AATOD continues to work to fulfill the commitment of the October, 2001 Five-Year Plan. The agenda is extremely ambitious.

We are making steady progress as OTP's improve the quality of their care, through accreditation and through access to our conferences and training initiatives. We will also be making increasing inroads in the criminal justice system in order to fulfill the future goal of increasing access to methadone treatment and to other approved pharmacotherapies in the criminal justice setting.

We believe that our work will steadily lead to greater public support for methadone treatment among the American public. The Five-Year Plan continues to be sound and it is the basis of much of our organizing work.



Implementing Accreditation and Working With Federal and State Regulatory Agencies

Our Association has continued to support the implementation of OTP accreditation throughout 2003, responding to many inquiries from the field. We also work with all federal agencies, which have primary jurisdiction over our field, including the Center for Substance Abuse Treatment within SAMHSA as it corresponds to accreditation and other related OTP policies. This was in evidence during the April 2003 national conference, which convened in Washington, D.C.

We have also continued to work with all of the State Methadone Authorities, each of whom was represented at the April 2003 conference. CSAT continues to support the travel of all State Methadone Authorities to our conference to participate in policy deliberations and to gain access of the most current information guiding our field.

This was the second consecutive conference to convene against the backdrop of a significant national challenge. The October 2001 national conference convened in St. Louis, Missouri three weeks following the September 11, 2001 attack. The April 2003 conference convened in Washington, D.C. several weeks after the United States invaded Iraq. In spite of these events, the conference continued to produce needed revenue, although we lost several hundred registrants per event.

Drug Court/Probation/Criminal Justice Initiatives

2003 represented a pivotal year in reaching the goals of the Five-Year Plan. AATOD continues to work with the National Drug Court Institute NDCI) in educating their members by participating in their conferences. Mark W. Parrino, President of AATOD, served as a plenary speaker during the May 2003 National Drug Court Institute conference, which included Dr. Andrea Barthwell (Deputy Director/ONDCP), Judge Peggy Hora (California Drug Court Judge) and Judge Freeman Wilson (Executive Director/NDCI).

AATOD also continues to work with association partners in the criminal justice system both in planning initiatives and in their conferences. Mark Parrino recently presented at the NASCA conference during October, 2003, representing AATOD's initiatives in guiding our field. The NASCA members represent the State Controlled Substances Authorities.

The most significant accomplishment has been to receive a Robert Wood Johnson Award, which will allow AATOD to meet one of the critical goals of the Five-Year Plan; increasing access to methadone and other approved pharmacotherapies to treat chronic opioid dependence through the criminal justice system. This includes educating correctional facility managers, probation and parole representatives, drug court judges in addition to attorneys within the criminal justice system.

Mallinckrodt, Inc. has also agreed to provide financial support in tandem with the Robert Wood Johnson Award so that AATOD would be able to work with partners in the criminal justice system, including the National Drug Court Institute, the American Jail Association (AJA) and the American Probation and Parole Association to advance these goals between 2004-2006.

The combined financial resources of the RWJ Award and the Mallinckrodt grant will be used for two purposes. The first will be to conduct an attitudinal survey among the criminal justice partners, as stated above, by working in conjunction with NDRI (a research-based organization in New York City). AATOD will also work with the Legal Action Center in focusing on five states in order to better understand the impediments of providing increased access to replacement pharmacotherapies to treat chronic opioid dependence in the criminal justice system.

This opportunity is expected to lay the foundation for genuine partnerships between AATOD, the criminal justice systems and federal and state authorities to create model laws and regulations, which will build upon the NIH 1997 recommendations to increase access to the use of such pharmacotherapies for people under legal supervision.



Educating America about the Value of Methadone Treatment

AATOD has worked steadily in 2003 to fulfill the goal of the Five-Year Plan in educating communities and elected officials about the value of methadone maintenance treatment. AATOD's Public Relations Committee updated the Community Education Kit "Medication Assisted Treatment for the 21st Century" , which was published by CSAT/SAMHSA during the summer of 2003. Thirty thousand of these kits were printed and have been distributed to programs within the United States in addition to representatives within the criminal justice setting as well.

These kits have also been recently shared with our European colleagues. A number of OTP's have reported significant success in using these kits to educate local communities and elected officials about the value of methadone treatment since the information represents the most current material for distribution in an easily readable format.

Media reports of methadone-associated mortalities also increased during calendar year 2003, especially with the publication of the February 2003 New York Times front-page article. We had anticipated this kind of media coverage and began working with federal agencies within DHHS as early as the summer of 2002, encouraging federal agencies to better study the nature of the problem.

Mark Parrino met with DHHS senior officials and the SAMHSA Administrator during November 2002 to emphasize the importance of this study. CSAT/SAMHSA subsequently convened a special planning meeting of federal agencies to compare their respective data resources during March 2003. This planning event served as a precursor to the May 2003 meeting, which CSAT/SAMHSA convened among all federal agencies, which have jurisdiction and oversight for this field. A draft report has been developed subsequent to the May 2003 meeting and is currently going through the clearance process prior to being released to the general public.

I had the opportunity to review the draft report as one of the three co-chairs of the May 2003 meeting. In effect, the report will exonerate the nation's OTP's from primary responsibility as it relates to the cause of these reported methadone-associated deaths.

Another source of media reporting has been the increased use of prescription opioids by Americans, at times, leading to dependence and abuse. AATOD has kept abreast of anecdotal reports from various OTP's throughout the United States, listing prescription opioids as primary drugs of abuse at time of admission.

AATOD has been working with Purdue Pharma since the summer of 2002 to develop a three-year trend analysis among OTP's in rural regions of the United States to document how patient admissions are reporting the use of prescription opioids at time of admission.

AATOD will be working with NDRI (a research-based entity in New York City) to develop the survey questionnaires, which will be completed by patients at time of admission. Approximately 75 OTP's will be involved in the study, which will begin during the first quarter of 2004 and conclude during 2007. The study will collect three years of data. It is expected to be the first study of its kind to involve so many OTP's in different parts of the country in order to better understand the influence that prescription opioids are having on admissions to the OTP setting.

Increasing Access to Methadone Treatment and Medical Maintenance

AATOD has been consistently working with states, which provide access to methadone treatment to increase access to care whenever needed. We continue to receive numerous requests from different OTP's in the United States, which are expanding their own treatment system or developing new treatment programs in different regions of the country. At present, the majority of new OTP openings are the result of the propriety sector investments.

We have also been focusing on the lack of treatment availability in states, which have a clear and proven need for treatment, such as Mississippi. AATOD has documented that over 575 Mississippi residents cross the border each day to gain access to care in Louisiana, Tennessee and Alabama. We have been working with SAMHSA/CSAT officials to focus on this problem so that Mississippi will approve access to methadone treatment within its borders.

Historically, AATOD has worked with Arkansas, Maine and Vermont to increase access to care. We hope to achieve a similar result in Mississippi during 2004.

Increasing access to medical maintenance treatment, by referring stabilized OTP patients to affiliated medical practitioners, has been much slower in its development. We have encouraged CSAT to support various treatment/research opportunities to better evaluate the different models of medical maintenance so that we can gain additional information to increase access to this treatment opportunity. The Five-Year Plan has supported increased access to medical maintenance treatment and we understand that this will be a slow but steady process. Ultimately, our system needs to provide increased access to new patient admissions to OTP's and to create the opportunity to refer our stabilized patients out of the OTP settings to affiliated medical practice offices. This is part of a natural continuum of care, which is used in other parts of the health care system in the United States.



Training Medical Practitioners/Clinicians in the OTP Setting

AATOD has continued to support training medical practitioners and other clinicians in the OTP setting through our Clinicians Training Course and Hepatitis C training initiatives. We convened a training opportunity during the Washington, D.C. conference and plan on offering a Clinicians' Course in San Francisco during January 2004. This builds upon our mission within the Five-Year Plan to have the most educated and trained practitioners in our field, responding to changing patient characteristics. We have been fortunate to secure the support of the National Institute on Drug Abuse (NIDA) in developing these training courses.

This continues the tradition which was initiated during the 1994 national conference and has convened during each subsequent conference. We have trained over 1,500 clinicians through these conferences and regional clinician course training events.

We also received a grant from the Center for Substance Abuse Treatment (CSAT) to focus on Hepatitis C Training for OTP staff, which began during the last quarter of 2002 and was implemented during 2003, concluding on October 15, 2003. We provided training to more than 50 program representatives during the April 2003 conference and also provided training to 60 programs on site in six states.

AATOD is currently involved in evaluating the impact that such on site Hepatitis C training has had in altering patient care within the OTP setting. This second phase of the Hepatitis C training initiative should be completed by March 2004 and subsequently reported to CSAT and the AATOD Board of Directors. It is anticipated that CSAT will continue to fund a second phase of Hepatitis C training during the summer of 2004. We will select a number of new states, which did not have an opportunity to participate in the initial pilot training.

It is important to note that program personnel appreciated the quality of the Hepatitis C initiative, which is reflected in the majority of the evaluations, which were collected at the conclusion of the on site Hepatitis C training.



Management Training/Policy Initiatives

AATOD has continued to work on program management initiatives as well, following the recommendation of the Five-Year Plan. At present, AATOD has been working with David Szerlip & Associates to conduct a professional liability insurance survey among OTP's in the United States. This is designed to assess liability risks within the OTP setting and to solidify existing professional liability insurance markets and create new markets as well. Results of this study will be shared with the AATOD Board and participating survey programs during March/April, 2004. All data collection will conclude by December 31, 2003.

AATOD's Board of Directors also responded to anecdotal reports of rapid methadone withdrawal schedules when patients did not have the ability to continue fee payment. The policy was published during July 2003 and has drawn favorable comments from administrators and patient advocacy groups in different parts of the United States.

Organizing the Treatment Community

We continue to work with existing member states in organizing their provider associations and in providing current information to elected and appointed officials to member states, especially in times of crisis. We have also worked to expand our individual program membership through the office of the Project Director. Accordingly, we have increased individual program membership for 2003.

We also continue to work with our international associates in increasing access to methadone treatment throughout the world. We have worked with EUROPAD as one of our principal partners in this international initiative, in addition to representatives from other countries as far reaching as Australia, China and Central Europe.

We have also encouraged the International Affairs Office within the National Institute on Drug Abuse (NIDA) to support the development of a professional conference within Central Europe during 2005. This represents an extremely ambitious goal, which would support the work of AATOD/EUROPAD and its European affiliates to have U.S. based researchers/clinicians work with our international colleagues to develop a two-day training conference to present the best practices in methadone treatment.

We have also supported the expansion of methadone treatment in South America through working with our colleagues in Mexico (Dr. Emilia Figueroa), who was given access to our clinician's course syllabus in order to make a presentation to South American physicians in Bogotá, Colombia during the summer of 2003. The response was favorable and it is hoped that the Colombian government will provide access to methadone treatment very shortly.