A Practical Approach to Opiate Addiction in a Rural Setting

Daniel Murphy, M.D.
Angela Morris-Hovenga, B.S.W.
Cedar Falls, Iowa

Iowa typifies middle America. It is largely a rural State in the Midwest with a strong interest in agriculture and no major cities. Yet there exists a growing opiate problem in this State, with "China White"—white Asian heroin—coming from Chicago and infiltrating the eastern half of the state and "Mexican Tar"—black heroin originating in Mexico—coming from the south and west. Most metropolitan areas of greater than 100,000 people in Iowa have noticeable heroin problems. The other half of the problem is opiate addiction in the form of prescription medication found in Iowa wherever there are people, doctors, hospitals, and pharmacies. Many preparations can be and are injected intravenously, thus potentially contributing to the AIDS epidemic. HIV cases are gradually becoming more frequent; hepatitis B and syphilis are also significant problems in Iowa. Shoplifting and prostitution are common among opiate addicts in an attempt to support their habit. Prisons are being built in Iowa to deal with the ever increasing court convictions. As a direct correlation, the cost to the State is rapidly escalating.

Methadone maintenance is becoming more widely accepted as the treatment of choice for heroin addiction. Still, problems remain. Vincent Dole (1989, p. 1,681) asks, "With affirmative reports in the literature that show methadone maintenance to be both safe and effective, why do physicians persist in calling the treatment, "controversial" and thus ensuring that it will remain a subject of controversy? . . . Why is there no active outreach to persuade the homeless and criminal addicts—the most heavily infected and socially destructive persons—to enter treatment? Why do community leaders oppose an effective treatment of the addicts who are living in their own neighborhoods? Why has the medical profession surrendered control of the medical treatment to politicians and paraprofessionals?" His answer includes both prejudice and self-interest as being significant factors.

History of Our Program

Since 1984, as part of a family practice, we have been running our methadone maintenance program beginning with 1 patient to our current number of 110 patients, with no letup in new applicants. We have built onto our facility and added a social worker and another nurse, along with more clerical help. We are now fully computerized and recently began to offer LAAM (levo-alpha-acetylmethadol) and naltrexone (pure opiate antagonist). We attract patients from a very wide geographic area. Figure 1 is a map of the counties in Iowa and Illinois where patients are located.

Successes

Since we began treating opiate addiction in a family practice, patients who remained on our program for at least 1 month have had a retention rate of 88 percent. At present, 50 percent of our patients are gainfully employed, 10 percent are in school, 20 percent are disabled, and another 5 percent are in miscellaneous acceptable categories. Only 15 percent are in what we would call "an unacceptable state" and are in need of further rehabilitation. We always address mental health issues and make use of both major and minor tranquilizers, antidepressants, disulfiram, counseling, and referral for help when indicated. In many cases, we become the family physician and treat patients as much as possible like any medical patient where one of the problems is substance abuse. We address acute illness, and many people, for the first time ever, are now recipients of continuity of care for ongoing problems.

County health authorities annually provide HIV, hepatitis B, tuberculosis, and syphilis testing at our clinic. Thus far we have only had two patients on our program positive for HIV. We are the only facility in this area with experience in opiate addiction in newborns and therefore we take care of these babies born to mothers on methadone.

Social and family issues are important to us and are discussed at counseling sessions. Our staff works with lawyers, hospitals, penal institutions, courts, and parole/probation officers to facilitate patient rehabilitation. We have remained economically viable, charging $180 per month to be on the methadone program. We have no Government funding but do collect from third party payers whenever applicable. James Cooper of the National Institute on Drug Abuse in talking about methadone and HIV (1989, p. 1,665) has spoken of "a brief window of opportunity in which to implement prevention efforts." Here in Black Hawk County, a metropolitan area with 120,000 people, we have heard no reference to heroin present in the community for the last 10 years, a sharp contrast to frequent reference to heroin in every other metropolitan area of greater than 100,000 people in Iowa.

Purpose and Methods

The key to our program's accomplishments is attracting and maintaining patients in treatment. Our own efforts are important, for example, in keeping up with the medical literature and attending conferences, such as the annual National Methadone Conference. We try to be innovative. For instance, when take-out methadone is "lost" or "spilled," we always ask if that patient knows of anyone who could benefit from our program. (It is possible that person has sold the methadone to another drug user who could benefit from our program.) More importantly, patients must feel that being on our methadone maintenance program is more acceptable than having a daily street opiate habit.

In this article we will explore the factors and characteristics of patient perception, especially those that relate to our rural location. We used an anonymous voluntary questionnaire, a portion of which used a Likert scale 1-5, to measure patient attitudes. Cooperation was excellent, as we received 87 questionnaires back over a 3-week period in January 1996.

Program

Demographics

The youngest patient is 19 years old and the oldest is 56 years, with a median age of 40 years. We now have 42 female patients and 66 male patients with 92 percent Caucasian, 12 percent African American, and 4 of other ethnic origins. Patients have used drugs for as short a period as 2 years and for as long as 36 years, with 62 of the patients having drug problems for greater than 15 years. Educational levels vary from having a college degree to only a ninth grade education. The average patient has a high school education. Slightly less than half of patients come from metropolitan areas of a population greater than 100,000; 30 percent came from towns of a population of 10,000 to 90,000 people, and 15 percent come from rural areas or towns with a population of under 10,000. (Approximately 6 percent did not note the size of their locale.) Length of time on the program for our patients is displayed in figure 2.

Over half of the people reported they heard about the program on the street. Six mentioned they heard about the program from another doctor, and six heard about it from a drug counselor. Patients also mentioned they heard about the program from probation officers, family, friends, newspapers, and other patients who were on the program.

Logistics of Transportation

Patients must come to our clinic at least once a week. The logistics of transportation are an extremely important consideration for our patients; in fact, some people spend as long as 3 hours coming one way to our clinic. The average time being spent going one way is 1 hour. About half of the patients said they ride with others on the program; the other half come by themselves. We do stress to patients that reliable transportation is important and that self-reliance is an important part of rehabilitation.

Weather has kept 31 patients from the clinic at one time or another, and 29 patients have missed their appointments due to car trouble. These problems make life and rehabilitation much more difficult for patients living in rural areas. Of those surveyed, 28 patients had been stopped by the police or highway patrol on their way to and from our program at least once. In several instances, methadone was confiscated. These situations come up quite frequently and make our job much more difficult. We are responsible for every milligram of methadone dispensed in our clinic by Federal and State legislation.

Transportation costs are significant. Of patients surveyed, 26 noted costs of greater than $15 per trip for transportation to our clinic. One must keep in mind the daily cost of an opiate habit for people entering our program in 1992 was $120 per day.

Diversion

About half of the patients answered "yes" when asked if they knew of program methadone being bought or sold; however, only 19 patients stated that they had ever bought or sold methadone. The question of methadone being bought or sold illegally is important to us, to regulators, and to the public. While surveys indicate that methadone is clearly not a drug of choice, it is used if other opiates are not available. While patient rehabilitation is enhanced in many cases by giving take-outs, care must be given to minimize the illicit selling of this prescribed medication. We have attended numerous meetings on this very point with Federal and State regulators and the Iowa legislature to be able to address the problems of addiction in rural Iowa. Where distances traveled are so great and conditions can be very difficult, take-out medication is crucial for the success of our program for Iowans.

Counseling

The survey revealed that 80 percent of patients thought that they received enough counseling in our program. Only three thought that the counseling was too much and only 10 thought there was not enough counseling. We have had difficulty in establishing group counseling due to logistics. Only eight people expressed an interest in having group counseling. Generally our counseling is one-on-one with a social worker, a nurse, or a doctor. We try to be personable, practical, and positive with our patients.

Patients' Perceptions Of Staff

New patients are quite rapidly known personally by every member of the staff. We go out of our way to treat each patient as an individual. Of the 87 respondents, 85 percent rated the staff as being "very professional," 10 percent rated staff as "usually professional," and two patients chose "frequently unprofessional." Three patients called the staff "very knowledgeable" and 19 chose "knowledgeable," with 1 thinking that staff were "uninformed." Patients stated they feel that they are being treated as individuals. This was demonstrated by 75 people answering "very much so" when asked that question. Of people surveyed, 76 felt that clinic rules were about right, and 10 thought that rules were too strict.

We do try to be positive whenever possible, but we also make use of negative reinforcement. For example, a $25 fee is charged for those patients coming to be dosed after hours; and also when the patient's frequency of trips to the clinic is increased according to government regulation; and when they are not complying with rules or doing as well as we expect that they should.

In our survey, we asked the open-ended question, "What is different about this program?" of the 48 patients who had been on another methadone program. Many of the patients' answers reflected that they felt that we treated people as humans, and that there is less cost, less hassle, and a much better staff. Words such as "respect," "understanding," and "caring" showed up frequently in the answers to our open-ended question. Several patients mentioned take-outs as being a big advantage of our program.

Key Factors

A part of the questionnaire listed all the factors that we thought might be important to patients. We also had several patients help us to make the list more inclusive. Patients were asked to rate each factor using the following scale: (1) Doesn't matter—none, (2) Minor—somewhat important, (3) Important, (4) Quite important, (5) Extremely important. We also recorded those questions that were not answered.

Results of the questionnaire are shown in table 1. Table 1 gives a weighted score for each item asked on the questionnaire, which reflects the relative importance of the individual items to patients. When patients were asked which factors were most important in keeping them in treatment, the most important factor, with a score of 4.6, was take-out doses of methadone for eligible patients. Take-outs are also shown to be important in the medical literature. The low cost of the program was also extremely important to our patients (a score of 4.4). Staff attitude, convenient dosing hours, and receiving a blocking dose of methadone all received high scores (4.3).

Interestingly, when patients were asked an additional question, "Which factor is the most important in keeping you in treatment?" the top-ranked factor, determined by the one factor that they picked most frequently, with 26 responses, was receiving a blocking dose of methadone. Most patients are maintained at 60 to 100 mg of methadone. This correlates well with articles in the medical literature that show receiving an adequate dose of methadone is one of the most important considerations in being successful with methadone maintenance.

Other responses to this additional question were similar to those shown in table 1. The low cost of the program was in second place, with 18 responses, and in third place with 17 responses was take-outs. Staff attitude received 15 responses, and being treated in a medical practice versus being treated in a strictly methadone clinic received 13 responses. This has been mentioned in the literature as "the dignity of standard professional atmosphere" (Novick et al. 1988) and is seen as an advantage of treating methadone maintenance patients as part of a private family practice. Convenient dosing hours received 13 responses, and access to a physician received 12 responses. Every item was mentioned by the patients in response to the question. Many patients marked more than one answer as important to maintaining them in treatment.

WS= Weighted score; 5= Extremely important; 4= Quite important; 3= Important; 2= Somewhat important; 1= Doesn't matter; TR= Total responses.

Note: Weighted scores were calcuted by multiplying the number of responses by 5 for responses in the "extremely important" category; by 4 for responses in the "quite important" category; by 3 for responses in the "important" category; by 2 for responses in the "minor—somewhat important" category; and by 0 for responses in the "doesn't matter" category. The sum of these scores was then divided by the number of responses to each factor, which resulted in the weighted score.

When asked for negative comments on the way our program works, no clear pattern came through. Distance traveled, inconvenient dosing hours, and cost did come up. A question on how the program could be improved prompted similar responses about distance, hours, and cost. One patient mentioned that the methadone program probably hurt the doctor's family practice and there is some validity in this.

A question on positive things that patients see in the program gave many a chance to express how grateful they were for the help they were receiving. Many superlatives were expressed about the staff and about being treated as an individual in a very personal fashion. People feel that we are genuinely interested in seeing them do well. Respect and improving self-esteem were mentioned frequently. The effort patients put into answering the questions was very gratifying to us as a staff. Finally, when asked if they would recommend the program to others in need, every person answered "yes."

Problems

We do still have major areas of concern in our program, not the least of which is in the area of public relations. We do not feel that we are understood by hospitals, jails, other treatment programs, police, community, or even by other physicians. Part of this is the fault of the press and the media. We must make a better effort at communicating with these various groups whenever possible. Although we try to do all we can to work with the various regulatory agencies, many times we still feel more like adversaries to these groups than allies. This diverts a significant amount of our energy and effort, making it extremely more difficult to consider ideas such as opening up medication units in more diverse locations in Iowa. Another issue concerns patients threatened by managed care. At present we are not able to bill Medicaid or Medicare for our methadone maintenance treatment.

We constantly feel the stress of working with people whose lives are in crisis. As Newman stated in the Annals of Internal Medicine, "Physicians should not be obliged to treat heroin addicts. The care of such patients has been judged so difficult that workers at one prestigious medical center have called for their segregation into dedicated units" (1990). We agree that treatment is difficult, but feel that such impersonal and preferential treatment would be counterproductive.

Cocaine continues to be a huge problem in Iowa, as we are sure it is elsewhere. We know that with time on methadone maintenance treatment, the use of cocaine gradually diminishes. Other methods of addressing this problem are desperately needed. We would like to see a higher employment rate among our patients. We could contribute to society more by becoming more active in outreach to attract patients in need. We are also frequently frustrated by dealing with patients with dual diagnosis, especially personality disorders. It is very easy to get caught up in having low expectations for making these people's lives more meaningful.

Conclusion

The ready cooperation of patients was heartening. We are sharing a copy of this article with each patient. Our hope is that through the cooperative effort, we will put more meaning into their lives and create a stronger therapeutic milieu. We were pleased to see that many of the factors that patients considered important were similar to those identified in the medical literature. The study has shown us that diversion of methadone must continue to be an extremely important consideration. We feel that with the proper use of methadone, the negative impact of opiate addiction on individuals and society can be greatly diminished.

Recommendations

Our program has demonstrated considerable success in addressing opiate addiction in a rural setting. Some of what we have found could be applicable to other programs. Access to treatment remains a major barrier. The recent Institute of Medicine study suggests treating methadone just as any other schedule II substance (Forum 1995). If local physicians in private practice are one day able to provide methadone maintenance, then this article may identify ideas for effective strategies.

References

Cooper, J.R. Methadone treatment and acquired immunodeficiency syndrome. Journal of the American Medical Association 12:1664-1667, September 22/29, 1989.

Dole, V.P. Methadone treatment and the acquired immunodeficiency syndrome epidemic. Journal of the American Medical Association 12:1681-1682, September 22/29, 1989.

Methadone treatment regulation; New challenges for change. Forum 4(2):6-7, Spring 1995.

Newman, R.G. Advocacy for methadone treatment. Annals of Internal Medicine 113:819-820, 1990.

Novick, D.M.; Pascarelli, E.F.; Joseph, H.; Salsitz, E.A.; Richman, B.L.; Des Jarlais, D.C.; Anderson, M.; Dole, V.P.; and Nyswander, M.D. Methadone maintenance patients in general medical practice. Journal of the American Medical Association, 259(22):3,299-3,302, 1988.

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