Consultation Document on Opioid Agonist Treatment
4. The Challenge:
Currently only a fraction of those addicts who can benefit from methadone treatment do so. We need to expand methadone and other heroin treatment modalities, such as residential treatment, to reach the untreated majority of the opiate addicted.
A. Policy barriers:
The laws governing methadone treatment—the Controlled Substances Act (CSA) and Narcotic Addict Treatment Act (NATA)—date from the 1970s, and were based on the political and social climate of the day, rather than rigorous study. Because they pre-date research breakthroughs on the nature of addiction, these laws arbitrarily limit the expansion of treatment capacity. In addition, they are combined with process-focused regulations, which do not address treatment quality.
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(1) No uniform application of standards for admission to methadone treatment: As the 1990 GAO study noted, there is a wide variance of policies among various methadone treatment organizations. FDA admission standards are not uniformly applied by programs in evaluating potential patients and assigning them to methadone programs. Not everyone will benefit from methadone treatment and the failure to apply uniform evaluation standards makes it probable that some addicts who would benefit from other modalities are being assigned to methadone or other treatment regimes inappropriate for them.
(2) Variance in oversight and limits on dosage level and take home medication. There is considerable overlap in governmental oversight and enforcement, with Federal, state, and local agencies involved in some states with different priorities and concerns. Federal regulations recommend dose limits but set take-home medication privileges on time spent in the program, rather than on clinical criteria. Both practices should be based on sound clinical criteria for decision-making, as the former practice can lead to under-treatment and the latter to diversion to illicit use.
(3) Lack of enforceable clinical guidelines: Paradoxically, in an environment in which methadone is over-regulated, there is a dearth of enforceable clinical guidelines. In lieu of outcome oriented measures, the Federal Government has developed a regime of regulatory oversight of methadone clinics that has controlled diversion to illegal use, but does little to enhance treatment quality. There is a substantial body of knowledge and a rare scientific consensus on both the utility of methadone treatment and its appropriateness for many addicts. This body of clinical knowledge -- rather than the current regulatory maze—should form the basis for the broader employment of methadone treatment. |
B. Expanding the role of methadone:
The ease with which methadone and other drug treatment programs are dismissed by some shows a lack of public understanding of the benefits of drug treatment in general and methadone treatment in particular. Drug treatment is misleadingly characterized as another form of welfare, as "something for nothing" when it is actually the single most cost efficient policy option for reducing the consumption of drugs and the commission of drug-related crimes.
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(1) Superfluous regulations can be curtailed: The Institute of Medicine of the National Academy of Sciences found in 1995 that a reduction in existing regulations could be accomplished without negative impact on health or safety standards. A consensus development conference, convened by the National Institutes of Health in 1997, strongly recommended broader access to methadone treatment programs for people who are addicted to heroin or other opiate drugs and the elimination of Federal and State regulations and other barriers that improperly impede access. And, earlier this year, a GAO review of the science identified methadone as the most effective treatment (to date) for heroin addiction. The conclusions of these prestigious bodies join the overwhelming body of scientific evidence supporting the expansion of methadone treatment within the overall context of an expansion of drug abuse treatment.
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Last Updated: March 4, 2002
