Not Measuring Up
Lower-than-recommended methadone doses for opiate addiction are more likely at facilities run by African-American directors.
Battling an epidemic of opiate addiction, U.S. drug treatment facilities have made progress with methadone. A daily dose of at least 60 milligrams of methadone is recommended to achieve therapeutic effects and has been associated with improvements that include significant decreases in heroin use, in relapse rates, and in HIV incidence.
Some patients of “opiate agonist treatment” facilities, however, receive less than 60 milligrams per day. A team of researchers led by Johns Hopkins Carey Business School Assistant Professor Jemima Frimpong, an expert on health care organizations, examined differences in methadone dose levels and the role that program directors may play in accounting for these variations. For a study published in Health Services Research, the team discovered that, overall, the proportion of patients getting lower than the recommended daily dose of methadone for opiate addiction has declined in recent years. However, facilities run by African-American directors were more likely to provide low methadone doses than facilities run by managers of other races and ethnicities.
This relationship was even stronger at facilities run by African-American directors serving a high proportion of African- American patients.
Lead author Frimpong says the finding was unexpected. She and her co-authors – doctoral candidate Karen Shiu-Yee of Columbia University and Professor Thomas D’Aunno of New York University – set out to determine a possible link between the characteristics of facility managers and the lower doses of methadone. While manager race and ethnicity were conceptually relevant to the analysis, the specific finding regarding African-American managers was not anticipated, Frimpong explains. But its importance became apparent as the researchers examined data compiled from 1995 through 2011 in the National Drug Abuse Treatment System Survey (NDATSS).
Frimpong and her colleagues suggest possible reasons for the lower methadone doses – for example, negative perceptions of methadone in the African-American community, and a preference among African-American directors for psychosocial treatment, including talk therapy, as a supplement to methadone in treating opiate addiction. The authors concede that further research is needed to better understand their finding regarding the relationship between the races of program managers and dosing patterns.
“We know that the problem of low dosing exists, and research has looked at how patient characteristics may play a role,” says Frimpong. “Our study extends such analyses and examines characteristics of managers and how they may in uence methadone dosing patterns in opioid treatment programs.”
In that way, she says, this new paper helps advance the literature. The ultimate goal of such research, adds Frimpong, is to encourage more effective treatment practices for the growing scourge of opiate addiction. As the Centers for Disease Control and Prevention noted in January 2016, “The United States is experiencing an epidemic of drug overdose (poisoning) deaths. Since 2000, the rate of deaths from drug overdoses has increased 137 percent, including a 200 percent increase in the rate of overdose deaths involving opioids (opioid pain relievers and heroin).”
“Because opiate addiction is increasing at such a disturbing rate, it is important that treatment programs are adopting and implementing evidence-based prac- tices. The available research suggests that too many persons with opiate addiction are not getting methadone dose levels shown to be effective.”
Previously, the CDC reported that 259 million prescriptions for painkillers were written in 2012, enough to supply every American adult with a bottle of pills.
“Because opiate addiction is increasing at such a disturbing rate,” Frimpong says, “it is important that treatment programs are adopting and implementing evidence-based practices. The available research suggests that too many persons with opiate addiction are not getting methadone dose levels shown to be effective.”
According to the NDATSS, the percentage of patients getting less than the recommended 60 milligrams of methadone per day actually decreased over 16 years – from 49 percent in 1995 to 23 percent in 2011.
“That is definitely an improvement, but it also means that nearly a quarter of patients were not getting dose levels more likely to be effective. The magnitude of opiate addiction remains a big problem. Therefore, an 80-percent success rate is not adequate. We still have a lot of work to do in order to address the opioid epidemic,” says Frimpong, who earned her PhD at the University of Pennsylvania’s Wharton School of Business. Her research, as seen in this study, focuses on organizational factors and the extent to which they affect health care practices and outcomes.
The study, titled “The Role of Program Directors in Treatment Practices: The Case of Methadone Dose Patterns in U.S. Outpatient Opioid Agonist Treatment Programs,” was supported by research grants from the National Institute of Drug Abuse.