Tag Archive: buprenorphine


Background

Methadone, a full mu-opioid agonist, is the recommended treatment for opioid dependence during pregnancy. However, prenatal exposure to methadone is associated with a neonatal abstinence syndrome (NAS) characterized by central nervous system hyperirritability and autonomic nervous system dysfunction, which often requires medication and extended hospitalization. Buprenorphine, a partial mu-opioid agonist, is an alternative treatment for opioid dependence but has not been extensively studied in pregnancy.

Methods

We conducted a double-blind, double-dummy, flexible-dosing, randomized, controlled study in which buprenorphine and methadone were compared for use in the comprehensive care of 175 pregnant women with opioid dependency at eight international sites. Primary outcomes were the number of neonates requiring treatment for NAS, the peak NAS score, the total amount of morphine needed to treat NAS, the length of the hospital stay for neonates, and neonatal head circumference.

Results

Treatment was discontinued by 16 of the 89 women in the methadone group (18%) and 28 of the 86 women in the buprenorphine group (33%). A comparison of the 131 neonates whose mothers were followed to the end of pregnancy according to treatment group (with 58 exposed to buprenorphine and 73 exposed to methadone) showed that the former group required significantly less morphine (mean dose, 1.1 mg vs. 10.4 mg; P<0.0091), had a significantly shorter hospital stay (10.0 days vs. 17.5 days, P<0.0091), and had a significantly shorter duration of treatment for the neonatal abstinence syndrome (4.1 days vs. 9.9 days, P<0.003125) (P values calculated in accordance with prespecified thresholds for significance). There were no significant differences between groups in other primary or secondary outcomes or in the rates of maternal or neonatal adverse events.

Conclusions

These results are consistent with the use of buprenorphine as an acceptable treatment for opioid dependence in pregnant women. (Funded by the National Institute on Drug Abuse; ClinicalTrials.gov number, NCT00271219.)

get the full article at: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1005359

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Patients on opioid replacement therapy have an increased risk of death early on in treatment, and again when they come off, researchers have found.

The risk was greatest — eight to nine times as high as that during treatment — immediately after coming off methadone or buprenorphine, Matthew Hickman, MD, of the University of Bristol in England, and colleagues reported in BMJ.

„The overall risk of death during opiate substitution treatment was lower than the risk of death out of treatment,“ they wrote.

The researchers conducted a prospective cohort study among primary care patients diagnosed with substance abuse and prescribed methadone or buprenorphine between 1990 and 2005.

A total of 5,577 patients given 267,003 prescriptions were followed up until one year after the expiration date of their last prescription.

Overall, the researchers found that the crude mortality rates were almost double for those who came off treatment: 0.7 per 100 person-years while on treatment and 1.3 per 100 person-years after coming off.

However, in the first two weeks of opiate substitution, the crude mortality rate was 1.7 per 100 person-years — just over three times higher than the rate during the rest of the time on treatment, the researchers said.

The first two weeks was a critical time period after treatment was stopped, too. Crude mortality rates were 4.8 per 100 person-years during the first two weeks post-treatment and 4.3 per 100 person-years during the third and fourth weeks.

That’s nine and eight times the risk of death when being on treatment, the researchers said.

Those rates fell to 0.95 during the rest of the time off treatment — a figure that was still nearly twice as high as patients‘ baseline risk.

The researchers said they were cautious about the potential mechanisms at work because they didn’t directly assess those factors in this study.

But, they said, the findings are generally consistent with the literature, which holds that risk of overdose is higher when opiate tolerance has temporarily fallen — after a patient has gone through an induction phase to start treatment, for instance.

So if, after ending replacement therapy, the patient goes back to using his drug of choice, „the first few occasions of opiate use pose the greatest risk of precipitating fatal overdose before tolerance has been re-established,“ according to the researchers.

They also observed that substitution therapy’s mortality benefits may relate to the duration of treatment, as opiate substitution treatment has more than an 85% chance of reducing overall mortality if patients are on it for at least 12 months.

They said that further research is needed to investigate the effect of average duration of opiate substitution treatment on drug-related mortality.

They also called for closer supervision of the induction phase of treatment, and for ongoing monitoring of the impact of opiate substitution treatment on mortality in the U.K. and other countries.

 

source: http://www.medpagetoday.com/Psychiatry/Addictions/23014

Summary

This survey investigated the current practices and challenges of physicians treating opioid dependence in Germany, France, Italy and
the UK. Doses favoured in Europe appeared to conflict with recommended best practice, with low mean methadone and buprenorphine
maintenance doses reported (44.3 and 9.5 mg, respectively). Mean time to buprenorphine maintenance doses was longer than recommended
at 14.4 days. Respondents also rated diversion and misuse management as their most difficult challenge in treating opioid
dependence. These data suggest that prescribing practices are likely to increase this problem, as well as impeding treatment success
by decreasing compliance and retention.

 

A lot of Theory but good: Bacha et al 12(3)2010

Bridget M. Kuehn

JAMA. 2010;304(3):261-263. doi:10.1001/jama.2010.963

When patients with HIV infection also are addicted to opioids, treating both disorders simultaneously may help improve outcomes and reduce the spread of HIV or other infections transmitted through needle sharing or risky sexual behaviors associated with injection drug use. But accessing such integrated care has sometimes been a challenge for such patients, who generally had to seek care for opioid abuse at addiction treatment centers and primary HIV care elsewhere. This could be logistically difficult and often led to delays in receiving care.

Now, however, buprenorphine prescribing by HIV clinicians is offering patients the option of receiving treatment for both opioid addiction and HIV infection, an approach that a growing body evidence indicates benefits individual patients and public health.

Figure 05072FA
There are currently about 19 000 US physicians certified to prescribe buprenorphine, but experts urge more physicians, particularly those in HIV primary care, to become certified to meet the demand for opioid addiction treatment.

Since 2002, buprenorphine, a partial opioid agonist, has been available in the United States as an office-based treatment for opioid dependence. Physicians who wish to prescribe the drug may under go a training program and become certified through the Substance Abuse and Mental Health Services Administration (SAMHSA) to prescribe buprenorphine (http://buprenorphine.samhsa.gov/). Methadone, a full opioid agonist, remains available through highly regulated, specialized treatment programs.

„Buprenorphine has definitely expanded access [to addiction care],“ said Amina Chaudhry, MD, MPH, an HIV clinician in Baltimore who prescribes buprenorphine. Chaudhry, who is also a medical officer at SAMHSA’s Center for Substance Abuse Treatment in Rockville, Md, explained that even in cities like Baltimore, where there may be specialty addiction programs nearby, the demand for such care often exceeds the available slots. And rural areas may have no specialty addiction programs at all within a reasonable distance.

IMPROVED OUTCOMES


Studies have suggested that patients with HIV infection and untreated opioid addiction often receive HIV treatment later in the course of their illness, may be less adherent to their antiretroviral therapy regimen, and may engage in behaviors such as unprotected sex or injection drug use that put themselves and others at risk of new infections. But treating patients for both HIV and drug use can improve such outcomes. Although much of this research has focused on the effects of methadone, emerging evidence suggests that buprenorphine has similar benefits and may have a few advantages over methadone treatment for patients with HIV.

A recent randomized trial found that office-based care can improve addiction-related outcomes for patients with HIV and opioid addiction and may lead to faster treatment for addiction (Lucas GM et al. Ann Intern Med. 2010;152[11]:704-711). Gregory M. Lucas, MD, PhD, of Johns Hopkins University School of Medicine in Baltimore, and colleagues randomized 93 patients at a Baltimore HIV clinic to receive buprenorphine therapy at the clinic or to receive a referral to specialty addiction treatment elsewhere. Patients randomized to clinic-based opioid agonist treatment with buprenorphine entered addiction treatment much more quickly (84% had initiated such care at 2 weeks compared with 11% in the referral group). During the 12-month trial, participation in opioid addiction treatment was significantly greater in the clinic-based care group (74% participated in such treatment vs only 41% in the referral group). Patients receiving buprenorphine in the clinic also had significantly fewer urine test results that were positive for opioids or cocaine and visited their HIV primary care clinicians more frequently.

However, the researchers did not find differences in HIV-treatment participation or HIV treatment effects between the clinic-based vs referral groups. The authors concluded that the improvements in addiction treatment may have been driven by streamlined access to care because patients referred to outside specialty addiction care may have experienced a delay in treatment initiation. The small sample size may have precluded identifying clinically significant differences in HIV treatment outcomes, they also noted.

The study was part of the Health Resources and Services Administration’s (HRSA’s) Buprenorphine in HIV Primary Care National Evaluation and Support Center (BHIVES; http://www.bhives.org). An analysis of pooled data from 10 sites participating in the HRSA program is under way.

David A. Fiellin, MD, associate professor of medicine at Yale School of Medicine and co-investigator on BHIVES, noted that the program is also probing which approaches to primary care delivery work best in HIV clinics. So far, he and his colleagues have demonstrated in a pilot study that an approach that uses a nurse or other staff member to help coordinate buprenorphine care by overseeing such tasks as urine testing, drug counseling, and medication monitoring can help to reduce drug use among HIV patients, has good retention rates, improves patient function, and promotes patient satisfaction (Sullivan LE et al. Clin Infect Dis. 2006;43[suppl 4]:S184-S190).

Previous studies had suggested that physicians‘ concerns about adherence to antiretroviral treatment by injection drug users with HIV played a role in the likelihood that such patients would be offered highly active antiretroviral therapy or at least experience a delay in receiving such treatment. But results of a French study suggest that integrated treatment of HIV and opioid addiction could allay such concerns. The study found that retention in opioid substitution therapy, either buprenorphine or methadone, is associated with improved virologic outcomes in patients treated with highly active antiretroviral therapy and who had opioid use disorders (Roux P et al. Clin Infect Dis. 2009;49[9]:1433-1440). The study included 53 patients receiving buprenorphine, 28 receiving methadone, and 32 who were not receiving opioid substitution therapy. The median duration of opioid substitution treatment was 25 months.

„Having one-stop shopping for patients means one less barrier to accessing care,“ Chaudhry said.

Buprenorphine also appears to have fewer interactions with antiretroviral drugs than methadone. Elinore F. McCance-Katz, MD, PhD, professor of psychiatry at the University of California, San Francisco, and her colleagues published an article reviewing drug interactions involving methadone and buprenorphine and other medications, including antiretroviral therapies (McCance-Katz EF et al. Am J Addict. 2009;19[1]:4-16). Two HIV medications in particular, efavirenz and nevirapine, have been documented to trigger opiate withdrawal in patients taking methadone but not in patients taking buprenorphine, despite observations of reduced levels of both methadone and buprenorphine when these antiretrovirals were given to patients receiving these opioid therapies, noted McCance-Katz in an interview. A possible reason for the observed differences may be that methadone is metabolized to an inactive substance while buprenorphine is metabolized to norbuprenorphine, which also has opioid effects and may protect patients from experiencing opiate withdrawal, McCance-Katz said.

„It’s very difficult to effectively treat patients [with HIV] if they are in withdrawal,“ she said. „They simply don’t comply with antiretroviral therapy if they are in withdrawal.“

Elevated concentrations of buprenorphine have been documented in patients with opioid dependence and HIV taking atazanavir; such elevated levels were associated with cognitive impairment in a few HIV patients in one case study, while another study in non–HIV-infected patients found only increased drowsiness (Bruce RD and Altice FL. AIDS. 2006;20[5]:783-784 and McCance-Katz EF et al. Drug Alcohol Depend. 2007;91[2-3]:269-278). Such elevations of methadone concentrations have not been documented with atazanavir.

„In general, buprenorphine has fewer interactions with HIV medications, but neither drug has been looked at extensively with many other medications,“ she said, adding that many patients with HIV may be taking a number of medications in addition to antiretroviral drugs.

Integrating buprenorphine treatment into the HIV care setting has another potential advantage: it may be easier for clinicians to spot interactions between addiction and HIV therapies when patients receive buprenorphine treatment at their primary HIV clinic, McCance-Katz said. For example, if a patient receives methadone at one clinic and antiretroviral therapy at another, there may be limited communication between clinicians at the 2 sites and adverse events may not be identified.


CLINICIAN ACCEPTANCE


About 19 000 US physicians are certified to prescribe buprenorphine and about 640 000 patients are receiving the prescriptions compared with about 4500 certified prescribers and a little more than 100 000 patients in 2005, according to Nicholas Reuter, MPH, senior public health analyst at SAMHSA. But access to buprenorphine therapy in the HIV primary care setting in the United States may be limited. Reuter noted that psychiatrists and physicians specializing in addiction treatment were early adopters of office-based buprenorphine prescribing. Today, 31% of the prescribers are classified as general or family practitioners, 21% as psychiatrists, 15% as internal medicine specialists, and the remaining third are other specialists who are not HIV clinicians, according to Reuter. (SAMHSA doesn’t track the number of HIV/AIDS specialists who are certified to prescribe buprenorphine.)

A survey of about 500 HIV clinicians (49.7% response rate) who attended International AIDS Society conferences in the United States in 2006 found that only 85 (17%) worked in offices that prescribe buprenorphine. Of the 323 physicians who responded, only 67 (21%) were certified to prescribe the drug, and only 19 (6%) had ever done so (Kunins HV et al. Fam Med. 2009;41[10]:722-728). Additionally, when presented with a vignette of an opioid-addicted patient with HIV, only 16% of the respondents endorsed primary care buprenorphine treatment as the best option for the patient compared with 49% who endorsed buprenorphine treatment in a substance abuse treatment program and 31% who endorsed methadone treatment in a specialty program.

Fiellin noted that other BHIVES efforts have found that clinicians may feel they do not have adequate training and resources to provide addiction treatment but are interested in receiving additional training. The clinics that have implemented primary care buprenorphine care as part of BHIVES have received technical support during implementation, and over time their satisfaction with and sophistication at providing buprenorphine care have improved, he noted.

Another program offering resources to buprenorphine-prescribing physicians is SAMHSA’s Physician Clinical Support System (PCSS), which is directed by Fiellin and includes McCance-Katz as among the clinical experts who work with the program. PCSS helps match new buprenorphine prescribers to more experienced mentors who work in similar settings, including HIV primary care. The program also has drafted a guidance document for buprenorphine prescribing to patients with HIV (http://www.pcssbuprenorphine.org/pcss/documents2/PCSS_OpioidTherapiesHIVDrugInteractions_022808.pdf).

SAMHSA is also working with primary care physicians at federally qualified health centers who may be treating many HIV-infected patients. Reuter explained that the agency would like these centers to offer both buprenorphine and methadone, although the latter would require a center to be licensed as an opioid treatment clinic. He noted that SAMHSA’s goal is to make sure there are as many physicians as possible qualified to provide care to opioid-dependent patients, who may require long-term or recurrent care. For example, the average duration of methadone treatment is 6.8 years. „Our concern is that as long as patients remain engaged in treatment they do very well,“ he said. „A number of patients discontinue and the relapse rate is very high.“

Chaudhry emphasized that primary care buprenorphine treatment is not necessarily a replacement for specialty addiction treatment with methadone or buprenorphine. For example, she noted that some patients may prefer to keep their addiction treatment separate from their HIV care.

„The more treatment choices that providers have to offer the better,“ she said.

A Role for Buprenorphine in Prevention?Between 2004 and 2007, of the 152 917 US individuals in 34 states diagnosed with new HIV infections, 13% of them (n = 19 687) were injection drug users, according to the US Centers for Disease Control and Prevention (MMWR Morb Mortal Wkly Rep. 2009;58[46]:1291-1295). For those who are already infected with HIV, buprenorphine treatment may reduce the likelihood they will spread the infection to others through needle sharing or unprotected sexual activity. And for opioid-dependant individuals who are not already HIV-infected, primary care buprenorphine treatment may reduce risky behaviors that put them at risk of HIV infection, according to a recent study.

Lynn E. Sullivan, MD, and colleagues from the Yale University School of Medicine in New Haven, Conn, compared drug-related and sex-related risk behaviors in 166 buprenorphine-treated individuals at baseline, 12 weeks, and 24 weeks (Sullivan LE et al. J Subst Abuse Treat. 2008;35[1]:87-92). Reports of intravenous drug use among the individuals declined over time, from 37% at baseline to 12% at 12 weeks, to 7% at 24 weeks. The researchers also found a decline in reports of sex while the patient or their partner was high between baseline (64%) and 12 weeks (13%), although such reports increased to 15% a 24 weeks, and inconsistent condom use with a regular partner remained unchanged.

Such benefits may be particularly important in regions of the world where HIV transmission is driven primarily by injection drug use. In Eastern Europe and Central Asia, for example, the Joint United Nations Programme on HIV/AIDS estimates that more than 80% of all HIV infections are caused by contaminated injection equipment (http://www.unaids.org/en/PolicyAndPractice/KeyPopulations/InjectDrugUsers/).

The HIV Prevention Trials Network, an international clinical trials network funded by the National Institute of Allergy and Infectious Diseases, currently has a phase 3 randomized trial under way in China and Thailand to assess whether buprenorphine in combination with naloxone (to reduce the abuse potential) decreases drug use and HIV-related risk behaviors (http://www.hptn.org/research_studies/HPTN058.asp). The trial, which is enrolling about 1500 HIV-uninfected injection drug users, will randomize individuals to receive either buprenorphine plus naloxone for 1 year or detoxification with buprenorphine plus naloxone for up to 18 days (with a second detoxification if necessary). Both groups will also receive counseling for HIV risk reduction. The study will assess cumulative HIV incidence and death and frequency of drug use and drug-related and HIV-related risk behaviors in the 2 groups.—B.M.K.

Abstract

Untreated opiate addiction remains a major health care crisis in New York and in most other urban centers in America. Optimism for closing the gap between need and demand for treatment and its availability has greeted the recent approval of a new opiate medication for addiction, buprenorphine – which unlike methadone may be prescribed by independent, office-based practitioners. The likelihood of buprenorphine fulfilling its potential is assessed in the light of the massive expansion of methadone treatment more than 30 years earlier. It is concluded that the key, indispensable ingredient of success will be true commitment on the part of Government to provide care to all those who need it.

Commentary

Over thirty years ago an editorial appeared in The New York Times under the headline, „A Drug Success.“ [1] The focus was the New York City Health Department’s Methadone Maintenance Treatment Program, which had expanded „so swiftly and so successfully…that there no longer are waiting lists for admission…“ Recently, another medication – buprenorphine – was approved for treating opiate addiction, [2] and there is hope that it will allow many more patients to receive help. Critical to significant expansion of treatment capacity will be „clinician attitudes and the extent to which they embrace buprenorphine . . .“ [3] However, to gauge the degree to which buprenorphine’s potential will be realized it is important to consider the factors that went into the success of methadone in the early 70s.

New treatment services were being established throughout the country in those days, but the most dramatic increase took place in New York City, and it was due first and foremost to the vision and commitment of one man, Gordon Chase, the City’s Health Services Administrator under then-Mayor John Lindsay. (Chase died in an auto accident in 1980 at the age of 47.) Chase, who had only a bachelor’s degree and had never worked in the field of health care, was determined that every single heroin user would be offered prompt access to treatment; to achieve this goal he concluded that methadone maintenance would have to be the cornerstone of the City’s efforts. He acknowledged readily that he knew very little about methadone (few at the time knew more – methadone had been introduced just five years before [4]); he had been persuaded, however, that without methadone the vast majority of those who needed and were willing to accept help would be abandoned.

Chase peremptorily dismissed the litany of reasons staff gave in urging him to „go slow“: rapid expansion of methadone treatment had never been attempted, and could be a widely publicized disaster that would undermine treatment efforts everywhere; individualization of care and „comprehensive ancillary services“ were considered indispensable components of treatment and required extensive time and staff training to establish; etc. Indeed, virtually every experienced professional in the country rejected the very concept of expansion on a massive scale. This may explain why Chase asked the author to implement his vision of „treatment on request“ for all addicts; I was a resident in Public Health at the time, whose only prior medical training had consisted of two years of general surgery, and whose administrative background was limited to a few months directing the New York City component of a national nutrition survey.

The consistent response by Chase to the nay-sayers within and outside City Government was to ask: „How convincing will your concerns and criticisms be to parents whose children sought help but were turned away, and subsequently died of an overdose?“ His argument was compelling,. In any event, Chase prevailed and within two years the City Health Department had established a program with an active enrollment of approximately 11,000! Concomitantly, the Health Department spurred („shamed“ is probably a more accurate term) other methadone and drug-free providers in New York and elsewhere to increase their own capacity markedly.

The net result for the City of New York was dramatic: a sharp reduction in addiction-related property crime, drug arrests, hepatitis and deaths attributed to drug dependence. [5] As for the Health Department’s new methadone program in particular, whether measured by retention rates, employment, drug use, health status or any other parameter, the extensively documented outcomes were every bit as good as those of other addiction treatment services. [6]

The New York City Health Department program was financed entirely by City and State funds and by Medicaid reimbursement for eligible patients. The Federal Government provided neither fiscal nor moral support for the City’s unprecedented response to opiate addiction, the most important clinical and public health challenge of the day. As for the rest of the country, without the demonstration by New York that massive, rapid expansion was feasible, it is likely that things would have proceeded at a snail’s pace.

Tragically, since the mid-70s there has been little if any further increase in addiction treatment capacity of any kind in America. Roughly the same 20 percent of the estimated heroin addicted population receives care today as did then – before the onset of AIDS. [7] Undoubtedly the greatest obstacle to accommodating more patients has been the absolute monopoly on methadone maintenance that has been given to „programs;“ independent, office-based practitioners are excluded from the field by law – a restriction on prescribing that applies to no other medication in the US pharmacopoeia.

A „new“ treatment option

The New York Times recently reported [8] that an estimated 36,000 patients receive methadone in the City – essentially the same number as three decades ago (according to one source, 34,000 patients were being treated with methadone maintenance in 1974 [9]). At the same time, The Times noted optimistically that prescriptions for buprenorphine are „expected to soar in the coming years“ (one year earlier the paper had run another optimistic story on buprenorphine under the headline, „New drug promises shift in treatment for heroin addicts“ [10]). In fact, however, if the past is prologue, the acceptance and utilization of buprenorphine may be a long time coming. As early as 1978 it had been described as a medication with „a unique pharmacology with immediately obvious therapeutic application as a maintenance drug in narcotic addiction“ [11]. And yet, to make this „immediately obvious“ medication a reality “ . . . took considerable financial commitment from NIDA [National Institute on Drug Abuse], more than two decades of dedicated effort by myriad researchers and practitioners, and the collaboration of a willing and savvy pharmaceutical manufacturer. It also literally took an act of congress“ [3].

The breakthrough itself, when it finally came, was not pharmacological but regulatory. Unlike methadone, buprenorphine could henceforth be prescribed for opiate dependence by any physician who is „certified.“ Certification requires nothing more than an application and demonstration that the physician has completed an eight-hour training course (which also is available on-line). While the demands imposed on „methadone programs“ are undiminished, and office-based physicians continue to be barred from making methadone available to their patients, buprenorphine can be prescribed to a new patient for a full month, and in some states (e.g., New York) the prescription can be refillable without further physician-patient contact for five additional months. Surely not good medical practice – but in contrast to methadone, not illegal! The one restriction that makes treatment with buprenorphine exceptional is that no physician or group practice may treat more than 30 patients at a time (this limit, as it applies to group practices, was eliminated in a bill passed by Congress and signed by the President in August, 2005 [12].

Despite all the hype, the ease of certification and the relative absence of regulatory constraints, there’s little to cheer about. Notwithstanding the very considerable effort of the Federal Government, and the extensive advertising and public relations campaign of buprenorphine’s manufacturer, the percent of previously untreated opiate-dependent individuals that receives this medication appears to be miniscule. Worse, it’s by no means clear that anyone cares; no Federal targets have been announced, and no one seems to be measuring the increment in patient numbers (and if they are, they are not talking, which also bodes ill). Of course, it is likely that the manufacturer is following its sales very, very closely, but it too has released no data.

One major barrier to significant expansion of addiction treatment with buprenorphine is the persistent mixed message sent by Government. We can hardly expect physicians, patients or the public at large to embrace treatment with one medication (buprenorphine), when Government itself continues to reflect and reinforce the stigma towards treatment with another medication (methadone) for the same patients and the same disease. We’ll never see significant numbers of physicians – i.e., „mainstream medicine“ – prescribe buprenorphine when methadone must, by law, be associated with a fully panoply of „comprehensive ancillary services,“ frequent urinalysis, stringent restrictions on „take-home privileges,“ and inspection and approval of all providers by „accreditation agencies.“ In addition, of course, there continues to be an absolute bar, regardless of circumstances, against treatment with methadone by independent office-based practitioners.

The experience three years after buprenorphine was approved speaks for itself. Less than 500 prescriptions for buprenorphine, from all sources, were written in New York City during the month of June, 2005. [13] If each prescription were for an unduplicated individual, the total recipients of this medication would be one-quarter of one percent of the estimated 200,000 untreated heroin-dependent population of the city. [14]

Conclusion

We need Government to give strong, unqualified support to the premise that addiction is a chronic medical condition. It must acknowledge forthrightly that neither buprenorphine nor methadone nor any other treatment modality, medication-based or drug-free, is a „cure.“ At the same time, it must stress the fact that addiction is eminently treatable. (The same reality of „treatable but not curable“ applies to all chronic illnesses.) Above all, however, we need leaders with the commitment, pragmatism and common sense that Gordon Chase personified. Sadly, such traits are rarely evidenced today by those who influence and implement policy – in government, academia or the private sector. Meanwhile, hundreds of thousands of opiate dependent people in New York and throughout the country continue to suffer and die, and society at large bears the associated fiscal and human costs. It is high time to reconsider the rhetorical question Chase posed almost 35 years ago: Are our rationalizations for tolerating the status quo truly persuasive? Would they be accepted by those who are suffering and dying as a consequence of inaction?

MORE THAN TWO THIRDS OF
people with addiction see a
primary care or urgent care
physician every 6 months, and many
others are regularly seen by other medical
specialists.1,2

These physicians are
therefore in a prime position to help patients
who may have drug abuse problems
by recognizing and diagnosing the
addiction, helping to direct patients to
a program that can meet their treatment
needs, and helping to monitor
progress after specialty treatment and
during recovery.3-6

Many physicians,
however, find the domain of drug abuse
particularly daunting and often avoid
the issue with their patients. This is understandable
given the relatively short
shrift drug abuse is given in formal
medical education. There is a widespread
misperception that drug abuse
treatment is not effective, which may
account for the reluctance of physicians
to even broach the subject of drug
abuse or treatment with their patients.
On the other hand, over the past 15
to 20 years, advances in science have
revolutionized our fundamental understanding
of the nature of drug abuse
and addiction and what to do about it.
In addition, there are now extensive
data showing that addiction is eminently
treatable if the treatment is welldelivered
and tailored to the needs of
the particular patient.

There is an array
of both behavioral and pharmacological
treatments that can effectively
reduce drug use, help manage drug
cravings and prevent relapses, and restore
people to productive functioning
in society.7-9
Of course, not all drug abuse treatments
are equally effective, and there
is no single treatment appropriate for
all patients. Fortunately, recent scientific
advances have provided insights
both into the nature of drug abuse and
addiction and into the principles that
characterize the most effective treatment
approaches and programs.10 These
treatment principles should make the
primary care or nonaddiction specialty
care physician’s tasks of screening
and referral much easier.

Read more: 20.03.10