Methadone maintenance treatment (MMT): a review of historical and clinical issues.

Methadone maintenance has been evaluated since its development in 1964 as a medical response to the post-World War II heroin epidemic in New York City. The findings of major early studies have been consistent. Methadone maintenance reduces and/or eliminates the use of heroin, reduces the death rates and criminality associated with heroin use, and allows patients to improve their health and social productivity. In addition, enrollment in methadone maintenance has the potential toreduce the transmission of infectious diseases associated with heroin injection, such as hepatitis and HIV. The principal effects of methadone maintenance are to relieve narcotic craving, suppress the abstinence syndrome, and block the euphoric effects associated with heroin. A majority of patients require 80-120 mg/d of methadone, or more, to achieve these effects and require treatment for an indefinite period of time, since methadone maintenance is a corrective but not a curative treatment for heroin addiction. Lower doses may not be as effective or provide the blockade effect. Methadone maintenance has been found to be medically safe and nonsedating. It is also indicated for pregnant women addicted to heroin. Reviews issued by the Institute of Medicine and the National Institutes of Health have defined narcotic addiction as a chronic medical disorder and have claimed that methadone maintenance coupled with social services is the most effective treatment for this condition. These agencies recommend reducing governmental regulation to facilitate patients access to treatment. In addition, they recommend that the number of programs be expanded, and that new models of treatment be implemented,if the nationwide problem of addiction is to be brought under control. The National Institutes of Health also recommend that methadone maintenance be available to persons under legal supervision, such as probationers, parolees and the incarcerated. However, stigma and bias directed at the programs and the patients have hindered expansion and the effective delivery of services. Professional community leadership is necessary to educate the general public if these impediments are to be overcome.

Changes in AIDS risk behavior among intravenous drug abusers in New York City.

Forty newly admitted patients to a methadone treatment clinic in New York City were interviewed to assess their patterns of intravenous (IV) drug abuse, sexual activity, and other risk behaviors for the acquired immunodeficiency syndrome (AIDS). The study revealed a marked decline in needle sharing since 1984 (46% to 14%), despite a concurrent doubling of the number of weekly IV drug injections per subject (10 to 21). High rates of promiscuous heterosexual activity were noted among men (80% said they were currently active with more than one woman), while the rates of condom use were low, as reported by both men and women (less than 30%). Recent reduction in weight were reported by 40% of subjects, and the average body mass of all individuals was subnormal. Thus, despite an apparent decline in needle sharing, high risk sexual behavior is apparently persisting, drug use is increasing, and nutritional deficits are prevalent among IV drug abusers. Synergism of these factors should be considered in the manifestation of HIV infection among IV drug abusers.

The relationship of preaddiction characteristics to the types and amounts of crime committed by narcotic addicts.

Postaddiction crime rates among narcotic (principally heroin) addicts in five different areas (theft, violence, dealing, confidence games, and other crime) were found to be substantially related to a number of preaddiction characteristics, especially criminal activity and drug and alcohol use prior to addiction to narcotics. Early family influences such as lack of religious training, history of parents' arrest, and use of drugs and alcohol by other family members also appear to play an important role. Early identification of extremely crime-prone individuals followed by intensive intervention efforts might reduce the amounts of crime such persons might otherwise commit.

A comparison by ethnic group and city of the criminal activities of narcotic addicts.

In an effort to update the results of earlier studies concerning the amounts and types of crimes committed by urban, male narcotic addicts, confidential interviews were conducted with addicts attending methadone maintenance clinics in Baltimore and New York. Samples were stratified by ethnic group (black and white in Baltimore; black, white, and Hispanic in New York), and the amounts and types of crimes committed were compared across groups, cities, and narcotic addiction status (actively addicted/not actively addicted) using six different measures all based on the concept of crime-days per year at risk. Consistent with previous findings, addicts were found to engage in a great deal of criminal activity, especially during periods of active addiction to narcotics. Differences in the amounts and types of crimes committed were found among ethnic groups and, to a lesser extent, between cities as well. For the Baltimore sample, comparison of findings with those derived from an earlier (1973-78) data base suggests that the amount of crime committed by addicts has increased in several categories as well as overall. However, minor differences in data collection procedures render this finding suggestive rather than conclusive.

A comparison by race/ethnicity of narcotic addict crime rates in Baltimore, New York, and Philadelphia.

In an effort to provide timely information concerning the criminal activities of narcotic addicts in three different metropolitan areas, male narcotic addicts attending methadone maintenance/detoxification centers in Baltimore, Philadelphia, and New York City participated in extensive, confidential interviews conducted between May 1983 and April 1984. The information obtained focused on the amounts and types of crimes committed during the addict's longest period of active addiction to opiates, their derivatives and synthetics, as well as his first period of nonaddiction. Crimes committed were placed in one of five categories as follows: Theft, Violence, Drug Sales, Deception/Forgery, and Other. Several different measures of criminal activity were utilized, all embodying the concept of crime-days per year at risk. Such crime-days measures involve annualizing, i.e., the number of crime-days accumulated by each subject in each category during a specified time at large in the community is expressed as crime-days per year at risk by taking the ratio of crime-days to total days at large and multiplying by 365. Addicts were compared by race/ethnicity (Black, White, and Hispanic) within cities as well as by race/ethnicity across cities using one-way analysis of variance procedures. Addict crime rates were also compared for the period of active addiction and nonaddiction. Several mean differences by race/ethnicity within city, as well as by race across cities, were noted. Moreover, crime rates tended to be higher during the period of active addiction. In this sense, then, drugs may be said to "drive" crime.

Issues of transference in methadone maintenance treatment.

Methadone maintenance treatment involves a great deal of governmental regulations and controls which have to be enforced by the clinician, thus having important transferential implications for therapy. This issue is explored on the basis of a case example, and recommendations are made to detach rule enforcement from therapy.

Locus of control and initiation of detoxification among male methadone maintenance patients.

Two hypotheses were derived linking locus of control to voluntary, "completion of treatment" detoxification from methadone maintenance: (1) methadone maintenance patients with an internal locus of control will be more likely to indicate a willingness to begin detoxification, and (2) among patients indicating a willingness to begin, those with an internal locus of control would be more likely to actually begin. Subjects were 115 male methadone patients. A nonsignificant trend was found in support of the first hypothesis, while the second was reversed at a statistically significant level (r = -.30, p less than .012).

Changes in future time perception of day hospital psychiatric patients in response to small group treatment approaches.

Attempted to assess the effects of small group approaches on future time perception of psychiatric patients in a day hospital. The research employed two patient groups within the day hospital: A control group, (N = 12) which received routine day hospital treatment, and an experimental group, (N = 12) which received, in addition, the small group treatment. Measures of future time perception were administered to both groups before and after a 12-week treatment. Results indicated significant positive changes in response to group treatment on Future Events and the dimension of Importance. However, no positive significant differences were found on Time Extension, Directionality, and Quality of Affect. While it is not within the scope of this research to evaluate whether the secured change can be maintained, it was clear that in immediate posttesting important changes had resulted from the treatment strategy.

Rehabilitation of the Puerto Rican addict: a cultural perspective.

Drug addiction has assumed major proportions in the Hispanic population. This paper questions whether treatment programs in Puerto Rican communities adequately relate their rehabilitative services to the realities of Hispanic culture. The experience of a clinic in the South Bronx is reviewed, and it is suggested that programs need to be aware of cultural differences, provide Hispanic staff to treat Hispanic patients, and build up acknowledged strengths, values, and folkways.

Methadone treatment and physical complaints: a clinical analysis.

In this study 102 male patients on the Harlem Hospital Methadone Maintenance Treatment Program were asked about physical complaints which they attributed to taking methadone. The most common complaints were sweating, constipation, drowsiness, sexual problems, and aches in bones and joints. There were no statistically significant differences between new patients and long-term patients, but long-term patients appear more likely to be bothered by sweating than new patients, and constipation occurs most frequently during the initial stages of treatment. Complaints were found, in general, to be minor and did not constitute a barrier to patient retention in treatment.

Multidisciplinary team malfunctioning on a state hospital unit: a case study.

The use of multidisciplinary teams in the care of psychiatric patients can be countertherapeutic unless attention is paid to the dynamics of team functioning. The authors present a case study of team malfunctioning on an inpatient unit in a state hospital that resulted from staff's role confusion and insecurity. Patient care was relegated to second place as major interpersonal conflicts among the staff were played out along ethnic and cultural lines. Resolution of the conflicts required identifying their source, clarifying staff roles, and initiating a special inservice training program focused primarily on the needs of paraprofessional staff.

Social rehabilitation of addicts: a two-year evaluation.

This paper points out the relationship that exists between treatment approaches with drug addicts and sociodemographic characteristics of the communities affected. It has been shown that while poor and middle class communities show good results with methadone maintenance approaches, in the area of secondary drug abuse they show marked dissimilarities. Also, the reasons for discharge are markedly different. It is speculated that the different attitudes existing at the two clinics studied provide contrasting environments that are selectively detrimental to program dropouts.

The role of folk healers in community mental health services.

This paper deals with the relationship between sociocultural factors and psychopathology in Hispanic groups in a disadvantaged urban area. The data were drawn from a 6-year collaborative undertaking between the Lincoln Community Mental Health Center and two local spiritualistic centers in the Southeast Bronx, New York. Comparisons are offered between classical mental health personnel and indigenous folk healers with emphasis on terminology, means of communication, and diagnosis techniques, as well as the utilization of social behavior and moral values. Relevant inferences are drawn regarding the broader relationship between religion and psychiatry. The importance of understanding of utilization of local folk resources in the planning and implementation of mental health services in urban ghettos is documented.

Psychiatry and folk healing: a dichotomy?

A mental health center's experience with folk healers in a Hispanic urban ghetto revealed a culturally accepted belief system based on a body of empirical knowledge that helps its members to cope with distress. The authors suggest that including folk healers as team members in the delivery of mental health services is a valuable contribution to psychiatry.

Detoxification of long-term methadone patients: problems and prospects.

Various aspects of the detoxification of rehabilitated methadone patients are considered in the light of experience at the Albert Einstein College of Medicine-Bronx Psychiatric Center MMTP and the reports of others in the field. Patients studied met certain eligibility requirements which were thought to enhance the probability of successful detoxification. A total of 228 (10.4%) of 2,814 patients were included in the project. Sixty-three patients have completed detoxification. A follow-up on these patients indicates that 22.2% claim abstinence from all drugs and are reporting to the clinic, 47.6% claim abstinence but have not reported to the clinic, 14.3% returned to methadone maintenance, and 15.9% are lost to contact. This and other studies emphasize the importance of adequate counseling during detoxification.