Choice in addiction treatment: A little more. Recovery-Oriented Methadone Maintenance?
A few days ago David McCartney posted an interesting piece titled “Choice in addiction treatment.”
That post got me recollecting about clinical practices in our outpatient methadone maintenance program that I thought I would briefly share – in case this historical information is somehow helpful or interesting to someone.
Our methadone maintenance program began operation in either 1968 or 1969. I was told a first-hand story of its founding, but don’t remember the year. (By the way, the first journal article describing methadone maintenance as a clinical practice was published in 1965, so those were some “early adopters” indeed).
When I began work in the 12 month residential drug-free therapeutic community in 1989, the methadone maintenance program was operated in the first few offices in the front of that residential program. And the two programs shared the same nursing and counseling staff. Believe it or not but when I started there the first nurse (RN) approved by the State to dispense methadone (who began work in 68/69), was still working in that program. And more amazingly, she continued to work there for at least my first decade working in that program.
Upon my arrival in 1989, our methadone maintenance program practices included:
- Patient limit of 50 total people on the program
- No minimum or maximum dose limit
- No minimum or maximum time on the program
- 7 day RN coverage on-site, 365 days per year, providing medication dispensing
- Phase system based on developmental milestones of improvement (stabilization, diminishment of clinically relevant problems, gains in practical life goals, sustainability of improved quality of life, etc.)
- Use of substances other than opioids was addressed according to clinical relevance (e.g. a moderate to severe problem in its own right; or use of a substance class that was not another use disorder, but represented a general relapse process; or seemingly no real relevance at all).
Later in my time there, our agency undertook a multi-year (1998-2007) change-project across the dozens of programs in our organization. That effort was called the Behavioral Health Recovery Management (BHRM) Project. We used the BHRM Principles to direct specific changes. At other times we would pick a Principle and use that Principle as a goal toward which we would make many changes at once or in a row.
During those years we made vast changes to policies and procedures at both the organizational and program levels. We went as far as wholesale elimination of the entire clinical guts of some programs and total replacement of their methods with new practices.
For the methadone maintenance program we adopted changes that included:
- Budgeting 10-15 blood draws per year. We did these to check the circulating methadone level both one hour before and four hours after, one dose. We used these levels to see if the patient’s body was metabolizing the medication properly (rather than us not believing the patient that their medication was not “holding” them).
- Viewing an addiction to another drug class (like alcohol, for example) as a co-occurring disorder. We would eventually refer the patient up to a short or long term residential level of care if necessary. But we would continue their methadone maintenance while they were there if they wanted to, and it was not clinically contra-indicated. In doing so we would hold their slot on the methadone program if they wanted to stay on the medication and continue in outpatient methadone maintenance after completing residential treatment.
- Adding a “Family Night With the Doc” quarterly. We had patients invite and bring their family members at least once, but it was optional after the first time. The night included elaborate snacks, beverages and desserts in a casual but organized format. The program physician would share some brief educational comments, take questions, and respond to any discussion topics raised by the family members and the patients in an open format.
- Having our patients continue to come to the very same group therapy for their entire first year off of methadone – if they chose to taper off the medication.
- Obtaining methadone dosing privileges at our County Jail. Our nurse would personally bring them an off-site dose each day, with the idea you would naturally stay on the program if you wanted to when released.
- Obtaining methadone dosing privileges inside all of our own drug-free short and long-term residential addiction treatment programs. Our nurse would personally bring them an off-site dose each day with the idea you would naturally stay on the program if you wanted to when you completed residential treatment
- Buying the starter kit, and providing free use of a large comfortable room in our program, during off-hours (no groups happening), for the patients to start and hold meetings of Methadone Anonymous. I personally worked with our patients on this idea for four years before the idea “took” and they started the meetings. I didn’t think it would take that long, but we just kept encouraging it. We knew that they needed to start and run it, as service, if they chose to. And that if we started it or controlled it that it wouldn’t work and wouldn’t last.
- Finding out which 12 step, faith-based, and other meetings in town (very specific days/times of certain meetings) were friendly toward the idea of methadone maintenance patients being “in recovery” and also allowing them to share – if they fit into the meeting and followed the guidance of the Chair. We tended to suggest they attend these meetings
- Finding out which 12 step, faith-based, and other meetings in town were openly hostile to that, and tended to suggest they avoid those meetings.
- Adding patient education and counseling that incorporated basic principles and practices from the Advocates for the Integration of Recovery and Methadone (AFIRM).
Some of our ideas and efforts made it into print. And so did some extensions of these efforts.
Suggested Reading
Hentoff, N. (1968). A Doctor Among the Addicts. Rand McNally & Co
Strain, E. C. & Stitzer, M. L. (Eds.). (1999). Methadone Treatment for Opioid Dependence.