We reported on the Association’s criteria for implementing a policy for referring stabilized methadone maintained patients from treatment programs to off-site physician based settings during the previous News Report of August, 1998. We recognize the challenges of implementing such a new referral system, especially in view of the history of restricting methadone treatment to licensed and regulated treatment programs.

We remind our readers that the underlying motivation for this policy was to provide stabilized patients with an option to receive their continued care in a setting that is different from the methadone treatment program. We have consulted with patient advocacy groups, including the National Alliance of Methadone Advocates (NAMA), and we have been informed that such options would be favorably received by stabilized patients in treatment settings.

The Connecticut Pilot project, which refers stabilized patients to
off-site medical settings, has been in existence for over a year and it is hoped that the state of Connecticut will be able to file a report with the Center for Substance Abuse Treatment (CSAT) about its progress very shortly.

The value of expanding access to medical maintenance treatment is to free up critically needed treatment slots for the untreated opiate dependent individuals, who need access to methadone treatment services. The Association’s criteria have been listed below and may seem conservative at first sight. We have always taken the view that this policy represents the first logical step in a long-term strategic plan, which will work in conjunction with other medications as well, such as Buprenorphine.

A number of people have cited international findings regarding methadone maintenance in physician offices, criticizing the Association’s policy as being rigid. We have received conflicting information about the success of such initiatives in Europe and Australia. Dr. John Caplehorn (Australia) has published findings about methadone related deaths in Australia as undertrained physicians prescribe methadone to newly admitted opiate dependent patients.

We continue to hold to the principles that certified physicians should be involved in treating methadone maintained patients in their private practice settings through this hub referral mechanism in addition to physicians who have demonstrated a knowledge in working with methadone maintenance treatment as documented by a two year involvement in a treatment program. We will continue to work with CSAT and other federal agencies to begin the process of referring such patients to private practice settings, however, a functioning treatment network needs to be established in order to implement this policy.

Criteria for Stable Patient Referral from Methadone Programs to Office Based Medical Practice Settings
“Expanding Access to Medical Maintenance Treatment”

Program Involvement: (We recommend the following criteria for choosing the participating agencies):
	Compliance with federal and state regulatory authorities.
	Adherence to CSAT's State Methadone Treatment Guidelines and the American Methadone Treatment Association's Ethical Canon.
	Licensed as a "Narcotic Treatment Program" for a minimum of two years.
	Demonstrated internal protocols for reviewing patient eligibility, utilizing a multidisciplinary team approach including, at a minimum, the program's Medical Director, Nurse Manager, and the patient's counselor.
	The program shall contract with the participating physicians.
Physician Involvement: (Demonstrated interest in the treatment of opioid dependent patients in his/her medical or psychiatric practices as defined by):
	Certification by the American Board of Psychiatry and Neurology with subspecialty certification in addiction psychiatry, certification by the American Society of Addiction Medicine (ASAM) or Specialty Board Certification of Physicians of the American Osteopathic Association. It is recommended that physicians with such certification sit for a course on opioid pharmacotherapy as offered by the American Methadone Treatment Association or a recognized medical society.
	Physicians without such certification, but with a documented two-year involvement in a methadone treatment program, should sit for a course on opioid pharmacotherapy as offered by the American Methadone Treatment Association or a recognized medical society.
	Knowledge of specific methadone prescribing practices as regulated by state and federal law.
	Practices consistent with CSAT's State Methadone Treatment Guidelines.
	Agreement to provide progress reports to the sponsoring "Narcotic Treatment Program".
	Agreement to work with the patient and program regarding relapses or unstable patients.
	Provision for urine screens.
	No pending state licensure actions against the participating physician.
	Proof of minimum individual professional liability coverage as required by the State Medical Board of Examiners or equivalent thereof.
Patient Eligibility: (The patient must meet the following criteria):
	Patient be physically and emotionally stable for 36 months.
	The patient should be free of alcohol and drug abuse for 36 months verified by toxicology screening.
	The patient has not been convicted of any criminal activity for 36 months.
	The patient has been employed or in a similar capacity (a student, homemaker or disabled) for 36 months as well as a stable living environment.
	Demonstrated responsible use of take home methadone through a participating licensed "Narcotic Treatment Program". There may be exceptions granted to the 36 month criteria. Exceptions must be based on the individual's progress in treatment and recommendations made by the treatment team as documented in the clinical record. The process for which this decision can be made must be endorsed and reviewed by the State Regulatory Authority.
Organizational Issues:
	Professional and agency liability:
	A copy of the physician's professional liability insurance would be included in the physician's file, which would be kept at the program site.
	Professional liability coverage would be incorporated into the contractual agreement with participating physicians.
Methadone distribution to participating physicians:
	The participating physicians will be registered under the umbrella of the narcotic treatment program license.
	A personnel file with resumes, license, registration numbers, personal professional liability insurance carrier, and contract to provide this service would be on file with the program.
	The administration and dispensing of methadone hydrochloride in an "off-site" physician based practice will require a change in federal and state laws and regulations.
Discontinuation of off-site services: (Patients will be referred back to the base "Narcotic Treatment Program" for continued services for the following reasons):
	Signs and/or symptoms of recurring drug or alcohol misuse.
	Negative methadone urine screens or positive for drugs not appropriately prescribed.
	Significant changes in mental/physical/behavioral status that would require more patient supervision.
	Noncompliance with medical care.
	Evidence of criminal activity (drug or other).

The Board of Directors of the American Methadone Treatment Association formed a Program Management Committee during 1997 to develop a series of training symposia for program managers. The Association convened the first management-training symposium in Washington, DC on December 8, 1998 with the assistance of an educational grant from Glaxo Wellcome, Inc.

The symposium began the process of highlighting the Association’s hallmark policy issues in improving the quality of care in methadone treatment programs across the United States:

 

	implementing meaningful patient satisfaction survey instruments;
	changing staff attitudes and improving patient outcome-implementing staff attitudinal surveys;
	preparing methadone treatment programs for accreditation;
	implementing pro active media and public relations strategies in methadone treatment; and
	preventing medical negligence claims in methadone treatment programs.