A 12-member expert panel convened in November by the National Institutes of Health strongly recommended broader access to methadone maintenance treatment for people who are addicted to heroin or other opiate drugs. The panel singled out the multiple layers of federal and state regulations as impediments to access.
Methadone dispensing is currently regulated by three federal agencies--the Drug Enforcement Administration, the Food and Drug Administration (FDA), and the Department of Health and Human Services. State laws add another level of oversight. Methadone can be dispensed only from facilities that obtain a special license and that comply with periodic inspections from numerous entities. In its consensus statement, the panel wrote that FDA regulations for methadone maintenance treatment in effect since 1972 have little if any impact on the quality of treatment and should be eliminated.
The FDA regulations, which describe procedures for methadone treatment in minute detail, limit the flexibility and responsiveness of treatment programs, require unproductive paperwork, and impose unnecessary administrative and oversight costs, according to the panel. Of particular concern is that the regulations discourage the higher doses of methadone that have been consistently shown to lead to better treatment retention and outcomes.
"We know of no other area of medicine where the federal government intrudes so deeply and coercively into the practice of medicine," said panel chair Lewis L. Judd, M.D., chairman of the department of psychiatry at the University of California, San Diego, School of Medicine. The panel recommended that methadone be regulated in the same way as any other Schedule II narcotic, and that alternative means such as accreditation be instituted for monitoring and improving the quality of methadone treatment programs.
A major reason for the strict regulation of methadone has been what the panel labeled "disproportionate" concerns about the diversion of metha done to street use. Such diversion is negligible, according to evidence presented at the panel's three-day meeting. What little does occur does not often go to recreational or casual use but to individuals with heroin addiction who lack access to clinically administered methadone.
In the United States approximately 600,000 people are addicted to heroin. Most do not receive treatment, and the financial costs of untreated heroin addiction to the individual, the family, and society are about $20 billion a year. Methadone, an opiate agonist, has been used in the U.S. to maintain heroin addicts since the 1960s. Studies have shown that, in combination with psychosocial treatments, methadone maintenance significantly lowers illicit opiate drug use, decreases illness and death from opiate use, reduces crime, enhances productive social activities, and slows the spread of diseases such as AIDS and hepatitis. Most recent data indicate that 115,000 people are currently in methadone maintenance treatment, many of whom will require continuous treatment over several years, and perhaps for life.
Besides overregulation, a formidable barrier to the effective use of methadone maintenance treatment is misperception and stigma attached to heroin addiction, the panel noted. Many people believe that opiate drug addiction is self-inflicted and that efforts to treat it will inevitably fail. The panel members reviewed two decades of studies on the natural history of opiate addiction, which covered the genetic, molecular, neuronal, and epidemiological levels. They concluded that opiate addiction is a brain disease, and therefore a medical disorder.
The panel noted that people from various cultural, ethnic, and socioeconomic backgrounds all exhibit consistent medical histories, signs, and symptoms of opiate addiction, indicating that such addiction is a medical disorder. In addition, continuous exposure to heroin has been shown to induce pathophysiologic changes in the brain. Other arguments raised by the panel for viewing opiate addiction as a medical disorder include the fact that, despite heroin addicts' expressed and strong motivation to stop, their craving induces continual self-administration, and, even after long periods of abstinence, they have a strong tendency to relapse.
At a public session during the panel's meeting, treatment professionals raised other issues related to deregulating methadone maintenance treatment. A primary concern was that physicians would simply prescribe methadone to addicted individuals without providing counseling or linking them to other supports, which are necessary for a good treatment outcome. Individuals with heroin addiction frequently require treatment for comorbid psychiatric disorders. Many also need vocational rehabilitation, housing, and other support services.
To ensure appropriate treatment, the panel recommended that all primary care specialties--general practice, internal medicine, family practice, obstetrics and gynecology, geriatrics, pediatrics, and adolescent medicine--be taught the principles of diagnosing and treating patients with heroin addiction. Training for other professionals, such as nurses, social workers, psychologists, and physician assistants, was also recommended. The panel emphasized that such widespread training would have the added benefit of preparing the health care community to provide leadership and public education about opiate addiction and treatment.
The panel recommended that future research should look at causative and risk factors for heroin use, changes in the brain resulting from repeated use, anatomical and neurophysiological substrates of craving, and patient characteristics that predict successful treatment outcomes. Strongly recommended is a scientifically credible national epidemiological study of the prevalence of heroin addiction in the U.S. Newly developed opiate agonists, such as LAAM (levo-alpha acetylmethadol), and antagonists, such as naltrexone, should continue to be evaluated in different patient groups.
To obtain the full consensus statement, Effective Medical Treatment of Heroin Addiction, call 888-NIH-CONSENSUS (888-644-2667) or visit the NIH consensus development program's Web site at http://consensus. nih.gov.
Federal programs operating under the Substance Abuse and Mental Health Services Administration (SAMHSA) have received a 1 percent funding increase in fiscal year 1998 compared with fiscal 1997, while funding for research on mental health and alcohol and drug abuse within the National Institutes of Health (NIH) has increased by 7 percent.
Legislation containing the fiscal 1998 appropriations was approved by Congress and signed by President Clinton in mid-November. Fiscal 1998 began last October 1.
Table 1 shows the level of funding for federal mental health and substance abuse programs for fiscal years 1997 and 1998. Of the three agencies under the SAMHSA umbrella, the Center for Mental Health Services received the biggest increase, but it totaled only about $6 million, just 1.4 percent above fiscal 1997. Funding for the Center for Substance Abuse Treatment was unchanged from 1997, and the Center for Substance Abuse Prevention received an increase of less than 1 percent. The SAMHSA appropriations included $18 million in new funding requested by the Clinton Administration to expand the National Household Survey on Drug Abuse to include data from individual states.
The National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse, which are located within NIH, each received an increase of slightly more than 7 percent, consistent with the level of increase for most other NIH institutes. NIH's overall funding increased by 7.1 percent.
A study of mental health coverage in 16 states under the federal government's new health insurance plan for uninsured children indicates that while all the states provide some coverage, in most states coverage is inadequate. In only one state-Texas-was parity for mental health coverage mentioned in a plan document.
The study was sponsored by the Coalition for Fairness in Mental Illness Coverage, a group of eight national professional and advocacy organizations based in Washington, D.C. It was conducted by the Hay Group, a management consulting firm.
The new State Children's Health Insurance Program, created under title 21 of the Social Security Act, was included in the Balanced Budget Act of 1997. It makes $4.275 billion in matching funds available to the states in fiscal year 1998, which began last October 1. A total of $24 billion has been authorized for the program over five years.
The new program gives states three options for initiating and expanding coverage for uninsured children: using the Medicaid program, a separate child health insurance program, or a combination of the two programs.
States choosing a separate child health insurance program must use one of three programs as a benchmark for coverage: Blue Cross/Blue Shield in the Federal Employees Health Benefits Program (FEHBP), the state employees' benefits program, or the state's largest health maintenance organization (HMO). States can either install a plan that is the same as one of the benchmarks or an alternative with the same actuarial value. The alternative must provide mental health benefits that are at least equal to 75 percent of the value of the mental health benefits in the benchmark.
The study analyzed mental health benefits in the benchmark plans using a benefits value comparison model developed by the Hay Group. The model, which provides a standardized actuarial value of benchmark plans, has been used extensively to examine the potential cost of changes in health policy at the federal and state level.
The study included states on which the Hay Group had already obtained data for another study or that were added to ensure a geographical representation. They were Alaska, Arizona, California, Connecticut, Florida, Georgia, Illinois, Kansas, Massachusetts, Minnesota, New Jersey, New York, North Carolina, Pennsylvania, Texas, and Utah.
Analysis showed that the overall value of the FEHBP plan was $1,460, of which $72, or 4.9 percent, was the actuarial value of mental health benefits per child. It covers inpatient mental health charges for up to 100 days, but enrollees are required to pay a $150 per day copayment at in-network facilities. Up to 25 outpatient visits are covered, but the plan pays only 60 percent of the cost; the other 40 percent must be paid by the enrollee. Inpatient care for alcoholism and drug abuse is limited to one treatment program, with a 28-day maximum, per lifetime.
The actuarial value of the state employee plans ranged from $1,248 for California to $1,740 for Utah. The mental health values ranged from $52 for Illinois to $115 for Texas. Mental health coverage as a percentage of total coverage ranged from 3.4 percent for Utah to 7.6 percent for Texas.
The Utah plan provides for 30 inpatient days; it covers 90 percent of the cost for the first ten days but only 50 percent of the cost for the remaining 20 days. Outpatient visits are covered at 50 percent, with an annual maximum of $1,500. The Illinois plan covers 30 inpatient mental health days (in-network only) and requires a $100 copayment by the enrollee per admission. Thirty outpatient visits are covered, with a $20 enrollee copayment per visit.
The Texas plan covers 30 inpatient days at 90 percent of the cost for the first 15 days and 70 percent for the remainder. The maximum mental health benefit is limited to $25,000, but the limit does not apply to severe mental illness or substance abuse, which is covered like any other illness or injury.
The actuarial value for the HMO plans ranged from $986 for Minnesota to $1,285 for Illinois. Mental health values in these plans ranged from $29 for NYLCare in Texas to $45 for the Harvard Community Plan in Massachusetts. Mental health coverage as a percentage of total coverage ranged from 2.7 percent for NYLCare in Texas to 4.4 percent for Health Partners Select in Minnesota.
More information about the report is available from the Coalition for Fairness in Mental Illness Coverage, 1400 K Street, N.W., Third Floor, Washington, D.C. 20005; phone, 202-682-6393; fax, 202-682-6287.
Pat Vosburgh, a former editor of this journal who played a key role in its early development, died December 3 in Bethesda, Maryland, of respiratory and congestive heart failure. She was 85.
Mrs. Vosburgh had been a freelance writer for newspapers and magazines in England and the United States when she joined the American Psychiatric Association staff in 1951. At that time the journal was less than two years old and was being published in a newsletter format under the name Mental Hospitals. Under her leadership as chief of the editiorial department, Mental Hospitals evolved into a journal focused on improving care in state mental hospitals and later, as Hospital and Community Psychiatry, expanded its coverage to include community services.
Mrs. Vosburgh was appointed editor of the journal in 1962. She resigned in 1970, when her husband, Frederick G. Vosburgh, retired as editor of National Geographic. She later became an accomplished photographer whose work appeared in National Zoo and other Smithsonian publications.