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Methadone Maintenance in Primary Care

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Project Summary:

Methadone maintenance treatment of heroin addiction has been found to be effective in reducing drug use, enhancing social productivity, and preventing the spread of infectious diseases, yet strict regulatory policies, budget constraints and social stigmatization have limited access to methadone. The emergence of AIDS among injection drug users, and an accelerating HIV epidemic among injection drug users in nearby Vancouver, B.C. has added urgency to the search for policies and programs that improve access and lower the cost of methadone treatment in Washington State. One identified policy response is the implementation of "medical maintenance" - providing methadone through community physicians outside traditional drug treatment programs. The purpose of this research is to use the planned development and implementation of a pilot medical maintenance program in King County, Washington as an opportunity to study the policy barriers, physician training challenges, and patient safety and acceptability concerns that must be resolved for such programs to be widely replicated. Methadone maintenance treatment is a highly regulated and controversial activity, and any effort to improve access to methadone services must respond to the numerous federal, state and local regulatory interests, as well as medical and community concerns. Phase I of this project will study a broadly inclusive policy development process as it defines the structure and protocols for a pilot medical maintenance program. Research using key informant interviews and a consensus meeting process will assist others as they approach the regulatory, administrative and political obstacles to, and opportunities for, medical maintenance. The regulatory history of methadone has led to a centralized treatment system, difficult to expand and isolated from mainstream medical care. Physicians who plan to care for methadone maintenance patients must overcome the lack of education and experience associated with this isolation. Phase II of this project will develop and conduct a physician training program and an ongoing clinical support system, and evaluate its effects on physician knowledge and attitudes. Phase III of this project will implement the medical maintenance model defined in phase I as a small feasibility pilot program. Patients will transfer their methadone maintenance treatment to a primary care medical setting, keeping close ties to the traditional methadone treatment program. Data documenting patient addiction severity, service utilization, and patient safety handling methadone will be collected, as will patient, provider, and program staff satisfaction information. This will assure the safety and feasibility of a medical maintenance model, and provide pilot data and estimates of key parameters necessary to the design of a randomized trial of medical maintenance. Integrating methadone maintenance and primary medical care is a concrete step toward both improved access to methadone treatment and coordination of treatment services for drug users. It will also increase physiciansÂ’ knowledge and experience concerning methadone treatment and substance abuse issues more broadly. Finally, it begins to address the isolation and stigma that have prevented methadone treatment from reaching its full potential.

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