Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
AM. J. DRUG ALCOHOL ABUSE,4(4), pp. 543-553 (1977)
Ten Years of Methadone Maintenance Treatment: Some Clinical Observations PAUL CUSHMAN, JR.," M.D. Assistant Professor of Medicine Columbia University Ditector Methadone Treatment and Clinical Pharmacology St. Luke's Howitat Center New York, New York 10025 ABSTRACT Ten years of methadone maintenance were reviewed in all 547 patients admitted to one clinic in New York City. High retention rates, reduced but still high mortality rates, increased employment, and minor degrees of recognized opiate abuse characterized those remaining in treatment. The treated patients appeared to evolve into a unique social and economic class, partly in the drug subculture and partly outside the drug world. Many were dependent on public assistance for living expenses, methadone treatment, and medical care. An interesting finding was their heavy demands for inpatient hospital care, often for drug-related reasons. A segment of New York City narcotic addicts was sequestered in an open-ended treatment process with considerable benefits to themselves and to society. Only a small fraction appeared to gravitate toward full economic support, to discontinuation of methadone, and to an enduring narcoticfree state.
INTRODUCTION The introduction of methadone in 1964 as an outpatient maintenance treatment of chronic narcotic addiction [I] soon spread to regional centers. One of these, St. Luke's Methadone Clinic, was initiated in 1966 for addicts residing in the upper West Side of Manhattan. After 10 years it is appropriate t o *Resent address: Wood VA Hospital, Wood, Wisconsin 53193. 543
CUSHMAN
544
examine the results of treatment in terms of several medical and social measurements. The data document the existence of a relatively stable population of treated addicts with some distinctive features which combine those of untreated addicts and the general population.
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
PATIENTS AND METHODS All 547 patients ever admitted to the St. Luke’s Clinic between 1966 and January 1, 1976 were studied, which included all who had consumed one or more doses of methadone. One hundred eight patients had been admitted to St. Luke’s as transfers after their induction into treatment had been completed elsewhere; 339 patients were admitted directly for all phases of treatment. The sole criteria for admission were a 2-year history of dependence on opioids and that the individual be at least 17 years of age. Individuals who were multiple drug abusers, had mixed addictions, or complicating medical or psychiatric problems were not denied admission when recognized in the intake procedure. The demographic features of the 547 patients were similar to those reported for New York City addicts in general [2]. 73% were male, 41% were Black, 33% White, 25% Hispanic, and 1% Chinese. Hospital, medical, and social records were reviewed, and patients contacted and directly interviewed. The computerized list kept on all New York City methadone-treated patients at the Community Treatment Foundation was consulted regarding status of all patients who had been terminated. Similarly, the New York City Death Register was searched for information about all terminated patients. Employment data were obtained by interview and confirmed by periodic auditing of payment stubs. Since patients left treatment for various reasons, a convenient but arbitrary classification was devised for the group of patients discharged and not readmitted at St. Luke’s at the time of the study: (A) absconders, jailed patients, and others discharged involuntarily because of rule infractions; (D) patients who left to detoxify themselves against the advice of the staff and without the clinic’s assistance in the detoxification procedure; (CT) those patients who sought and completed detoxification with the assent of the staff. They could be considered to have had completed treatment. Since some did not achieve detoxification despite their desires to do so (31, only those who actually completed the detoxification were included as CT. Vigorous efforts were made to follow all terminated patients. Some of the CT patients participated in a structural aftercare. Most were seen haphazardly
TEN YEARS OF METHADONE MAINTENANCE TREATMENT
545
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
and sporadically, often in response to letters, telephone calls, messages, or chance encounters on the streets. The follow-up data must be considered somewhat incomplete and less than satisfactory. Since there were differences in employment data between the earlier patients and those admitted after 1972, the patients were divided into three cohorts: Cohort I was admitted between 1966 and 1972, Cohort I1 was admitted between 1972 and 1974, and Cohort I11 was admitted between 1974 and 1976.
RESULTS The pattern of the clinic’s growth was triphasic (Fig. ,l). Initially growing slowly, it grew sharply in 1970 to 1972, and then slowed down as the numbers
500
1 PATI ENTS TERMINATED
A L L PATIENTS E V E R TREATED
400
- -* \PATIENTS TRANSFERRED
fA
-
300
d
t-
d
100
I
1970
I
1972
1
1974
Fig. 1. A decade of methadone treatment. Cumulative census data.
I
1976
546
CUSHMAN
Table 1. Demographic Characteristics of Deaths in Methadone Maintenance
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
Category of persons at risk Methadone maintained Male Female Mean age 40 (28 to 64 years) Terminated patients Mean age 36 (26 to 53 years) Untreated addict@ Young adult New Yorkersb
Number of deaths Number of person Death probability years at risk XlOO observed 25 19 6
1,655 1,241 414
1.5 1 1.52 1.50
11
367
3.00
1.8 million
8.25 0.56
aTaken from Gearing’s 1974 data of 109 persons followed from 1965 to 1972. 1969 to 1970,0.56 i 0.23, age 20 to 54 years.
of patients remained in active treatment (receiving methadone) on January 1, 1976. The net retention rate was 5376, which included 64 patients who had been discharged and readmitted. An additional 73 discharged patients had been transferred to other methadone treatment centers. Since adequate information was often unavailable regarding these transferred patients, the outcome data do not include them, and only the time that they were actually in treatment in St. Luke’s Hospital was used in the calculations of the treatment years at risk. One hundred fifty-eight patients were discharged alive. Twenty-five patients died while in active treatment. Since there were 1655 person-years at risk over 10 years, the mortality rate of treated patients was 1.51%. This rate is far below the 8.1% rate reported by Gearing [4] for untreated addicts, but it was still significantly higher than observed in the general population (age 20 to 54 years) [5] (Table 1). These mortality figures may be incomplete since death may have accounted for unexplained cessation of treatment by other patients. How many other unrecognized deaths occurred is unknown, but their number was minimized by the vigorous efforts to locate all patients who abruptly discontinued treatment, i.e., contacts with local hospitals, the jails, the city morgue, and medical examiner’s offices as well as efforts to reach the family, friends, neighbors, erc. and home visits. The causes of death were established in all 25 known deceased. Autopsy reports were reviewed in 17 and the medical examiner’s office data in 5 other cases; 3 other deaths were accounted for after interviews with family, friends, and witnesses. The causes of death are presented in Table 2. It is evident that there is a high incidence of death due to trauma, infections, and drug abuse (including alcoholism and its sequelae).
541
TEN YEARS OF METHADONE MAINTENANCE TREATMENT Table 2. Causes of Death
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
Categories of causes of death Trauma Assassination Other Infections Tuberculosis Other (SBE) Cancer Cardiovascular Drug abuse Overdose Alcoholism Other Renal failure Infarcted bowel Intracranial bleed Hyperglycemic coma GI bleed Totals
During treatment 5
After treatment 3
20%
21%
3 0
3 2
3
12
0
5 3 4
20 12 16
2a 0
14
I
50
2
14
2 1
2 2
1 2a 5
20
Hepatitis 1 Unknown 1
1 1 1 1 1 25
100%
14
99%
~~
aOne cancer patient and all 2 alcoholicshad clinical evidence of serious disease during treatment.
The mortality figures in the 158 patient terminated group are far less satisfactory than those in the treated group. However, 14 persons were known to have died since leaving treatment. Since there were 297 person-years at risk in the terminated group, a mortality rate of 4.7% was calculated, which was a significantly higher rate than that of the patients continuing in treatment. The causes of death, where known, are also listed in Table 2. Thus both the treated and terminated patients not only had high death rates but also had similar causes of death. Both groups had, in addition to the usual perils, an unusually high incidence of death due to alcoholism, drug abuse, and trauma-much higher than that expected in the general population. Patients in treatment appeared to have made extensive use of inhospital medical care. In the past 4 years (1971 to 1975) there were 191 separate hospitalizations in 1,021 patient-years at risk for a rate of 18.7%. These figures are significantly higher than those reported by New York City’s Blue Cross, a private insurer. The latter report was 105 hospital admissions per 1,000 subscribers in the 1.3 million population of subscribers age 20 to 54 years for a rate of 10.5% in 1975 (personal communication). The more common reasons for admission among the patients were: drug detoxification, accounting for 59 admissions; 10 admissions for psychiatric care; 13 for sickle cell disease;
158
Total
50
43
36
56
26
(%I
Patients retreated
14
14
1
55.6
Presumed narcoticfree (%)
4
0
3
6
3
dead (%)
KnOWn
1.1 f 1.3 years (60) 2.1 f 1.4 years (21)
7
1.5 f 1.1 years (23)
Interval between last methadone and last followvpb
29
15
21
100
(%I
information
No
%X:Patients detoxified with assent of staff and who have completed treatment. A: Patients who absconded, jailed, or who had been administratively discharged. D: Patients who left to detoxify themselves, seeking enduring abstinence from narcotics. h u m b e r in parentheses is the number of patients used for calculating if different from the number of patients in the sample. Since categories overlap, percentages may exceed 100.
9
Insufficient data
67
42
89
29
A D
(%I
29
31
use
MICOtiC
m
sample
Recognized
Number
cr
Patient categorya
Table 3. Present Status of Patients Discharged Alive, Other Than Transfers
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
P
00
01
TEN YEARS OF METHADONE MAINTENANCE TREATMENT
549
101 COHORT I
1966-1972
COHORT I1
1972-4
COHORT I l l
1974-6
A L L COHORTS
1966-1976
75 UMBER 290 122 122
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
(122129042%)
150
86 86
18611 50 57%)
106
82 82
l82/106:77%)
547
290 290
12901547:53%)
50
25
0
A
Fig. 2. Legitimate employment before and during treatment. A: Pretreatment employment rate of all patients in each cohort before admission. B: Pretreatment employment rate of patients still in treatment. C: Present employment rate of a l l patients currently in treatment. D: Pretreatment employment rate of terminated patients.
and 8 each for minor surgery, GI disease, and alcoholism; 6 each for trauma, cardiac disorders, pulmonary causes, cancer, and pregnancy; and 5 each for hepatitis, hypertension, urological disorders, diabetes, cerebrovascular accidents, and major surgery. There were 25 other hospital admissions with other diagnoses. The current status of all terminated patients was reviewed (Table 3) in January 1976. The known narcotic user category included those who admitted their use and had urines positive for opioids. The presumed narcotic-free group included those who consistently denied the use of opiates, and whose urines were negative for methadone and morphine when obtained. Twenty-six percent of the CT group had returned to methadone treatment as had 36% of the selfdetoxified group. Fifty-seven percent of the CT group and 14% of the selfdetoxified groups appeared to be stable, narcotic-free. Employment rates are presented in Fig. 2 for the three cohorts. It is evident that those who remain in active treatment obtained increased employment to a modest extent over their employment status on admission. The change is most striking in the first cohort and much less so in the cohort admitted less
CUSHMAN
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
550
than two years ago. Employment status was not a major influence in retention rates. At the time of the survey, 34% in Cohort I were on public assistance. Cohorts I1 and III included 44 and 55% unemployed welfare recipients, respectively. Since the employment and welfare rates remained stable for the past several months, the majority of the latter two cohorts appeared to be content with, reconciled to, or unable to change their present economic lot. Thus a sizable number were receiving chronic methadone treatment plus welfare as their main or sole legitimate source of support, with a stable residence, and often no legitimate past-time or occupation.
DISCUSSION The results of treatment over a 10-year period in a single methadone clinic were reviewed. The data show that the clinic had impressive holding power over those subjects admitted for treatment, as reflected in the net retention rates which were much higher than those reported by other methadone maintenance treatment centers [6-111. This high retention rate resulted in prolonged patient-clinic interaction, and provided numerous opportunities over many months for medical and psychiatric care, plus assistance in various economic and social matters of importance to the patient. Since the clinic offered indefinite treatment, in that the availability of methadone was assured as long as the patient wanted it, the main treatment goals were the substitution of methadone for the patients’ narcotic needs, a fured domicile, and legitimate income. Later the patients were encouraged to undertake much more profound and difficult rehabilitation steps, i.e., legitimate employment, change in social milieu away from the street drug subculture, and nonchemical means of dealing with their psychological problems, frustrations, and difficulties. Still later many patients were encouraged to leave the drug subculture entirely, including the social and pharmacological activities of the methadone clinic. The treatment seemed to be effective regarding drug abuse since recognized illicit drug abuse, reported elsewhere [12], was sharply reduced. To a large extent the turbulent life-style of the street heroin user was replaced by a newer style of the stable, methadone recipient. Partly in the drug subculture by virtue of retaining a number of street practices and partly in the nondrug establishment world, the patients had evolved into a unique social class. Several noteworthy factors characterize this social class of chronic methadone patients. First, they had distinctive health care problems with heavy use of
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
TEN YEARS OF METHADONE MAINTENANCE TREATMENT
55 1
hospital services. In addition to the usual hospital care that any adult urban population may require, they were hospitalized for (1) illicit drug abuse, chiefly detoxification and acute intoxication; (2) alcoholism; (3) a number of elective surgical procedures deferred during heroin use; and (4) various psychiatric indications, presumably in greater frequencies than would be expected in the general population. Second, this group of patients had a higher mortality rate than the general population. Such causes of death as trauma and drug abuse, relatively unusual in the general population, were especially prevalent in the patients although much less so during treatment than in the untreated addict. It is notable that the recognized mortality rates in patients who left treatment were much higher than those who remained in treatment. This fact raises serious questions about the wisdom of the societal and governmental policy of encouraging patients to leave treatment and detoxify. Third, the methadone patients were only partly self-sufficient economically. There was a trend toward increasing economic productivity with time, despite the appearance of a major recession in 1974 to 1976. It is heartening to record the successes by many patients in securing employment despite their many disadvantages and the employer prejudices they had to overcome. In addition to the self-supported group, the data document the presence of a large welfare-supported subgroup of patients who accepted indefinite methadone treatment which was itself paid for by public funds. Fourth, there was a continued trend in the direction of ultimate detoxification. While the clinic assisted all those seeking detoxification by appropriate schedules of medication reduction and offered psychologicd support, the number (about 15%) who succeeded in completing detoxification was not great [13, 141. Many others failed to detoxify and many others returned to methadone treatment after being detoxified. The clinic appeared to have sequestered several scores of New York City addicts in an open-ended treatment process with an unusually high retention rate. This may possibly relate to the patient population treated. Conceivably, they may have been more highly motivated for indefinite maintenance treatment, for undertaking the expected rehabilitation steps, or for adaptation to the clinic’s treatment procedures than those attending other treatment centers. In this regard it should be pointed out that methadone programs have many important differences apart from the administration of methadone itself [12]. It is likely that the clinic was doing a good job in identifying and meeting the needs of these particular patients. Further, the staff and patients had collectively developed a therapeutic ambiance in which most patients felt
CUSHMAN
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
552
comfortable, had developed a sense of personal worth and dignity, felt a participant in their treatment, and had elected to remain in treatment. The data show some changes in retention rates for Cohort I11 (77% over 2 years) compared to Cohorts I and I1 (88 and 85%, respectively, over 2 years). While there may have been some changes in the patients during the decade, notably the more recent patients were younger and more likely to have been involved with multiple drugs, there is no doubt that the treatment program has changed. Instead of an optimistic, innovative atmosphere with support by press and community forces, it had changed into a static atmosphere with little outside support and subjected to considerable criticism led by an unfavorable press. In addition to the reduction in its public image, the clinic’s options in the rehabilitative process have been sharply curtailed by many restrictive governmental regulations limiting therapist-patient relationships markedly. Indefinite methadone treatment was a valid therapeutic aim for many patients. Those who remained in treatment reached a new steady state including little recognized opiate abuse, prolonged life expectancies, and enhanced economic productivity. Many had evolved into a unique social class, partly in the drug subculture and partly in the nondrug world. They were largely dependent on public assistance for personal support and for underwriting their medical needs including methadone treatment. The majority of the patients entered and remained in treatment, with some movements out to other clinics plus in and out of detoxification. Only a small fraction appeared to gravitate toward full self-support, discontinuation of methadone, and a lasting narcotic-free state.
ACKNOWLEDGMENT Supported in part by a grant from the National Institute of Drug Abuse. REFERENCES [ 11 Dole, V. P., and Nyswander, M. E., A medical treatment for diacetyl-morphine meroin) addiction: A clinical trial with methadone hydrochloride,J. Am. Med.
ASSOC.193~646-650(1965). [2] New York City Narcotics Register: 1974 Statistical Report, Unpublished. [ 31 Cushman, P., and Dole, V. P., Detoxification of rehabilitated methadone maintained patients, J. Am. Med. Assoc. 226:741-752 (1973). [4] Gearing, F. R., and Schweitzer, M. D., An epidemiologic evaluation of long-term methadone maintenance treatment for heroin addiction, Am. J. Epidemiol. 100: 101-112 (1974).
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
TEN YEARS OF METHADONE MAINTENANCE TREATMENT
55 3
Life insurance data, Adults in New York city, 1969-1970. Cited in F. R. Gearing and M.D. Schweitzer,Am. J. Epidiol. 100:108 (1974). Jaffe, J. H., Zaks,M. S., and Washington, E. N., Experience with methadone in a multi-modality program for the treatment of narcotics users, Int. J. Addict. 4:481490 (1969). Brown, B. S., Jansen, D. R., and Benn, G. J., Changes in attitude toward methadone, Arch. Cen. Psychiatry 323214218 (1975). Goldstein, A., and Judson, B. L., Efficacy and side effects of three widely different methadone doses, in Proceeding o f the Fifth National Conference on Methadone neatment, NAPAN, New York, 1973, pp. 2140. Louria, D. B., Sheffet, A., Lavenhar, M., and Quinones, M., Evaluation of addiction treatment programs, in Abstracts, National Drug Abuse Treatment Conference, New Orleans, 1975, p. 23. Patch, V. P., Fisch, A., Levine, M. E., McKenna, G. J., and Raynes, A. E., Daily visits, no “take home” methadone and seven day per week operation: Patient retention and employment patterns subsequent to cessation of take home privileges, in Proceedings of the Fifth National Conference on Methadone Treatment, NAPAN, New York, 1973, pp. 1272-1277. Ling, W., Charavastra, C., Kamin, S. C., and Klett, J., Methadyl acetate and methadone as maintenance treatment for narcotic addiction, Arch. Cen. Psychiatry 33~709-720(1976). Cushman, P., Trussell, R., Newman, R., Bihari, B., and Gollance, H., Methadone maintenance treatment of narcotic addiction: A unit of w e based on over 50,000 years of patient treatment, Am. J. Drug Alcohol Abuse 3:221-231 (1976). Cushman, P., Detoxification of rehabilitated methadone patients: Frequency and predictors of long term success, Am. J. Drug Alcohol Abuse 1:393408 (1974). Stimmel, B., and Rabin, J., The ability to remain abstinent upon leaving methadone maintenance: A prospective study, Am. J. Drug Alcohol Abuse 1:409-420 (1974).
AM. J. DRUG ALCOHOL ABUSE,4(4), pp. 543-553 (1977)
Ten Years of Methadone Maintenance Treatment: Some Clinical Observations PAUL CUSHMAN, JR.," M.D. Assistant Professor of Medicine Columbia University Ditector Methadone Treatment and Clinical Pharmacology St. Luke's Howitat Center New York, New York 10025 ABSTRACT Ten years of methadone maintenance were reviewed in all 547 patients admitted to one clinic in New York City. High retention rates, reduced but still high mortality rates, increased employment, and minor degrees of recognized opiate abuse characterized those remaining in treatment. The treated patients appeared to evolve into a unique social and economic class, partly in the drug subculture and partly outside the drug world. Many were dependent on public assistance for living expenses, methadone treatment, and medical care. An interesting finding was their heavy demands for inpatient hospital care, often for drug-related reasons. A segment of New York City narcotic addicts was sequestered in an open-ended treatment process with considerable benefits to themselves and to society. Only a small fraction appeared to gravitate toward full economic support, to discontinuation of methadone, and to an enduring narcoticfree state.
INTRODUCTION The introduction of methadone in 1964 as an outpatient maintenance treatment of chronic narcotic addiction [I] soon spread to regional centers. One of these, St. Luke's Methadone Clinic, was initiated in 1966 for addicts residing in the upper West Side of Manhattan. After 10 years it is appropriate t o *Resent address: Wood VA Hospital, Wood, Wisconsin 53193. 543
CUSHMAN
544
examine the results of treatment in terms of several medical and social measurements. The data document the existence of a relatively stable population of treated addicts with some distinctive features which combine those of untreated addicts and the general population.
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
PATIENTS AND METHODS All 547 patients ever admitted to the St. Luke’s Clinic between 1966 and January 1, 1976 were studied, which included all who had consumed one or more doses of methadone. One hundred eight patients had been admitted to St. Luke’s as transfers after their induction into treatment had been completed elsewhere; 339 patients were admitted directly for all phases of treatment. The sole criteria for admission were a 2-year history of dependence on opioids and that the individual be at least 17 years of age. Individuals who were multiple drug abusers, had mixed addictions, or complicating medical or psychiatric problems were not denied admission when recognized in the intake procedure. The demographic features of the 547 patients were similar to those reported for New York City addicts in general [2]. 73% were male, 41% were Black, 33% White, 25% Hispanic, and 1% Chinese. Hospital, medical, and social records were reviewed, and patients contacted and directly interviewed. The computerized list kept on all New York City methadone-treated patients at the Community Treatment Foundation was consulted regarding status of all patients who had been terminated. Similarly, the New York City Death Register was searched for information about all terminated patients. Employment data were obtained by interview and confirmed by periodic auditing of payment stubs. Since patients left treatment for various reasons, a convenient but arbitrary classification was devised for the group of patients discharged and not readmitted at St. Luke’s at the time of the study: (A) absconders, jailed patients, and others discharged involuntarily because of rule infractions; (D) patients who left to detoxify themselves against the advice of the staff and without the clinic’s assistance in the detoxification procedure; (CT) those patients who sought and completed detoxification with the assent of the staff. They could be considered to have had completed treatment. Since some did not achieve detoxification despite their desires to do so (31, only those who actually completed the detoxification were included as CT. Vigorous efforts were made to follow all terminated patients. Some of the CT patients participated in a structural aftercare. Most were seen haphazardly
TEN YEARS OF METHADONE MAINTENANCE TREATMENT
545
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
and sporadically, often in response to letters, telephone calls, messages, or chance encounters on the streets. The follow-up data must be considered somewhat incomplete and less than satisfactory. Since there were differences in employment data between the earlier patients and those admitted after 1972, the patients were divided into three cohorts: Cohort I was admitted between 1966 and 1972, Cohort I1 was admitted between 1972 and 1974, and Cohort I11 was admitted between 1974 and 1976.
RESULTS The pattern of the clinic’s growth was triphasic (Fig. ,l). Initially growing slowly, it grew sharply in 1970 to 1972, and then slowed down as the numbers
500
1 PATI ENTS TERMINATED
A L L PATIENTS E V E R TREATED
400
- -* \PATIENTS TRANSFERRED
fA
-
300
d
t-
d
100
I
1970
I
1972
1
1974
Fig. 1. A decade of methadone treatment. Cumulative census data.
I
1976
546
CUSHMAN
Table 1. Demographic Characteristics of Deaths in Methadone Maintenance
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
Category of persons at risk Methadone maintained Male Female Mean age 40 (28 to 64 years) Terminated patients Mean age 36 (26 to 53 years) Untreated addict@ Young adult New Yorkersb
Number of deaths Number of person Death probability years at risk XlOO observed 25 19 6
1,655 1,241 414
1.5 1 1.52 1.50
11
367
3.00
1.8 million
8.25 0.56
aTaken from Gearing’s 1974 data of 109 persons followed from 1965 to 1972. 1969 to 1970,0.56 i 0.23, age 20 to 54 years.
of patients remained in active treatment (receiving methadone) on January 1, 1976. The net retention rate was 5376, which included 64 patients who had been discharged and readmitted. An additional 73 discharged patients had been transferred to other methadone treatment centers. Since adequate information was often unavailable regarding these transferred patients, the outcome data do not include them, and only the time that they were actually in treatment in St. Luke’s Hospital was used in the calculations of the treatment years at risk. One hundred fifty-eight patients were discharged alive. Twenty-five patients died while in active treatment. Since there were 1655 person-years at risk over 10 years, the mortality rate of treated patients was 1.51%. This rate is far below the 8.1% rate reported by Gearing [4] for untreated addicts, but it was still significantly higher than observed in the general population (age 20 to 54 years) [5] (Table 1). These mortality figures may be incomplete since death may have accounted for unexplained cessation of treatment by other patients. How many other unrecognized deaths occurred is unknown, but their number was minimized by the vigorous efforts to locate all patients who abruptly discontinued treatment, i.e., contacts with local hospitals, the jails, the city morgue, and medical examiner’s offices as well as efforts to reach the family, friends, neighbors, erc. and home visits. The causes of death were established in all 25 known deceased. Autopsy reports were reviewed in 17 and the medical examiner’s office data in 5 other cases; 3 other deaths were accounted for after interviews with family, friends, and witnesses. The causes of death are presented in Table 2. It is evident that there is a high incidence of death due to trauma, infections, and drug abuse (including alcoholism and its sequelae).
541
TEN YEARS OF METHADONE MAINTENANCE TREATMENT Table 2. Causes of Death
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
Categories of causes of death Trauma Assassination Other Infections Tuberculosis Other (SBE) Cancer Cardiovascular Drug abuse Overdose Alcoholism Other Renal failure Infarcted bowel Intracranial bleed Hyperglycemic coma GI bleed Totals
During treatment 5
After treatment 3
20%
21%
3 0
3 2
3
12
0
5 3 4
20 12 16
2a 0
14
I
50
2
14
2 1
2 2
1 2a 5
20
Hepatitis 1 Unknown 1
1 1 1 1 1 25
100%
14
99%
~~
aOne cancer patient and all 2 alcoholicshad clinical evidence of serious disease during treatment.
The mortality figures in the 158 patient terminated group are far less satisfactory than those in the treated group. However, 14 persons were known to have died since leaving treatment. Since there were 297 person-years at risk in the terminated group, a mortality rate of 4.7% was calculated, which was a significantly higher rate than that of the patients continuing in treatment. The causes of death, where known, are also listed in Table 2. Thus both the treated and terminated patients not only had high death rates but also had similar causes of death. Both groups had, in addition to the usual perils, an unusually high incidence of death due to alcoholism, drug abuse, and trauma-much higher than that expected in the general population. Patients in treatment appeared to have made extensive use of inhospital medical care. In the past 4 years (1971 to 1975) there were 191 separate hospitalizations in 1,021 patient-years at risk for a rate of 18.7%. These figures are significantly higher than those reported by New York City’s Blue Cross, a private insurer. The latter report was 105 hospital admissions per 1,000 subscribers in the 1.3 million population of subscribers age 20 to 54 years for a rate of 10.5% in 1975 (personal communication). The more common reasons for admission among the patients were: drug detoxification, accounting for 59 admissions; 10 admissions for psychiatric care; 13 for sickle cell disease;
158
Total
50
43
36
56
26
(%I
Patients retreated
14
14
1
55.6
Presumed narcoticfree (%)
4
0
3
6
3
dead (%)
KnOWn
1.1 f 1.3 years (60) 2.1 f 1.4 years (21)
7
1.5 f 1.1 years (23)
Interval between last methadone and last followvpb
29
15
21
100
(%I
information
No
%X:Patients detoxified with assent of staff and who have completed treatment. A: Patients who absconded, jailed, or who had been administratively discharged. D: Patients who left to detoxify themselves, seeking enduring abstinence from narcotics. h u m b e r in parentheses is the number of patients used for calculating if different from the number of patients in the sample. Since categories overlap, percentages may exceed 100.
9
Insufficient data
67
42
89
29
A D
(%I
29
31
use
MICOtiC
m
sample
Recognized
Number
cr
Patient categorya
Table 3. Present Status of Patients Discharged Alive, Other Than Transfers
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
P
00
01
TEN YEARS OF METHADONE MAINTENANCE TREATMENT
549
101 COHORT I
1966-1972
COHORT I1
1972-4
COHORT I l l
1974-6
A L L COHORTS
1966-1976
75 UMBER 290 122 122
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
(122129042%)
150
86 86
18611 50 57%)
106
82 82
l82/106:77%)
547
290 290
12901547:53%)
50
25
0
A
Fig. 2. Legitimate employment before and during treatment. A: Pretreatment employment rate of all patients in each cohort before admission. B: Pretreatment employment rate of patients still in treatment. C: Present employment rate of a l l patients currently in treatment. D: Pretreatment employment rate of terminated patients.
and 8 each for minor surgery, GI disease, and alcoholism; 6 each for trauma, cardiac disorders, pulmonary causes, cancer, and pregnancy; and 5 each for hepatitis, hypertension, urological disorders, diabetes, cerebrovascular accidents, and major surgery. There were 25 other hospital admissions with other diagnoses. The current status of all terminated patients was reviewed (Table 3) in January 1976. The known narcotic user category included those who admitted their use and had urines positive for opioids. The presumed narcotic-free group included those who consistently denied the use of opiates, and whose urines were negative for methadone and morphine when obtained. Twenty-six percent of the CT group had returned to methadone treatment as had 36% of the selfdetoxified group. Fifty-seven percent of the CT group and 14% of the selfdetoxified groups appeared to be stable, narcotic-free. Employment rates are presented in Fig. 2 for the three cohorts. It is evident that those who remain in active treatment obtained increased employment to a modest extent over their employment status on admission. The change is most striking in the first cohort and much less so in the cohort admitted less
CUSHMAN
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
550
than two years ago. Employment status was not a major influence in retention rates. At the time of the survey, 34% in Cohort I were on public assistance. Cohorts I1 and III included 44 and 55% unemployed welfare recipients, respectively. Since the employment and welfare rates remained stable for the past several months, the majority of the latter two cohorts appeared to be content with, reconciled to, or unable to change their present economic lot. Thus a sizable number were receiving chronic methadone treatment plus welfare as their main or sole legitimate source of support, with a stable residence, and often no legitimate past-time or occupation.
DISCUSSION The results of treatment over a 10-year period in a single methadone clinic were reviewed. The data show that the clinic had impressive holding power over those subjects admitted for treatment, as reflected in the net retention rates which were much higher than those reported by other methadone maintenance treatment centers [6-111. This high retention rate resulted in prolonged patient-clinic interaction, and provided numerous opportunities over many months for medical and psychiatric care, plus assistance in various economic and social matters of importance to the patient. Since the clinic offered indefinite treatment, in that the availability of methadone was assured as long as the patient wanted it, the main treatment goals were the substitution of methadone for the patients’ narcotic needs, a fured domicile, and legitimate income. Later the patients were encouraged to undertake much more profound and difficult rehabilitation steps, i.e., legitimate employment, change in social milieu away from the street drug subculture, and nonchemical means of dealing with their psychological problems, frustrations, and difficulties. Still later many patients were encouraged to leave the drug subculture entirely, including the social and pharmacological activities of the methadone clinic. The treatment seemed to be effective regarding drug abuse since recognized illicit drug abuse, reported elsewhere [12], was sharply reduced. To a large extent the turbulent life-style of the street heroin user was replaced by a newer style of the stable, methadone recipient. Partly in the drug subculture by virtue of retaining a number of street practices and partly in the nondrug establishment world, the patients had evolved into a unique social class. Several noteworthy factors characterize this social class of chronic methadone patients. First, they had distinctive health care problems with heavy use of
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
TEN YEARS OF METHADONE MAINTENANCE TREATMENT
55 1
hospital services. In addition to the usual hospital care that any adult urban population may require, they were hospitalized for (1) illicit drug abuse, chiefly detoxification and acute intoxication; (2) alcoholism; (3) a number of elective surgical procedures deferred during heroin use; and (4) various psychiatric indications, presumably in greater frequencies than would be expected in the general population. Second, this group of patients had a higher mortality rate than the general population. Such causes of death as trauma and drug abuse, relatively unusual in the general population, were especially prevalent in the patients although much less so during treatment than in the untreated addict. It is notable that the recognized mortality rates in patients who left treatment were much higher than those who remained in treatment. This fact raises serious questions about the wisdom of the societal and governmental policy of encouraging patients to leave treatment and detoxify. Third, the methadone patients were only partly self-sufficient economically. There was a trend toward increasing economic productivity with time, despite the appearance of a major recession in 1974 to 1976. It is heartening to record the successes by many patients in securing employment despite their many disadvantages and the employer prejudices they had to overcome. In addition to the self-supported group, the data document the presence of a large welfare-supported subgroup of patients who accepted indefinite methadone treatment which was itself paid for by public funds. Fourth, there was a continued trend in the direction of ultimate detoxification. While the clinic assisted all those seeking detoxification by appropriate schedules of medication reduction and offered psychologicd support, the number (about 15%) who succeeded in completing detoxification was not great [13, 141. Many others failed to detoxify and many others returned to methadone treatment after being detoxified. The clinic appeared to have sequestered several scores of New York City addicts in an open-ended treatment process with an unusually high retention rate. This may possibly relate to the patient population treated. Conceivably, they may have been more highly motivated for indefinite maintenance treatment, for undertaking the expected rehabilitation steps, or for adaptation to the clinic’s treatment procedures than those attending other treatment centers. In this regard it should be pointed out that methadone programs have many important differences apart from the administration of methadone itself [12]. It is likely that the clinic was doing a good job in identifying and meeting the needs of these particular patients. Further, the staff and patients had collectively developed a therapeutic ambiance in which most patients felt
CUSHMAN
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
552
comfortable, had developed a sense of personal worth and dignity, felt a participant in their treatment, and had elected to remain in treatment. The data show some changes in retention rates for Cohort I11 (77% over 2 years) compared to Cohorts I and I1 (88 and 85%, respectively, over 2 years). While there may have been some changes in the patients during the decade, notably the more recent patients were younger and more likely to have been involved with multiple drugs, there is no doubt that the treatment program has changed. Instead of an optimistic, innovative atmosphere with support by press and community forces, it had changed into a static atmosphere with little outside support and subjected to considerable criticism led by an unfavorable press. In addition to the reduction in its public image, the clinic’s options in the rehabilitative process have been sharply curtailed by many restrictive governmental regulations limiting therapist-patient relationships markedly. Indefinite methadone treatment was a valid therapeutic aim for many patients. Those who remained in treatment reached a new steady state including little recognized opiate abuse, prolonged life expectancies, and enhanced economic productivity. Many had evolved into a unique social class, partly in the drug subculture and partly in the nondrug world. They were largely dependent on public assistance for personal support and for underwriting their medical needs including methadone treatment. The majority of the patients entered and remained in treatment, with some movements out to other clinics plus in and out of detoxification. Only a small fraction appeared to gravitate toward full self-support, discontinuation of methadone, and a lasting narcotic-free state.
ACKNOWLEDGMENT Supported in part by a grant from the National Institute of Drug Abuse. REFERENCES [ 11 Dole, V. P., and Nyswander, M. E., A medical treatment for diacetyl-morphine meroin) addiction: A clinical trial with methadone hydrochloride,J. Am. Med.
ASSOC.193~646-650(1965). [2] New York City Narcotics Register: 1974 Statistical Report, Unpublished. [ 31 Cushman, P., and Dole, V. P., Detoxification of rehabilitated methadone maintained patients, J. Am. Med. Assoc. 226:741-752 (1973). [4] Gearing, F. R., and Schweitzer, M. D., An epidemiologic evaluation of long-term methadone maintenance treatment for heroin addiction, Am. J. Epidemiol. 100: 101-112 (1974).
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by UB Kiel on 10/26/14 For personal use only.
TEN YEARS OF METHADONE MAINTENANCE TREATMENT
55 3
Life insurance data, Adults in New York city, 1969-1970. Cited in F. R. Gearing and M.D. Schweitzer,Am. J. Epidiol. 100:108 (1974). Jaffe, J. H., Zaks,M. S., and Washington, E. N., Experience with methadone in a multi-modality program for the treatment of narcotics users, Int. J. Addict. 4:481490 (1969). Brown, B. S., Jansen, D. R., and Benn, G. J., Changes in attitude toward methadone, Arch. Cen. Psychiatry 323214218 (1975). Goldstein, A., and Judson, B. L., Efficacy and side effects of three widely different methadone doses, in Proceeding o f the Fifth National Conference on Methadone neatment, NAPAN, New York, 1973, pp. 2140. Louria, D. B., Sheffet, A., Lavenhar, M., and Quinones, M., Evaluation of addiction treatment programs, in Abstracts, National Drug Abuse Treatment Conference, New Orleans, 1975, p. 23. Patch, V. P., Fisch, A., Levine, M. E., McKenna, G. J., and Raynes, A. E., Daily visits, no “take home” methadone and seven day per week operation: Patient retention and employment patterns subsequent to cessation of take home privileges, in Proceedings of the Fifth National Conference on Methadone Treatment, NAPAN, New York, 1973, pp. 1272-1277. Ling, W., Charavastra, C., Kamin, S. C., and Klett, J., Methadyl acetate and methadone as maintenance treatment for narcotic addiction, Arch. Cen. Psychiatry 33~709-720(1976). Cushman, P., Trussell, R., Newman, R., Bihari, B., and Gollance, H., Methadone maintenance treatment of narcotic addiction: A unit of w e based on over 50,000 years of patient treatment, Am. J. Drug Alcohol Abuse 3:221-231 (1976). Cushman, P., Detoxification of rehabilitated methadone patients: Frequency and predictors of long term success, Am. J. Drug Alcohol Abuse 1:393408 (1974). Stimmel, B., and Rabin, J., The ability to remain abstinent upon leaving methadone maintenance: A prospective study, Am. J. Drug Alcohol Abuse 1:409-420 (1974).
