Chapter 3 - Clinical Application of LAAM Therapy
Both clinical and practical considerations are involved in deciding which patients are appropriate for levo-alpha-acetyl-methadol (LAAM) treatment. Patients can be inducted directly onto LAAM or can be transferred from methadone to LAAM. This chapter provides guidelines for selecting patients for LAAM treatment and stabilizing them on the medicine.
Dose scheduling is key to successfully maintaining stabilized patients on LAAM. Two factors specific to LAAM--its long-acting nature and the fact that regulations do not permit take-home doses--make dose scheduling more complicated than with methadone. Dosing can be scheduled every other day, if the clinic is open on Sunday. Three-times-weekly dosing (two 48-hour doses and a 72-hour dose) can also be used. Programs should have procedures for addressing Monday holidays and other planned and unplanned interruptions of regular LAAM dosing. For planned absences, supplemental doses of methadone may be given to patients who are allowed take-home methadone. The chapter describes approaches to addressing dosing and scheduling issues.
Selection of Patients
Research to date provides no clear-cut indicators that determine which individuals will benefit most from LAAM therapy. Until more ic effects of drugs used to supplement LAAM.
People who have been on methadone maintenance a long time but still report for medication six or seven times a week because of State or local policy on take-home methadone. These patients in particular may appreciate that fewer clinic visits are required by LAAM therapy.
Chronic relapsers, including those who have been on methadone for a long time but who remain uncommitted to the goals of treatment. Most chronically noncompliant patients do not appear to benefit from daily visits to the clinic, and many visit the clinic only because they are not allowed take-home medication. Many such patients disrupt clinic routines and, over a long period of time, have exhausted staff attempts to engage them in treatment. Members of the consensus panel felt that use of LAAM therapy with some of these patients would have the advantage of reducing disruptive clinic visits and making it easier for staff to provide care to others. Panel members understood that recommending LAAM therapy for this group was controversial; patients in this group should be carefully selected. LAAM therapy should never be used as a punishment.
Daily clinic attendance by the three groups may be reduced with LAAM therapy. Patients who have been stable on methadone maintenance for a period of years probably receive take-home doses and would experience no reduction in visits when transferring to LAAM. However, according to Federal regulations, a patient must be in opioid substitution therapy for 2 years before he or she is eligible for enough take-home methadone to allow only two clinic visits per week. Thus, patients in the first 2 years of methadone treatment may benefit from LAAM therapy. (After 3 years of treatment, the Food and Drug Administration [FDA] regulations permit a 6-day supply of methadone for patients meeting certain conditions, thus allowing them once-a-week clinic visits. State regulations vary.)
Practical Considerations and Clinical Factors
In considering candidates for LAAM therapy, common sense and practical considerations should prevail. Patients with mobility problems may find LAAM treatment an attractive alternative, because fewer visits mean less frequent travel requirements. Similarly, patients in inner cities who lack transportation, those in rural areas who must drive long distances to the clinic, and those with scheduling conflicts may also find LAAM therapy a desirable alternative. Patients (such as those with dementia) for whom age or illness makes managing take-home medication difficult may also derive some benefits. Patients in States where take-home doses of methadone are not allowed or are in practice severely restricted may also benefit from the introduction of LAAM treatment. Patients in these States could have more opportunities to engage in other productive life experiences (such as employment and job training) under LAAM's reduced dosing schedule. However, treatment choices based on these considerations alone should be avoided.
Among the appropriate target population for LAAM therapy are three main groups:
- People entering treatment, either from the street or in their first 2 years of methadone maintenance
- People who have been on methadone maintenance a long time but still report for medication six times a week because of State or local policies on take-home methadone
- Chronic relapsers, including those who have been on methadone for a long time but who remain uncommitted to the goals of treatment.
Although use of LAAM raises these and other practical issues, the decision to use LAAM should be governed by clinical factors, including the patient's desire and the belief that LAAM offers the optimal means for achieving the goals of maintenance treatment. LAAM therapy should not be selected because a clinic is trying to achieve formulas or meet quotas of LAAM patients.
The decision to use LAAM should be framed from the patient's perspective. Staff may find it useful to present the available range of opiate addiction treatment alternatives to a patient in a manner similar to that used in family planning counseling. Such conversations may extend over more than one counseling session to allow the patient to assimilate the information. (However, treatment with methadone can begin right away.) To help the patient make an informed choice, program staff should present the advantages and disadvantages of the treatment options and give the patient the opportunity to ask questions and to participate in the treatment selection.
Every treatment choice has particular advantages and disadvantages. For example, some patients may need daily clinic visits as a component of their treatment program; less frequent visits may help other patients establish a more normal routine that is not as structured around clinic visits as is necessary when receiving methadone. For the latter group, use of LAAM offers distinct benefits. Although use of LAAM eliminates the need for daily clinic visits, it also eliminates the option of take-home medication. For some patients, the loss of take-home medication as an indicator of treatment progress may present problems. For others, take-home medication may not be achievable, and LAAM will provide an alternative method of reducing the frequency of clinic visits.
To help the patient make an informed choice about LAAM treatment, program staff must present the advantages and disadvantages of all treatment options and give the patient the opportunity to ask questions and to participate in the treatment selection.
Intake and Assessment
The components of the psychosocial assessment for LAAM therapy are consistent with those for methadone treatment. Guidelines for assessment of patients are presented in two other TIPs State Methadone Treatment Guidelines and Matching Treatment to Patient Needs in Opioid Substitution Therapy.
Patients who are being considered for LAAM therapy can be divided into two major groups: those who are already in an opioid substitution therapy program and those who are not. The latter category includes patients who are not currently dependent on opioids, for example, those recently released from incarceration or chronic care institutions who meet FDA criteria for admission without proof of current physical dependence, 21 C.F.R. Part 291 Section 291.505(d)(1)(iii)(A) (1993).
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