Counsel's office.

Procedures Related to Application and Admission

Application and admission procedures have remained essentially unchanged since the NYC ADP began:

Every potential applicant to one of the Program's clinics is interviewed by a counselor, who explains the objectives and operation of the Program. An Application Form is completed which contains identifying information, sociodemographic history, and the pattern of drug use. Two items substantiating identification are required.

The applicant must sign a copy of the General Information and Program Rules, and the Program's Consent to Treatment Form.

If the applicant is under 18 and does not meet the definition of "emancipated minor," a Parental Consent Form must be signed by a parent or guardian.

A medical history is obtained by a physician or nurse, and a general physical examination is performed. No applicant may receive medication without a complete physical examination being recorded in his (her) chart.

The following medical screening tests are ordered routinely at the time of admission: chest x-ray and/or skin test for tuberculosis; hemoglobin or hematocrit; serology; sickle cell test for all black and Hispanic applicants; and a Pap smear, gonnorhea smear, and pregnancy test for all women. Additional diagnostic tests are ordered at the physician's discretion.

Prior to completing the admission process and administering the first dose of medication, the clinic contacts Central Office to ascertain whether the applicant is, or has been within 28 days, a patient in the Program. (The result of this telephone check is given immediately to the clinic staff.)

Initially, the detoxification "cycle" began (i.e., medication was initiated) only one day each week. This policy was based on the assumption that if treatment commenced for all patients on the same day, screening, dispensing of medication, record keeping, and other administrative procedures would be facilitated. In April, 1972, however, in order to reduce the waiting period between application and admission (which could be as long as 6 days), a decision was made to admit patients twice a week. The result was dramatic: in the first 3 months following the change, the number of applications increased from an average of 53 per clinic per week to 72. Furthermore, the loss of applicants failing to return as scheduled to begin treatment decreased from 18% to 8%. Although other factors unrelated to Program policies may have been associated with this improvement, the NYC ADP began in early 1973 to provide same-day admission for all eligible applicants from Monday through Friday. Contrary to expectations, these changes did not appreciably compound the clerical or dispensing tasks of the clinic personnel.

Dosages

At the outset the Program strongly recommended, but did not mandate, that the initial methadone dosage not exceed 40 mg and that for the first 2 or 3 days the dosage be split, with half administered in the morning and half in the afternoon. The latter recommendation was ignored by most clinics when it became apparent that patients did equally well with a single daily dose and were generally reluctant to make two trips each day to the facility. In the light of this experience, Program guidelines were subsequently modified, and by 1973 a single daily methadone dose was routine in all Program clinics.

The policy regarding the amount of initial medication, however, created far more difficulty. Several clinic physicians, emphatically supported by the counseling staff (lxxviii), insisted that it was possible to gauge an applicant's "habit size" with a reasonable degree of accuracy, and that dosage flexibility was essential to permit appropriate, individualized treatment. Reluctant to mandate inflexible dosage limits, I permitted the administration of dosages considerably higher than the suggested maximum of 4O mg, although with growing concern.

The implementation of a rigid policy regarding dosage limitations followed an incident in January, 1972, when an 18-year-old patient was admitted to one of the Program's clinics and given a starting dose of 60 mg. Six hours later the patient was dead, and the clinical history and toxicological findings at autopsy strongly suggested that the cause of death was acute methadone intoxication. I immediately sent a directive to all clinics prohibiting the administration of more than 30 mg of methadone in a single dose; no exceptions to these limits were permitted under any circumstances. In the following three years, in which there were almost 50,000 admissions to the Program, no other fatalities attributed to administered methadone occurred. Clinics have rarely resorted to the option of referring patients with particularly high dependence to in-patient facilities, and the dropout rate prior to completion of detoxification has not been affected by this change in dosage policy.

Duration of Treatment

When the Program began, a limit to the duration of detoxification treatment seemed indicated both to accommodate the anticipated demand and to distinguish the treatment regimen from low-dose maintenance. If the NYC ADP were to achieve its stated objective of making ambulatory detoxification available promptly to all eligible addicts who sought this service, it was clear that patients seeking long-term care would have to be referred to other sources which existed in the community.

The original limit of 7 days was based on reports from other programs that this time period was generally sufficient to withdraw most addicts from their heroin dependence with minimal discomfort; it was also based on the expectation that clinic capacity would be inadequate to accommodate all the applicants. Although there were over 12,000 admissions to the NYC ADP during the first 12 months of operation, however, the daily patient load rarely exceeded 50 patients per clinic. Consequently, it was decided to permit clinics to "hold over" patients for an additional week (i.e., the maximum duration of treatment permitted was 2 weeks). Despite this added flexibility, the prescribed course of detoxification has remained 7 days for the great majority of admissions, and there has been very little pressure from either the clinic staff or patients to extend further the duration of treatment.

Notes

lxxv. Referral for in-patient treatment is also made when applicants indicate concurrent history of heavy barbiturate or alcohol use, in view of the reported hazards associated with the detoxification of the poly-drug addict. Approximately 5% of applicants have been referred for these reasons.

lxxvi. Such a procedure is suggested by the food and drug administration (201).

lxxvii. Detoxification programs in New York City do not participate in the "Methadone Information System" operated by The Rockefeller University, which includes patients in maintenance programs only.

lxxviii. In the NYC ADP approximately one-third of the counselors are ex-addicts.