Disclaimer: nothing in this post should be taken or held as clinical instruction, clinical supervision, or advisory concerning patient care, and neither should the content in the attached documents.
Dr. Austin Brown’s idea that Recovery Review can or does serve as an archive of what is thought, can be thought, or has been thought about addiction, addiction recovery, and addiction treatment, etc. has had me thinking.
One idea I’ve considered, decided, un-decided, re-decided, and am now enacting is the posting of a monograph I started writing back in 1998 and finished in 1999. It’s about Methadone Maintenance Therapy (MMT).
Below, you’ll find the latest version that was finalized in 2006.
Given that 2026 is the 20-year anniversary, and for somewhat nostalgic purposes as well, I thought I’d go ahead and post that MMT monograph here, this year.
The original 1999 version gained some additions in 2001. And another version was completed in 2002. The only other update was completed in 2006.
The story of the document is as follows
When I arrived at my first full-time job in 1989, I was a counselor in a traditional 9-12 month or longer residential co-ed therapeutic community (TC). I had just finished my graduate internship and was an MA-candidate at that point. The residential program was in the inner city. It had an outpatient methadone maintenance clinic run out of the first few offices in the front of the residential program. The group room and counseling office for the methadone program were at the front of the house. Next was the nurses’ station, which had a Dutch-door for medication dispensing for both the outpatient and residential programs.
Here’s a picture of that building where I started in 1989.
Guess what? It turned out that the first RN approved to dispense methadone for MMT in the entire history of the state of Illinois opened that methadone clinic in 1968 or 1969 (I can’t remember which). And she was still working there when I arrived in 1989. She didn’t retire until I was there for almost ten years. Needless to say, she had a long institutional memory.
Further, the staff of the TC and the methadone program shared some duties. For example, I was collecting some of the urine samples for the outpatients on the methadone clinic from the time I was hired in the TC. And the team of nurses and program physician worked both programs. The same one clinical director oversaw both programs.
When that clinical director, Daniel Kelts, left in 1996 to teach full time, I was placed in his seat. I remained there until 2008.
Methadone Maintenance and the BHRM Project
I knew in 1996 that one of my most urgent and important responsibilities was to read as much of the initial and latest methadone maintenance literature as I could. I did a rather large initial amount of reading and sustained a significant amount of reading for several years.
Meanwhile, the Behavioral Health Recovery Management (BHRM) project got underway in our agency around 1997 or 1998. That ten-year project was highly influential in producing clinical innovation, including the invention of recovery coaching, and making changes in our organization’s programs in alignment with BHRM principles. The BHRM project also resulted in us adopting the latest cutting-edge promising practices, best practices, and evidence-based practices as developed by national authors in practice guidelines written for our project. Most of those clinical practice guidelines are here on Recovery Review.
In 1999 we heard about the notice of proposed federal rulemaking that would move the oversight of methadone programs from regulatory compliance under the FDA to a clinical accreditation model under Joint Commission and CARF. This served to intensify both my required and self-imposed learning and reading. During that time, our CEO Mike Boyle, who led the BHRM project within our organization, noticed that the field lacked an up-to-date clinical practice guideline on methadone maintenance therapy that was comprehensive and authoritative.
I had been noticing, by the way, from 1996 onwards, that I would from time to time be asked a clinical consultation or knowledge-based fact question by various staff in the methadone clinic (counseling staff, RNs, LPNs, and sometimes even the physician). And some of the exact same questions were asked by a variety of staff over time. Weary of answering the same question(s) multiple times, and wanting to synopsize my learning about MMT, I decided to start to write what turned into the MMT Primer I’ve uploaded down below in this post.
Fortunately, Eric Corty, PhD, under whom I had a graduate assistantship in my first year of graduate school, and who guided my thesis project, was a national researcher in methadone maintenance (including with John Ball) just prior to coming to our university. And he had done his post-doctoral fellowship at the Philadelphia VA inside the clinical research team in addictions headed by Charles O’Brien, Anna Rose Childress, Ronald Ehrman, and Thomas McLellan. Eric was generous enough to read iterations of my methadone maintenance primer and give me feedback while I was working on it.
(By the way, Eric, as a subject matter expert consultant, met with Dan Kelts routinely to provide Dan the supervision of his clinical supervision and program management. During my first year of graduate school, Eric had me attend his supervision of Dan and listen, as a part of my assistantship. Eric and I would de-brief each of these supervision meetings when they were concluded. My gratitude to Dan for allowing me to sit in as a fly-on-the-wall during the supervision of his supervision for an academic year is impossible to put into words. And so are the results that were produced in me resulting from that opportunity).
Another reason I wanted to write this primer was that it could serve as a competency-based defensive maneuver against our impending initial Joint Commission accreditation survey. I wanted to have a demonstration of historical, comprehensive, and current competence at the ready, if needed.
The document
My first edition of the MMT Primer was completed in 1999. Around 2000, Mike Boyle then gave me a simple demand I had to fulfill. And completing it was one of the hardest things I’ve ever had to do in my entire career. He simply told me to construct a medication algorithm for MMT. This was predictable from Mike, as we were implementing the exhaustive algorithms for all of psychopharmacology that were available from the Texas Medication Algorithm Project (TMAP) across all of the psychiatric prescribers in our organization during the BHRM project. But yes, his instruction to me was that simple and short.
Once I got the algorithm assembled, I showed it to our methadone program physician, and he suggested that I should simply change one occurrence of the word “hold” (that I used to refer to keeping the dose the same) to “maintain” – to be in line with conventional medical language. I was floored he had no clinical changes to direct or suggest. The algorithm appears in the appendix of the MMT Primer.
The second edition was completed in about 2001, and my next was completed in 2002. Mike then forced me to send the primer to William White. Mike’s idea was that the primer would serve internally in our agency as our practice guideline for MMT, as there was no commensurate or superior clinical guideline currently in our field at that time. When Bill read it, he scheduled a meeting with me during his next trip to our agency, and we began to compose a paper together at his suggestion. That paper was published in Counselor in 2003. Given the topic of MMT and the way we handled it in that paper, a part of me expected repercussions – such as mass cancellations of subscriptions to Counselor from across the country. Or worse.
Given that it’s now 20 years since the 2006 final revision, I thought I’d post the MMT Primer here and now, especially given Dr. Brown’s comments.
Below I’ve provided the link to two posts from 2021. These are the best window into the TC and methadone clinic as sister programs I’ve provided here at Recovery Review so far. And the recovery-oriented methadone maintenance post outlines specific innovations in the methadone clinic that resulted from and during the BHRM project.
The link to the paper Bill did with me in 2003 after he read the Primer is also down below.
Resources
Coon, B. August 13, 2021. We All Need to Learn “Prevention”. Recovery Review.
