Tag Archive: Methadone


Kidnappings, incarceration and the world’s worst heroin habit

In a country with more than two million heroin addicts, Irina Teplinskaya was one of the first. It was back in 1981, as a 14-year-old girl in the Baltic port of Kaliningrad, that she first tried the drug. She came from a prestigious family of senior Communists and was one of just a few who could afford the exciting new drug. She became addicted and suddenly, instead of a move to Moscow to study, her life began to take a very different path. She spent over a decade in prison and contracted hepatitis C, tuberculosis and HIV. right align image
During her last stay in jail, which ended in 2007, her HIV transitioned into full-blown Aids. Her life could have been very different, she says, if people had treated her drug addiction as an illness rather than a crime.
„The answer for me and for millions of others is simple,“ says Ms Teplinskaya, 44, who now works for an organisation advocating a more humane drug policy in Russia – substitution therapy. Almost every country in Europe allows treatment using methadone. Like heroin, it is an opiate, but is administered orally, meaning no risk of HIV transmission through needles.

Russia is the world’s largest heroin consumer and, to add to that, risky injecting practices have fuelled one of the world’s fastest-growing HIV epidemics. With tens of thousands of people dying every year, in a country where the population is shrinking, the twin epidemics are a catastrophe.
Campaigners say methadone would help tame both the heroin and HIV epidemics. As well as preventing HIV transmission, giving addicts methadone also brings them into the medical system, help steer them away from committing crimes to fund their habit and takes trade away from illegal dealers. Even China uses the technique to treat drug addicts. But Russian officials will have none of it. Government figures say it is perverse to treat drug addiction with other drugs and favour methods based on full withdrawal, sometimes against an addict’s will. It’s risky even to discuss methadone – advocates can be accused of „pro-drugs propaganda“ and taken to court.

„There is no logical reason behind Russia’s opposition to substitution therapy,“ says Anya Sarang, a campaigner who advocates the introduction of methadone. „I’ve been fighting this battle for 12 years and I don’t understand the mentality at all. The scientific evidence is all there to prove that it works.“

Ms Sarang and a group of Western academics published a study in the British Medical Journal last year which found that the widespread introduction of substitution therapy could cut rates of HIV transmission in Russia by up to 55 per cent. Estimates vary, but it’s thought that more than two million Russians inject heroin and the drug causes 30,000 deaths per years, as well as tens of thousands of new HIV cases. Russia is located on the transit route for drugs from Afghanistan to Europe and cheap heroin is readily available – a dose of heroin on the streets costs about 600 roubles (£12). If methadone therapy is not available, activists say programmes that offer addicts clean needles and syringes to avoid HIV transmission are essential.

The government, however, is adamant that only aggressive punitive measures can work to tackle drug use. Needle-exchange programmes funded by foreign donors have been discontinued in recent years, leading many addicts to share injecting equipment.
While there is some discussion about whether needle exchanges should be reintroduced, methadone is completely taboo. Leading Russian drugs specialists denounce substitution therapy as a failed Western imposition and see it as a „legalisation“ of drug use.

„We have no evidence from the international community that methadone is effective,“ said the Health minister, Tatyana Golikova, this week, reiterating a long-held government policy.
Others go further. Evgeny Roizman is a former Russian MP from the city of Yekaterinburg in the Ural mountains. He runs a series of clinics there where drug addicts go cold turkey, without methadone or any other drugs to ease the withdrawal symptoms.

He insists that methadone advocates are simply being disingenuous. „These people will say anything to get Western funding,“ says Mr Roizman. „I have worked with drug addicts for years, and I can tell you: methadone doesn’t work.“

He wants to bring in a range of policies, including harsher penalties for drug dealers and compulsory drugs testing in all Russian schools and colleges. „We need forced treatment for drug addicts,“ he says. „We need to force them into special institutions where there are no drugs and where they can be treated. This is the answer, not methadone.“

Last year, a disciple of Mr Roizman was sentenced to three-and-a-half years in prison for kidnapping drug addicts. Yegor Bychkov said addicts‘ parents had given him permission to „cure“ their children. „Patients were tortured, chained up to steel beds, starved,“ says Ms Sarang. „It was absolutely outrageous and when the court case against him started, we thought there would be a scandal.“

But a huge wave of support for Mr Bychkov swept through the country. Even many from Russia’s beleaguered human rights community joined with church figures and government officials to condemn his trial and in the end the court suspended his sentence and he was released. Mr Bychkov was „overenthusiastic“, said Mr Roizman, but his heart was in the right place.
Ms Teplinskaya, who is still a heroin user, travelled to Moscow last week to meet Navi Pillay, the UN High Commissioner for Human Rights, and ask her to press the Russian government on substation therapy. „I think I could have done a lot of good things for my country,“ she said. „But instead, I’ve lost my home, my health and my family. Methadone could have helped me lead a normal life.“

But her opponents are confident their views will prevail. Mr Roizman says: „They can shout as much as they want with their Western money. Methadone will never be legal in Russia.“

source:http://www.independent.co.uk/news/wo…t-2220673.html

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MOSCOW, Feb 10 (Reuters) – Activists have asked the UN human rights

chief to pressure Russia to legalise the heroin substitute methadone when she visits next week amid a worsening HIV/AIDS crisis, an international health group said on Thursday.

UN High Commissioner for Human Rights Navi Pillay will meet President Dmitry Medvedev, government officials and around 60 rights campaigners during a five-day visit to Moscow.

‚This is a national health crisis and a human rights priority in Russia that must be raised at the highest levels,‘ said senior human rights analyst Damon Barrett from the London-based International Harm Reduction Association (IHRA).

The IHRA and 16 other HIV-focused rights organisations have sent a letter to Pillay asking her to push for HIV/AIDS and drug-fighting measures including the introduction of methadone, during her meetings with Russian government.

The UN’s World Health Organisation (WHO) says Russia has one of the fastest growing HIV/AIDS epidemics in the world, fueled up to three million heroin addicts, many of whom use dirty needles, local health organisations say.

Unlike most countries, Russia refuses to finance harm reduction programmes such as needle exchanges, or to legalise the replacement drug methadone.

The Health Ministry says there is no proof methadone is effective, while the country’s top doctor Gennady Onishchenko has called methadone ‚just another narcotic‘.

‚The fact that the government’s policy is so incomprehensible is what makes it so frustrating,‘ Barrett said.

The WHO says there are a million HIV-positive people in Russia, and deems methadone essential in fighting the epidemic.

Pillay will meet Russian activist Irina Teplinskaya during her visit, said the Moscow-based Andrey Rylkov Foundation, for whom Teplinskaya volunteers. HIV-positive and a heroin user, Teplinskaya has become a symbol of Russia’s drug woes.

‚Because there is no opioid substitution therapy in Russia, drug-dependent people are not able to receive treatment for HIV… they are forced to spend whole days acquiring money in a criminal way so they can buy drugs,‘ Teplinskaya said in a speech she will deliver to Pillay on Sunday.

((For a special report on Russia’s heroin and HIV/AIDS problem: ))

Methadone Detoxification

Summary

  • The physical process of detoxification is, in itself, relatively easy to achieve.
  • Long-term abstinence from opiate use is much harder to achieve.
  • Most opiate users will undergo detoxification many times before they achieve lasting periods opiate free.
  • Prescribed medication to assist in these detoxes will probably be a feature on more than one occasion.
  • Lofexidine is a useful non-opiate treatment for both community and in-patient rapid detoxification.
  • It is important that services respond to the requests for help in a therapeutic way that reduces drug-related harm and helps the client move on and learn from their experiences.
  • Drug users who become abstinent are vulnerable to relapse.
  • Drug services should offer full support for at least 6 months following detox.


Introduction
Methadone detoxification is a complex area dealt with in various sections throughout this book.

This section deals with the practical issues around prescribing and the rate of detox, the anxieties for clients about detox and the alternatives to methadone in detox.

This section should be read in conjunction with:

  • Section 2 – where there is a discussion of the research into methadone detoxification
  • Section 4 – where withdrawal symptoms are discussed
  • Section 7 – where there is discussion of the different detox durations and their indications and contra-indications
  • Section 11 – where there is discussion of detoxification which does not end in lasting abstinence.

People reducing from methadone are often anxious and afraid of the withdrawal syndrome and relapse.

Relapse following detox is an often neglected area because drug services and drug users tend to concentrate on the withdrawal syndrome and process of detoxification.

Effective follow up is vital in ensuring that detoxification is more than a reducing dose of methadone mirrored by a concurrent rise in heroin (or other depressant drug) use or a prelude to a short period of abstinence followed by relapse that the prescriber is unaware of.

Information for clients on the issues around detoxification and residential rehabilitation is available in the Detox Handbook and the Rehab Handbook – also available from ISDD (address on back cover).

Reasons for detoxing
In an ideal world people would detox from a stabilising dose of methadone or illicit drugs when they, and their prescriber, agreed that they were ready and able to do so without significant risk of early relapse. However people may want to detox when either they or their prescriber do not feel they are ready because:

  • Service prescribing policy dictates the regime on offer
  • They have a new job
  • They are moving to a new area
  • Of changes in their relationship
  • Attitudes of staff involved in methadone prescribing
  • Unrealistic staff beliefs about client’s ability to achieve abstinence
  • Unrealistic client beliefs about their ability to achieve abstinence
  • Stigma associated with having a methadone prescription
  • Dislike of practical aspects of a regime, such as the collection frequency
  • Change of drug of choice e.g. methadone to benzodiazepines or alcohol
  • Exclusion from a prescribing programme
  • Imminent or actual prison sentence.

These are discussed below.

Attitudes of staff
Opiate users are sensitive to the attitudes of the staff they come into contact with and sometimes choose not to seek, or to terminate treatment because of the attitudes and behaviour of staff.

This can probably be best avoided by offering services that are:

  • Client centred
  • Empowering
  • Flexible in their treatment approaches
  • Not seen to subscribe rigidly to any duration of methadone treatment
  • Non-judgmental and respectful
  • Staffed by people who are well trained and receive good supervision.

Following these principles also means that, having discussed the options, if a client decides to detoxify against advice the staff should still offer their full support and encouragement during and after the detox. They should also endeavour to discuss possible outcomes in a way that does not set the client up to fail but allows the making of contingency plans that can be brought into play if the detox does not work.

Unrealistic staff beliefs about a client’s ability to detox
It is easy for workers to fall into the trap of prematurely believing that people can achieve abstinence and encourage the client to detox. Often the client will continue down this road because they do not want to upset the worker and this can continue afterwards, with the client not wishing to re-refer themselves to a prescribing service for fear of admonishment from, or upsetting, the people who helped them before.

Cushman and Dole87 found that of a group of methadone maintenance clients who were assessed as ‚rehabilitated‘ and detoxed with the anticipation of success, some asked to be returned to maintenance during the detox and 25% returned to maintenance after detox (mainly because of protracted withdrawals).

Therefore support, encouragement and optimism should always be tempered by continual reassessment and meaningful negotiation.

Unrealistic client beliefs about their ability to detox
Clients too can be unrealistically optimistic about their ability to get off opiates. Often people will present after many years of heavy opiate use, adamant that in a few weeks they will be able to get themselves together and detox successfully.88

This belief sometimes stems from concentrating on the physical aspects of opiate withdrawal. If past experience of relapse during or after opiate detox has been that the withdrawal symptoms were the main factor causing relapse, this can reinforce the belief that if the physical symptoms of withdrawal can be reduced to tolerable levels by a methadone detox, abstinence will be easily achieved.

Another factor can be the flawed but understandable and apparently logical conclusion that ‚if all my problems are heroin-related then if I give up heroin all my problems will go away‘. The experience of many is that the compulsive behavioural aspects of their drug taking and the social and emotional difficulties that they experience once opiate-free add a previously ignored and difficult-to-overcome dimension to their drug use.

Stigma associated with having a methadone prescription
Many people on a maintenance methadone prescribing programme say ‚the act of having to take an opiate every day is a reminder that I’m a junkie‘.

For the relatives and friends of people on methadone it can be perceived as being ‚as bad as heroin‘ – regardless of any associated lifestyle improvements that have been achieved. Indeed associated improvements often serve only to increase the pressure on the person to detox as the perception is that they do not need the methadone anymore.

Heroin users are often dismissive of those on methadone and street myths of the terrible long-term health consequences of methadone treatment still abound. So the person receiving methadone often feels stigmatised from all sides.

Heroin users who feel the need to seek help for the first time also feel this and may request a methadone detox so that they can rationalise their request as one for a short-lived intervention that does not involve long-term methadone treatment.

Dislike of practical aspects of a regime, such as the collection frequency
Avoidance of longer-term treatment may also include factors such as a desire not to have to:

  • Collect methadone daily from a drug service or pharmacy.
  • Attend a drug service on a regular basis
  • Engage in a counselling relationship
  • See other drug users when collecting the prescription and/or methadone

It is important for the worker involved to have an awareness of these issues if they are factors in a request for methadone detoxification.

Change of drug of choice
Sometimes poly drug users change their drug of choice in a cyclical way from, say, heroin to benzodiazepines to alcohol to amphetamines and back to heroin; or simply switch from heroin to, say, alcohol and back again.

They may ask for a detox at the end of the opiate part of the cycle – either as a new referral as a heroin user or following a period on methadone. In these cases treatment may or may not be appropriate, but if commenced should be carefully monitored.

Clients going to prison
Clients who have a prison sentence coming up present drug services with a dilemma. On the one hand premature detox may lead to relapse with risk behaviour prior to prison. On the other hand arriving at a prison where detox facilities are poor or non-existent in full methadone withdrawal is likely to result in illicit heroin use. The sharing of injecting equipment in prison is much more prevalent than in the community. The best that can be done is to:

  • Offer as much support as possible
  • Help them make informed choices
  • Inform them of the risks of intravenous drug use in prison
  • Appropriately influence the pre-sentence report.

Blind or open reductions?
There is no evidence to suggest that knowing or not knowing the frequency or size of dose reductions is more effective in helping people detox using methadone.

The answer for most people who attend prescribing and dispensing services that are flexible enough to offer both, is to consider the pros and cons of each approach in conjunction with the prescribing staff, and to make an informed decision for themselves as to which is the most appropriate regime. Generally a key factor is the level of control that a person feels they have over their lives. Anyone who feels in control is unlikely to opt for blind dose reductions.

The arguments for and against blind and open reductions are set out below.

Arguments for blind dose reductions Arguments against blind dose reductions
Reduced anxiety around the day of dose reduction Possible constant anxiety about when reductions are going to happen
Objective self assessment of withdrawal symptoms Constant anxiety about and experience of withdrawal symptoms
Concentration on issues around coping rather than drug dose Client not taking responsibility for the dose reductions or their response to them
Reduced anxiety about passing psychologically important doses e.g. 20mg,10mg, 5mg Inability to ‚take credit‘ for success so far

Arguments for open dose reductions Arguments against open dose reductions
Client takes responsibility for the dose reductions and their response to them Increased anxiety and expectations of withdrawal symptoms at times of dose reductions
Ability to plan life around reductions Weeks of concentration on drug dose as the major factor in determining ability to function is not always helpful preparation for a drug-free life
The rate of reduction can be negotiated once detox has started Client is more able to identify psychologically significant doses at which to stop – which can weaken resolve


Setting the appropriate rate of detox
Almost everyone undergoing methadone detoxification will experience withdrawal symptoms, and for many these will be serious enough to be a major contributing factor in either relapse to heroin use or a request for methadone maintenance – even if all other preconditions for a successful detox are in place.87

For people detoxing following a period on methadone maintenance, faster detoxes are associated with higher drop-out rates and slower detoxes are associated with lower drop-out rates.89

In general detoxes consist of gradual reductions of 5mg or 10mg in the daily dose to a given level, usually 20-30mg (depending on the starting dose and the client), and then become more gradual, either in terms of time between reductions and/or size of daily dose reduction.

Negotiation between worker and client is an important component of any detoxification. A negotiated detoxification in which the client is able to take responsibility for coping with the dose reductions is likely to reduce the risk of concurrent illicit opiate use and be a better foundation for continued abstinence afterwards.

Prescribers without specialist experience who agree to a short-term programme without support from a specialist service should seek support if their patient is unable to detox successfully at the agreed rate.

Detox regime suggestions

Long-term detox regimes are seldom the optimum treatment option, to read an additional piece on long-term detox written for this online edition of the book, please click here.

All the regimes below are for methadone mixture 1mg/1mL. All detox regimes are a plan only and should be subject to regular, i.e. weekly or fortnightly, review against the treatment aims.

The definitions, indications and contra-indications for each of the regimes below are given in Section 7 – Treatment aims and choices. It is important that detox regimes are only entered into with clear treatment aims and following a thorough assessment that has established that these aims are achievable.

The very low doses (i.e. less than 5mg) suggested in the following regimes are of little physiological value as they are unlikely to make much difference to the level of physical withdrawal. However withdrawal symptoms can also be aggravated by anxiety and where low dose prescribing at the end of a detox reduces anxiety it is likely to reduce subjectively experienced withdrawals.

Where a client has high levels of anxiety about making the final reductions they are often afraid of being drug free and of the changes this will bring. It is therefore important that low dose prescribing is coupled with counselling.

Short-term detoxification: decreasing doses over one month or less Two week detoxification regime

  • 20mg for 3 days
  • 15mg for 4 days
  • 10mg for 3 days
  • 5mg for 4 days

This regime has the advantage that it is easy to prescribe as there is a dose drop at the end of each week.

An alternative starting slightly higher could be:

  • 25mg for 3 days
  • 20mg for 3 days
  • 15mg for 3 days
  • 10mg for 3 days
  • 5mg for 2 days

For people who need more methadone to stabilise or who are detoxing from an existing methadone prescription there are two main choices. Either reduce the dose prior to the final detox or reduce the dose by 25%-50% each day until 20mg is reached and then complete the programme as above. However it must be recognised that these large early reductions will probably result in intense withdrawal symptoms.

If required, ‚holding‘ on a given dose on one or two occasions during the detox may increase the client’s sense of control and decrease their anxiety. Delays in the rate of reduction should usually be accompanied by an increase in psychological support.

Longer-term detoxification: decreasing doses over 1-6 months

1 month detoxification regime

From a starting dose of 40mg:

  • 40mg for 4 days
  • 35mg for 3 days
  • 30mg for 4 days
  • 25mg for 3 days
  • 20mg for 4 days
  • 15mg for 3 days
  • 10mg for 4 days
  • 5mg for 3 days

From a starting dose of 25mg:

  • 25 mg for 4 days
  • 20mg for 3 days
  • 15mg for 4 days
  • 10mg for 3 days
  • 8mg for 4 days
  • 6mg for 3 days
  • 4mg for 4 days
  • 2mg for 3 days

4 month detoxification regime
Following initial stabilisation, and a period in which the client remains heroin free, the daily dose can be reduced by 5mg or 10mg every week or fortnight until 30mg is reached.

The rate of reduction in the daily dose is then reduced to 5mg every week or fortnight until 10-15mg is reached. At this point daily dose reductions can be reduced to 2 or 2.5mg every week or fortnight.

A typical 4 month regime using these principles from a starting dose of 45mg would be:

  • 45mg for 14 days
  • 35mg for 14 days

  • 30mg for 14 days
  • 25mg for 14 days

  • 20mg for 14 days
  • 15mg for 14 days

  • 10mg for 14 days
  • 7mg for 14 days

6 month detoxification regime
A 6 month detox regime using the same principles as the 1-5 month detox, from a start of 60mg might be:

  • 60mg for 14 days
  • 50mg for 14 days

  • 40mg for 14 days
  • 30mg for 14 days

  • 25mg for 14 days
  • 20mg for 14 days

  • 15mg for 14 days
  • 10mg for 14 days

  • 8mg for 14 days
  • 6mg for 14 days

  • 4mg for 14 days
  • 2mg for 14 days

Detoxification following exclusion from a methadone prescribing programme
Sometimes methadone prescriptions are stopped. The reasons for doing this are discussed in Section 10: Practical issues in methadone prescribing – Terminating treatment.

The client should be aware of exactly what the rate of detox will be before the prescription is terminated. Abrupt cessation of opiates is not fatal in people who are otherwise healthy. The rate of reduction therefore usually seeks to strike a balance between continuance of the prescribing programme under a new guise, and a rate of reduction which gives the individual little chance of achieving abstinence if they want to.

A regime such as the following is commonly used:

  • 10mg reduction in the daily dose every day until the patient is receiving 30mgs daily

and then:

  • 5mg reduction in the daily dose each day with 2 days on 5mg at the end.

However any of the above regimes could be employed.

Anxiety
Client expectations of anxiety are one of the best indicators of the intensity of withdrawal symptoms and there can be little doubt that the two are closely linked.

As with all anxiety-provoking situations, levels of anxiety during and after methadone detoxification can be reduced through information being given to the client about what they can expect to happen and why it is happening, and the opportunity being given to discuss the issues that are raised.

Emotions such as anger and depression can trigger withdrawal symptoms in people who are stabilised on methadone – this is known as ‚pseudo withdrawal syndrome‘. If clients become more aware of these feelings during a detox then this too will increase the severity of their withdrawal symptoms. Counselling during and after the detox can help deal with these emotions and reduce the physical consequences.

Abstinence phobia
S M Hall in 1979 described abstinence phobia as an exaggerated response to comparatively mild withdrawal symptoms.90

Indeed many clients become very anxious as soon as dose reductions begin and feel unable to continue with the detoxification. Hall suggested that previous actual or observed traumatic experience of withdrawal symptoms may be the cause of this fear. Unfortunately her attempts to use standard cognitive behavioural therapy in a controlled trial – which has been shown to be effective in other anxiety disorders – were unsuccessful.

This being the case, choices for clients who demonstrate high levels of anxiety during detox are limited as they are unlikely to achieve abstinence without considerable support. Slowing the rate of reduction and increasing support is the first line response. Following this in-patient detoxification or residential rehabilitation might be options.

If the anxiety cannot be resolved, and relapse is the outcome of all attempts at detox, the most appropriate response may be methadone maintenance.

Alternatives to methadone in detoxification

Clonidine
This is similar in its action to lofexidine (see below), the major difference being its more powerful hypotensive action which contra-indicates its use in anything other than an in-patient setting. Clonidine has never had a product licence for opiate detoxification.

Lofexidine (BritLofex)
Lofexidine hydrochloride is now fully licensed in the UK for management of the symptoms caused by withdrawal. Lofexidine is not an opiate and does not stimulate opiate receptors and therefore does not have the psychoactive effect nor the dependency potential of opiates.

It works by inhibiting the release of noradrenaline. Noradrenaline is a key chemical transmitter that acts on the nervous system, the action of which has been suppressed by opiates: see Section 4: The physiology and pharmacology of methadone.

As lofexidine is not an opiate, increasing the dose too quickly, or beyond the recommended maximum, will not necessarily reduce withdrawal symptoms but it will increase the risk of side effects such as hypotension (low blood pressure). This should be made very clear to patients who are self administering their lofexidine tablets.

The safety of lofexidine in pregnancy has not yet been established.

Lofexidine is unlikely to:

  • Completely eliminate withdrawal symptoms (the extent to which it reduces withdrawal symptoms varies)
  • Greatly affect the insomnia associated with opiate withdrawal
  • Stop cravings for opiates
  • Reduce anxiety
  • Be effective if used in the absence of careful assessment and support during and after treatment.

The effect of these factors can be reduced by:

  • Giving the client full information about what to expect
  • Using low-dose prescribed night sedation for a defined period (lofexidine may potentiate the action of anxiolytics and hypnotics)
  • Offering support and counselling during and after the detox.

Side effects
Hypotension (low blood pressure) is the principle possible side effect that can occur during treatment with lofexidine. Although this could prohibit its use for some clients and may result in discontinuation of treatment in others, in practice there is rarely a clinically significant reduction in blood pressure.

Blood pressure should be monitored, especially while the dose is increasing. For in-patients if the standing systolic BP has dropped by more than 30 mmHg (and is associated with symptoms of dizziness and light-headedness or over-sedation) the next dose of lofexidine should be withheld until the systolic BP is less than 30mmHg below the baseline.

Sedation is more likely to occur in clients concurrently prescribed (or taking) benzodiazepines and/or other central nervous system depressants.

Lofexidine is safe for community use in patients who are:

  • Able to control their use of the drug
  • Unlikely to use illicit drugs concurrently
  • Willing to comply with the regime
  • In regular contact with the prescriber/drug worker.

A typical 10 day out-patient lofexidine regime
Reduce the methadone dose to 15mg daily and ask the patient to take their last dose in the evening.

The following morning (detox day 1) begin the following regime:

Day of detox Maximum number of tablets to be taken in the morning Maximum number of tablets to be taken at lunch time Maximum number of tablets to be taken at 6pm Maximum number of tablets to be taken at night
Day 1 2 0 0 2
Day 2 2 0 2 2
Day 3 2 2 2 2
Day 4 3 2 2 3
Day 5 3 3 3 3
Day 6 3 1 2 3
Day 7 2 0 2 3
Day 8 2 0 1 2
Day 9 1 0 0 1
Day 10 0 0 0 1


Notes:

  • The action of lofexidine is reduced by tricyclic antidepressants and they should not, therefore, be prescribed concurrently.
  • Patients may determine their own dose, titrated against withdrawal symptoms, up to the maximum doses shown.
  • Blood pressure and pulse should be monitored regularly, especially while the dose is increasing.
  • The maximum dose phase i.e. ‚Day 5‘ may be continued for up to 6 days prior to beginning the ‚Day 6-10‘ reduction regime if withdrawals remain severe or if there has been additional illicit drug use.

The patient must be told:

  • To omit or take less than the maximum dose if giddiness is a problem
  • That once the maximum dose is reached taking more tablets will only increase the side effects and will not further diminish the withdrawal symptoms
  • That the worst withdrawal symptoms will be experienced on days 1-5
  • That there may be an immediate drop in tolerance to opiates – so if they relapse, the risk of overdose will be high.

Dihydrocodeine
In an attempt to reduce the severity of withdrawal symptoms some services switch detoxifying clients from methadone to dihydrocodeine for the final part of the process – usually when the daily methadone dose reaches around 15mg.

The rationale for this is that dihydrocodeine is:

  • A shorter-acting drug that may interfere with natural endorphin production less than methadone, thus reducing the severity of long-term withdrawals
  • A relatively weak opiate (30mg of dihydrocodeine = 3mg of methadone)
  • Easy to reduce slowly without practical difficulties, especially if the 10mg/5mL elixir is used.

There have been no controlled trials comparing subjective experience of withdrawals when detoxing on methadone, heroin or dihydrocodeine, but some clinicians have found the switch helpful, particularly if the anxiety of withdrawal is focused on the problems of coming off methadone.

However the treatment can have drawbacks. The experience of a ‚high‘ on dihydrocodeine can be greater than with methadone and thus clients can attempt unsustainable methadone dose reductions in pursuit of the ‚reward‘ of a ‚better drug‘.

Switching drug can also detract from the other psychological causes of withdrawal symptoms, neglect of which is unlikely to be therapeutic.

The product licence for dihydrocodeine does not include treatment of opiate dependence.

Methadone v heroin in detoxification
There is a commonly held belief amongst drug users that the withdrawal symptoms are worse and more prolonged when coming off methadone than heroin.

Given that methadone is a longer-acting drug this is probably true. However the experience of withdrawal is probably exacerbated by factors which are different with regard to most methadone detoxes as opposed to most illicit heroin detoxes.

Most illicit heroin withdrawal symptoms are:

  • Part of a fluctuating drug-using pattern and associated with shortages of heroin
  • Result in only a few days‘ abstinence
  • Self-medicated, to some extent, with benzodiazepines, alcohol or other drugs
  • Not part of a planned attempt to become drug free.

Most methadone withdrawal symptoms are:

  • A planned part of a clear intention to become drug free
  • At the end of a planned detox with an intention to give up drug use
  • Experienced without the relieving effects of concurrent drug use.

These factors probably all increase the stress associated with methadone dose reductions and serve to increase the subjective experience of withdrawal symptoms. Discussion of these issues with the client will probably serve to reduce the severity of the withdrawal experience.

Follow up/relapse prevention
People who have been using opiates for some time and who detoxify using methadone often benefit from support and assistance for some time afterwards. Plans and support mechanisms for the period after the detox should be in place before it commences.

Risk of relapse is always high as there are many potential causes of relapse including:

  • Protracted withdrawal symptoms
  • Insomnia
  • Environmental cues
  • Contact with current users
  • Stress
  • Anxiety
  • Low self esteem
  • Depression.

The person who has succeeded in getting off opiates will need help to resist these cues to relapse. Often clients are reluctant to return to prescribing services for follow-up support and there are often few services for those that do.

Support that would help and could be provided by drug services includes:

  • ‚Coming off/staying off‘ therapeutic groups
  • Relapse prevention training
  • Individual counselling
  • Self help groups
  • Life skills instruction, assertiveness, etc.
  • Naltrexone treatment.

Support that could be suggested/facilitated by drug services includes:

  • Careers advice
  • Further education
  • Narcotics Anonymous meetings
  • Vocational training.

 

A wonderful Source: http://www.drugtext.org/library/books/methadone/section9.html#methtop

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

Drug addicts should completely end their addictions rather than just cut their use, the government’s new strategy states.

Ministers said their „drugs-free recovery“ policy would include former addicts mentoring current ones.

The plans could see addicts lose benefits if they do not co-operate.

The former Labour government’s strategy was to reduce the harm caused by drugs by initially stabilising addictions, rather than trying to end them.

Parts of the strategy will apply to the whole of the UK, but in England ministers want to set up a network of former addicts to help drug users overcome their dependency.

Under the Home Office plans, treatment and rehabilitation centres would fall under the control of local partnerships which would target the specific needs of communities.

The strategy outlines the setting up of „Community Recovery Champions“ networks where people who have recovered from drug dependency could mentor others who seek their help.

Ministers said they will also target the supply of drugs in the UK, with a renewed focus on seizing the assets of those involved in the drugs trade, both at home and abroad.

‚Legal highs‘

Prescription-based treatments, such as the heroin-substitute methadone will continue, but it is not yet clear how much funding will be allocated.

Ministers also want to link drug treatment with welfare benefits in England, Wales and Scotland.

They launched a consultation paper in August that suggested a „financial benefit sanction“ if addicts did not take action to address their substance dependency.

Powers to temporarily ban ‚legal highs‘ until they are proven to be medically safe will come into effect immediately.

But Oscar Dagnone, medical director at CRI, an organisation that works with drug addicts, warned against trying to implement a „one-size fits all“ anti-drugs policy.

„We have to focus on the individual. Everyone is different,“ he said.

„I have never seen a drugs problem. I have seen people with problems and using drugs to deal with their problems. The issue we have in the UK is we have just been focussing on what we see as ‚problematic drug users‘. Everyone is in a different situation.“

 

http://www.bbc.co.uk/news/uk-11943958

Some pharmacists in Vancouver’s Downtown Eastside routinely pay cash to drug addicts for filling their prescriptions, a CBC hidden-camera investigation has found.

The practice was revealed after several doctors complained that pharmacies were giving $10 a week or more to clients for each prescription filled if the drugs were dispensed daily. The daily prescription entitles the pharmacist to a daily dispensing fee, rather than a single fee for a long-term prescription.

A CBC hidden camera captured this image of a pharmacist giving cash to a customer filing a prescription on Vancouver's Downtown Eastside.

A CBC hidden camera captured this image of a pharmacist giving cash to a customer filing a prescription on Vancouver’s Downtown Eastside. (CBC)In the drug-ravaged neighbourhood, $10 cash buys a „rock“ of crack cocaine.

„All of a sudden we had a lot more [illegal-drug] dealers hanging around our clinic,“ said Dr. Helen Weiss of the Vancouver Native Health Clinic (VNHC) on East Hastings Street. „The cash deal is available to everyone who goes to certain pharmacies.“

„Now you have patients being very demanding and trying to be very directive as to what they should get in terms of their prescriptions,“ said Dr. David Tu. „There is a lot of frustration amongst the doctors.“

The more prescriptions a pharmacy fills for customers covered by PharmaCare — the provincial agency that uses taxpayers‘ money to help eligible British Columbia residents cover the cost of eligible prescription drugs — the more money it can charge.

Most of the addicts in the Downtown Eastside are covered by the plan.

The province pays pharmacies $8.60 each time they dispense a drug, even if it’s just a single pill handed out daily. On top of that, the pharmacies get an additional $7.70 per daily dose for dispensing methadone and supervising the patient as they drink it.

The doctors at VNHC believe that if the daily dispensing were eliminated, pharmacists would have no incentive to encourage daily prescriptions or pay kickbacks.

„It’s a waste of money, certainly — in the area of hundreds of thousands of dollars that could be so much better spent,“ Tu said.

‚All of a sudden we had a lot more [illegal-drug] dealers hanging around our clinic.‘— Dr. Helen Weiss

Recently, CBC placed a hidden camera on an addict who needed a prescription filled for Tylenol 3. He went into AYC Pharmacy, a few doors down from the VNHC, and asked the manager, Manji Farbeh, for a $10 payback.

„For this we don’t give you $10 — $5, just $5,“ Farbeh replied.

She explained she wouldn’t pay $10 because the addict’s prescription was only good for a week.

The addict, whom CBC News has agreed not to name, replied: „Five? Come on. How am I supposed to get a [cocaine] rock for five bucks?“

Farbeh laughed, then a pharmacist handed the addict a $5 bill. Outside the pharmacy, other customers told the addict they have been paid more.

„There was one time when I got my methadone they gave $30,“ said one female customer who was recorded by the hidden camera. A male customer added: „Ten bucks a week. That and 20 bucks every two weeks for my methadone.“

Bernadette Murphy, spokeswoman for B.C.’s Ministry of Health, said it is a violation of the pharmacist’s contract with government to pay customers for prescriptions.

„There are rules set out in the British Columbia PharmaCare Pharmacy Participation Agreement which basically says that no incentives shall be offered as an inducement to secure prescription orders,“ Murphy wrote in an e-mail.

Interview requested

CBC News requested an interview with the owner of AYC Pharmacy, where the addict with the hidden camera was given a cash incentive.

Nikhil Buhecha’s lawyer responded by letter, indicating he was willing to participate under certain conditions. Buhecha did not respond to subsequent phone calls. Buhecha also owns Abbott Renuka Pharmacy, which is also in Vancouver’s Downtown Eastside.

CBC News obtained prescription records for a patient who gets nine different pills dispensed daily at Buhecha’s pharmacies. From his business alone, the records show, the pharmacy could charge the province almost $2,400 a month in dispensing fees. At the $10-a-week cash rate per prescription, the cash payback to the customer could reach $400 a month.

Dr. Helen Weiss, left, and Dr. David Tu of the Vancouver Native Health Clinic say there is a lot of frustration among  doctors over the kickbacks for prescriptions.

Dr. Helen Weiss, left, and Dr. David Tu of the Vancouver Native Health Clinic say there is a lot of frustration among doctors over the kickbacks for prescriptions. (CBC)The doctors at VNHC said they’ve seen a sharp increase in patients asking for unnecessary and perhaps dangerous drugs.

„People come in and they are on multiple prescriptions,“ Weiss said. „People are trying to get on methadone who actually are not narcotic addicts simply because they can get a small [cash] incentive and then perhaps sell it on the street.“

Weiss said she watched as one of her patients was screamed at by her boyfriend because she didn’t get a prescription he could cash in.

Tu said a patient of his was given a dangerously high amount of methadone after she switched to a cash-paying pharmacy.

„They double-dosed her,“ Tu said. „She could have died, and we had to watch her for 24 hours.“

CBC News watched outside AYC Pharmacy early one morning as dozens of patients lined up to get their methadone. Several walked out with a Styrofoam cup full of liquid before drinking from it. Very few of them drank from their cups in front of the pharmacist.

Apparent rule violation

That is also an apparent violation of rules governing pharmacists, which state they are supposed to make sure patients drink all their methadone before leaving the premises.

Guidelines posted at the College of Pharmacists of B.C. website read: „After the patient drinks the methadone, a short conversation is required to ensure that the methadone has been swallowed. Confirmation … is necessary as some patients may try to keep the methadone in their mouth until they can spit it into a container.“

Doreen Littlejohn, a nurse with the nearby Native Health Society, confirmed that 10 patients surveyed recently said they often leave AYC with a full Styrofoam cup of methadone in hand.

„I asked everyone who came in that day if they are able to take their methadone with them, and they all said yes,“ Littlejohn said.

„There is a lot of methadone for sale on the street,“ Weiss said, „and it’s because people manage to walk out with it. That methadone has high street value and you sell it to someone — a very powerful narcotic — and they don’t know what they are doing and there can be overdoses.“

The doctors at VNHC wrote letters of complaint to the Ministry of Health and the B.C. College of Pharmacists. Weiss said PharmaCare’s director of pharmaceutical services, Bill Mercer, assured her in January of 2008 that tough action would be taken and asked her not to go to the media with her concerns.

„The people I spoke with genuinely seem concerned but I think they are very limited in what they can do,“ Weiss said, „partly because our patients have no credibility.“

7 months of silence

The VNHC doctors said they have heard nothing from the authorities in the seven months since they lodged their complaints.

„They need to investigate,“ Tu said. „They need to take these allegations seriously because the system is going to crumble if they don’t.“

Tu is especially worried the competitive pressure from pharmacies that pay kickbacks will drive those that don’t out of business.

B.C. Health Minister George Abbott said he is concerned about cash payments made for prescriptions on Vancouver's Downtown Eastside.

B.C. Health Minister George Abbott said he is concerned about cash payments made for prescriptions on Vancouver’s Downtown Eastside. (CBC)„Pharmacists are our partners,“ he said. „They are an essential part of the health-care system. We rely on them so heavily and then to have them be people that are behaving unethically according to their own pharmacy code, and in such ways that I feel that I can’t trust them — that’s what hurts. That’s what this is about, I think.“

„We are very concerned about this,“ B.C. Minister of Health George Abbott said. „If the practices as alleged are occurring as alleged then obviously there’s a range of remedies that we can employ, and that range of remedies would certainly include an end or termination of opportunity for the pharmacy in question to distribute methadone.“

Tu and Weiss believe the solution is simple: The province should pay pharmacists only one dispensing fee per prescription, not every time they dispense a single pill.

„If people weren’t making money out of these daily dispense meds, there wouldn’t be the need to be behaving this way,“ Weiss said. „If there was only a weekly dispensing fee at max, this wouldn’t happen.“

Read more: http://www.cbc.ca/canada/british-columbia/story/2008/09/07/bc-prescription-for-profit.html#ixzz160AC5OM0

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

PORTO, Portugal—This country’s move to decriminalize illicit substances—Europe’s most liberal drug legislation—turns 10 years old this month amid new scrutiny and plaudits.

Portugal’s decriminalization regime has caught the eye of regulators in Europe and beyond since it was implemented in 2001. Proponents credit the program for stanching one of Europe’s worst drug epidemics. Critics associate it with higher crime and murder rates. Approaching a decade in force, it is providing a real-world model of one way to address an issue that is a social and economic drag on countries world-wide.

Norway’s government formed a committee to look at better strategies for dealing with drug abuse and sent two delegates to Portugal in early May. Danish politicians have also talked of moving toward full decriminalization. In March, Danish parliamentarian Mette Frederiksen of the opposition Social Democrats praised the Portuguese model.

„For us, this is about the addicts leading a more dignified life,“ she told Danish daily Berlingske. „We want to lower the death rates, the secondary symptoms and the criminality, so we look keenly to Portugal.“

Markel Redondo for The Wall Street JournalA patient takes her methadone dose at a Porto rebab center that is part of Portugal’s decadelong experiment with drug decriminalization.

PORTDRUG

PORTDRUG

Decriminalization has been criticized by United Nations bodies. In its 2009 annual report, the International Narcotics Control Board expressed „concern“ over approaches that decriminalize drugs or introduce alternative treatments. „The movement poses a threat to the coherence and effectiveness of the international drug-control system and sends the wrong message to the general public,“ the board wrote.

In July 2000, Portugal moved beyond previous liberalization regimes in places like the Netherlands by passing a law that transformed drug possession from a matter for the courts to one of public and community health. Trafficking remained a criminal offense but the government did away with arrests, courts and jail time for people carrying a personal supply of anything from marijuana to cocaine to heroin. It established a commission to encourage casual users to quit and backed 78 treatment centers where addicts could seek help.

Portugal’s Fight Against Drugs

About 500 patients from Porto’s Cedofeita rehab center take methodone daily.

In 2008, the last year for which figures are available, more than 40,000 people used the rehab centers and other treatment programs, according to the Institute for Drugs and Drug Addiction, a branch of Portugal’s Ministry of Health. The ministry says it spends about €50 million ($64.5 million) a year on the treatment programs, with €20 million more provided through a charity funded by Portugal’s national lotteries.

Before decriminalization, Portugal was home to an estimated 100,000 problem heroin users, or 1% of the country’s population, says João Goulão, director of the Institute for Drugs and Drug Addiction. By 2008, chronic users for all substances had dropped to about 55,000, he says. The rate of HIV and hepatitis infection among drug users—common health issues associated with needle-sharing—has also fallen since the law’s 2001 rollout.

Portuguese and European Union officials are loath to give publicly funded treatment centers sole credit. They say the drop in problematic drug users could also be attributed to heroin’s declining popularity in Portugal and the rising popularity of cocaine and synthetic drugs among young people.

At the same time, Portugal’s drug-mortality rate, among Europe’s lowest, has risen. Mr. Goulão says this is due in part to improved methods of collecting statistics, but the number of drug-related fatalities can also be traced to mortality among those who became addicted to heroin during the country’s 1980s and 1990s epidemic.

Violent crime, too, has risen since the law’s passage. According to a 2009 report by the U.N. Office on Drugs and Crime, Portugal’s drug-use and murder rates rose in the years after decriminalization. The general rise in drug use was in keeping with European trends, but the U.N. noted with some alarm that cocaine use doubled and cocaine seizures jumped sevenfold from 2001 to 2006.

Murders rose 40% in the period. The report tentatively links that with drug trafficking, but points out overall murder rates in Portugal remain low.

Pedro do Carmo, deputy national director of Portugal’s judiciary police, says he doesn’t see link the rise in violent crime with decriminalization. Instead, he praises the program for reducing the fear and stigma attached with drug use. „Now, when we pick up an addict, we’re not picking up a criminal,“ he says. „They are more like victims.“

The Portuguese began considering drug decriminalization following a leap in heroin addiction decades ago in the country, a major entry point for drug trafficking from Latin America and North Africa.

The then-ruling Socialist Party government of Prime Minister António Guterres launched a political debate to discuss how to resolve the problem. Members of the right-wing People’s Party decried any tolerance for drug use, saying it would invite drug tourism.

Mr. Guterres’s government pushed through a full decriminalization law. A subsequent center-right coalition led by José Manuel Barroso, now president of the European Commission, didn’t repeal it.

The legislation was the first in a series of liberal policy shifts in this predominantly Roman Catholic country. In May, President Aníbal Cavaco Silva ratified a law allowing same-sex marriage, making it the sixth European country to do so. In 2007, Portugal went from having among the toughest restrictions on abortion to among the most liberal.

Portugal’s focus on close-knit community and protecting the family may be at the heart of many of these reforms, say some observers. In a 1999 report that paved the way for new drug legislation, current Portuguese Prime Minister José Sócrates implored that „drugs are not a problem for other people, for other families, for other people’s children.“

Portugal’s rehab clinics, called Centros de Atendimento de Toxicodependentes, are central to the strategy. In the lively northern port city of Porto, dozens of patients pop in daily to the Cedofeita rehab center to pick up free doses of methadone. Others have scheduled therapy or family counseling sessions, also free.

„The more they can be integrated in their families and their jobs, the better their chances of success,“ says José González, a psychiatrist at Cedofeita. Mr. González says that about half of his 1,500 patients are in substitution treatment, 500 of which take methadone daily. He says there is no defined model or timeline for treatment.

The European Monitoring Centre for Drugs and Drug Addiction, a Lisbon-based European Union agency, says methadone or other substance-substitution programs are generally viewed as successful but has observed that some Portuguese are beginning to question long-term methadone therapy.

„Now that the epidemic is under control for the most part, people start asking questions,“ says Dagmar Hedrich, a senior scientific analyst with the EMCDDA. „The question now is what is going to happen next? There is a part of the population who do not have the possibility of leaving the treatment.“

Strict limits on how long drug addicts are allowed to stay on heroin substitute methadone have been proposed by the government body responsible for treatment strategy, in what will be seen as a watershed in UK drugs policy.

The National Treatment Agency for Substance Misuse (NTA) is describing the move as a rebalancing of the system in favour of doing more to get addicts clean.

But cynics will regard the shift by the NTA, which has faced criticism and calls for it to be scrapped, as a late attempt to save itself before the coalition review of arm’s-length government bodies.

Martin Barnes, the chief executive of the DrugScope charity, which represents 700 local drugs agencies, said: „A goal of avoiding open-ended prescribing through improved practice is not the same as, and should not be confused with, the setting of time limits.“

An estimated 330,000 people in England and Wales are addicted to heroin, crack cocaine or both. More than 200,000 are in contact with treatment agencies, but most are „maintained“ on methadone or other synthetic opiates, at a cost of £300m a year, rather than pushed towards abstaining from all drugs, whether prescribed or illegal. Strict time limits on methadone treatment would require a big expansion of residential care for addicts.

In a report last week the influential Centre for Social Justice, set up by former Conservative party leader Iain Duncan Smith, called for the NTA to be scrapped and replaced by an „addiction recovery board“ covering drugs and alcohol misuse. The report repeated claims that only 4% of drug addicts are emerging clean from treatment.

The NTA, which is responsible for England, disputes this figure, saying that the number of people „successfully completing treatment free of dependency“ rose to 25,000 in 2008-09, about 12% of those who were in „effective“ treatment.

However, the agency has accepted that it needs to revise its approach in view of the change of government. In draft changes to its business plan, approved by the NTA board but not yet signed off by ministers, it states: „We intend to take forward the government’s ambition for a rapid transformation of the treatment system to promote sustained recovery and get more people off illegal drugs for good.“

The aim, the draft says, is to rebalance the system and „ensure successful completion and rehabilitation is an achievable aspiration for the majority in treatment“.

The idea of time limits is drawn from new Department of Health clinical guidance for opiate prescription in prisons. The guidance requires that offenders serving sentences of six months or more should have any prescription reviewed at least every three months. The prison guidance states: „If there is some exceptional reason why abstinence cannot be considered, then the reason must be clearly documented on the clinical record at each three-month review.“

In the draft revision of its business plan, the NTA says: „No one should be ‚parked‘ indefinitely on methadone or similar opiate substitutes without the opportunity to get off drugs. New clinical guidance has introduced strict time limits to end the practice of open-ended substitute prescribing in prisons. This principle will be extended into community settings.

„New clinical protocols will focus practitioners and clients on abstinence as the desired outcome of treatment, and time limits in prescribing will prevent unplanned drift into long-term maintenance.“

The NTA declined to comment on its proposals. But word of its policy shift is prompting excited debate in the £1.2bn drugs treatment sector. The methadone issue became totemic for critics of the Labour government’s social and criminal justice policies, and was raised repeatedly by David Cameron during the general election campaign.

Karen Biggs, the chief executive of Phoenix Futures, a leading treatment provider, welcomed the move towards a „better balance“ in the treatment system. „There are excellent examples across the country of recovery-orientated treatment systems that help people move from the most chronic addictions to a life of recovery,“ Biggs said. „A balanced treatment system which is ambitious for the individuals and communities with which it works will contribute to the wider social policy objectives of the coalition government.“

ABSTRACT
Objectives To examine survival and long term cessation of
injecting in a cohort of drug users and to assess the
influence of opiate substitution treatment on these
outcomes.
Design Prospective open cohort study.
Setting A single primary care facility in Edinburgh.
Participants 794 patients with a history of injecting drug
use presenting between 1980 and 2007; 655 (82%) were
followed up by interview or linkage to primary care records
and mortality register, or both, and contributed 10 390
person years at risk; 557 (85%) had received opiate
substitution treatment.
Main outcome measures Duration of injecting: years from
first injection to long term cessation, defined as last
injection before period of five years of non-injecting;
mortality before cessation; overall survival.
Results In the entire cohort 277 participants achieved
long term cessation of injecting, and 228 died. Half of the
survivors had poor health related quality of life. Median
duration from first injection to death was 24 years for
participants with HIV and 41 years for those without HIV.
For each additional year of opiate substitution treatment
the hazard of death before long term cessation fell 13%
(95% confidence interval 17% to 9%) after adjustment for
HIV, sex, calendar period, age at first injection, and
history of prison and overdose. Conversely exposure to
opiate substitution treatment was inversely related to the
chances of achieving long term cessation.
Conclusions Opiate substitution treatment in injecting
drug users in primary care reduces this risk of mortality,
with survival benefits increasing with cumulative
exposure to treatment. Treatment does not reduce the
overall duration of injecting.
INTRODUCTION
Injection drug use is an important public health problem
with a prevalence of around 1-2% among young
adults in the United Kingdom and a standardised mortality
ratio over 10 times that of the general
population.1 Deaths in those who inject opiates are
mainly a consequence of overdose and bloodborne
infection.2 The principal treatment for dependent
users is opiate substitution therapy, commonly oral
methadone,3 which in the UK is mostly delivered in
primary care settings. Opiate substitution treatment
can reduce opiate use, mortality, and transmission of
bloodborne infections, though most evidence comes
from relatively short term studies.4-8
Short periods of cessation from injecting are relatively
common,9 but few studies have long enough follow-
up to observe long term cessation, and the impact
of opiate substitution treatment on the overall duration
of injecting is unclear.10
We report on a follow-up study of the Edinburgh
addiction cohort.11 This study included injecting drug
users, most of whom were using heroin, recruited
through Muirhouse Medical Group, a single primary
care facility in a deprived area of Edinburgh, during a
rapid local HIV epidemic.12 We describe the duration
of injecting and survival and assess the influence of
opiate substitution treatment and other factors on
these outcomes.
METHODS
Data source
Methods are described in detail elsewhere.11 13 Briefly,
between 1980 and 2006 all patients at a large primary
care facility in Edinburgh who reported a history of
injecting drug use were recruited to the study. Opiate
substitution treatment was publicly funded and accessible
to patients throughout the study period, in keeping
with national guidelines. Cohort members were
flagged with the General Register Office for Scotland
to allow for tracing of deaths and changes of general
practitioner. From October 2005 to November 2007
we attempted to contact all surviving cohort members
to conduct a follow-up interview. Information was also
collected from primary care notes when these were
available.

Read the whole study, it is the longest ever:Methadon, scotland

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?

Methadone & Pregnancy
“Is methadone safe for my baby?” is usually the first question  we hear           from women.
Pregnant women have been treated with methadone for more than  25  years          and neither methadone or other opiates have not been  shown to  directly          cause birth defects. However, your baby may  experience some side  effects          from methadone. The most common  are smaller-than-normal head  size, low          birth weight, and  withdrawal symptoms. As babies born dependent  on methadone           grow, they usually will fall in the normal range for size and   development.

Methadone is not the only thing that can cause these symptoms.   Smoking          cigarettes, drug use, your biological makeup,  nutrition, and how  well          you take care of yourself are just a  few examples of things that  can affect          the health of your  baby.
Whether or not you are pregnant, you only get the benefits of   methadone          if you are stable on your dose. There is no ‘magic  number’ of  milligrams          to stay below. If you feel any  withdrawals or cravings to use,  make sure          you talk to your  counselor about adjusting your dose. When you  feel withdrawals,           so does your baby and that can lead to complications and even   miscarriage.

Research does not necessarily show any connection between a mother’s dose and withdrawal symptoms in the baby.

It might seem that the more milligrams a mother is taking, the worse the withdrawal symptom s will be, however this is not the case. That’s why we encourage you to focus on finding a dose that works for you and not to worry about the amount of milligrams. If you are tapering, most clinics will stop your taper and keep you at your current dose. Some women ask about tapering off methadone while they are pregnant. The Government’s Center for Substance Abuse Treatment says this: “Medical withdrawal of the pregnant women from methadone is not indicated or recommended.” and here at methadoneandpregnancy.com agree with them. Remember- If you were not ready to taper before you were pregnant, you are not ready to taper because you are pregnant. Medically, pregnant women have been safely tapered off of methadone, but it’s only been done on an inpatient basis where they can monitor the fetus for any distress. You should never try to detox yourself. This can be very dangerous to you and your baby. This can also put your recovery in jeopardy. Usually when women learn more about methadone use during pregnancy and see other healthy babies at the clinic with their moms, they decide to continue methadone treatment. It’s not uncommon to need a dose increase during your pregnancy. By the third trimester the amount of blood in your body just about doubles! Because of this your dose of methadone may need to be increased to help keep you and your baby free from withdrawal symptoms. In fact, an increase in methadone (if you need it) during this time can help improve growth and reduce risk of premature delivery. We cannot stress it enough; make sure you are stable on your dose! If for some reason you aren’t able to make it to the clinic for one day make sure you call the clinic and let them know you aren’t able to make it in. Do your best to get there the next day as early as possible. If you’re having problems with transportation, talk to your counselor. They will help you to figure out how you can get to the clinic every day. Many people wonder: does methadone use during pregnancy increase the chance of my child becoming an addict? There are not many studies that have looked at long-term effects of babies born depended on methadone. The other problem is that there are so many factors influencing drug use, it would be difficult to pinpoint methadone as the ‘cause’ if a child did start using drugs. We do know that there is a genetic component to addiction, so regardless if you are in methadone treatment or not, if you or the baby’s father has had substance abuse problems, the child may be at an increased risk of being an addict or having problems with drug use. While you are pregnant some clinics require that you meet with the Nurse Practitioner (NP) or other medical staff at least once per month. The medical staff wants to check in with you to make sure your pregnancy is going smoothly and ask about your prenatal visits. This is an excellent time to ask any medical questions. If you have any questions at anytime feel free to talk to your counselor or medical staff at the clinic. Your questions are important and deserve to be answered! Clinic staff may ask you to sign a release so we can speak with your prenatal providers. The release is needed so we can talk with your prenatal provider about your treatment at the clinic. It’s also important to have a release in place so if there are any medical concerns the clinic will be able to assist you. Medications such as Suboxone, Nubain, and Stadol could cause you to have severe withdrawal symptoms if you are taking methadone. Be cautious of medications that you are prescribed or given. You should always check with your medical providers before taking any medication. You should never take anyone else’s prescription medication. And be careful about taking any medications, even if it’s offered to you from a friend or family member. Some people store more than one type of medication in a bottle and you might be given something that could harm you, your pregnancy, or cause you to have a positive drug screen. All of your providers are here to support you and want to help you to have a healthy and safe pregnancy! Let us know what you need and how we can help. 1. Methadone maintenance treatment Methadone maintenance treatment (MMT) is the treatment of choice for opioid dependant pregnant women 2. Methadone is a long-acting opioid that enables women to cease or reduce their heroin use and related behaviours, in accordance with a harm minimization philosophy. MMT throughout pregnancy is associated with improved fetal development, infant birth weight, and reduces the risk of perinatal and infant mortality in heroin dependant women (level III 2, 1). The aims of methadone maintenance treatment are to:
  • Reduce or eliminate illicit heroin and other drug use
  • Improve the health and wellbeing of those in treatment
  • Facilitate social rehabilitation
  • Reduce the spread of blood borne diseases
  • Reduce the risk of death associated with opioid use
  • Reduce the level of crime associated with opioid use 2
  • Withdrawal from heroin, without MMT is associated with risks to the fetus and a high risk of relapse2. Women should be informed of these risks, and if it is to be attempted it should ideally be done in the 2nd trimester, supervised in a specialist unit (Consensus,1). While inpatient supervision of withdrawal is not available at the Women's, WADS clinicians are able to provide outreach services to pregnant women undergoing withdrawal in specialist detoxification units.
2. Methadone stabilisation program Heroin dependant women should have priority access to methadone treatment, which includes admission to an inpatient obstetric unit for stabilization and rapid dose titration, with respite from the external environment (Consensus,1). This service is offered at the Women's, under the supervision of WADS care coordination team inpatient stabilisation brochure, at any gestation. Admission is for 5 days (Monday to Friday). Inpatient admission is necessary as rapid induction onto methadone is required. Legislative requirements must be met, including obtaining a permit for prescribing methadone from DHS before commencing, as per the Women's CPG: Methadone and Buprenorphine Dosing Procedures. Care in pregnancy should be provided as per CPG: Care of Women with Alcohol and Drug Issues in Pregnancy. 2.1 Criteria for methadone stabilisation program Women will be assessed as being
  • dependent on opioids
  • motivated to undertake induction onto MMT
  • willing to comply with the whole program and methadone regime.
Women not suitable for treatment with methadone3:
  • Severe hepatic impairment
  • Hypersensitivity to methadone
  • Unable to give informed consent (eg. Major psychiatric illness) or age under 18, consider jurisdictional requirements for obtaining legal consent
Specialist advice should be sought for clients with severe respiratory depression, acute asthma, acute alcoholism, head injury and raised intracranial pressure, ulcerative colitis, biliary and renal tract spasm, patients receiving monoamine oxidase inhibitors. 3. Methadone induction procedure Women should commence on a dose of methadone that should be titrated to the woman's symptoms with rapid increases1. The starting dose should be 20mg, and is reviewed at 4 hourly intervals or earlier if required. At each review, if the woman has objective signs of withdrawal (eg. Pupils dilated, restless, see short opiate withdrawal scale in appendix of National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn), then give an additional 5-10mg. If there are no signs of withdrawal no extra dose is given until the next scheduled review. The maximum dose in the first 24 hours should not exceed 50mg. Extreme caution should be exercised when assessing the woman's requirements on subsequent days if a dose of over 30mg is used on day 1, in order to prevent accumulation and possible toxicity from methadone. The same process should be repeated on day 2 (when the woman will almost certainly require less methadone), commencing again with 20mg and giving additional doses of 2.5 to 10mg as required, with a maximum dose increase of 50mg. If at any time the woman becomes sedated (small pupils, drowsiness), increase frequency of observation and ensure no further methadone is administered until sedation is reversed. Women should be encouraged to remain on the ward for 30-60 minutes post dose, for observation. Women should be cautioned regarding the use of other drugs whilst on methadone. Urine drug screening is not routine, but may sometimes be requested if there are concerns about harmful concurrent drug use. 3.1 Vomiting Vomiting is a serious concern in pregnant women on methadone. Vomiting of a methadone dose may lead to withdrawal in both mother and fetus (consensus,1). If a methadone dose is vomited (consensus,1):
  • Within 10 minutes of dosing - consider giving a repeat dose
  • Within 10-60 minutes of dosing - consider giving half a repeat dose
  • More than 60 minutes after dosing - consider half a repeat dose if withdrawal occurs
Prevention of vomiting (consensus,1):
  • Women should be discouraged from ingesting methadone on an empty stomach
  • Women should be encouraged to sip their dose slowly
  • If the dose consistently causes vomiting, consider splitting the dose or giving rectal prochlorperazine 30-60 minutes before dosing
  • If woman vomits constantly not in relation to dose, assess and treat according to the Women's CPG: Hyperemesis Gravidarum.
sources: http://www.thewomens.org.au/Methadon...ioninPregnancy Health Conditions of Drug-exposed Infants Birth weight Birth weight is an important factor associated with children’s overall health and development. Children who weigh under five-and-one-half pounds at birth are more likely to have serious medical problems and to exhibit developmental delays. Drug-exposed infants often do not exhibit normal development. Prematurity The risk of prematurity (birth at less than thirty-seven weeks) is higher in drug-exposed infants. Other complications can include an increase in acute medical problems following birth, and extended periods of hospitalization. Birth weight under three pounds has been associated with poor physical growth and poor general health status at school age. Low Birth weight infants also have an increased risk of neurosensory deficits, behavioral and attention deficits, psychiatric problems, and poor school performance. Premature infants may have experienced bleeding of the brain tissue, hydrocephalus, bronchial problems, eye disease, and interferences with the normal ability to feed. Small for Gestational Age (SGA) This term is used to describe infants whose Birth weight is below the third percentile for their gestational age (i.e., 97% of infants the same age are heavier than the SGA infant). It is common for women who abuse cocaine to experience decreased appetite and provide inadequate nutrition for themselves and their baby. Failure to Thrive (FTT) Infants who were exposed to alcohol and/or drugs may exhibit this disorder, which is characterized by a loss of weight, or slowing of weight gain, and a failure to reach developmental milestones. This can be due to medical and/or environmental factors. The infant’s behavior includes poor sucking, difficulty in swallowing, and distractibility. Many of these children live in chronically dysfunctional families which places them at greater risk of parental neglect. Neurobehavioral symptoms Within seventy-two hours after birth, many infants who were exposed prenatally to drugs experience withdrawal symptoms, including tremors and irritability. Their skin may be red and dry; they may have a fever, sweating, diarrhea, excessive vomiting, and even seizures. Such infants may require medication for calming. Other infants exposed to stimulants show a pattern of lethargy during the first few days after birth, are easily overstimulated, and may go from sleep to loud crying within seconds. These behaviors usually decrease over time and subside in toddlerhood. Infectious diseases Infants with prenatal drug exposure may be exposed prenatally or postnatally to infectious and/or sexually transmitted diseases contracted by their mothers. The most common infectious diseases seen in infants are chlamydia, syphilis, gonorrhea, hepatitis B, HIV, and AIDS. Sudden Infant Death Syndrome (SIDS) Children who have been exposed prenatally to alcohol and/or drugs have an increased risk of dying from sudden infant death syndrome. The causes of SIDS are unknown and its occurrence is almost impossible to predict. Apnea/cardiac monitoring is recommended for these infants. Fetal Alcohol Syndrome Mothers who consume large quantities of alcohol during pregnancy may have babies who are born with Fetal Alcohol Syndrome (or FAS). A diagnosis of FAS is based on three factors: 1) prenatal and postnatal growth retardation; 2) central nervous system abnormalities, and, 3) abnormalities of the face. Many of these children display significant disabilities, learning disorders, and emotional problems as they mature. Each of the above conditions associated with prematurity or drug exposure has programmatic implications for caregivers; the children who exhibit these conditions are often referred to as "medically fragile". Developmental Outcomes There are many unknowns involved in trying to predict the outcomes of infants and children exposed to drugs. While we know that there are certain physical problems that may remain with the child, in a structured and nurturing environment, many of these children are able to grow and develop quite normally. A small percentage of children have been found to have moderate to severe developmental problems. But regardless of their health status, all children who have a history of prenatal substance exposure should receive developmental evaluations on a regular basis: at least once during the first six months; at twelve months; and at least every year thereafter until school age. Early identification of social, language, cognitive, and motor development problems is essential. Developmental Patterns in Children Exposed Prenatally to Drugs Birth to fifteen months
  • Unpredictable sleeping patterns
  • Feeding difficulties
  • Irritability
  • Atypical social interactions
  • Delayed language development
  • Poor fine motor development
Toddlers from sixteen months to thirty-six months
  • Atypical social interactions
  • Minimal play strategies
Preschool children from age three to five While average preschoolers are beginning to share and take turns, demonstrate language skills, and increase their attention spans in a group setting, the drug-exposed toddler may be hyperactive, have a short attention span, lose control easily, have mood swings and problems moving from one activity to another. These children may also experience difficulties processing auditory or visual information/instructions. School and teenage years There has not been sufficient research into the long-term biological effects of drug exposure on older children and teenagers, however, we do know that children with the behaviors described above are at greater risk of abuse and neglect, learning disabilities, and behavioral problems. Obviously, it becomes imperative to identify these problems at a very early age, access the necessary resources for the child, and build a team of professionals who regularly monitor the progress of each child. Supporting a drug-exposed child in the course of his life may require advocating vigorously for specialized educational services; providing recreational and employment opportunities that allow a measure of success; educating parents; and providing counseling. Techniques in Working with Drug-exposed Infants and Young Children Respite and crisis care programs working with drug-exposed infants and children may not know the exact drugs to which each child was exposed. A combination of substances, including alcohol and tobacco, may be involved. There are a few techniques, however, which can be used in a general plan of care that may be individualized to meet the specific problems of each child:
  1. Provide a calm environment: low lighting; soft voices; slow transition from one activity to another.
  2. Be aware of signs of escalated behavior and frantic distress states before they occur, e.g., increased yawns, hiccoughs, sneezes, increased muscle tone and flailing, irritability, disorganized sucking, and crying.
  3. Use calming and special care techniques on a regular basis, such as
    • swaddling blankets tightly around the infant
    • using a pacifier even when the infant is not organized enough to maintain a regular suck
    • rocking, holding, or placing the infant in a swing, or Snuggly™ carrier
    • massaging the child
    • bathing in a warm bath, followed by a soothing application of lotion
    • rubbing ointment on diaper area to prevent skin breakdown
  4. Encourage developmental abilities when the infant is calm and receptive using only one stimulus at a time. Look for signs of infant distress and discontinue the activity if this occurs.
  5. Gradually increase the amount and time of daily developmental activities; encourage the child to develop self-calming behaviors and self control of his own body movements.
Behavior Descriptions and Suggested Strategies Feeding problems Feed the baby more often; feed smaller amounts at one time; allow the infant to rest frequently during feeding. Place the infant upright for feeding; after feeding, place the child on his side or stomach to prevent choking; if vomiting occurs, clean the skin immediately to prevent irritation. Irritability/unresponsive to caregiver Reduce noise in the environment; turn down lights; swaddle the infant: wrap snugly in a blanket with arms bound close to the body. Hold the infant closely; put the infant in a bunting-type wrapper and carry it close to your body. Rock the infant slowly and rhythmically, either horizontally or with its head supported vertically, whichever soothes. Place the child in a front-pack carrier; walk with the infant; offer the infant a pacifier or place it in an infant swing. Goes from one adult to another, showing no preference for a particular adult Respond to specific needs of child with predictability and regularity.

May have poor inner controls/frequent temper tantrums


Use  books,  pictures, doll play, and conversation to help the child explore  and express a range of feelings.

Ignores  verbal/gestural  limit setting
Talk  the child  through to the consequence of the action.

Shows decreased   compliance with simple, routine commands
Provide  the child  with explicitly consistent limits of behavior.

Exhibits tremors  when  stacking or reaching
Observe  the child  and note the onset of tremors, their duration, and how the  child compensates for them; provide a variety of materials to enhance  development and refinement of small motor skills, e.g., blocks, stacking  toys, large Leggos™, and puzzles with large pieces. Sand and water play  are soothing and appropriate.

Unable to end or let  go  of preferred object or activity
Provide  attention  and time to children who are behaving appropriately; provide  child with an opportunity to take turns with peers and adults.

Delayed receptive  and  expressive language
Create  a stable  environment where the child feels safe to express feelings,  wants, and needs; use stories/records/songs; use hands-on activities to  reinforce the child’s language abilities.

Expresses wants,  needs,  and fears by having frequent temper tantrums
Remove  and help  calm the child; redirect the child’s attention; verbalize the  expected behavior; reflect the child’s feelings. Praise attempts toward  adaptive behavior. Set consistent limits.

Difficulty with  gross  motor skills (e.g. swinging, climbing, throwing, catching,  jumping, running, and balancing)
Provide  appropriate  motor activities through play, songs, and equipment. Offer  guidance, modeling, and verbal cues as needed.

Over-reacts to  separation  of primary caregiver
Offer  verbal  reassurance; be consistent, and help the child learn to trust  adults.

Withdraws and seems  to  daydream or not be there
Provide   opportunities for contact; move close to the child, make eye contact,  use verbal reassurance; allow, identify, and react to the child’s  expressions of emotions.

Frequent temper  tantrums
Understand  that a  tantrum is usually a healthy release of rage and frustration;  protect the child from harm; remove objects from the child’s path if he  is rolling on floor. Some children do not want to be held during a  tantrum and doing so can cause more frustration. Remain calm, using a  soothing voice; anger will only escalate the child’s frustration. Do not  shout or threaten to spank the child–the adult needs to be in control.  Help the child to use words to describe emotions. Read stories about  feelings. Help the child gain control by making eye contact, sitting  next to the child, giving verbal reassurance, and offering physical  comfort (rubbing back, etc.). Note the circumstances that provoked the  tantrum, and try to avoid such confrontations when possible. Provide a  neutral area for the child to work through the tantrum, (e.g., a large  cushion or bean bag chair). Some children want to work through a tantrum  alone; keep the child in sight, but do not interact until he is calm.

Parent  Involvement
It is critical to the  success  of the drug-exposed infant that the eventual caregiver (parent,  relative, foster parent, respite provider, adoptive parent) learn the  care routine, control techniques, and background of the children for  whom they will be providing care. Understanding the etiology of  drug-exposure, the types of medical problems that arise, the  developmental patterns, and the techniques for handling drug-exposed  infants and toddlers is imperative.

Program social workers,  case  managers, child care staff, and nursing staff must all work  together with the caregiver to offer parent education ("hands-on"  opportunities to provide care under the guidance of professionals), and  encouragement for families who undertake the care of a drug-exposed  infant. The caregiver’s understanding of the child’s behavior, physical  "cues," and developmental problems, goes a long way in helping the  drug-exposed infant, toddler, and teen succeed. It also assists the  caregiver in setting realistic expectations for children who enter the  world battling the the effects of their parent’s addiction.

Many children who were   prenatally exposed to drugs will grow and develop without unusual  problems. However, for those infants who have physical indicators, the  respite and crisis care provider can make a difference by providing,  perhaps, the first stable, nurturing environment. Here, the child can be  observed, positive routines for care can be established, and parents  can receive the critically necessary education and support to enable  them to care for an alcohol or drug-exposed child.

Summary
Staff training, caregiver   training, and parent education are all critical elements of any program  that will be successful with these children. Physical elements of the  environment (lighting, noise, and space) may need to be adjusted to  accommodate their care. The inclusion of medical support, i.e., nurses  and physicians who are familiar with the problems of these children, is  essential. In summary, the care of alcohol and drug-exposed children is a  team effort that requires coordination, case management, special care  techniques, and education to be successful in any respite or crisis care  situation. With these components in place, agencies and families can  witness the positive growth and development of children who have been  greatly at risk.

About the Author: Jeanne Landdeck-Sisco, MSW, is the Executive Director of Casa de los  Niños  in Tucson, Arizona, which was the first crisis nursery in the  U.S., established in 1973. Ms. Landdeck-Sisco served as the first  President of the ARCH National Advisory Committee for Respite and Crisis  Care Programs from 1991-93 and remained on the committee until 1996.
Resources
Center for Substance Abuse   Prevention National Resource Center for the Prevention of Perinatal  Abuse of Alcohol and Other Drugs, 9302 Lee Highway, Fairfax, VA 22031,  (800) 354-8824.
National Organization on  Fetal  Alcohol Syndrome, 1815 H Street, N.W., Suite 710, Washington, DC  20006, (202) 785-4585.
References
Besharov, Douglas J. When   Drug Addicts Have Children. Washington, DC: Child Welfare League  of America, 1994.
Hargrove, Elisabeth, et  al. Resources Related  to Children and Their Families Affected by  Alcohol and Other Drugs. Chapel Hill, NC: NEC*TAS, 1995.

Special acknowledgment is  given to Rosemarie Dyer, R.N., Nursing Supervisor at Casa  de los Niños, who has developed the agency’s program for drug- and  alcohol-exposed infants and from whose training material many of the  techniques and caregiver responses have been drawn; and to Anna  Binkiewicz, M.D., Casa de los Niños Board Member and Medical  Director, who has provided on-site medical treatment of Casa’s medically  fragile children.

Prescribing heroin to addicts who can’t kick their habit helps them stay off street drugs, British researchers said Friday.

So far, doctors have had little hope of treating the 10 percent or more of heroin users who don’t respond to methadone, the standard anti-addiction medication. Fueled by drug cravings, those users often spiral downward into crime and diseases spread by dirty needles and unhealthy living.

Short of actually getting addicts off the drug, „heroin clinics“ can at least get them off the streets.

„What we are dealing with here is a very severe group of heroin addicts, where all of the treatments have been tried and have failed,“ said Dr. John Strang, an addiction expert at King’s College London, who led the new study.

„They are like oil tankers heading for disaster,“ he added. „The question we were asking was, ‚Can we change the trajectory of these tankers?‘ And the answer was, ‚Yes we can.'“

To test how prescription heroin would work for this group, Strang and his colleagues invited 127 addicts into supervised injecting clinics. The researchers then randomly chose who would get heroin, injected methadone or typical swallowed methadone.

After six months, 101 addicts had stuck with their treatment. More than two-thirds of those on heroin had no sign of street heroin in their urine at least half the time they were tested; before the study, they had been using the street drug almost every day.

In comparison, less than a third of the addicts on either type of methadone had a similar number of „clean“ tests.

At this point, said Strang, several users have continued in the program for more than two years. He did not have exact numbers, but told Reuters Health that some had been able to get jobs and reconnect with their families.

„These sorts of changes are typical of what we are seeing,“ he said. „People are not only physically getting better, but they’re getting back into society.“

The researchers had to treat about two addicts for each one who get off of street drugs at least half of the time.

An estimated 3.7 million people in the US have used heroin at some point in their lives, according to the National Institute on Drug Abuse. Of current users, studies suggest that some 200,000 spend time in jails each year.

The most common drug treatment for heroin users is methadone, a synthetic drug related to heroin. Although methadone decreases the cravings for its chemical cousin, it doesn’t produce the same high, according to experts. This could help explain why a substantial proportion of addicts in treatment backslide.

Before the new study, a handful of other reports had indicated that prescription heroin could help these people. But the scientific community wasn’t completely convinced, in part because earlier urine tests weren’t very sophisticated.

„What this study did is that it used a very novel urine test that can differentiate between street heroin and prescription heroin,“ said Thomas Kerr, director of the Urban Health Research Initiative at the University of British Columbia in Vancouver, Canada. Street heroin contains papaverine, a remnant of the opium poppy that can be detected in the urine.

Now, he said, „the evidence is quite clear that there is a place for prescription heroin for the treatment of individuals who do not respond to methadone.“

Only a few European countries prescribe heroin to addicts, and in the US this practice has been illegal since before World War I.

Many argue that giving addicts more of the substance they abuse makes little sense, and would be like treating an alcoholic with whiskey. But Kerr said that analogy wasn’t apt. „I would argue it’s completely immoral and unethical to fail to treat those individuals and to allow them to suffer and allow the community around them to suffer,“ Kerr said. Strang said he supported the UK Government’s 2008 Drug Strategy, which proposes rolling out prescription heroin. „Now that we know that it works, we have to debate whether or not we should use it,“ he said. SOURCE: The Lancet, May 28, 2010. http://www.thelancet.com/

Pharmacists have the unique knowledge, skills and responsibilities for assuming an important role in substance abuse prevention education and assistance…  Pharmacists, as health care providers, should be actively involved in reducing the negative effects that substance abuse has on society, health systems and the pharmacy profession.

— American Society of Health-System Pharmacists (2003)

Competency framework

Unless they have taken special training, most pharmacists are unaware of the clinical and practice issues surrounding methadone and their impact on client safety because they have had little or no exposure to them during their undergraduate pharmacy education.

The role of the pharmacist in MMT is unusual and there is no similar model in other therapeutic areas. Daily interactions with clients, along with direct clinical assessments, supervised dose administration and close monitoring do not usually occur in other types of pharmacy care. Pharmacists require a set of key competencies to ensure client safety in methadone maintenance treatment.

The panel recommends that:

15. Pharmacy managers/owners, hospital pharmacy directors and the Ontario College of Pharmacists support and encourage pharmacists providing methadone services to have education in and/or demonstrate knowledge and skills in core competency areas. These areas include:

a. Substance use disorders, including opioid dependence. [IV]

b. The varied models of substance abuse treatment, including harm reduction and its implications for pharmacy. [IV]

c. The impact of attitudes and stigma on client care. [III]

d. Methadone maintenance treatment clinical guidelines and their rationale, particularly with respect to practices to protect client safety, including:

  • assessing initial and increased doses for appropriateness
  • assessing methadone-dosing histories (for missed doses and irregularities in pattern of pickup) before dispensing a dose of methadone to a client
  • ensuring the safe provision of “carries” (take-home doses) to clients
  • dealing with intoxicated clients, including understanding the risks of polysubstance abuse. [IV]

Pharmacists need to understand substance use disorders, particularly addiction, and to understand the difference between “use” and “use disorders.” Pharmacists need to be able to identify individuals with substance use disorders and to help motivate them to seek change and treatment. As one of the most accessible health care professionals, the pharmacist can play an important role and refer patients to appropriate services and substance use treatment programs. Many MMT clients have concurrent substance use disorders with substances such as alcohol, benzodiazepines or cocaine. Pharmacists should understand the risks associated with polysubstance use and the risk of toxicity.

Although pharmacists may already be involved in harm reduction, for example, by providing sterile needles and syringes to people who use injection drugs, further involvement could include offering advice to people with substance use problems about health issues and how to minimize health risks. A random survey of 2,017 Canadian pharmacists by Myers et al. (1998) found that while more than 88 per cent of pharmacists were comfortable with the harm reduction role in providing needles and syringes, this comfort did not extend to providing methadone services. This may be due to a misunderstanding of the benefits of methadone maintenance treatment and its role as a harm reduction approach. Educational initiatives need to address such misunderstandings and other negative attitudes or misperceptions that may be held by pharmacists.

Pharmacists must have a good understanding of the critical safety issues associated with methadone. Methadone has a unique pharmacological profile that makes it useful in the treatment of opioid dependence; however, it is different from other opioids and the implications of its long half-life can lead to risks of accumulation contributing to methadone overdose and deaths.

The initiation phase of methadone treatment can be a time of high risk for toxicity and pharmacists’ understanding of dosing recommendations is critical at this stage. Pharmacists need to exercise particular vigilance in monitoring client dosing for appropriateness. For example, where clients have missed several doses (defined as three or more), or fewer (one or two) during periods of methadone dose escalation, pharmacists must understand the concept of loss of tolerance and risks to clients if the usual regular methadone dose is administered (CPSO, 2005).

Pharmacists also have to understand the safety issues associated with “carries.” Having a written carry agreement with the client is one way to help the client understand these issues as well. Pharmacists should be aware of some of the signs that indicate a formerly stable client on a high level of carries is relapsing to instability (e.g., missing observed dosing days, lost carries) (CPSO, 2005).

Pharmacists in Ontario need to be familiar with the CPSO’s most recent Methadone Maintenance Guidelines (2005), the OCP’s Policy for Dispensing Methadone (2006), and CAMH’s Methadone Maintenance: A Pharmacist’s Guide to Treatment (Isaac et al., 2004).

Understanding the risks of polysubstance use and knowing how to deal with intoxicated clients are particularly important core competency areas for pharmacists, with significant safety implications. The pharmacist should have an understanding of the impact that polysubstance use (for example, use of benzodiazepines, alcohol and cocaine) can have on the client taking MMT. Through dialogue and checking for signs of excessive dosing or substance use such as sedation, slurring of speech, smelling of alcohol and unsteady gait, the pharmacist should be able to assess if a client is intoxicated before dosing.

Recommendations from the coroner have highlighted the need for assessing clients for intoxication because deaths have occurred through combination of methadone and other drugs, including alcohol (OCP, 2008).

In an Australian survey (Peterson et al., 2007), pharmacists identified the risk of overdose associated with methadone alone and in combination with other psychoactive drugs as the greatest problematic issue for pharmacists in deciding to provide a methadone service.

In a survey of 148 pharmacists in Australia (Koutroulis et al., 2000), when asked about how they would respond to clients who presented intoxicated for their methadone dose, 44 per cent said they would withhold the dose and inform the client of this. This is the desirable course of action. However, 32 per cent of pharmacists said they would provide the usual dose, 16 per cent would dispense a reduced dose without the client knowing and nine per cent said they would blind the dose with a placebo. Only two per cent of the pharmacists indicated that they would breathalyse an intoxicated client.

Pharmacists who withheld the methadone dose were more likely to inform the prescriber (74 per cent) than pharmacists who dispensed the usual or modified dose. In a focus group, the reasons for dispensing to an intoxicated client were categorized as follows:

  • insufficient communication between prescriber and pharmacist
  • downplaying the risk of toxicity
  • personal beliefs and values
  • fear of what the client would do if dose refused
  • difficulty in recognizing intoxication and lack of education and training.

Further, Koutroulis et al.’s survey suggested that pharmacists who had more than 10 methadone clients were more likely to provide the usual methadone dose than pharmacists with 10 or fewer clients.

Educational offerings

Many physicians and pharmacists don’t think they see addicts in their practice. The reality is they probably are treating them for other disorders, but the patient just hasn’t been identified as an addict. This also means that dependence treatment needs to become part of regular pharmacy practice as well.

— Open discussion, physicians and pharmacists (Raisch et al., 2005)

The panel recommends that:

16. All pharmacy students receive education on substance abuse, including opioid dependence, its treatment and practical intervention strategies, in their undergraduate curriculum. [IV]

Future pharmacists need to be adequately educated on substance use so that they are prepared upon graduation to care for patients with substance abuse disorders. In particular, opioid dependence and its treatment should be required components in the curriculum. Pharmacists who have had education in this area are likely to feel more comfortable providing pharmaceutical care to this group of clients.

Currently there are two faculties of pharmacy in Ontario, at the University of Toronto and at the University of Waterloo. The Waterloo faculty initiated their program in January 2009; therefore, their plans for curriculum on substance abuse education are still in the development phase.

At Toronto’s Faculty of Pharmacy, pharmacy students receive a rigorous scientific and clinical education over four years but receive little or no education on substance abuse and its treatment. Since the early 1990s, an elective fourth-year problem-based course has been offered (Busto et al., 1994). This course has one 2-hour segment on opioid abuse and treatment. It includes a didactic component, as well as an MMT client interview and discussion of stigma and attitudes. The course is elective and only a small proportion of the fourth-year class has taken this course offering.

Over the last five years enrolment in this elective has increased from 9.7 per cent of the class (13/134 students) in 2003–2004 to 34.2 per cent of the class (79/231 students) in 2008–2009 (personal communication, Dr. B. Sproule, April 29, 2009). Clearly, most future pharmacists have no exposure to substance use, opioid dependence and treatment with methadone.

The lack of specific undergraduate educational activities about substance abuse results in a missed opportunity to positively influence the knowledge, skills and attitudes of future pharmacists in this area.

As the most accessible of all health care professionals, pharmacists have an important role to play to help prevent and treat substance abuse disorders in their clients (Tommasello, 2004). Preparation for this role should begin in the undergraduate pharmacy training.

Experiential learning and other innovative teaching methods, for example, involving real patients (or simulated cases), audiovisual vignettes or other online modules may enhance pharmacy students’ understanding of substance dependence issues and attitudes.

One college of pharmacy in the United States, in addition to a required substance abuse course, offers an elective to illustrate addiction recovery principles. Students taking the elective are asked to give up a habit that is causing them problems for six weeks and they meet weekly to discuss the addiction recovery process. This course has been offered for 15 years and 50 per cent of the substance abuse course students are enrolled (Baldwin, 2008).

From the client consultation interviews

Clients’ need for pharmaceutical care
“I would have liked to know more about methadone before I started. It would have helped me make a better decision. You shouldn’t just tell a sick person ‘this will make you better.’ ”

“There has been a lack of care and communication and confusion with my HIV meds. The methadone wasn’t holding me due to medication interactions.”

“I felt sick for weeks and didn’t know it was because my dose was too high.”

The panel recommends that:

17. Professional organizations, addiction and mental health agencies and pharmacists’ employers promote the development of, and provide encouragement for all practising pharmacists to participate in, educational events on substance abuse and opioid dependence, including the growing problem of prescription opioid abuse. [III]

Most pharmacists receive little training on opioid dependence and treatment in their undergraduate experience, and it is important that all pharmacists further their knowledge in this area, even if they are not yet providing MMT services. There are indications that abuse and dependence on prescription opioids is increasing in Ontario and Canada. There was an increased number of patients addicted to prescription opioids entering the CAMH methadone maintenance program following the rapid expansion in the availability of MMT in Ontario in the 1990s (Brands et al., 2002; Brands et al., 2000). More recently, the number of individuals seeking detoxification treatment from controlled-release oxycodone at CAMH has also increased significantly (Sproule et al., 2009). In addition, in a cohort study of illicit opioid users, the proportion using prescription opioids increased from the year 2002 to 2005, with regional differences noted across Canada (Fischer et al., 2006). Pharmacists need to increase their knowledge base in prescription opioid addiction, particularly to understand the difference between addiction and physical dependence. Continuing education programs on pain treatment rarely (or inadequately) discuss the issue of opioid abuse and dependence.

A survey in British Columbia of 257 pharmacists (Cohen & McCormick, 2008) found that a slight majority reported training on how to identify signs of prescription drug misuse or abuse. This training was more common in younger pharmacists. The mean amount of training was 13.6 hours. Many pharmacists learned to identify prescription drug misuse through personal experience: they detected multi-doctoring using the provincial PharmaNet prescription drug profile or by recognizing early refills of prescriptions. Most intervened by calling the physician to confirm prescriptions or by confronting the customer directly. The primary reason they gave for not intervening was concern over how the customer might react (i.e., they were afraid that the client would be confrontational or they feared for their own safety). Pharmacists recommended additional training on prescription drug misuse.

Jones et al. (2005) surveyed 42 community pharmacists in Wales and found that at one month after a structured educational evening event there was little maintained change in attitudes. This suggests that changing attitudes is a long-term process. There is a need for reinforcing changes through continuing education.

Practising pharmacists (484) in Florida were surveyed while attending continuing education programs (Lafferty et al., 2006). Of the respondents, 67.5 per cent reported participating in two or fewer hours of addiction/ substance abuse education in pharmacy school and 29.2 per cent said they had received no addiction education. Pharmacists who had more education counselled clients more frequently and felt more confident in dealing with substance abuse clients. Of those surveyed, 53 per cent reported they had never referred a patient to substance abuse treatment in their whole career.

Brooks et al. (2001) conducted a survey in the United States of 556 pharmacists, comparing those who had taken training in addiction treatment to those who had not, and found that those who had taken training would more likely refer clients to community resources and be more involved in working with their chemically dependent clients.

The panel recommends that:

18. The Ontario College of Pharmacists revise the current requirements for pharmacies providing MMT services to mandate earlier training to promote safety. The designated manager and one pharmacist must complete the training within six months of starting to dispense methadone. [IV]

19. CAMH or another approved provider of methadone training develop a brief electronic document (e.g., one page) outlining the key safety features of providing MMT services that can be made available for immediate use by pharmacies initiating MMT services. [IV]

20. CAMH produce an electronic version of its most recent pharmacist’s guide to methadone maintenance treatment that can be purchased online and downloaded immediately so that pharmacies initiating MMT services can access it without delay. [IV]

21. CAMH make the online component of its Opioid Dependence Treatment Course available immediately upon enrolment to pharmacists new to providing MMT services, with the stipulation that these pharmacists attend the workshop component within six months of beginning the course. [IV]

22. CAMH or another approved provider of methadone training monitor and respond to waiting lists for training programs by, for example, offering the training more frequently or by exploring other delivery methods, such as webinars or video conferencing, to help meet the needs of pharmacists in remote areas. [IV]

Since undergraduate training on substance abuse and opioid dependence is lacking, most pharmacists do not have an adequate knowledge base from which to provide MMT services safely.

Having the most essential knowledge and references easily accessible and as early as possible will help facilitate pharmacies starting a methadone service and assist those who are deciding whether to provide MMT.

The online component of the CAMH Opiate Dependence Treatment Interprofessional Education Program would provide a good introduction to providing service, and a brief methadone information sheet would complement this program. The methadone information sheet could include some of the key points in providing MMT service, for example, observing dosing, diluting dose in orange drink, identifying the client, assessing the client for intoxication and informing the prescriber of missed doses.

Having a current version of the CAMH Pharmacist’s Guide available in a downloadable format would enable pharmacists to have this mandatory reference as soon as they need it. The other two references pharmacists dispensing methadone require, the CPSO Methadone Maintenance Guidelines and the OCP Policy for Dispensing Methadone, are currently available electronically.

The panel recommends that:

23. The Ontario College of Pharmacists and providers of methadone training collaborate on ongoing training requirements based on needs identified during the College’s pharmacy inspection process. [IV]

The Ontario College of Pharmacists undertakes regular inspections of community pharmacy practice in the province. Practice issues related to methadone service provision identified during these inspections could be shared with educational service providers for consideration in future training initiatives. This would be an effective mechanism for updating methadone training to reflect current practice issues in the field.

The panel recommends that:

24. CAMH or another approved provider of methadone education deliver methadone training in a manner consistent with interprofessional education principles. [IV]

Since MMT practice is best delivered in a collaborative manner (Health Canada, 2002), a multidisciplinary approach in education will prepare pharmacists to work effectively with other health professionals as a team.

The panel recommends that:

25. The Ontario College of Pharmacists and community colleges providing pharmacy technician training develop core competency requirements for regulated pharmacy technicians providing MMT services. [IV]

Pharmacy technicians are important members of the pharmacy team. They may be involved with preparing and dispensing methadone, and interact with MMT clients in the pharmacy. Core competencies should be developed and educational programs designed to optimize the role of pharmacy technicians in the safe delivery of methadone services. This issue may be particularly important in view of the new regulated status for pharmacy technicians that will be implemented soon in Ontario, where pharmacy technicians will be able to take more responsibility for dispensing.

The panel recommends that:

26. CAMH or another approved provider of methadone education undertake a needs assessment of pharmacists who have participated in the initial MMT training, and then use this information to develop an updated or advanced MMT course for pharmacists. [IV]

27. Professional pharmacy organizations, the Ontario College of Pharmacists, pharmacy managers/owners and hospital pharmacy directors encourage pharmacists to take courses on motivational interviewing, intervention strategies to use with difficult patients, and concurrent disorders, to enhance pharmacists’ skills in dealing with opioid-dependent clients. [IV]

Pharmacists who are already in MMT practice and have taken initial MMT training may wish to update and improve their skills. Since pharmacist training is recommended by the Ontario College of Pharmacists every five years, a new, higher level course would meet the needs of this experienced group of providers. Pharmacists who have taken initial MMT training should be surveyed for their input about topics to include within this higher level course. This advanced training could include, for example, methadone use in pregnancy, in patients with concurrent disorders (e.g., pain, psychiatric disorders, HIV) and in other special populations.

Any interaction with a client has therapeutic potential. Pharmacists using motivational techniques in their interactions with clients may enhance clients’ treatment. The issue of dealing with difficult, demanding clients has been identified by pharmacists as an area in which they would like more training (Cohen & McCormick, 2008). Training in de-escalation techniques to avoid potentially unsafe interactions could help pharmacists achieve greater satisfaction in their practice, as well as improve client outcomes.

The panel recommends that:

28. Drug information service providers ensure that staff is trained on and familiar with common issues in MMT treatment and have a mechanism to refer to experts when necessary. [IV]

Pharmacies must subscribe to a drug information provider service. The staff at the drug information provider should be able to respond to general questions on MMT and substance abuse. To do this they would require training in MMT to understand the patient safety issues and relevant guidelines. For more complex questions, the drug information service should have an arrangement with expert service providers to assist in consultation.

The panel recommends that:

29. Professional pharmacy organizations develop a mechanism in conjunction with the Ontario College of Pharmacists to ensure that pharmacists dispensing methadone are informed in a timely fashion of new educational resources available. [IV]

A timely direct communication via e-mail from the Ontario College of Pharmacists, the Ontario Pharmacists’ Association or another professional pharmacy organization is recommended when any new methadone-related item is posted on the website of either the OCP or the CPSO.

The panel recommends that:

30. Professional pharmacy organizations, CAMH and funding agencies develop a mentorship program to link new methadone service providers with experienced providers. [IV]

31. Professional pharmacy organizations and CAMH promote the CAMH Addiction Clinical Consultation Service to pharmacists providing MMT services. [IV]

The Addiction Clinical Consultation Service (ACCS) is a service provided by CAMH. It is designed to serve health and social service professionals, including pharmacists, who have client-specific questions related to substance abuse. The accs is not designed to deal with health emergencies or immediate or legal issues. The health care worker calls a central phone number and, depending on the question, accs may provide referral to a consultant team member (physician, therapist/counsellor or pharmacist) who will communicate with the health care worker within four hours. Awareness of the service should be promoted to support pharmacists providing methadone services.

Very few studies have considered heroin users’ views on substitute prescribing, in
particular with regards to subutex. The aim of this study was to conduct detailed
qualitative analysis, using the Grounded theory approach, on heroin users’ views on
substitute prescribing, paying specific attention to methadone and subutex. Semistructured
interviews were conducted with nine subjects recruited from an
abstinence-based, structured day care treatment program. All of the subjects were
either currently on a subutex prescribing program, or had remained abstinent from
illicit substances following the completion of a subutex treatment program. Five major
themes emerged from the analysis. These were reasons for obtaining a methadone
prescription, experiences with methadone programs, views on methadone, views on
subutex and views on an ideal opioid treatment program. Most of the findings were
supported by previous qualitative studies such as that of Neale (1999a) and Fischer
and colleagues (2002). However, there does appear to be some discrepancies
between qualitative and quantitative research with regards to consumer satisfaction
of methadone, in comparison to subutex, as a substitute drug. This study clearly
highlights the need for further research into users’ views on substitute prescribing,
with emphasis being placed on qualitative research considering users’ experiences
with subutex.

Read the full File: methadoneversussubutex kopie

METHADONE-ASSOCIATED OVERDOSE DEATHS
Factors Contributing to Increased Deaths and Efforts to Prevent Them
March 2009
GAO-09-

GAOmethadonedeaths

Methadone maintenance is somewhat of a mystery to clinicians not involved in addiction medicine, and opioid addicts don’t fare well in the emergency medical system. Many nurses and physicians have trouble dealing with them objectively and don’t want to be involved. Well-managed methadone maintenance is, however, a different story. Few EPs dole out methadone, but maintenance patients show up in the ED with legitimate complaints. Patients on high-dose methadone can experience painful conditions or injuries requiring additional analgesia. It’s not easy, but if one can put aside preconceived notions about addiction, methadone maintenance presents a fascinating challenge to the EP.

Figure. Clients line…

Most  have treated methadone maintenance therapy (MMT) clients in the ED, and have dealt with withdrawal, missed appointments, and overdose. I have visited a few methadone clinics, and the whole concept is fascinating, giving great insight into a government-sponsored medical entity.

Treatment Improvement Protocol Series 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Program

This massive document summarizes the consensus of the U.S. Health and Human Services on MMT, which is administered through the Substance Abuse and Mental Health Services Administration and the Center for Substance Abuse Treatment, branches of HHS. This 14-chapter document has everything you want to know about MMT.

Edit by Exilope: http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssamhsatip&part=A82676

Initial Screening: Anyone can walk into an MMT clinic and request treatment. Initial screening exams and interviews determine the applicant’s eligibility and the process includes an assessment of their readiness to accept treatment. Ongoing, if not daily interventions, are required to keep the patient in the system and off the opioid. The addiction severity index collects basic information, and it can be used to track progress. Much of the information is supplied by the addict, and truthfulness on their part is paramount for success.

Comment: I suspect most people don’t walk in off the street thinking about MMT for the first time. All potential clients likely consider it many times or talk about it with fellow addicts. They are often prompted to try MMT by those who have been through the process, some more than one time. One would assume that an opioid addict who shows up at the clinic has hit rock bottom or finally has accepted they have an addiction they cannot control. Many are in overt withdrawal. They are ready to sign up.

First impressions are lasting ones. The HHS recommends a plethora of warm and fuzzy approaches to help the addict adjust and feel supported. A nonconfrontational and nonaccusatory attitude is stressed. Unlike the ED, MMT clinics want to be in the business of dispensing methadone. Clinics are usually prepared to provide immediate information, if not methadone treatment, on the first day.

A variety of preprinted documents are handed out that describe the services, rules, and expectations of the program. Policies are in place to deal with disruptive and violent clients and pregnant women. Clinics also try to identify treatment barriers and offer financial assistance and psychiatric crisis intervention. Many patients also have underlying psychiatric disorders, legal difficulties, child care issues, and transportation and family concerns. Cultural, ethical, and spiritual factors also complicate MMT. Those patients who seem in crisis can be referred for inpatient medical facility or psychiatric care. The correlation between opioid addiction and the risk of suicide is well known, and initial screening and periodic assessment helps determine that ongoing risk.

Admission Issues: A significant delay between the first contact, initial screening, and methadone treatment, especially failure to quickly address withdrawal, adversely affects the number of applicants who enter the program. It’s difficult to deal with an opioid addict in withdrawal; his patience wears thin, and he wants treatment now. Recognizing the realities of crowding and limited resources, MMT clinics can provide an interim maintenance program without formal screening or actual admission to the site. By federal regulation, medication can be administered for up to 120 days with only minimal screening procedures.

Violent or threatening patients can be turned down, but I have been amazed at how understanding and supportive some of the staff are; it’s similar to the mentality emergency physicians use to treat those who are not the nicest people. MMT, like emergency medicine, is a service industry, and the customers often possess the mentality of the McDonald’s client. They want it now, they want it their way, and they don’t want to pay much for it. Frustrated clients who elope are, however, a loss for everyone. Programs are not free, and cash and insurance are accepted, but often the down-and-out addict qualifies for local aid.

Information, Collection, and Dissemination: During the first few visits, a substance abuse history is obtained, and treatment options are discussed. Consent to treat is elicited, and addicts must sign a bevy of documents that provide further information on the multifaceted MMT process. Patients must be 18 or have parental approval. Otherwise, the services are confidential even to family members. Confidential information is not given to any inquiry except the court. The specifics of the individual’s opioid addiction, including recent pattern changes and binges, are gathered. Other drugs such as benzodiazepines and alcohol are often confounding issues, and the patient’s daily pattern of opioid abuse is determined, essentially by his own admission.

The opioid withdrawal history and the energy required to maintain the addiction is sought. Many patients are in withdrawal when they come to the clinic, making historical information open to exaggeration, but many downplay their use (like the alcohol history obtained in the ED). Some withhold a history of other addictions, perhaps thinking they might supplement the methadone if needed. Blood tests for specific drugs are not required nor usually performed to quantify use. A serum drug level is of no value in this scenario. Questioning the history can intimidate the prospective client and set up an adversarial relationship at the beginning. Again, unlike the ED, MMT clinics put a lot of trust in the truthfulness of the addict.

Medical Assessment: The aim of medical assessment is to determine the safety of methadone use. The drug is often dispensed on the first visit because of withdrawal. It is generally required that someone be addicted for one year before admission. There appears to be some flexibility in this criterium, especially for prisoners, pregnant women, or those previously treated. There may be uncertainty about past narcotic use, but generally a broad definition is accepted for opioid addiction, and one need not administer Narcan to test for withdrawal.

Generally, the staff obtains a medical history that documents drug-related diseases such as hepatitis, AIDS, tuberculosis, or STDs. Within 14 days of admission, a basic physical examination is performed, including blood tests for HIV, syphilis, and hepatitis. Federal regulations do not require a full panel of laboratory tests; that appears to be a state issue. Patients usually are tested randomly by a urine screen immunoassay test for additional drug abuse at least eight times each year per SAMHSA. Because methadone does not yield a positive opioid result unless specifically tested, a positive opioid screen usually means exogenous drugs.

Multiple Substance Abuse: It is common knowledge that opioid addicts often abuse other substances, especially alcohol, amphetamines, benzodiazepines, prescription opioids, cocaine, sedatives, and marijuana. CNS depressants are particularly dangerous when combined with opioids. Patients generally are asked to report other substances they used in the past. The accuracy of this form depends, of course, on patient honesty. Alcohol is a favorite of most, and heroin addicts particularly like to add cocaine for additional euphoria. Benzodiazepines are commonly used to boost methadone and enhance the high. Patients also self-medicate because of withdrawal symptoms or because they are anxious, depressed, or lonely.

MMT clients all know using an exogenous substance can kill them and defeat the purpose of MMT. Using exogenous drugs negatively affects attendance rates and cooperation with other programs. Interestingly, patients are not frequently discharged from MMT because they abuse other substances. The main goal is to retain the patient in MMT, allowing for human frailty, lack of self-control, and poor judgment. MMT clients are given multiple chances despite violating explicit rules and regulations.

Drug Testing: Clients are randomly tested for other drugs, usually with an immunoassay urine screen. This is not a perfect system because it only identifies those using other substances frequently and only detects drugs that show up on a urine screen. Of course, it has to be your urine, and there is always someone around who wants to give a clean sample for the right price.

Periodic drug testing provides objective evidence of treatment success and monitors patient progress. Typical urine testing evaluates for commonly abused substances with a qualitative immunoassay technique that has cutoff concentrations. Testing drug levels in the blood is not helpful because tolerance, time of use, and the need to send the test to a reference lab does not allow for meaningful interpretation of data. Most drugs remain in the system and are excreted in the urine for two to four days following use. Measuring methadone serum levels during treatment has minimal value and is not done routinely, but this may be used to identify a rapid or slow metabolizer. Obviously, urine tests are not quantitative; they merely give positive or negative results.

Urine collection may be monitored to avoid contamination or substitution. There are no firm and fast rules for the method of testing, and direct observation is not mandatory. The most common test is an enzyme-multiplied immunoassay technique (EMIT), which uses antibodies to specific drugs or metabolites. Oxycodone is often not identified with this test; nor are clonazepam, Seroquel, hallucinogens, fentanyl, Demerol, dextromethorphan, propoxyphene, and a variety of street drugs. On-site dipstick urine testing is common, but some clinics will confirm the initial clinic screen via a reference laboratory. Many clinics test patients at intake to prove they used opioids recently. The continued use of heroin or other opioids may prompt an increase in the methadone dose because it’s common to supplement during withdrawal.

Retaining Patients in MMT: The longer the patient stays in MMT, the less likely he will revert to using opioids. Staying in MMT for more than a year is associated with constructive lifestyles changes, decreased criminal behavior, and less transmission of infectious diseases. Older patients and those not in the criminal justice system tend to stay in the program longer. Those who have tried it before and failed are better candidates for retention the next time around.

But the key to MMT success, as this HHS publication notes, is: Adequate individualized medication dosages are probably the most important factor in patient retention because they contribute to patient comfort and satisfaction by reducing withdrawal symptoms and craving. The serum half-life of methadone is stated to be 24 to 36 hours, but in reality there is an extremely wide range (13-58 hours). Excessive methadone use occurs when daily visits and individual dose adjustment are not made.

Take-Home Medication: Methadone is usually dispensed daily in a liquid form, and ingestion is witnessed. This keeps patients from diverting tablets. Methadone diversion is a huge problem in this country, but that methadone is usually not obtained from clinics. A single take-home dose is common on Sundays and holidays. After six months to a year, compliant and reliable patients can take home one to four weeks of methadone, but initially, doses are only dispensed daily at the clinic. The requirement to show up every day can be problematic.

Figure. Christine Ad…

Dosing Schedule: A dose of 30 mg to 40 mg of methadone is the upper limit for the initial dose, per regulation. Initial dosing should be followed by increases over subsequent days until withdrawal symptoms are suppressed. A steady state of a dose is not reached for three to five, sometime seven days after a dosage change. The goal is to reach 80 mg to 120 mg methadone per day, a level that has been proven to improve compliance to the program. Using smaller doses or failing to increase the dose when withdrawal is still present is ineffectual and counterproductive. Withdrawal often prompts exogenous drug use or elopement.

The actual schedule is not set in stone, but daily dose increases of 5 mg to 10 mg a day for the first five to seven days to reach 60 mg a day are common. The 60 mg per day dose is maintained under daily observation to reach a steady state. The first week or two of MMT are the most dangerous for the patient and the time during which most fatalities occur. With daily observation and individual dose adjustments, induction is safe and effective as long as the patient is truthful and abstains from other drugs.

The quoted serum half-life of methadone can be misleading, and provides only a rough estimate to forecast dosing requirements and effectiveness. Methadone is eliminated more quickly from the blood and the effects wear off sooner until sufficient levels are obtained to saturate tissues, especially the liver. Smokers have increased clearance, and significant liver damage slows clearance. The optimal dose can only be determined by observing the individual daily, debriefing him on how he feels, and altering dosages in a safe, effective manner.

There is no uniformly suitable dose range or limit for all patients. Some require 400 mg to 700 mg a day while others do well on 80 mg to 120 mg a day. During induction, clinical observation and patient symptoms are the best indicators of whether a dose is too small or large. When this protocol is followed, methadone induction is safe and effective.

Comment: There are eight MMT clinics in Philadelphia, usually for heroin addiction, but more frequently for prescription opioid addiction. Most opioid addicts know the concepts of MMT well, and visit various clinics off and on throughout their addiction. The rules of MMT are straightforward, and each state is allowed some latitude on various issues. Some addicts have learned to work or abuse the system, but MMT is a godsend, if not a true lifeline, for many opioid addicts.

Addiction to hydrocodone, hydromorphone, and oxycodone is likely more widespread than street heroin. There is little difference between the prescription pill addict and the hardcore street heroin user on everyday issues or potential benefit from MMT. The well-to-do business man, the bored housewife, the professional athlete, or the Hollywood celebrity seem to prefer pills over the needle. Some physicians readily prescribe a slew of addicting medications, prescriptions are stolen or altered, and anyone can buy a few Percocet at the local high school. The Internet provides drugs as well as directions on use and how to beat drug tests and avoid overdose. Of course, heroin can be smoked and snorted as well, but there is less of a stigma involved with popping a pill than buying a bag of heroin on a lonely street corner.

I am quite impressed with the understanding approach to MMT and the dedication of the clinic personnel. Methadone manufacturers stress that their product should be used only under strict HHS guidelines, and they actually reference the Federal Register code in the package insert. The dangers of inappropriate methadone use are well-reported in the literature, but it’s likely an underused drug for chronic pain control.

Society has written off many opioid addicts or would drop them in a heartbeat at any sign of deceit or additional drug use. Not so for MMT clinics; they bend over backwards to give everyone yet another chance. Using additional substances during MMT is very common. Klonopin, Xanax, Soma, and Seroquel are popular in my area to boost methadone’s high, and none show on a urine screen. It’s easy to buy any of these on the street, usually right outside the door of the clinic. It’s best to never underestimate the ingenuity or resourcefulness of an opioid addict so MMT works best in an environment of mutual trust and truthfulness. Lying to the counselor about past or present drug use or beating the drug test is tempting, but in the end, it can be a fatal error.

Studies in Europe have suggested that injectable diacetylmorphine, the active ingredient
in heroin, can be an effective adjunctive treatment for chronic, relapsing opioid
dependence.
Methods
In an open-label, phase 3, randomized, controlled trial in Canada, we compared
injectable diacetylmorphine with oral methadone maintenance therapy in patients
with opioid dependence that was refractory to treatment. Long-term users of injectable
heroin who had not benefited from at least two previous attempts at treatment
for addiction (including at least one methadone treatment) were randomly assigned
to receive methadone (111 patients) or diacetylmorphine (115 patients). The primary
outcomes, assessed at 12 months, were retention in addiction treatment or drugfree
status and a reduction in illicit-drug use or other illegal activity according to
the European Addiction Severity Index.

Read more: heroin_vs_methadone_2009

Background: The objective of this research was to evaluate data from a randomized clinical trial that tested injectable
diacetylmorphine (DAM) and oral methadone (MMT) for substitution treatment, using a multi-domain dichotomous index, with
a Bayesian approach.
Methods: Sixty two long-term, socially-excluded heroin injectors, not benefiting from available treatments were randomized
to receive either DAM or MMT for 9 months in Granada, Spain. Completers were 44 and data at the end of the study period
was obtained for 50. Participants were determined to be responders or non responders using a multi-domain outcome index
accounting for their physical and mental health and psychosocial integration, used in a previous trial. Data was analyzed with
Bayesian methods, using information from a similar study conducted in The Netherlands to select a priori distributions. On
adding the data from the present study to update the a priori information, the distribution of the difference in response rates
were obtained and used to build credibility intervals and relevant probability computations.

Read more: heroin_vs_methadone_2_2009

INTRODUCTION: Subjects using opioids on a chronic basis have been reported to have a high prevalence of abnormal sleep architecture and central sleep apnea (CSA). The severity of CSA is, in part, related to blood opioid concentration. The aim of this study was to investigate subjective daytime sleepiness and daytime function in patients who are on stable methadone maintenance treatment (MMT) and to assess the possible mechanisms involving abnormal sleep architecture, CSA severity, and blood methadone concentration. METHODS: Fifty patients on MMT and 20 normal control subjects matched for age and body mass index were tested using polysomnography, blood toxicology, Epworth Sleepiness Scale (ESS), Functional Outcome of Sleep Questionnaire (FOSQ), and Beck Depression Inventory (BDI). RESULTS: The patients receiving MMT had significantly worse daytime function, were depressed, and had increased daytime sleepiness when compared with the control subjects (FOSQ 15.47 +/- 3.19 vs 19.4 +/- 0.47, BDI 14.64 +/- 10.58 vs 2.05 +/- 2.46, ESS 7.1 +/- 5 vs 2.05 +/- 1.76; all p values < 0.001). Nevertheless, daytime sleepiness in the patients receiving MMT was, on average, within the normal range (ESS < or = 10). Multiple regression analysis demonstrated that the severity of CSA, blood methadone concentration, and abnormalities in sleep architecture were not significant in predicting the variance of ESS or FOSQ (all p values > 0.05) in these patients receiving MMT. The BDI was the best predictive variable for FOSQ, explaining 16% of the variance (p = 0.004). CONCLUSIONS: Patients on stable MMT have, in general, normal subjective daytime sleepiness but impaired daytime function that partially relates to depression. The changes in sleep architecture, presence of CSA, and blood methadone concentrations do not significantly affect subjective daytime sleepiness and daytime function in these patients.

Study objectives: Methadone, a long-acting μ-opioid agonist, is an effective treatment for heroin addiction. Our previous data show that 6 of 10 methadone maintenance treatment (MMT) patients had central sleep apnea (CSA). This study aims to confirm these results and to investigate the pathogenesis of the CSA.

Methods: Twenty-five male and 25 female MMT patients and 20 age-, sex-, and body mass index (BMI)-matched normal subjects were tested with polysomnography, blood toxicology, and ventilatory responses to hypoxia and hypercapnia. Resting cardiorespiratory tests were performed in the MMT group

Results: MMT patients and normal subjects were 35 ± 9 years old (mean ± SD), and BMI values were 27 ± 6 kg/m2 and 27 ± 5 kg/m2, respectively. Thirty percent of MMT patients had a central apnea index (CAI) > 5, and 20% had a CAI > 10. All normal subjects had a CAI < 1, and no difference was found in obstructive apnea-hypopnea index between the two groups. Methadone blood concentration was the only significant variable (t = 2.33, p = 0.025) associated with CAI and explains 12% of the variance. Awake Paco2, antidepressant use, reduced ventilatory response to hypercapnia, and widened awake alveolar-arterial oxygen pressure gradient together explain a further 17% of the CAI variance.

Conclusions: Thirty percent of stable MMT patients have CSA, a minority of which can be explained by blood methadone concentration. Other physiologic variables may also play a role in the pathogenesis of CSA in MMT patients, and further research is indicated in this area.

Background: Mu agonists have been an important component of pain
treatment for thousands of years. The usual pharmacokinetic parameters
(half-life, clearance, volume of distribution) of opioids have been known for
some time. However, the metabolism has, until recently, been poorly understood,
and there has been recent interest in the role of metabolites in modifying
the pharmacodynamic response in patients, in both analgesia and adverse
effects.

A number of opioids are available for clinical use, including
morphine, hydromorphone, levorphanol, oxycodone, and fentanyl. Advantages
and disadvantages of various opioids in the management of chronic
pain are discussed.
Objective: This review looks at the structure, chemistry, and metabolism of
opioids in an effort to better understand the side effects, drug interactions,
and the individual responses of patients receiving opioids for the treatment
of intractable pain.
Conclusion: Mu receptor agonists and agonist-antagonists have been used
throughout recent medical history for the control of pain and for the treatment
of opiate induced side effects and even opiate withdrawal syndromes.

Read more here: 2008;11;S133-S153

The present review aims to clear up the issue of the neurological processes underlying the personality changes induced by chronic opioid use. The effects of methadone treatment on brain functions have been analyzed, too. Brain disintegration becomes evident very soon after an onset of chronic heroin abuse and continues throughout the period of drug consumption. A considerable proportion of opioid addicts are characterized by conspicuous neuropsychological deficits, which preclude the maintenance of complete opioid abstinence in this patient subgroup. At present, there are no data to testify that the effects of methadone maintenance on brain functions exceed the adverse neurological effects of chronic heroin use.

Polunina_9(2)2007 02.10.

The National Institute on Drug Abuse (NIDA) supports most of the world’s research on drug abuse and addiction.
NIDA-funded research enables scientists to apply the most advanced techniques available to the study of every aspect of
drug abuse, including:
• genetic and social determinants of vulnerability and response to drugs;
• short- and long-term effects of drugs on the brain, including addiction;
• other health and social impacts of drug abuse, including infectious diseases and economic costs;
• development and testing of medication and behavioral treatments for abuse and addiction; and
• development and evaluation of effective messages to deter young people, in particular, from abusing drugs.
Included in this document are selections of topic-specific articles reprinted from NIDA’s research newsletter,
NIDA Notes. Six times per year, NIDA Notes reports on important highlights from NIDA-sponsored research,
in a format that specialists and lay readers alike can read and put to use. Selections like the current one are intended to remind regular NIDA Notes readers and inform other readers of important research discoveries during the periods they cover.

.A_Collection_of_Articles_That_Address_Heroin_Prevention,_Treatment_and_Research

MethadoneUsersandRiskydecisions 12

Reinforcing properties of psychoactive substances are considered to be critically involved in the development and maintenance of
substance dependence. While accumulating evidence suggests that the sensitivity to reinforcement values may generally be altered in
chronic substance users, relatively little is known about the influence reinforcing feedback exerts on ongoing decision-making in these
individuals. Decision-making was investigated using the Cambridge Risk Task, in which there is a conflict between an unlikely large reward
option and a likely small reward option. Responses on a given trial were analyzed with respect to the outcome on the previous trial,
providing a measure of the impact of prior feedback in modulating behavior. Five different groups were compared: (i) chronic
amphetamine users, (ii) chronic opiate users in methadone maintenance treatment (MMT), (iii) chronic users of illicit heroin, (iv) ex-drug
users who had been long-term amphetamine/opiate users but were abstinent from all drugs of abuse for at least 1 year and (v) matched
controls without a history of illicit substance use. Contrary to our predictions, choice preference was modified in response to feedback
only in opiate users enrolled in MMT. Following a loss, the MMT opiate group chose the likely small reward option significantly less
frequently than controls and heroin users. Our results suggest that different opiates are associated with distinctive behavioral responses
to feedback. These findings are discussed with respect to the different mechanisms of action of heroin and methadone.

BMJHeroine

Introduction
An estimated 25 000 heroin addicts live in the Netherlands
(population 16 000 000 inhabitants).1 Most users
(75-90%) inhale heroin (“chasing the dragon”).2 About
three quarters of these addicts are served by a comprehensive
treatment system, including various kinds of
abstinence oriented treatment facilities and a wide
range of facilities focusing on stabilisation or
minimisation of harm.1 However, 5000-8000 people
on methadone maintenance treatment regularly use
illegal heroin, have serious physical and mental health
problems, and live in socially marginalised conditions,
characterised by illegal activities and a lack of social
contacts outside the drug scene.3–5
A large cohort study in Switzerland ascertained the
feasibility, safety, and efficacy ofmedical prescription of
injectable heroin to 1969 addicts. There were considerable
improvements in physical and mental health, various
aspects of social integration, and illegal drug use in
237 patients who completed 18 months of heroin
treatment.6 Although this study indicated that heroin
assisted substitution treatment is feasible, the effectiveness
of treatment was difficult to judge because no
(random) controls were available, before and after
comparisons were restricted to those who completed
treatment, and participants were obliged to take part in
mandatory psychosocial counselling and care.7–9 In a
small randomised controlled trial (n = 51) in which
intravenous heroin was compared with some standard
treatment, functioning of the participants in the heroin
group was significantly better after six months.10 However,
these positive effects could have been the result of
the additional, and mandatory, psychosocial interventions
in the group allocated to heroin.
We examined the effectiveness of medically coprescribed
heroine in two open label randomised controlled
trials among heroin addicts who had responded
insufficiently to methadone maintenance treatment.

HeroinAdd8-4

  1. CONTENTS
    Combating the Stigma: Discarding the Label “Substitution Treatment” in Favour of “Behaviour-Normalization Treatment”
  2. In the Service of Patients: The Legacy of Dr. Dole
  3. Injecting Buprenorphine Tablets: A Manageable Risk
  4. QTc Prolongation in Methadone Maintenance: Fact and Fiction
  5. Methadone: Is It Enough?

HeroinAdd4-3

  • CONTENTS
    Harm reduction and specific treatments for heroin addiction.
    Different approaches or levels of intervention? An illnesscentred
    perspective

    Methadone Treatment in Croatia

    The renaissance of methadone treatment in America

    Methadone and commonplaces

    Methadone maintenance and HIV infection

    Breast-feeding for a methadone-maintened mother: a case
    report

    Methadone Maintenance treatments in European
    extracommunity target

HeroinAdd5-2

  1. Introduction ………………………………………………………………………………………………….8
    The Clinical and Therapeutic Aspects of Personality Disorders
    in Addicted Patients …………………………………………………………………………………….14
    Addiction and symptoms of psychopathology ………………………………………………….14
    Addiction and psychopathological dimensions ………………………………………………..14
    Addiction and Personality Disorders ………………………………………………………………16
    Antisocial Personality Disorder (APD) …………………………………………………………………………18
    Personality and the etiopathogenesis of addiction …………………………………………..19
    The self-medication hypothesis for addictive disorders …………………………………………………..19
    The role of subjective effects: the self-selection hypothesis …………………………………………….20
    Sensation-seeking behaviour and impairment of gratification: what is too little
    or too much? ……………………………………………………………………………………………………………..21
    The psychology of addiction: evolution of theoretical models. ………………………….22
    Psychodynamic theories ………………………………………………………………………………………………22
    Beyond psychodynamics …………………………………………………………………………………………….24
    Addiction and Bipolar Spectrum ……………………………………………………………………25
    Treatment of Personality Disorders during Methadone Maintenance ……………….30
    Conclusions …………………………………………………………………………………………………31
    The Clinical and Therapeutic Aspects of Mood Disorders
    in Addicted Patients …………………………………………………………………………………….32
    Epidemiology ……………………………………………………………………………………………….32
    Assessment and evaluation of depression in addicted patients ………………………….34
    Family History of Mood Disorders …………………………………………………………………35
    Primary or secondary nature of comorbid mood disorder in relation
    to addiction ………………………………………………………………………………………………….36
    Impact of comorbid mood disorders on the natural course
    of heroin addiction ……………………………………………………………………………………….37
    Substance use among Bipolar Patients …………………………………………………………..38
    Addiction and Suicide …………………………………………………………………………………..38
    Heroin addiction and its consequences on mood …………………………………………….41