TREATMENT
TREATMENT TRAINING SESSIONS
New Developments in Oversight and
Treatment of Opiate Addiction:
Pharmacology and Behavioral Therapies
Mark W. Parrino, M.P.A.
President
American Methadone Treatment Association
United States
Good morning. It’s a pleasure to be here.
Part of my remarks will focus on research and
policy: Why methadone maintenance treatment
is so widely used in the United States and other
countries. The presentation will also focus on
community education—the need to inform the
public about the value of methadone
maintenance treatment. Some additional issues
of clinical management include pregnancy,
treating, and comorbidity, such as HIV infection
and other infectious diseases with people on
methadone maintenance. And in addition, I will
come back after Dr. Barthwell has concluded to
finish some administrative concepts about
program design, how best to operate
methadone maintenance treatment programs,
and so that you don’t run into the flaws in
Mexico the way we did in the United States in
the early part of methadone maintenance
treatment. So, I thank you for your gracious
introduction, for inviting me to speak and
hopefully this will help all of you in other parts
of the country and in Mexico.
So, with that, I’m the President of the American
Methadone Treatment Association, which was
founded in 1984. The association represents
approximately 650 methadone treatment
programs in the United States and we’re
organized through statewide methadone
program association chapters. Some of the
largest chapters are from the states of
California, New York, Illinois and Texas. In fact,
in addition to Dr. Barthwell being the President
elect of the American Society of Addiction
Medicine, she also represents the Illinois
Methadone Provider Association to our Board of
Directors, which is not atypical of Dr. Barthwell.
She represents many different organizations at
once.
The focus here will be three major issues
effecting the future of opiate addition in the
United States. The first is a change in program
oversight in the Federal government from the
Food and Drug Administration to the Center for
Substance Abuse Treatment. These are two
Federal agencies in the United States. For the
past 25 years, since 1974, the Food and Drug
Administration has provided Federal oversight to
methadone treatment. This made sense at the
beginning of the major change in methadone
treatment in the early 1970s, but lost its
applicability over the course of the last 5 years.
The plan is to use accreditation standards, which
are outcome oriented standards as a way to
evaluate the success of methadone maintenance
treatment, to measure the improvement of the
well-being of the patients who are in treatment.
It’s a very serious and major shift in how
methadone maintenance treatment will be
evaluated in the United States, and our
association has supported such a practice.
The second major issue is having stabilized
methadone maintained patients who have been
in treatment in methadone programs in the
United States, have the ability to transfer out of
the clinics, into private physician office practices.
This is called medical maintenance. The idea
behind this is to free up needed places for new
patients to come into methadone maintenance
treatment and to give the successfully stabilized
patients an opportunity to gain access to a
different kind of treatment experience once
they’ve successfully demonstrated stability in the
treatment system.
The third major policy issue is the development
and use of new medications to treat opioid
dependency. Methadone maintenance treatment
has been the most evaluated, studied and used
treatment for opiate dependence that we have
in the history of any medicine. No other
medicine has been scrutinized and evaluated so
carefully to treat a disease. No other form of
cancer treatment, or any other disease, has
been so carefully evaluated. So methadone
maintenance treatment is the most studied care.
And according to our Federal agencies and the
National Institute on Drug Abuse and the
National Institute of Alcoholism and Alcohol
Abuse, methadone maintenance treatment has
been found to be the most effective medical
treatment available to treat opiate dependence.
Of the new medications, the most current one is
called buprenorphine. It’s certainly to be found
effective. The question becomes effective for
what patient, during what part of the addiction
cycle? From our perspective and what we’ve
known in reviewing the research, it is probably
best geared to the younger, or more naive
opiate dependent person. The individual who
has not been using opiates for a very long
period of time. In the United States, if I were to
give you a sketch of the most typical opiate
dependent person, it would be as follows. The
individual began using heroin at the age of 17,
after using alcohol and some other drugs
including marijuana. The young person doesn’t
complete high school in most cases. Rarely gets
to college. Generally gets involved with the
criminal justice system. Is arrested. Spends
some time in jail. The individual rarely gets
training for an employable skill. Most times the
individual, as they get into their 20s, because of
using dirty needles, becomes susceptible to
hepatitis C or to HIV infection. The person
generally enters a methadone treatment
program somewhere around the age of 27 to 29
years old. As a result, the patient has been
exposed to a lot of other illnesses, to the
criminal justice system and presents the
program with many challenges in terms of
providing rehabilitation or in some cases,
habilitation. So, keep in mind that treating this
disease is extremely complex. And all of my
remarks should be put in the context that while
methadone is effective, you need more than
medication to treat the complexity of opiate
addiction. It is not simple to treat and it will
take some time. It is also important to show at
the outset that while some people will be able to
be free and will not use methadone very long,
history shows that the majority of people who
do best in methadone treatment will remain in
methadone treatment for 5 years or for many
cases, for the rest of their natural lifetime.
This is not a setback. This is not a problem. This
is just the treatment they require.
As I said, the Association was founded in 1984.
We represent about 650 of the programs in the
United States. This slide demonstrates from the
National Household Drug Abuse Survey, the
increasing trend of using heroin in the United
States. I know that in Mexico, you’re also having
a very serious problem with people using heroin,
including young people. This trend has been
mirrored in other countries. This is not new. And
the reason is that heroin is becoming more
available. It’s more available at purer levels, and
it’s less expensive.
Now, understand that when you look from the
left side to the right side of this graph, in 1995,
you have 140 thousand brand new heroin users
in the United States. This was for one year. You
notice the increase from 1993 to 1995. I would
argue that Mexico and other countries are
having the same problem. To let you know that
this is not just a problem between the United
States and Mexico, internationally renowned
researchers, Dr. Jerry Stimson and Dr. Don
Dejoulas, did a worldwide study of the number
of countries using heroin. In 1991, 80 countries
were reporting heroin use intravenously. In
1995, 121 countries were reporting intravenous
heroin use. HIV infection follows the pattern. In
1991, 50 countries are reporting HIV infection as
a result of intravenous heroin use. But by 1995,
81 countries are reporting HIV infection as a
result of intravenous drug use.
In Mexico, I don’t know if you’ve seen HIV
infection and AIDS or hepatitis C. And I don’t
know to what degree you see dramatic
percentages. But I can guarantee you, that if
you do not treat intravenous heroin use
effectively, and if you don’t provide access to
treatment, you will see an increase in HIV
infection, of AIDS, of other infectious diseases,
hepatitis B, C and Delta, to say nothing of the
kind of opportunistic infections that untreated
heroin users get. What this slide does not show
is the number of young people using heroin. It
tells you that 140 thousand people in the United
States used heroin for the first time in 1995. But
of this group, 2½ percent of 8th grade students
used heroin in the United States. This is a
dramatic difference. It is also striking to note
that in the last nine years, the average age of
the heroin user was about 22-24 years old. The
average age of the heroin user in 1998 dropped
to 16½ years old. This may not seem dramatic
at first blush, but I can tell you that that drop in
the average age in so short a period of time is
alarming. It’s exactly why health officials in the
United States are trying to increase access to
treatment.
What you’re going to be receiving now is the
Association’s news report from December 1999.
In that news report, you will see the breakdown
of all the methadone treatment patients and
programs in the United States. It’s in the middle
of that booklet and it’s in a purple background
and it’s short. Our association conducted the
survey to demonstrate the number of patients in
treatment. This is not an estimate. This is an
actual count. So, once again, this gives you a
breakdown of where the treatment programs
are, what states and what number. According to
the White House Office of National Drug Control
Policy, the estimate of untreated heroin users is
about 800 thousand. It probably is more, but
the number has increased over the course of the
last several years. So, if I could recommend that
the Mexican government do anything, my
recommendation is capture good information at
the very beginning. The value of what the
United States government has done is, it has the
National Institute on Drug Abuse which really
funds 85% of the world’s research on drug
abuse. The only reason we have such good
information about methadone treatment and
why it works is because of the National Institute
on Drug Abuse. More recently the Center for
Substance Abuse Treatment is a relatively newer
agency that’s really been in existence for about
10 years or so, and this is a much more critical
agency in terms of treatment and treatment
effectiveness. In fact, one of the first treatment
approved protocol statements that CSAT
developed was on methadone treatment. And
one of the slides that I will show you comes
from this book.
I would recommend that if you have an interest,
please access this document. It took about 18
months to develop and given the quality of the
document and the material it covers, it is
actually remarkable. It is as useful today as it
was 8 years ago when it was first published. So,
I really recommend it to you. It’s a basic
guidelines of the most effective treatment
practices.
Now, what we have to do in the United States,
when we go to Congress and to state
legislatures, is we have to demonstrate in hard
terms what the costs are of dealing with drug
abuse. So, here this came from the California
Drug and Alcohol Treatment Assessment of
1994. Dr. Gerstein and his colleagues conducted
the survey. If you look to the right of the chart,
in the pie, the cost to society for the impact of
drug and alcohol abuse in the year before
entering treatment is $4.4 billion each year. This
is the cost to society. The reason I show you
this slide first is to demonstrate the reality that
like it or not, every country has an economic
impact. If the politicians, or government
agencies wish to ignore it, you’re going to pay
for this, one way or another. I will also
demonstrate how inexpensive treatment is
compared to this kind of number.
The average cost per year for one heroin addict
is based on a study in 1991 by Dr. Vincent Doyle
and Dr. Don Dejolais. While the slide represents
a study of nine years ago, and this is based on
New York State, the average, the relative cost,
between the category is pretty much the same.
On the left side of the graph, you will notice that
the cost of untreated heroin is about $45,000
per person, per year. And look at how the cost
is calculated. Security, theft and heroin use.
To incarcerate the person is about $35,000 per
inmate per year. For residential treatment,
$14,000. For methadone maintenance
treatment, about $4,500 per patient per year. If
the society or the government, does not want to
treat the patient, you pay $45,000 per year. If
you want to treat the patient with methadone,
you pay $4,500 to $5,000 per year. Which costs
more? We also have to demonstrate to Congress
and state legislatures, the value of methadone
maintenance treatment even compared to other
forms of treatment. So, here, you look at clients
who reduce costs to taxpaying citizens by 50%
in the year following treatment. Look all the way
to the right. If patients continue, not end, but
continue methadone treatment, society gets
55% savings for the person staying in
methadone treatment. Look at the bar next to it.
The discharged methadone. You notice how that
goes down to 19.5%, which means if the patient
remains in treatment, and the longer the patient
remains in treatment, not only is it better for the
patient, but it’s better for the country. It’s better
for the culture. So, any policy, any directive
about methadone maintenance treatment should
also include the fact that treatment should be
open-ended. What that means is that you leave
the patient in treatment as long as they’re doing
well. You do not create artificial barriers to end
treatment at any particular point in time as long
as the patient continues to do well.
This slide shows the strategies for improving
methadone treatment process and outcome. As
I indicated at the beginning of these remarks,
what’s most important is that you follow what’s
happening to the patient. The hallmark of
methadone maintenance treatment is that the
patient improves. That’s its hallmark. That’s its
value. You will notice that was in the Journal of
Drug Abuse in 1997, and you probably saw the
slide if you were in the morning lecture, because
this comes from Dr. Dwayne Simpson and his
colleagues. In the first bar, to the far left of the
graph, the injection frequency drops from 94%
in the patient before treatment, to 35% as the
patient is in methadone treatment. The opiate
use, from 100% to 48%. And this is all within
the first year. If you look at cocaine use, you
don’t see as dramatic a change. You see from
43% to 31% because methadone maintenance
treatment is not necessarily going to prevent
cocaine use. If the patient is at the right
methadone dosage it will decrease the drug
seeking behavior and the use of cocaine, but it
will not eliminate it. Methadone maintenance
treatment at the right dosage level eliminates
the use of heroin. We know that from research.
You will also notice the change in alcohol abuse,
from 31% before to 18% during treatment, and
crime or jail decreases dramatically.
One of the true hallmarks of methadone
maintenance treatment is a decrease in crime.
You’ll notice this comes from Dr. John Ball’s
study in 1989, published in 1991. The red bars
show crime in the untreated heroin user before
they enter methadone treatment. The yellow
bars show crime during methadone treatment.
You notice the dramatic change. Now, the
following slides represent a history. When
methadone maintenance treatment was
expanded in the United States, it was in the
early 1970s, during the Nixon Administration.
You would not think that the Nixon
Administration might expand access to
methadone treatment, but they did so because
crime would be reduced. It became clear that as
the methadone maintenance patient continues
and as people leave using heroin to get into
methadone treatment, crime decreases sharply
and the reduction continues. This slide
demonstrates it.
This slide is shown to break the myth that the
untreated heroin user is a predatory criminal.
Dr. John Ball, who did this study, wanted to
know what kind of crime the untreated heroin
user would commit. Society has the myth that
the untreated heroin user commits predatory
crime so that people will be hit on the head, will
be held up at gunpoint, or at knifepoint. This is
not true. This study looked at 6 clinics in New
York, Philadelphia and Baltimore. Go from the
left side to the right side of the graph, and look
at the kind of crime that’s committed. In the
New York City clinics, and Philadelphia and
Baltimore, all the way to the left, in the yellow
color, that’s theft. The blue is drug business.
Green is organized crime. And then to the far
right is organized crime, but look at violent
crime, all the way to the right. In New York
programs, 1.1% of untreated heroin users would
commit violent crime: in Philadelphia, 1.6%; in
Baltimore, .7%. The reason I show this slide is
to remind you that the untreated heroin user
commits crime to support an illicit addiction.
They are not looking to harm people. I’m not
forgiving the fact that crime is committed. I’m
just trying to demonstrate the kind of crime that
is committed. These are people who are sick,
these are people who have a disease; these are
human beings who need access to treatment;
they are not criminals; they should not be put in
jail. They should be treated. And as you saw
from one of the earlier graphs, it’s also less
expensive.
To bring you back to the 1970’s—and I show
you this as a piece of history in the United
States—this slide was developed by Drs. Doyle,
Dejolais and Joseph. Between 1971 and 1973,
19,900 untreated heroin users entered
methadone treatment in New York City. This is
the largest single expansion of any methadone
system in the country. It never happened again.
In one city, 20,000 people enter methadone
treatment during a 24 month period. Look at
what happens in the same period of time:
decreases in complaints to the police
department for burglary; robbery and grand
larceny decreased by 77,000. So, 20,000 people
enter methadone treatment, and there are
77,000 fewer complaints of burglary in the same
24 month period. In terms of drug arrests, you
see 25,000 fewer drug arrests. This means that
fewer police are chasing after untreated heroin
users. This means that courts are not filled with
this kind of case. This means that police are able
to do other kinds of work rather than lock up
people because they’re buying heroin illegally on
the streets. This saves taxpayers all the money
you saw in the first graph. This is part of the
cost of untreated addiction and $45,000. This is
part of that cost.
Now, this is also before HIV infection and AIDS.
It’s the same period: 1971-1973, New York. But
as those 20,000 entered treatment, you see a
reduction of contagious serum hepatitis by
1,500 cases. The reason methadone
maintenance treatment became much more
supported by public health officials in the United
States is because of HIV infection and AIDS.
This is from New York State Department of
Health, 1996. Compare New York City with the
rest of the United States, looking at only one
reason of transmission for AIDS through
intravenous drug use. In New York City, 45% of
people with AIDS get it as a result of untreated
intravenous drug use. If you look throughout the
United States, 25% of people with AIDS get that
AIDS as a result of untreated intravenous drug
use. Treating AIDS is extremely expensive to
say nothing of the human torment that people
with AIDS go through. You can prevent this by
getting into methadone treatment, as I will
demonstrate in the subsequent slides.
This was in 1989-1990: HIV seropositivity
among new and established methadone
maintenance treatment patients. For those
people who had been newly admitted to
methadone treatment, you had 45% of the
patients entering treatment who were HIV
positive. Compare that to patients who were
already in methadone treatment, who had not
been exposed to HIV infection. Look at the
difference. It’s 27.2%, a major difference. This
is another value to methadone treatment. Not
only is it less expensive than untreated, not only
does it reduce crime, but it reduces AIDS and
HIV infection. If you look at the effect of
methadone treatment on HIV positivity rates in
a different way, you see the value of keeping a
patient in treatment. In the first bar to the left,
the person who’s not in treatment is 47% HIV
positive. If you’re currently in treatment but
were not infected at the time of entering
treatment, the percentage drops to 23%. If
you’ve been in methadone maintenance
treatment for five years, the percentage drops
to 17%. If you’ve been in treatment without
needle use, the percentage of HIV infection
drops to 12%. And if you’ve been in treatment
for five years or more without needle use, the
percentage of HIV infection drops to 6%. Once
again, this demonstrates the value of retention
and treatment as opposed to discharging the
patient. As the patient remains in treatment, you
continue to see the benefit.
This slide is related to methadone dose. Most
patients do well with between 80 and 100 mg of
methadone. It is true that some patients will do
well on lower dosages, but on average, the
patient should be receiving a dosage between
80-100 mg per day. Look at the frequency of
heroin use and methadone dose. You will notice
that the percentage of patients using
intravenous heroin decreases steadily as the
dose of methadone increases. Ultimately, the
most effective dosage range, as you will see, is
above 70 mg. So, for all programs, it’s
instructive to remember this lesson. There are a
number of programs in the United States that
have used 50 and 60 mg for the majority of
their patients. These patients are not getting the
appropriate dosage of methadone. As a result,
these patients are using heroin, cocaine,
continuing to drink and are using other drugs as
well. The most basic issue for methadone is its
effective pharmacology. Methadone is effective
at the appropriate dosage level, and will
extinguish the use of heroin as this slide
demonstrates.
This shows, in another way, as the patient
enters and stays in methadone treatment, how
the patient’s use of heroin steadily decreases.
This also comes from the John Ball study. And I
would argue that if the programs in this study
used 80-100 mg of methadone, you would see a
much sharper decline in the number of people
using heroin. This slide demonstrates that
beyond treating heroin, we’re also treating an
extremely complex disease. This shows the
lifetime and recent prevalence of psychiatric
symptoms among the patients in the John Ball
Study. Just look at the first two lines. The
incidents’ prevalence of serious depression and
serious anxiety among the people in treatment:
48% of the patients have a lifetime prevalence
of serious depression and 51% have a lifetime
prevalence of serious anxiety. So, while you’re
treating heroin, you’re also treating other
diseases as well. And a major component of
methadone treatment has to be counseling,
individual counseling and group counseling,
because after the patient is stabilized on a dose
of methadone, you must deal with the fact that
so many of the patients have underlying
problems of mental health. I don’t know if this is
the case also in Mexico, but I would assume that
the cultures are not that dissimilar. Because this
is also the case in Switzerland, in Italy, in
Australia, in England and in France.
This study that was conducted in the early
1990’s, with Dr. Thomas McLellan and his
associates. Dr. McLellan wanted to study the
different levels of methadone maintenance
treatment. How much treatment should you give
a patient? And how valuable will it be? What’s
the difference? There were three different
patient groups in the study. In minimum
methadone maintenance, you have a minimum
daily dose of 60 mg per day, but no regular
counseling and no extra service. In the standard
methadone service, which is mostly the kind of
methadone treatment that’s provided in the
United States, you have a minimum daily dose
of 60 mg plus regular counseling but no
additional service. In the last study group,
enhanced methadone treatment, you have the
same dose of 60 mg but regular counseling, on-site
medical and psychiatric care, family therapy
and employment counseling. Which means this
is a very comprehensive treatment. It’s also
more expensive. The first group, it’s about
$1,500 per patient per year. The second group
is about $4,500 per patient per year. The third
group is about $7,500 per patient, per year. So,
the more treatment is, the more it costs.
Look at the number of patients who actually
seek additional care when they’re in the
methadone program. Remember there are three
different study groups. They’re all at the same
dosage level, everyone of them. Some people
improperly suggest that the patient will not
access treatment services, even if it’s given to
them. This slide shows that’s not true. If you
look at other drug use, family care and
psychiatric care, when those services are
provided to the patients, the patients will use
the care. This slide demonstrates this.
This slide, from the same study, also shows the
difference in the use of opiates. What’s most
interesting about this slide however, is that
while you see a difference in how the patient is
responding, the top group is showing a very
high use of heroin. Fifty to sixty percent of the
patients are using heroin while they’re on their
dose of 60 mg of methadone. In the middle
group, the standard, they’re using a little less
heroin. But it’s still there. And in the lower
group, which is the enhanced methadone
treatment in yellow, you have the least amount
of heroin being used. Why is this slide
interesting? Because all groups are maintained
on the same dose of 60 mg. So, even though
opiate addiction is a brain disease, it also
responds to behavioral changes, too. If you
provide the patient with adequate counseling,
adequate medical care, adequate services to
respond to their needs, psychiatric, comordibity,
in addition to the other medical problems of HIV
infection and AIDS, what you have are patients
doing better in the methadone treatment
programs.
This comes from Dr. Vincent Doyle who is the
co-founder of methadone maintenance
treatment with his wife, Dr. Marie Neiswander.
And I’m going to read the statement for you.
“The problem was one of rehabilitating people
with a very complicated mixture of social
problems on top of a specific medical problem,
and that practitioners ought to tailor their
programs to the kind of problems they were
dealing with.” The strength of the early
programs, as designed by Marie Neiswander was
their sensitivity to individual human problems.
What I have demonstrated in the slides is that
you cannot treat a complicated disease just with
simple solutions like a dose of methadone alone.
This slide comes from Dr. Ball and Ross and his
associates. They found that the program
characteristics that were associated with success
in methadone treatment are the ones listed
here. If the programs provide comprehensive
services the patients get better. If the programs
have integrated medical, counseling and
administrative services, once again, the patient’s
health will improve. If the patient’s getting
individualized care where the staff of the
treatment facility responds to the patient, the
patient gets better. If the clinic has adequate
dosing policies, the patient will get better. If
there is sufficient and stable staff, patients will
get better. If there is sufficient staff training, the
patients will get a better quality of care and will
ultimately improve.
This is the staffing pattern that’s used in the
United States for most of the treatment
programs. Nurses comprise 27%, physicians
13%, and counselors and social workers make
up the majority. Look at this for a few minutes.
It demonstrates the relapse to heroin use at the
end of methadone maintenance treatment.
Eighty-two percent of people on methadone will
relapse to using heroin within 12 months of
ending methadone maintenance treatment.
82%. This has been replicated mostly in
Switzerland, in Hong Kong and in Australia. This
is a geo-political and national and international
problem. What you have here is the same thing
replicated in other countries. What this
demonstrates is as the patient enters and
remains in treatment, it’s best to leave them in
treatment.
Next, we need to educate the public about
methadone. In spite of what I have just shown
you, most people don’t support methadone
maintenance treatment. I understand that
there’s even a medical society in Mexico—psychiatrists—that don’t support methadone
treatment.
This is not philosophy. This is medicine. This is
medicine treating a disease the way doctors
treat heart disease. Or the way doctors treat
diabetes. So, why is it that we get into a debate
about how to treat heroin users? The reason I
suggest to you is because heroin use is not seen
as a disease by most people in the public. The
people who use heroin are seen as criminals.
They are seen as very strange human beings
that may not be seen as human at all. It’s seen
as a criminal problem, and that people should
be locked up, rather than treated. So what our
association decided to do, was fund the
development of a brief video tape, which I’m
going to show to you now. It’s the story of
successful methadone patients and their
families. It only lasts seven minutes, and I know
that you will have the text of it interpreted but
this is most instructive for you to understand.
This is going to be our association’s campaign to
educate the public.
This tells you the narrative story. This is the new
kit—with stripes in it. This is designed for the
community, for legislators, for judges. This is
designed for people who know nothing about
methadone maintenance treatment. This kit
goes with this video.
The point of this is to put a human face to
heroin addiction. It’s to demonstrate that
methadone maintenance is a human treatment
and it helps people. The idea is to break down
the barrier that most people have about the
person using heroin, which is pretty similar to
the person who’s using methadone. It’s to break
through the stigma. The value of this is to
remind people who don’t use drugs and have no
understanding of methadone, that the people
that we’re treating are pretty much just like they
are. This video is from the person’s perspective,
not from my perspective as the President of the
Association, not from the perspective of the
research scientists who did the graphs. It’s to
remind people that we’re all in the same boat,
that we’re all dealing with people just like
ourselves. Someone who had seen this tape said
to me, why are you making this so emotional?
My answer was, because a lot of people don’t
want to listen to the science those who take the
point of view that methadone doesn’t work.
This community education kit, this video is a
method of trying to break through a lot of the
cultural barriers. We were told this is the same
in many countries—in European countries and
the same thing happened in Germany. In
Germany, only until the last five to six years did
methadone treatment expand. At the beginning
of the 1990’s, the only way a person using
heroin could get on methadone treatment in
Germany was if the person had HIV infection.
That was the criteria for admission.
Slides are an effective way to explain to
legislators to policy makers, to people who don’t
like methadone treatment, that this is the story
of methadone treatment in facts. This is not
philosophy. Do I think it works? These slides,
this book,—absolutely. What this does is tell
you our associations, policies and positions—about everything I’ve talked about: about
accreditation, about policies for new
medications. This tells you where our
association stands on every major policy
initiative about methadone treatment in the
United States. The community education book
tells you how to educate people in the
community. For those of you who operate
methadone treatment programs in Mexico, for
those of you who are in government positions,
to try and influence other people, you need to
use this kind of community education book
because it tells you a great deal about
methadone maintenance treatment.
You always will have to educate the public. It
never ends. I operated a methadone treatment
program for 15 years in New York City. I always,
every single week, had to educate someone
about methadone maintenance treatment.
Always.
Andrea G. Barthwell, M.D.
President, Encounter Medical Group
United States
Question and Answer Session
I want to make sure we’re all on equal footing
relative to the biological rationale for methadone
therapy, which then sets out the reason for the
chronic care of a patient who needs methadone
replacement therapy in a medical context. We,
at this point in the United States have very few
people receiving office-based opioid therapy in
the doctor’s office, and there is no established
rate for that. Some physicians who are doing it
provide self-payment option for those patients
receiving it in that way. And if they are seeing
the patient once a month with the standard cost
of a medical visit and the patient’s insurance is
picking up the cost of the methadone, it would
be expected to average between $40-60 or $80
a month. In the least funded publicly funded
clinics, clinics receive anywhere from $38 to up
to $80 per week for services, and that would be
chronic and lifelong. In those settings where
patients, or clinics, are subsidized to provide the
care, patients might pay on a sliding fee scale
anywhere between $1 and $50 a week in
addition to what the clinic gets. And clearly, the
larger the clinic, the lower you can get your
costs. One of the things that artificially inflates
the cost in the clinic is an arbitrary
determination of the kinds of services that
people receive. So the cost of providing care to
individuals who need less group therapy is
transferred over to providing care to those
individuals who need more. We have an average
cost that the clinic receives. For some patients it
takes more money to treat, some patients less.
Q. Who is going to continue to pay for clients’
methadone treatment?
A. I want to comment that the necessity for
that level of treatment with daily medical visits,
daily psychiatric visits and so forth, drops down
dramatically as people are restored to more
normal functions. And, we have to consider that
the treatment in an ideal or perfect world would
be phased. And phasing of treatment early on
would provide more intensive support and
structure. But as the person is normalized and
cured of the addictive behaviors while on
methadone, the need for those supportive
services could conceivably drop off. The person
could begin to engage in therapeutic activities in
a self-directed way where they’re going to 12-
step meetings and they don’t have to have a
therapist encouraging or supporting their
participation in that. They’re doing that on a
voluntary basis, in the same way that long-term
recovered and recovering alcoholics continue to
go to their 12-step meetings to support their
continued growth and change across their life.
So, I appreciate your question about who’s
going to pay for this, and what does it cost long-term,
looking at a cost of $40 per week every
week for the rest of your life seems like a
difficult proposition. And we really need to
encourage the development of other ways of
delivering the medication when the medication
replacement therapy is all that’s needed and
developing phases to allow for that.
Q: My question to you doctor is, earlier we
heard that there’s a rising number of
adolescents using heroin, and in fact it is so
immense of a problem that the average heroin
user now, I believe, is 16 or so? And so that
really presents a whole different treatment, a
whole milieu of different treatment strategies
because it seems that up until this point we’ve
been talking about dealing with heroin addicts in
terms of adults. This really changes a lot. I’d be
interested in any comments that you may have
in terms of dealing with adolescent heroin
addicts in the future.
A: The adolescent drug user who is using
heroin is more typically using it within a pattern
of poly-substance abuse and using it within a
pattern of emotional behavioral problems that
are not necessarily specifically drug addiction.
We know from all of the studies of the onset of
this disorder, it is more likely to be a primary
disease without greater underlying psycho-pathology
if the age of onset is delayed. When
we see individuals who start with early drug
involvement, their drug involvement is a part of
a complex of psycho-behavioral problems, and it
is more likely to be a symptom of a greater
underlying problem than when you see onset of
addiction in an adult. So you cannot talk about
adolescent drug abuse in the same way that you
talk about adult, or adolescent addiction in the
same way that you talk about adult addiction.
The earlier the age of onset, the more likely you
are going to find psycho-behavioral problems
underlying that disorder and that behavior.
Your treatments therefore cannot be as directed
at the primary disorder as they are in the adult,
and they have to take in to account the
developmental stages of the adolescent and be
appropriate to that adolescent’s developmental
stage. They also have to take into account
whether another psycho-behavioral disorder
exists along with the addiction, where you’re
more likely to be dealing with dual diagnosis or
if the addiction is one of the criteria for a
greater psychological disorder. And that’s one of
the ways in which that psychological disorder is
being expressed in the adolescent. So, you’re
not going to be able to treat it as simply, with a
biological intervention, as you are adult
addiction. And again, we’re going to have to
encourage treatments directed at the psycho-behavioral
disorders for the adolescent and less
focused on the biological. The adolescent may
need the biological support if repeated
treatments fail to turn their behavior around.
But the adult is going to be more easily
responsive to a biological support, a
replacement therapy, when placed on a platform
of talk therapy. In the adolescent, the platform
of talk therapy is going to be critical to have
established and you may or may not be able to
treat them without the biological therapy.
I had a question yesterday about other medical
conditions and the management of this disorder
in hospitalized patients, pregnant patients and
patients with pain.
This set of slides was developed by this group of
people – Dr. Flowers, from Wisconsin, Dr.
Maxwell from Chicago, and Dr. Samosa from
Ohio. They came together and developed this
workshop for the Addiction Technology Transfer
Center that’s funded by SAMHSA through CSAT
which exists in the Chicago area. The Great
Lakes Addiction Technology Transfer Center.
These slides will be available to you online
through the CSAT Web site by the end of the
summer for individuals who would want to use
them in presentations. We have developed this
lecture, and I’m giving you an abbreviated
version of it, for use in the hospital setting for a
medical grand rounds. It can be delivered in less
than an hour, allowing time for questions and
answers. I’m using it because it illustrates some
of those points you discussed yesterday.
We start out by making the point that addiction
is a chronic disease of the brain. It’s a primary,
chronic disease with genetic, psycho-social, and
environmental factors that influence its
development and manifestation. And again,
across the life cycle, each of those aspects may
weigh in more than another depending upon the
age of initiation and the person’s basic condition
when they make their first contact with the
chemical. The disease is often progressive and it
is fatal. When you look at addiction you don’t
diagnose it by the nature of the drug. It matters
not what drug is being used, addiction is not
diagnosed by physical dependence alone. Clearly
methadone addresses the physical dependence.
I said that because it’s a drug to which the
addict is cross-tolerant, it blocks the withdrawal
syndrome and the withdrawal syndrome is the
external evidence, that physical dependence has
occurred. Physical dependence can be defined
as one having an experience of adverse physical
consequences when drug use stops. So it’s a
cyclical kind of definition. You know it exists
because when you’re not using, you’re sick. And
when you’re sick and you can relieve that by
using again, you know it exists.
It is also not diagnosed by the dosage, how
much the person is taking, how often they take
it, or how long they’ve been taking it.
Individuals have different characteristics to their
dependence. So it’s much broader than what
was taken, how often, and how much. Addiction
is similar to other chronic diseases. It has
features in common with insulin dependent
diabetes mellitus. It has features in common
with hypertension. It has features in common
with coronary artery disease. Those features
include that there is both a biology and an
environmental contribution to its cause. People
who are genetically predisposed to coronary
artery disease can have the chance that genetic
predisposition will become expressed if they
grow up in an impoverished area and eat
inferior food that’s high in fat content. People
can have a genetic predisposition to insulin-dependent
diabetes mellitus that may never get
expressed if they have grown up in an
environment where exercise is valued and they
exercise and maintain a very slim figure
throughout their life. So biology and
environment contribute to the disease.
Chronic diseases often have a poor response to
behavior interventions alone. Have you ever
tried to treat a diabetic with diet alone and seen
how unsuccessful you are? Chronic disorders
typically require both biological and behavioral
interventions in order to get a more idea
management of them. Pharmacological
management is usually necessary for the control
of high blood pressure. Someone can make a
decision that they’re going to eliminate stress,
change their diet, workout and do a number of
things. Reduce the salt in their diet to help bring
their blood pressure within a normal range. But
even with a strict adherence to a behavioral
management program, some individuals will not
get their high blood pressure under complete
control and will have to have that behavioral
program supplemented with a biologically
directed program, pharmacological management
in other words.
The chronic course of these diseases is
characterized by remissions, where the disease
gets worse or it appears to be worse with an
aggressive deterioration over time. All of those
things characterize chronic medical conditions
and characterize addictions, particularly opiate
addiction. But addiction is different from other
chronic diseases because there’s a stigma
attached to it. The behaviors which support
getting the drugs are criminalized so that the
disease is put in a criminal context. And over
time we have had very limited pharmacological
interventions available to us. There is not a lot
of incentive for the pharmaceutical industry to
develop treatments for these disorders. And
when we have had pharmacological treatments
developed, there has been a lot of
misunderstanding and misinterpretation of
them. For example, methadone.
There are over 900 peer reviewed publications
over the last 30 years which talk about the
safety and efficacy of methadone. There are
only 237 about the oral hypoglycemic, and there
are only about 426 about a drug for an
antidepressant; yet there is generally more
public acceptance of these other drugs. We look
at the evidence on these other drugs and accept
that they are an important component that
physicians can use in the managing high blood
sugar, depression, and other mood disorders.
The number of studies which support the safety
and efficacy of them are small and insignificant
in comparison to the literature and the data
available in high quality, peer reviewed journals
about methadone. Yet, we find methadone not
achieving the same level of acceptability as
Prozac. Within 6 months of Prozac’s being
released for use by physicians of a specialized
nature, many general practitioners were using it
readily in their personal practices. And patients
were going to their physicians asking for the
drug for a variety of things for which it hadn’t
been approved, including weight control.
On the other hand, we see no outpouring of
support or adoption of this medication,
methadone, for a variety of reasons that we’ve
been struggling with over the last two days.
Empirical studies have proven that methadone is
effective. More than 900 studies over more than
30 years document that methadone is effective
in the treatment of heroin addiction, and they
prove that methadone is extremely safe. No
organ pathology has ever been associated with
either acute or chronic methadone treatment.
There are more deaths annually from the use of
non-steroidal anti-inflammatory drugs than from
illegal drug use. Yet, when you hear methadone
discussed, you hear a lot of concern about
methadone overdose and methadone deaths.
And they typically have nothing to do with the
fact that the person was on methadone. In fact,
methadone has been life-sustaining and life-giving
to more people than not.
We do know that methadone is not safe for non-addicts,
just as insulin is not safe for non-diabetes.
Individuals should not take a
medication for which they don’t have a medical
disorder. There will be some problem with safety
in that instance. Empirical studies have proven
that methadone is life prolonging, and I think
I’m not going to dwell on this because Mark
dealt with that. But, you can see that for
individuals in methadone maintenance
treatment, the ratio of observed deaths to
expected, based upon the patient population is
8.4. For those who are not in treatment, the
death rate ratio of observed to expected is
seven times that. For those who are
involuntarily discharged from treatment, it’s
about six times that. It’s surprising to see how
much of the administrative policy governing the
treatment of narcotics addicts has been based
upon theoretical opinions, political pressures and
wishful thinking. And there’s a tremendous body
of scientific evidence that we have accumulated
over the last 33 years.
Some people are concerned about providing
methadone because they think they’re going to
create addicts by giving them methadone.
Remember, we said yesterday that methadone
works because the heroin addict is cross-dependent to it. It therefore maintains the
underlying dependence on heroin but it
suppresses all the other behavioral effects that
an untreated heroin addict would present with.
And the incidents of iatric, iatrogenic, meaning
physician-caused opioide addiction is clinically
insignificant. We just do not see people
becoming heroin addicts because someone
treated their heroin addiction with methadone.
We are careful in our review of who needs to go
on methadone, as Mark pointed out. And
typically people have had multiple failures at
other forms of treatment before we will initiate
methadone. Methadone treatment is a sound
medical practice. For individuals who are
admitted to the hospital with an untreated
heroin addiction, it can ensure a continuation of
the medical-surgical stay. Without treatment,
the individual will experience withdrawal and
leave treatment prematurely. It decreases the
physiological stress on the patient who’s
presenting for another medical condition. It
ensures that the management, the staff will
have fewer management problems with a
patient. If the person is in the hospital
experiencing heroin withdrawal, they are going
to push the nurses’ buttons regularly and
frequently, trying to get some relief from
withdrawal. And it increases patient compliance
with prescribed medication regimens during the
hospital stay and afterwards because the person
isn’t having their life interfered with because
they need to go get heroin to relieve
withdrawal.
We recommend that when patients present to
physicians for medical care, that the physician
continue existing methadone maintenance if a
person is in a program. What we find frequently,
however, is that when patients get admitted to
the hospital, the admitting physician, who may
not be knowledgeable about methadone, will try
and do us a favor by reducing or eliminating
that person’s dependence upon methadone. And
they’ll seize the opportunity of the patient being
in the hospital to reduce or eliminate their dose
for us. And while the person may be able to
tolerate a reduction in dose while they’re in the
hospital and not in that complex environment
where they use their heroin, as soon as they
return to the street, they’ll resume heroin use.
What we try to teach people about individuals
on methadone, is that when patients present in
medical settings they don’t routinely report an
inflated methadone dose. They tell their
hospital-based doctor what they’re getting at the
clinic. They don’t increase their dose. Unless
they’re receiving treatment in a clinic that uses
inadequate methadone doses. We advise the
physician to call the clinic to coordinate care and
follow-up. But we also recommend that for
treating physicians, or if you’re going to work
with a patient who’s in your clinic to get them
hospitalized, that you advise the admitting
physician to maybe increase their dose by up to
20% to cover them during the hospital stay
because, there are additional stressors on our
patients when they get admitted to the hospital.
So, if I have someone on 100 mg, when they
present to the hospital, if I have a chance to
work with the doctor before them going in, I’ll
ask the doctor to cover them with 120 mg while
they’re there to cover the additional stress. To
allow them to be adequately covered from
what’s associated with being in the hospital, the
fear, the anxiety, the pain, the personal
intrusions that occur when a person is
hospitalized.
If a person presents to a medical care with
heroin addiction who is not on methadone, we
recommend that methadone replacement be
initiated. And our clinics make ourselves readily
available to our hospital system to admit those
patients at discharge. We have found that the
reluctance among physicians to treat with
methadone while the patient is in the hospital
can be reduced or eliminated if the physician
knows that the patient can enter a clinic when
being discharged. Otherwise, they feel kind of
like they have been put on the spot by the
patient’s addiction, and they feel helpless in
terms of managing it long-term. So, we make
ourselves available to them.
Methadone in that setting is prescribed not as a
definitive addiction treatment because again, we
want the other services to be provided to the
person, but as an acute replacement to the
heroin which is lost to the patient upon being
admitted to the hospital. Opioide withdrawal
syndrome will not increase the chance of
abstinence after discharge, so by letting
somebody go through withdrawal in the
hospital, they’re not more likely not to return to
heroin once they’ve been discharged. And a
person having a good experience with
replacement therapy while in the hospital may
seek treatment for their heroin addiction after
they’re discharged. We want people to know
that there is no medical indication to withdraw
methadone in the hospital setting.
In our country we have some Federal
regulations and there is a quote out of the
regulation which states, “This section is not
intended to impose any limitations on a
physician or authorize hospital staff to
administer or dispense narcotic drugs in a
hospital, to maintain or detoxify a person as an
incidental adjunct to medical or surgical
treatment of conditions other than addiction.”
While we have a Federal regulation that keeps
us from treating addiction with a narcotic drug,
except under a methadone program sponsor,
that regulation does not keep the physician from
treating an addiction, as long as the finding of
addiction is incident to admission to a hospital
for another reason. So, in order to complete
treatment for the primary reason for which the
person’s admitted to the hospital, if you have to
provide methadone under that situation, you
can. There’s nothing in the law that keeps you
from doing that.
Now, in order to treat this disease, you have to
recognize opioide addiction is a disease and
have to understand that patients don’t always
volunteer that they’re heroin dependent or on
methadone. Patients have to be asked
specifically. But they don’t generally give a false
report of being addicted to heroin if they’re not.
So people won’t tell you I’m a heroin addict just
to get methadone from you in the hospital. We
have found no incidents of that. But how you
ask the patient as to whether they’re an addict
or not will certainly influence how they respond.
So, if the question sounds like “You don’t use
drugs do you?” You don’t encourage the patient
to report it appropriately. You need to say, “In
my experience, when treating people with
hepatitis C, there is a chance that they have
used heroin in the past, or are currently using
heroin. I see this enough in my practice to know
that this happens, and we’ve developed a way
of helping the person deal with their heroin
addiction while they’re in the hospital for their
hepatitis C. And we use methadone to treat that
while you’re in the hospital. So tell me, are you
currently using heroin, and how much? Are you
on a methadone program? Have you ever been
on a methadone program? When you were on
methadone in the past, what was your dose?”
So, asking the questions in a way that
communicates to the patient that you’re
concerned about them, and that you have some
solutions for the problems that they’re going to
face. Some familiarity with those problems,
encourages the patient to disclose.
In order to initiate methadone for someone
who’s not on it, you have to assess the degree
of opioide dependence. And I never, ever
recommend that you do a narcane challenge
test in order to determine how addicted the
person is. What you will do in a narcane
challenge test is precipitate withdrawal in the
heroin dependent person and make them very
sick, and rupture the therapeutic relationship
you’re trying to establish. So I encourage you to
use the clinical history and understand that
using $10 worth of heroin is approximately
equivalent to 10 mg of methadone. You can go
up to 30 mg for the initial dose, and add 10 mg
every four hours until the person is comfortable.
And at the end of the first 24 hours, add up how
much you’ve given and you’ve established the
daily dose that will be required.
You want to look for signs and symptoms of
withdrawal. We’ve talked about them yesterday
and they’re on your handout. And also look for
signs and symptoms of intoxication. If you see
signs and symptoms of withdrawal, the patient
needs more. If you see signs and symptoms of
intoxication, you can stop increasing the dose.
And administer the dose that it took to get to
that point the next day.
Understand that if, at a very low dose, you can
eliminate the objective signs of withdrawal. At a
low dose, you may eliminate subjective
symptoms of withdrawal. Remember grade 0
compared to grade 1 through 4 from yesterday.
And you want to exceed both the very low and
the low dose and get them into a therapeutic
range where there are no signs of symptoms of
withdraw or intoxication, and the patient reports
being comfortable. You cannot base where you
stop dosing on what you see alone. The patient
has to report being comfortable. If the patient
continues to report not being comfortable but
they’re exhibiting signs of intoxication, you’ll
want to watch them.
Now the pain management. Often you will see
people who are on a methadone program and
they’ll go into the hospital for surgery and they’ll
have post-operative pain. And the doctor will
say well, they’re on methadone. That should be
taking care of their pain. So the one take home
message for you here is that the maintenance
dose from a methadone program does not
provide any analgesia. In order to get analgesia,
you have to add to the maintenance dose a
short acting opioide. Something that you’re
going to give every 3-6 hours for pain. Now,
when the person is on an opioide blockade dose
of methadone, it’s going to create a higher dose
requirement for the medication that you give
them for pain. So if you were someone that I
was going to give 100 mg of Demerol to, I’d
have to give you 125 mg in order to bring about
adequate pain relief. So the rule of thumb is a
25% higher dose. If I were going to give you
Demerol every 4 hours for pain, I have to give it
in shorter intervals, 25% shorter interval, so I’d
start to give it to you every 3 hours. So if a
standard dose is 100 mg every four hours for
pain, in the individual on methadone
maintenance, I want to give 125 mg every 3
hours for pain. A 25% higher dose with a 25%
smaller interval. And I also want to review the
nursing notes as to the person’s level of comfort
from pain following the dose and at the end of
that interval because I might have to shorten it
even more. I might have to increase the dosage
even more. I also want to see whether I’m
getting significant sedation. Because if I’m
getting significant sedation, I might want to
back off on the dose or back off on the interval.
And lengthen the interval.
Never, ever use the mix antagonist agonist, or
an antagonist for pain relief. You will precipitate
withdrawal with mixed agonis antagonist. And a
patient controlled analgesia is extremely
appropriate in the population. Since the person
has a greater tolerance for and a greater need
for pain relief, something that they can manage
themselves, by pushing the button and
delivering the dose will reduce the management
problems associated with inadequate relief in
the population. And if your patient controlled
analgesia is turned off at 10 mg every four
hours you want to set it at a 25% higher ceiling,
understanding that the patient will require more.
Sometimes physicians and nurse practitioners
and other health professionals will see a person
who is addicted and mis-attribute inadequately
treated pain as addiction. This pseudo addiction
is an iatrogenically caused disorder. Physicians
and nurse practitioners who write inadequate
pain management regimens bring this disease
about. It’s caused by the poor management of
acute pain in addicted and non-addicted
populations. And it’s characterized by a drug-seeking
behavior exhibited on the part of the
patient. The patient is pushing the nursing
button at shorter and shorter intervals, asking
for more and more pain relief. And it gets
labeled as drug-seeking behavior, which it is.
They’re seeking adequate medication to relieve
pain. So it’s medication-seeking behavior that
gets mislabeled as drug-seeking behavior. And it
results in a terrible, terrible misunderstanding
between the patient and the physician, or the
healthcare provider and the patient. That person
misperceives the patient as an addict and the
patient misperceives their healthcare provider as
uncaring. So it needs to be diagnosed where it
exists.
Pregnancy: I said yesterday that opioid
withdrawal is not life-threatening to the adult. It
is life-threatening to the fetus. Fetal withdrawal
is well-established before the mother becomes
symptomatic. Before the mother feels
withdrawal, the fetus is in withdrawal. And the
fetus is suffering from withdrawal before the
mother knows that she’s in withdrawal. Opiates
are extremely benign to fetal tissue when given
in a way that is supportive in a medical
environment. There are no known terradigenic
effects of opioide like drugs. Opium, heroin and
methadone are not known to cause birth
defects. We see negative outcomes from
pregnancy in the heroin addict because of
repeated withdrawal for the fetus and because
of the lifestyle associated with heroin using. But
all of that can be normalized by putting the
mother on an adequate dose of methadone
throughout her pregnancy. What we see in
terms of the neo-natal withdrawal once the child
has been delivered has no known direct
relationship to the dose of methadone that the
mother required to maintain her during the
pregnancy. So you may have a mother who’s on
10 mg of methadone whose child experiences
some neo-natal withdrawal. You may have
another on 80 mg whose child does not
demonstrate any visible neo-natal withdrawal.
We do not establish the dose for the mother
based upon what we predict the child will
experience. We provide the dose to the mother
based upon what the mother needs in order to
achieve the goals of methadone maintenance
during the pregnancy, which is to eliminate the
target symptom, heroin use. If we put the
mother on too low a dose of methadone,
thinking we’re doing the child a favor, we will
see continued heroin use on the part of the
mother, continued fetal withdrawal, continued
risk of infection, continued premature rupture of
the membranes, continued early delivery and all
of the other complications associated with
heroin use during pregnancy.
Multiple dependencies: Methadone does not
cover withdrawal from alcohol or sedative
hypnotics. So additional treatment will be
necessary. If you have a person who is
dependent upon heroin and valium and alcohol
and cocaine, and you start them on methadone,
it will address the heroin addiction, but not the
other dependencies. Remember in that setting
that if they stop the valium and the alcohol, it
poses a life-threatening withdrawal risk to the
adult. You are obligated to treat and address the
sedative withdrawal and the alcohol withdrawal
with medication assisted detoxification. It would
be recommended in that instance to sequence
the coming off of the alcohol and the sedative
hypnotics with a taper of benzyoldiazepines, and
a maintenance dose of methadone. If your goal
is to detox from all drugs, you don’t have
someone who is a candidate for methadone
maintenance, for example, you withdraw from
the benzylodiazepines, and then withdraw from
the methadone. Otherwise, you withdraw from
the benzylodiazepines and leave the methadone
dose unchanged and initiate psycho-social
therapies to address the cocaine, alcohol and
Valium dependence.
Frequently in a methadone program you’ll see
individuals whose heroin use stops and their use
of alcohol or sedatives or cocaine continues, or
they initiate on methadone. Those individuals
again will require psycho-social therapies to
address their other dependencies. Methadone
cannot be held responsible for stopping those
other dependencies. It is very specific
biologically to the receptors that respond to
heroin.
Drug interactions: Certain medications that will
be prescribed by the patient’s physician can
lower the methadone level in the blood, creating
for the patient a crisis of methadone withdrawal.
And if it is not anticipated and then addressed,
the individual may resume heroin taking to self-medicate
the withdrawal they’re experiencing.
We recommend that if there is a choice that can
be made for another medication, that that
medication be selected. Avoid those medications
that lower the methadone dose unless they are
medically necessary. And if they are, if there’s
not a good alternative medication to use in the
population, the fact that the person is going on
these medications be anticipated and the
physician putting this patient on those
medications coordinate with the methadone
prescriber, to have the methadone dose
increased in response to it, as needed. There
are also medications that can raise the
methadone level, and the patient may complain
of sedation after these medications are started.
If it is going to be transient, the person may
accommodate to the increased effective dose.
And you may leave them alone. You may want
to reduce it and when they stop taking these
other medications, make sure that you increase
their methadone level again. But again, you
raise or lower the methadone level as needed,
based upon both your physical findings and the
patients’ subjective reports of comfort.
If methadone is initiated when the patient is in
the hospital or continued when they’re in the
hospital, we recommend that a simple phone
call to the clinic will do when the person’s
admitted to verify the dose and to let the clinic
know that the person won’t be showing up there
for the next few days. And then on the day of
discharge, call the clinic to let them know what
the last dose was and when it was administered.
If you’ve increased the dose during the hospital
stay from 100 to 120 mg. you’ll want to inform
the clinic that the person will probably be
comfortable back at 100 but that they should
watch them in the event that their body has
adjusted to the increased dose, depending upon
how long the increased dose was in place. If the
person wasn’t at a clinic at the point where they
were admitted to the hospital, you look for a
clinic to transfer them to if the patient has
agreed to that. But if the clinic cannot take the
patient immediately and they’re saying we need
three days to run them through the admission
process, in the United States methadone can be
continued up to three days after discharge
where it is dispensed daily at the hospital. They
cannot be given medication to cover them for
three days. They have to go back to the hospital
every day for three days.
What are the take home messages? That
addiction is a brain disease. That over 900
studies over 30 years have shown that
methadone works. Withdrawing someone from
methadone when they go into another medical
setting is bad medicine. And withdrawing
someone from methadone when they go to jail
is bad medicine. There is no indication to
withdraw the person from the medication in the
same way that there is no indication to withdraw
someone from insulin when they become insulin
dependent. When you see a stable person on
methadone, there is no indication to withdraw
the methadone. You are doing them no favor.
You have to understand that they’re stable
because they’re on methadone. When you see a
stable diabetic on insulin, you don’t think to
discontinue the insulin. You’re not doing them
any favor and you will precipitate a crisis in their
life. Likewise, you will precipitate a crisis in the
person’s life who is stable on a dose of
methadone.
Methadone maintenance is separate from pain
management. The methadone dose that they’re
taking on a daily basis is addressing the
addiction. The pain management has to be
addressed separately. There are no real legal
barriers to the proper care of the heroin addict
within the medical context. There should be no
real legal barriers to the proper care of heroin
addiction in the prison context. People don’t go
from needing this medication on one day for its
life-sustaining, life-giving and life-restoring
properties, to not needing it the next day just
because their life situation changed.
Dr. Parrino: With that, there are several pieces
of information that both of us have not covered
yet. First, to follow on some of Dr. Barthwell’s
remarks. The importance of treating the patient
who’s pregnant and treating the patient properly
is truly important. I’ll give you one example
when I was an administrative director of a clinic
in New York. It was on a Friday afternoon, at
about 3:00. Our admissions were closed for the
day. The clinical supervisor of the facility
approached me and said, “We have a 41 year
old woman who has just seen the doctor and
she has found that she is six months pregnant.
She has just been withdrawn from methadone
from another methadone treatment program.
We believe that it is important to admit her
immediately and try to restore her methadone
dose.” Obviously we were concerned about the
mother and the fetus. We admitted the patient.
We tried to increase her dose over the course of
the weekend, and I called the administrator of
the clinic that the patient had been maintained
on and inquired why this patient had been
withdrawn. The answer was, first, they did not
know she was pregnant. Secondly, she was an
alcoholic and she refused treatment for alcohol.
I explained that the patient had been pregnant
more than 6 months, which was determined
through medical exam. Unfortunately, within five
days, the patient had a spontaneous abortion
and the child was lost. So, what Dr. Barthwell
presented to you is not only critical, but it’s
critical to the child that you don’t see.
Ultimately, everything that we do has been so
carefully studied, that we’re giving you the
benefit of these 30 years of research and
information. In terms of prison facilities, it’s
unfortunate that the only prison system in the
United States that dispenses methadone, is
Rikers Island in New York City. Our association
has tried to work to increase access to
methadone treatment in prison systems
throughout the United States. But, most prison
officials simply do not want to provide access to
methadone treatment services. Again, the prison
officials take the position that most of society
takes: that methadone is not really a medication
and that the heroin user is not really suffering
with a disease, that the heroin users brought
this disease on themselves. As one warden in a
prison said to me, “He created the disease, let
him suffer without it in jail.” So Rikers Island has
demonstrated there is a significant cost savings
from giving methadone treatment.
We have found through research that for certain
patients, there is an irreversible change in the
brain structure. In the neuro-chemistry. And for
those people, they are going to need a
replacement, pharmaco-therapy as you suggest,
for an indefinite period of time, or for the rest of
their lives. NIDA is still doing research using
some of the new computer temography studies,
and in certain cases you’ll also find that for
different people there may be some reversibility.
It depends on the individual. It depends on the
length of time the person has used heroin. It
depends on the individual’s brain chemistry. Dr.
Barthwell will talk more about that particular
aspect. In terms of other kinds of treatment
intervention, methadone maintenance treatment
is effective. But it’s not necessarily the
treatment of choice for all heroin users. Some
heroin users, again depending on length of time
in treatment, may not need a pharmaco-therapy
like methadone, or even others, like
buprenorphine. Some patients do well with drug
free, in-patient, therapeutic communities. But
we have found that many of the patients who
are in methadone treatment have tried to
discontinue their use of heroin, whether they’ve
been in residential drug-free treatment or
they’ve been through self-help groups. So, the
clear majority of the people on methadone
treatment have tried this already. And have not
succeeded. Ultimately, for most people,
methadone is the last treatment choice – not
the first. So, in this regard we have found that
the replacement pharmaco-therapy is really the
most effective for the majority of the people
because of the length of time using, their
history, and most of those patients have really
tried using and stopping on their own many
times over, even in jail, in psychiatric facilities
and withdrawal wards.
Víctor Manuel Guisa
Centers for Youth Integration (CIJ)
Mexico
Dr Guisa’s presentation focused in the clinical
research for treatment. The psychological,
sociological, and environmental factors related
to drug abuse were emphasized. His
presentation-included discussion of a study
entitled “Imagen del Padre en pacientes
adictos,” (English translation: The Father’s
image of patients with addictions). Research
projects that were suggested included:
- Bicultural aspects in migrant populations
- The impact of drug abuse on children of
addicts
- Drugs and violence
- Drug abuse among adolescents and young
adults
- Effectiveness of drug treatment
- Drug abuse with comorbid conditions
- Clinical research in LAAM and Methadone
treatment
- Vaccines for cocaine addicts
- Epidemiology
In conclusion, Dr Guisa stressed the
effectiveness of treatment of opiate addiction
such as the use of LAAM and methadone. He
underscored the need to incorporate methadone
treatment methods at Centers for Youth
Integration.
Program Accreditation
Stephen Shearer
Health Care Consultant
United States
The topics of the workshop that Mr. Schearer
led included:
- Presenting the benefits of accreditation of
programs by a recognized accreditation
body
- Describing the program accreditation
processes of the Joint Commission and CARF
- Discussing the new CSAT guidelines for
opioid replacement therapy
- Discussing the concepts in the Patient
Rights, Assessment and Care standards of
the Joint Commission
- Question and Answers session
Nora Gallegos
National Council on Addictions
(CONADIC),
Ministry of Health
Mexico
Click to see the slide presentation.
Innovations in the Treatment of Stimulant
Use Disorders
Jeanne Obert
Executive Director
Matrix Institute on Addictions
University of California at Los Angeles
United States
The cocaine epidemic that began in the United
States in the 1980’s and the present widespread
methamphetamine problem have presented
treatment providers with tremendous
challenges. Patients dependent on stimulants
have been particularly unresponsive to
traditional psychosocial treatments and no
effective pharmacologic interventions have been
discovered. The lack of medical necessity for
hospitalization during the withdrawal and the
treatment phases argues against inpatient
treatment as an option. The most effective
interventions presently available to treatment
providers working with stimulant abusers are the
structured, outpatient, psychosocial
interventions. This presentation will present an
overview of those models of psychosocial
treatment that have documented efficacy. One
of the models, the Matrix Model, will be
presented in detail. Participants will be made
aware of specific interventions that have proven
effective for the different stages of recovery
from stimulant dependence.
Click to see the slide presentation.
