Introduction

It has always been a challenge to employ and retain qualified medical practitioners within methadone treatment programs (OTP's).

A number of critical reports began to surface during the 1990's, beginning with the General Accounting Office Evaluation of Methadone Treatment Program Practices. This report and subsequent research studies found variation in how medical practitioners established therapeutic dosage levels for the patient population. In many instances, patients were maintained on subtherapeutic dosages.

The current patient population continues to change with younger people being admitted to OTP's and a greater percentage of patient admissions reporting dependence on prescription opioids, some with no injection history. This requires even greater vigilance on the part of medical practitioners when admitting new patients into treatment.

Changing Patient Characteristics and New Medications

Patient characteristics have continued to change over a course of the past fifteen years. Increasingly, patients have been admitted to OTP's who are HIV and Hepatitis C positive in addition to presenting a series of co-occuring psychiatric and medical disorders. Younger patients are also being admitted to care in addition to people abusing prescription opioids, as stated above.

Methadone has been the most extensively used and researched medication to treat chronic opioid dependence within the OTP setting. The FDA approved LAAM to be used in OTP's during July of 1993 and issued a Black Box Warning during April 2001 following a series of cardiac related reports due to LAAM use. Roxane Laboraties, the sole manufacturer of ORLAAM decided to discontinue the production of the medication as of January 2004.

The Food and Drug Administration (FDA) recently approved buprenophine as the latest medication to treat chronic opioid dependence and the Drug Abuse Treatment Act of 2000 has created a new opportunity for qualified physicians outside the OTP setting to use buprenorphine and other schedule III/IV/V narcotics to treat chronic opioid dependence. The Center for Substance Abuse Treatment/SAMHSA published a Federal Register Notice on May 22, 2003 to include buprenorphine as a medication of treatment within the OTP setting.

AATOD's Response to Changing Patient Characteristics and the Development of New Medications

AATOD recognized the need to ensure that OTP's have access to the most current practice recommendations, responding to the aforementioned changing patient characteristics. AATOD worked with ASAM to publish the first TIP for CSAT in 1993 "State Methadone Treatment Guidelines". These guidelines are currently being amended to incorporate the other three methadone specific TIP's to produce one reference volume.

AATOD also worked with ASAM clinicians to develop a clinicians training course, which premiered at the 1994 National Methadone Conference and has convened at each subsequent AATOD sponsored event. AATOD also initiated a series of regional clinicians course seminars outside of the conference setting, collectively training more than 1,500 clinicians over the course of the past nine years.

Recommendations to the Field

The AATOD Board of Directors recommends that every OTP in the United States evaluate the current qualifications of its medical practitioners to be certain that all are properly trained and subscribing to current therapeutic practices with regard to the use of the methadone and buprenorphine.

It is critically important to have well-trained medical practitioners employed and retained within the OTP setting in order to best respond to the changing needs of the patient population.

It is also recommended that all OTP medical practitioners take specialized training courses concerning the use of methadone, buprenorphine, and other approved medications for the treatment of opioid dependence. Buprenorphine training should be completed before an OTP decides to initiate buprenorphine prescribing/ maintenance within the OTP setting. This would also apply to medical practitioners, who also have experience in prescribing methadone and LAAM.

As indicated above, AATOD offers clinician-training courses during the course of the year. It is also recommended that OTP's encourage their medical practitioners to participate in such course offerings, as they are made available. In this way, medical practitioners within the OTP setting will gain access to the most current information available in responding to the needs of our patients.