Editorials - June 15, 2001 - American Family Physician

Editorials

Methadone Maintenance

SHARON STANCLIFF, M.D.
AIDS Institute, New York State
Department of Health
New York, New York

See article in this issue.

The development of addiction remains poorly understood, but evidence now supports the proposition that opioid addiction has a physiologic basis influenced by both genetics and the environment. Much addiction research has focused on an apparent "reward pathway" of the mesolimbic system, where opioid-mediated dopamine pathways help to generate the positive-feedback system that supports species-sustaining activities such as eating and procreation. The central role of endogenous opioids to this system suggests the mechanism by which the drive to administer exogenous opioids can become as intense as the drives for food and sex.

Changes that have been observed in association with chronic administration of opioids include physical atrophy of dopamine-producing neurons in the ventral tegmental area. Such changes may account for some of the aversive symptoms of opioid withdrawal. It is theorized that neuroadaptations to chronic drug exposure may also lead to the long-term anhedonia that many opioid users experience and may explain why sustained abstinence is so difficult for many users.¹

In 1997, a National Institutes of Health (NIH) consensus development panel concluded that methadone maintenance is the most effective treatment for opioid addiction.² Methadone is initiated at 20 to 40 mg and gradually increased until the patient reports clinical comfort and urine screens are free of other opioids. Most studies suggest that patients generally require a methadone dosage of 60 to 120 mg per day to stop using and craving heroin, although some patients respond to lower dosages and others require much higher dosages.³

Methadone maintenance is a long-term therapy. The majority of patients who discontinue methadone relapse to heroin use, and no factors reliably predict which opioid-dependent patients may do well without pharmacotherapy.⁴ Long-term methadone treatment has no major adverse effects. Constipation and increased sweating are the most common side effects, and they tend to diminish over time. Because methadone can be used safely during pregnancy, it is the treatment of choice in opioid-dependent pregnant women.³ Physicians need to be aware of methadone's interactions with other drugs and should be alert for information about possible interactions as new medications are introduced.

Studies have found that persons on methadone maintenance are three to six times less likely to become infected with the human immunodeficiency virus (HIV), even if they continue to use drugs.^5,6 One study compared heroin addicts who were receiving methadone maintenance treatment with heroin addicts who were not receiving this treatment.⁶ Follow-up of HIV-negative patients over 18 months showed seroconversion rates of 3.5 percent among those who remained on methadone versus 22 percent among those who were not treated with methadone. Heroin addicts who are already infected with HIV also benefit from methadone treatment. One study⁵ found that HIV-positive patients with a history of heroin addiction who were receiving methadone maintenance were less likely to be hospitalized than their counterparts who were not taking methadone.⁷

Regulations require frequent attendance at methadone programs, and the number of methadone maintenance spots is highly restricted. Many patients are required to attend six to seven days per week, and only after three years can patients who are considered to be socially rehabilitated decrease their attendance to weekly. Thus, many patients have no access to treatment, and others are deterred by the strict regulations. The NIH Consensus Report stated, "The unnecessary regulations of methadone maintenance therapy and other long-acting opiate agonist treatment programs should be reduced, and coverage for these programs should be a required benefit in public and private insurance programs."² In March 2001, the federal regulations were modified, allowing more liberal take-home privileges. Each state has the option of adopting these regulations."⁸

As Krambeer and associates⁹ note in their article on methadone therapy, which appears in this issue of American Family Physician, there is a move toward a greater role for office-based prescribing, also termed "office-based opioid therapy." In New York City, a highly successful pilot project has been operating for more than 15 years. A federal waiver allows stable patients to participate in "medical maintenance" through monthly visits to a primary care physician, from whom they receive methadone in addition to regular medical care.³

Until office-based prescribing becomes common, primary care physicians can play a supportive role in methadone therapy. Because methadone use is highly stigmatized, opioid addicts may require a great deal of education about the benefits of this treatment. Because misconceptions about methadone are widespread, it may be helpful to include family members in educational efforts. Krambeer and associates⁹ suggest that patients become involved in Narcotics Anonymous (NA); however, NA and other similar programs often consider methadone maintenance to be contrary to recovery. In becoming knowledgeable about methadone as a treatment for opioid dependence, the primary care physician can play an important role in bringing this highly effective modality to its full potential.

Sharon Stancliff, M.D., is a medical consultant at the AIDS Institute of the New York State Department of Health, and medical director of the Harlem East Life Plan Methadone Maintenance Treatment Program, New York. Dr. Stancliff received her medical degree from the University of California, Davis, School of Medicine, Sacramento, and completed a family practice residency at the University of Arizona College of Medicine, Tucson. She also completed the Nicholas Rango HIV Clinical Scholar's Program in the AIDS Institute at Beth Israel Medical Center, New York.

Address correspondence to Sharon Stancliff, M.D., New York State Department of Health, 5 Penn Plaza, 1st Floor, New York, NY 10001.

REFERENCES

Nestler EJ. Neuroadaptation in addiction. In: Graham AW, Schultz TK, Wilford BB, eds. Principles of addiction medicine. 2d ed. Chevy Chase, Md.: American Society of Addiction Medicine, 1998:57-71.

Effective medical treatment of opiate addiction. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. JAMA 1998;280:1936-43.

Lowinson JH, Payte JT, Salsitz E, Joseph H, Marion IJ, Dole VP. Methadone maintenance. In: Lowinson JH, et al., eds. Substance abuse: a comprehensive textbook. Baltimore: Williams & Wilkins, 1997: 404-15.

Magura S, Rosenblum A. Leaving methadone treatment: lessons learned, lessons forgotten, lessons ignored. Mt Sinai J Med. 2001 Jan;68(1): 62-74.

Drucker E, Lurie P, Wodak A, Alcabes P. Measuring harm reduction: the effects of needle and syringe exchange programs and methadone maintenance on the ecology of HIV. AIDS 1998;12(suppl A): S217-30.

Metzger DS, Woody GE, McLellan AT, O'Brien CP, Druley P, Navaline H, et al. Human immunodeficiency virus seroconversion among drug users in- and out-of-treatment: an 18-month prospective follow-up. J Acquir Immun Defic Syndr 1993;6: 1049-56.

Weber R, Ledergerber B, Opravil M, Siegenthaler W, Luthy R. Progression of HIV infection in misusers of injected drugs who stop injecting or follow a programme of maintenance treatment with methadone. BMJ 1990;301:1362-5.

Opioid drugs in maintenance and detoxification treatment of opiate addiction. Final Rule Federal Regist. 2001;66:4075-102.

Krambeer LL, von McKnelly W Jr., Gabrielli WF Jr., Penick EC. Methadone therapy for opioid dependence. Am Fam Physician 2001;63:2404-10.

Medical Surveillance: The Role of the Family Physician

ROBERT J. MCCUNNEY, M.D.
Massachusetts Institute of Technology Medical Department
Cambridge, Massachusetts

Medical surveillance is a term with a variety of synonyms, including medical monitoring. Medical surveillance is designed to detect early adverse health effects associated with certain work duties, such as exposure to occupational hazards.¹ It serves as the proverbial safety net in support of primary prevention methods used in occupational settings throughout the world.

For some substances, the Occupational Safety and Health Administration (OSHA) has established standards that require medical surveillance with defined protocols. In cases that lack specific guidelines, standards of practice--as well as the OSHA general duty clause--support the concept of periodic evaluations of employees who are exposed to health risks at work. The "Guide to Clinical Preventive Services" addresses numerous illnesses in terms of the availability and effectiveness of screening measures for prevention; these guidelines may also be valuable in occupational and environmental settings.²

In the context of medical surveillance examinations, a variety of ethical issues may surface. The major potential conflicts involve revenue generation and information transfer.³Because the components of an evaluation may vary in some settings, depending on the judgment of the physician, opportunities exist to provide questionable services in order to generate reimbursement. A notable example is the OSHA respirator standard. Physicians can use their own discretion to determine the appropriateness of certain ancillary studies, such as pulmonary function testing. For example, a physician may require a host of ancillary tests to approve an employee for respirator use. If the provision of these additional services generates revenue for the physician or the clinic, an obvious conflict may arise.

The other major ethical challenge in the context of medical surveillance is the disposition of medical information following the examination. For example, where is the information stored? For how long? Who has access to the information? What does the employer know? What does the physician tell the patient? Ideally, these questions should be addressed before examinations are performed. In general, the physician is responsible for informing the employer of work-related abnormalities because of the employer's responsibility for providing a safe workplace.⁴The employer must recognize occupational health problems and implement appropriate interventions. It is wise, however, for physicians to ask for a signed medical release before the examination so that patients are well aware of the disposition of their medical information. Medical results that have no bearing on the workplace should be kept confidential. The OSHA standards regarding access to medical records provide further guidance on confidentiality.⁵

In its Code of Ethical Conduct, the American College of Occupational and Environmental Medicine (ACOEM) emphasizes the importance of confidentiality⁶:

"Keep confidential all medical information, releasing such information only when required by law or overriding public health considerations, or to other physicians according to accepted medical practice or to others at the request of the individual."

This guideline is particularly appropriate for medical surveillance and other employment-related evaluations. In worker's compensation cases, for example, employers can learn the diagnosis of the condition for which compensation benefits are sought but cannot be informed about ailments with no bearing on the workplace. In all cases, it is wise to inform patients about where their medical information will be stored and who may have access. Recently, the Federal Department of Health and Human Services issued guidelines for the privacy of health-related information that is stored electronically.⁷

Prevention in medical surveillance is based on the fundamental principle of screening--that is, the administration of a test or tests at an interval such that an asymptomatic condition is recognized sufficiently early in the disease process so that intervention slows, halts or reverses the ailment. Medical surveillance is ideally performed along with a work-site review conducted by an appropriate professional, such as an industrial hygienist. In fact, physicians would be wise to understand the work for which surveillance examinations are conducted. A review of air monitoring data, supplemented by a work-site visit and discussions with plant officials, including labor and management representatives, can be instrumental in understanding the risks that may be present.

Medical surveillance, a fundamental aspect of prevention, can be instrumental in uncovering early signs of occupational illness and in ensuring the safety and integrity of primary prevention.

A shortage of occupational medicine physicians has created opportunities for family practitioners in this specialty of the American Board of Preventive Medicine. The family physician who serves as a medical advisor to a local facility plays a major role in the clinical assessment--the history, physical examination and laboratory studies that are often part of medical surveillance programs. Although family physicians do not customarily participate in the analysis of group data, preliminary review of certain clinical information may indicate trends that warrant further examination.

Family physicians who are interested in this aspect of occupational medical practice are likely to continue to find opportunities to hone their skills.

Robert J. McCunney, M.D., is the director of occupational and environmental medicine at the Massachusetts Institute of Technology, Cambridge.

Address correspondence to Robert J. McCunney, M.D., M.P.H., Massachusetts Institute of Technology Medical Department, 77 Massachusetts Ave., 16-267, Cambridge, MA 02139-4307 (e-mail: mccunney@mit.edu). Reprints are not available from the author.

REFERENCES

Harber P, McCunney RJ, Monosson I. Medical surveillance. In: McCunney RJ, ed. A practical approach to occupational and environmental medicine. 2d ed. Boston: Little Brown, 1994:358-75.

U.S. Preventive Services Task Force. Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. 2d ed. Baltimore: Williams & Wilkins, 1996.

McCunney RJ, Brandt-Rauf P. Ethical conflict in the private practice of occupational medicine. J Occup Med 1991;33:80-2.

McCunney RJ. Preserving confidentiality in occupational medical practice. Am Fam Physician 1996; 53:1751-6.

OSHA Regulations. Access to employee exposure and medical records. Standards--29 CFR 1910. 1020.

Teichman RF. ACOEM Code of Ethical Conduct. American College of Occupational and Environmental Medicine. J Occup Environ Med. 1997 Jul;39(7):614-5.

Appelbaum PS. Threats to the confidentiality of medical records--no place to hide. JAMA 2000; 283:795-7.

Please Don't Call Me 'Provider'

ROBERT B. TAYLOR, M.D.
Oregon Health Sciences University School of Medicine
Portland, Oregon

Recently I received a memo: "Provider Meeting: All PCPs should attend." I don't know about you, but I am fed up with being called a "provider." Yes, I know, I provide medical care to my patients. And "provider" is part of "primary care provider," or PCP.

Let's look at how these terms came into use. The word "primary" used in regard to physicians appeared in the 1966 Millis Report, which called for "physicians who can put medicine together again."¹ The report proposed a "primary physician" who "would, by assuming primary responsibility for the patient's welfare in sickness and health, provide continuing and comprehensive care to the citizens of the United States."²In describing health care, we came to use the phrase "primary care" to distinguish first contact, continuing and comprehensive care from secondary care (still in debate) and tertiary care provided in large medical centers. Over the years, "primary physician" and "primary care" were melded into "primary care physician" as government and others sought a comprehensive term to refer to family physicians, general internists and general pediatricians. The "provider" term arose with insurance companies as they have invaded health care over the past two decades. Thus "provider" (or "primary care provider/PCP") can be considered to be the brainchild of federal bureaucrats and the managed care industry. Certainly no physician ever woke up one morning and stated, "From now on, I want to be called a PCP."

I am a physician and proud of it. I worked hard to obtain my degree, and I continue to work hard to keep my medical knowledge and skills up to date. I am also a medical doctor, in the sense that the word "doctor" comes from the Latin "docere," meaning to teach. I highly value my role as educator for patients, students, residents and sometimes colleagues.

Calling me a "provider" lumps my physician colleagues and me with individuals who are frankly less qualified and yet aspire to do the same work we do. Although I believe that physicians respect the work of physician assistants and nurse practitioners, such respect does not justify the use of terms that, although "politically correct," diminish us as professionals. Some pundits have even predicted that these other "providers" will replace fully trained physicians, but this seems highly unlikely given the increased complexity of generalist physician care today.³ Nevertheless, grouping generalist physicians with less trained "providers" lends credibility to their claims.

The word "provider" also encourages us to consider health care a commodity and the physician-patient encounter a business transaction. Pellegrino⁴ describes the implications of this paradigm shift in writing about the commodification of medical and health care. If we, as physicians, move from a professional to a market ethic, then we surrender professionalism to a commercial mentality.

There are racial, ethnic and even gender insults, and we all know what they are. We protest when they occur. Well, I consider "provider" a professional insult; it is personally demeaning, and it devalues my education and my degree. Why should you and I be forced to suffer repeated use of a derogatory professional insult?

If you agree, I suggest that you photocopy this editorial. Keep copies in your desk and send one--with a short personal note--to anyone who calls you a "provider."

Robert B. Taylor, M.D., is professor at the Oregon Health Sciences University School of Medicine.

Address correspondence to Robert B. Taylor, M.D., Department of Family Medicine, Mail Code FP, Oregon Health Sciences University School of Medicine, 3181 Southwest Sam Jackson Park Rd., Portland, OR 97201.

REFERENCES

The graduate education of physicians: the report of the Citizens Commission on Graduate Medical Education. Chicago: American Medical Association, 1966.

Millis JS. Foreword. In: Taylor RB, ed. Family medicine: principles and practice. New York: Springer-Verlag, 1978.

St Peter RF, Reed MC, Kemper P, Blumenthal D. Changes in the scope of care provided by primary care physicians. N Engl J Med 1999;341:1980-5.

Pellegrino ED. The commodification of medical and health care: the moral consequences of a paradigm shift from a professional to a market ethic. J Med Philos 1999;24:243-66.

EDITOR'S NOTE: At American Family Physician, we have a policy of avoiding the term "provider" when referring to physicians. Parenthetically, I find it surprising how many of my physician colleagues have adopted the term when referring to themselves. I doubt that neurosurgeons refer to themselves as "providers." Why do we?--jay siwek, m.d.

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