A DRAMATIC LEGAL TURNAROUND:

A South Carolina conviction of manslaughter has been overturned - at last! The charge - and a 12-year sentence without possibility of parole! - was the result of a stillbirth that the prosecutor alleged was due to the use of cocaine during pregnancy. There was nothing to link the stillbirth to the cocaine use, as noted by a host of experts

For the full story on the National Advocates for Pregnant Women Website
Click here

RUSSIA: FLAT-EARTHISM RULES!

The top physician-hygienist and the leader of nation's consumer protection agency, Gennadi Onischtschenko, declared at the end of a conference on AIDS in Eastern Europe and Central Asia that there is as yet no evidence to support the notion that methadone treatment is effective. Go figure(from Ria Novosti, 3 May 08 - more information available in German at http://de.rian.ru/russia/20080503/106442797.html

Special thanks to our Hamburg colleague Hans-Guenter Meyer Thompson for bringing this to our attention

WHY IS ABSTINENCE NOT POSSIBLE FOR SOME

Dole and Nyswander speculated that when people become addicted to heroin there is a physical change in their systems that may or may not be reversed with abstinence, and to the extent it isn't, it could explain the tendency to relapse after abstinence is achieved. Without question, long-time abstinence after dependence on morphine still leaves lab animals "different" - they develop tolerance vastly more quickly than opiate-naive animals though God only knows why or how (same difference in development of tolerance applies to humans, by the way). The other possibility they put forth was that some people are genetically, physiologically, predisposed to react differently to heroin when exposed than are the majority. We know virtually everyone drinks, but only some 15% or so go on to become progressive, self-destructive alcoholics. About the same proportion was found for Vietnam GIs coming homne after having used huge amounts of very pure heroin for a year or more - about 85% promptly quit upon returning to US and the remaining 15% were quickly indistingishable from addicts whose drug experience was entirely domestic. How did the 15% differ from the 85%? To this day no one has the answer.

Many folks dismissed their hypothesis and I remember a very highly respected leader in the field (maybe the MOST respected leader) at a conference pointing to enforced abstinence in a prison setting, for instance, and the total inability to detect any abnormality among inmates who had been using heroin for years and then were incarcerated. But Dole and Nyswander stuck to their guns. And then, when endorphins were discovered, their hypothesis suddenly made great sense. Endorphins are formed by a hormone system, and we know that every hormone system gets screwed up (a non-scientific description, but it'll do) if one introduces from outside a substance that is essentially the same as the hormone. Take steroids long enough and it can be sheer hell to be weaned off them - and some people never can be. Same with thyroid hormone - or any other. So it makes absolutely perfect sense that taking into the body something akin in all respects to endorphins will screw up the endorphin system - maybe forever, maybe for a while, maybe a great deal in some people and hardly at all in others.

Alas, no one has been able to identify - YET - just what that abnormality is and how it can be measured. But the bottom line: it don't make any difference. The fact is that most people who are addicted to heroin can't achieve and maintain abstinence - can't or won't, makes no difference. They will keep using dope and risk their own health and lives and harm others. That's the reality and wishing it were different doesn't help. And then there's methadone, which enables many (not all) people to lead productive, satisfying, reasonably healthy lives and dramatically lessens the danger of dying. So what's not to like? Beats the hell out of me. I've never understood it, and my experience with nicotine patches makes me even more amazed that so many people detest methadone treatment - I smoked 45 years, never went a day without smoking, hated it for decades and would have given anything to be able to quit. And finally with the patch for 2 years I cut down to about 5 a day and then quit. What kind of idiot would say: yeah, but what proves you needed the patch? And then go on, "I have an uncle whose maid quite smoking without anything" - as if that makes the slightest difference.

PEAK-TROUGH TESTING:

We've been copied on correspondence involving a long-time methadone patient who has not been doing well on doses that very slowly and grudgingly were raised to about 80-mg per day. The "clinic" insisted she have peak-trough blood concentration testing done - and pay for it! Based on the results they claim there's no rationale for increasing the dosage and instead are threatening to decrease it. Some comments on peak-trough testing follow:

Tom Payte is the expert on this... My understanding: peak-trough relationship merely indicates that one might have a "fast metabolizer". It's indicated not to determine adequacy of dosage, but to help formulate response to patient discomfort and less than optimal therapeutic results.

If one has a patient not doing well, and there's a big big gap between the peak concentration and the lowest in the course of a day, then it might make much more sense to split the dose rather than "just" increase it. In fact, increasing it in such cases might lead to more discomfort/problems, because there'll be a higher peak, still a very rapid metabolism and thus in the course of the day an even greater gap between the high and low concentrations. Thus: rationale for splitting doses - I've heard Tom Payte talk about some (very few) patients whom he had to give doses six times a day before they responded well.

I see zero rationale ever for decreasing a dose based on P-T levels. Ultimately, I'm a believer in clinical observation rather than fancy and expensive lab tests. Patient's dojng well on a dose, great. If not, and most definitely if patient has been getting dosage that for most is sub-optimal (e.g., less than 80) then of course increase the dose! It's when the dose gets up[ to 150-200 and the patient still reports doing poorly, especially toward end of day, then logic dictates trial of splitting the dose - say half AM and half PM. What counts is how the patient is doing - NOT what a lab test shows (identical reasoning for my disdain for urine tests!).

AA (as in Abstinence Advocates who despise medically-supported treatment of addiction) TAKE NOTE:

Vincent Dole gave a presentation in 1991 to the American Society of Addiction Medicine (reprinted in Clin Exp Res, 1991, 15(5): 749-752), in which he told about being asked in the early 60s to become a "lay" member of the Board of Alcoholics Anonymous - only 7 non-alcoholic trustees are permitted worldwide under the constitution of AA. Vince had just published the initial studies on methadone, demonstrating its unparalleled efficacy in treating heroin dependence, and he couldn't figure out why he was asked to join the board of AA, which had never utilized medication in helping alcoholics.

At the last meeting he attended with Bill W before the AA founder's death it was explained. "[H]e spoke to me of his deep concern for the alcoholics who are not reached by AA, and for those who enter and drop out and never return. Always the good shepherd, he was thinking about the many sheep who are lost in the dark world of alcoholism. He suggested that in my future research I should look for an analogue of methadone, a medicine that would relieve the alcoholic's sometimes irresistible craving and enable him to continue to progress in AA toward social and emotional recovery..."

Bill W was a wise and compassionate man! Hopefully some day soon an "analogue" to methadone indeed will be found - and when it is, one can only pray it will be embraced by those who are committed to helping those afflicted by alcoholism.

BUPRENORPHINE AND METHADONE:

Vastly different requirements - and practices. For methadone treatment of opiate dependence, 6-7 visits each week are mandated for every single patient for several months after treatment begins. For buprenorphine, there are no requirements whatsoever.

According to data presented on Feb. 21, 2008, by the Director of CSAT, SAMHSA, 35% of patients surveyed reported they had NO return visit to the physician for at least 30 days after the very first prescription for buprenorphine was given (no information was provided as to how many returned after the first 30 days). Clearly, this means that during those first 30 days of treatment there was no urinalysis, no assessment of dosage adjustments that might be indicated, no followup of any possible medical or mental co-morbidities, no determining whether "counseling" as needed and, if so, whether it was received and how effective it was, etc. And yet, the Director's presentation also stated that 40% of prescribing physicians believed buprenorphine treatment to be "very effective" for patients receiving treatment for 8-30 days (one must wonder how they knew).

At the very least, the disparities would seem to cry out for a reassessment of the rationale for the extraordinarily onerous and expensive demands that are imposed on patients and providers alike when the medication employed in treating the disease of opiate addiction is methadone rather than buprenorphine.

"POLICE MENTALITY" :

Beware of generalizations. Thus, the chair of the police union for the Netherlands has recently stated, "It is pointless to fight against the supply of cannabis." He went on to say that "...he would much rather see soft drugs legalized in The Netherlands ... [and he] is in favour of letting long time addicts use hard drugs under supervision." The thinking of this experienced, senior police official is clear: "In his opinion this is the only way to effectively fight drug related crime."

For full story

CHALLENGING SUCCESS OF HONG KONG'S ADDICTION TREATMENT RESPONSE:

South China Morning Post (HK) reported on April 10th that the government Auditor is urging that existing treatment services be “shaken up.” Sometimes one loses sight of the forest for the trees; local Audit staff seem unaware that Hong Kong’s response to the problem of heroin addiction, and most particularly its methadone programme, have for over three decades been acknowledged by countries throughout the world to be a model of effectiveness, and one that many have sought to emulate. The extremely low HIV infection rate among drug users in Hong Kong is dramatic testimony to that effectiveness. Among the Audit Director's recommendations: reallocation of funds from methadone to other forms of treatment, and “…stepped up efforts to encourage more methadone patients to undergo detoxification . . . “

Success on the narcotic addiction front is exceedingly rare; Hong Kong must not jeopardize what it has achieved. For full Audit report (which was released March 2008) on Treatment and Rehabilitation Programmes in Hong Kong, click here

NIMBY DISCOVERS BUPRENORPHINE:

From Johnson City Press (Tenn.), 16 April, a report of community outrage over a "clinic" where buprenorphine is prescribed for opiate dependence. The article notes that City Code restrictions have long governed establishment and operation of programs treating patients with methadone, but "Suboxone is an especially difficult narcotic for municipalities to regulate, as any licensed physician may prescribe it." Obviously, the fear and loathing that NIMBY reflects are directed at the patients receiving care; the particular medication that's provided is irrelevant!

FROM HAMBURG, GERMANY: SUCCESSFUL PREGNANCY OUTCOME WITH HEROIN-ASSISTED TREATMENT OF OPIATE DEPENDENCE:

A successful outcome has just been described in a 31 year old long-time addict who had failed to respond favorably to methadone maintenance. Eur Addict Res. 2008;14(2):113-4. Ultimately, therapeutic decisions require weighing of the alternatives, and whatever reservations one might have about clinical prescribing of heroin to pregnant women, for those whom methadone does not help and who reject other forms of care, the alternative is probably abandonment!

THANKS TO COLLEAGUE HANS-GUENTER MEYER-THOMPSON for calling our attention to this article.

INSPIRING ADVOCACY RESPONSE TO DISTRESSING ATTACKS ON METHADONE IN INDIANA:

A good example of the insane policies that people have to fight off - seemingly constantly - in many places in this country, matched by some comprehensive, thoughtful and determined advocacy that has kept the outcome from being much worse. For full first-hand report, click . . . .
http://www.drugpolicy.org/news/040808indiana.cfm

METHADONE PATIENT RAISES IMPORTANT QUESTION:

QUESTION:
"I am a patient in a clinic in ______ state and have been for 6 plus years. This is the only clinic I have ever been to so I have nothing to compare it with, but things have gotten progressively worse. It seems as though now there is an UNWRITTEN rule that is being enforced clinic wide that is you are 10 years or more on the clinic, and doing well patients are being forced into a detox and being told that "You have reached a point where you cannot benefit from the clinic anymore". We are talking about people that have a good amount of clean time, have take homes and attend all appointments and groups.

There is definitely a trend of prodding, if not forcing clients that would like to stay on Methadone Long Term off of the clinic. I am wondering if this is a practice used by other clinics or perhaps new regulations causing this drastic change in policy? This isn't the first time this clinic has changed their philosophy regarding Methadone Maintenance Treatment. Over the past 3 years they have changed from the "Harm Reduction" model which allowed much more room for relapse, to the "total abstinence" model which is VERY strict regarding dirty urines. I know of dozens of clients kicked off over the past 2 years for frequent relapse... which for quite some time we were told that relapse was "part of the disease".... Is this change of philosophy common among other clinics of is the one I am going to just really bad? "

ANSWER from ICAAT: It's terrible! Bottom line: whatever the circumstances - duration of treatment, excellence of response, stability of work/home, age, etc etc etc - I believe there's no evidence anywhere that contradicts the assumption that relapse remains the rule rather than the exception when treatment is stopped. There is absolutely no justification for encouraging detox, and as for terminating people because they don't achieve complete "abstinence from drug use while in treatment" - the question that's critical is: what's the basis for concluding that the patient will be at less risk of illness, incarceration and death if I discontinue treatment rather than continue to try to afford help to her/him in the program.

The problem is: what can a patient do in fighting a policy/practice of the clinic which has the ultimate say in everything, including dosage, take-home "privileges," and even termination. Some suggestions: expressing concern to the accreditation body - either anonymously or with an assurance upfront that confidentiality will be assured. And/or express concern to state drug authority. Beyond that, I fear that a patient who fights a clinic will ultimately lose, one way or the other.

If the patient needs an advocate with accrediting or regulatory bodies, We are happy to assist in whatever way possible.

METHADONE MAINTENANCE AND ALCOHOL CONSUMPTION:

An extensive systematic review by Srivastava and colleagues found 15 major studies that reported on clinical experience. Of these, 3 reported that after admission patients increased their consumption while receiving methadone, 3 reported a decrease, and 9 found no significant change. we had to wonder if perhaps the same distribution might be found if one studied alcohol consumption patterns after enrollment in a clinic treating diabetes, or hypertension, or any other chronic medical condition. Publication was in J Subst Ab Treat (2008). 34:215-223.

THE LUCK OF THE DRAW

Mr. David Paterson, newly elevated Governor of NY, recently acknowledged (presumably because he realized it would get out anyway!) that he used cocaine and marijuana in his younger years. Had he been unlucky enough back then to get busted for possession of a single joint, or a trace amount of coke, he'd probably be in jail now, or trying to overcome a "criminal record" and find a job, or perhaps dead. Instead, because he had the good fortune not to have been in the wrong place at the wrong time, he is responsible for governing NY State - and however one judges his likelihood of governing well, no one has suggested for a moment that he's unqualified in the light of his acknowledgment.

Justice should not hinge on luck. Hopefully, the new governor will reconsider our drug policies in light of his own experience. He has long advocated changing the Draconian Rockefeller Law; now he should push for an even more radical change in how we approach drug use in our state and nation. If any political leader can empathize with the real victims of the drug war, he can!

MISLEADING REFERENCES TO DANGERS OF METHADONE:

An article in the International Herald Tribune of March 20 was entitled, “Nine middle school girls get sick from methadone pills.” In the US, “methadone pills” are only provided for the management of pain; for many years Federal regulations have demanded that all methadone used in the treatment of dependence be in dissolved, liquid form. So in this unfortunate case it’s clear that wherever the methadone came from, it was not from comprehensive methadone treatment programs. And yet, the article describes methadone as “a drug commonly used to treat heroin addiction.” Certainly, it is that – and it’s used in treating opiate dependence with unparalleled effectiveness. The message that the average reader of this story will take home, however, is clear: by a miracle nine young girls avoided being killed by methadone, “commonly used to treat addiction.” Inevitably, the article will add to what already is the greatest hurdle that faces patients and providers in their efforts to overcome addiction - misunderstanding and the fear and stigmatization it leads to.

ARTICLE FOLLOWS
INTERNATIONAL HERALD TRIBUNE AMERICAS 20 March 08
9 middle school girls in Missouri are sickened after apparently eating methadone pills The Associated Press Published: March 20, 2008 ST. JOSEPH, Mo.: Nine middle school girls were sickened after apparently eating methadone pills supplied by a 16-year-old boy, police said. The girls were hospitalized Wednesday and being kept for observation at Heartland Regional Medical Center.

"It appears that the students are doing OK," St. Joseph police Capt. Kevin Castle said. The teen suspected of providing the prescription methadone — a drug commonly used to treat heroin addiction — was charged with distributing a controlled substance. Officials are still trying to determine where he got the drugs.

Castle said the Benton High School student is believed to have given the pills to a middle school girl on a school bus. Police believe the girl then distributed the pills to other girls, most or all of them eighth-graders. The girls first complained of feeling nauseous and groggy, and at least one was salivating excessively, school administrators said. Around noon, the girls were crying as they walked to ambulances, and one hysterical girl was taken from the school on a stretcher.

School and police officials said it is unclear whether the girls knew what they were taking. All nine of the Spring Garden Middle School girls face potential sanctions, officials said. District administrator Cheri Patterson sent a letter home with students discussing the situation. It encouraged parents to talk to their children. "Drugs, whether prescription or not prescription, are dangerous drugs. And as some of our students found out, you take a scary risk when you ingest them," Patterson said in the letter.

UNODC, WHO AND UNAIDS SPEAK OUT FOR HARM REDUCTION:

In a statement by the Joint United Nations Programme on HIV/AIDS, 14 March 08 at the meeting in Vienna of the Commission on Narcotic Drugs, “a set of measures for people who use drugs” was recommended. Recommendations number one and two called for needle and syringe programmes, and “opioid substitution therapy.” One can only hope governments are listening, and for none is heeding and implementing the recommendations more imperative than for the United States and the Russian Federation – the former clinging to its “flat-earthist” policy of rejecting the evidence for efficacy of needle/syringe exchange in curtailing spread of the virus, and the latter persisting in its refusal to legalize a form of treatment that has been shown to have unparalleled therapeutic outcomes.

MMT IN CHINA: NEGATIVE ATTITUDES IN FACE OF POSITIVE RESULTS

Does this heading sound familiar? It basically sums up the entire history of MMT worldwide over the past 40 years. Now China: in a brief summary of experience with methadone in recent years (AmJDrugAlcAb 34:127-131, 2008) it's noted that MMT has "reduced injection drug use and criminal behavior and improved social behavior... employment increased ... [and] high-risk consumption patterns like injecting diminished significantly." In short, "MMT programs have successfully mitigated harm related to heroin abuse." And yet, "... objections to MMT from general health care providers and the public about substituting one addiction for another ..." persist.

A NEW LOW IN UNINFORMED REMARKS ABOUT METHADONE TREATMENT:

Bill Aitken, a "senior Tory politician," told BBC-Scotland, "We have a very high proportion of the drug-abusing population sitting fat, dumb and happy on methadone," The barrier of stigma and prejudice facing patients receiving methadone in the hopes of leading a reasonably self-fulfilling, productive life in society has just been made higher. Scotland has no corner on the market of stupid politicians, God knows, but this example of stupidity is mighty bad. For BBC story,

http://news.bbc.co.uk/go/em/fr/-/2/hi/uk_news/scotland/7299452.stm

UN INCB CALLS TO SHUT DOWN CANADIAN DRUG INJECTION SITES:

According to an article in "The Citizen" (western Canada) The UN INCB has recommended that Canada “shut drug injection sites” (March 5). One has to wonder what the folks at the UN Narcotics Control Agency have been smoking. First, to the extent Canada is violating any UN conventions with supervised injection facilities and distribution of “handouts of paraphernalia” it is in very good company; injection sites have been widely available in Switzerland, Germany and The Netherlands, for example, for years, and needle/syringe exchange programs operate in countries throughout the world (yes, even in the USA, where the Federal government has a rigid flat-earth view of harm reduction). If the UN body has evidence that these services “enable” illicit use, as it claims, it’s keeping it close to the chest, since no credible reports of such adverse effects have been published. To the contrary: experience – including that of Canada - has consistently proven that these measures add to the safety of drug users as well as the general community, and actually facilitate referral to long-term treatment. And one would expect no less, since the alternative is abandonment. Go Canada!

STRATEGIES TO CONTROL BUPRENORPHINE ABUSE:

On Feb 23rd the Baltimore Sun published the following article.

I wrote to seek clarification from Dr. Fiellin's reference to Physician Clinical Support System's (PCSS) role in physician compliance with buprenorphine prescribing guidelines

***************************************************************
LETTER TO DR. DAVID FIELLIN
RE BALTIMORE SUN FEB 23 ARTICLE
***************************************************************

March 7, 2008

Dear David:

The comments attributed to you by the Baltimore Sun in its Feb. 23 article on “strategies to control bupe abuse” are of concern. Specifically: “’There is not an active surveillance system in place to identify physicians who are practicing outside the guidelines,’ Fiellin said. When they are found, he said, his group will work to report them.”

Which guidelines? All those contained in the 198-page publication, “Clinical guidelines for the use of buprenorphine” – to which you contributed as member of the “buprenorphine expert panel”? Or are there guidelines of particular concern based on evidence that they are causing misuse/abuse/diversion?

What is the plan for “finding” doctors who deviate from the guidelines?

To whom is the ASAM “group” planning to report the doctors it identifies?

It may well be that you were misquoted and/or that your remarks were distorted by being taken out of context. As they stand, however, they surely will dampen the already quite limited enthusiasm of physicians to obtain and utilize the authority to prescribe. I also worry that your sentiments will give impetus to pressure to impose on buprenorphine many of the same demands and restrictions that for decades have served to exclude office-based physicians from caring for opiate-dependent patients with methadone. In any event, physicians prescribing or thinking of prescribing buprenorphine have a right to know what to expect: the practices ASAM plans to monitor and how, and to whom non-compliance will be reported. Notification to all waivered physicians of ASAM’s intentions should be easy to arrange. I urge you and ASAM to do so.

Sincerely
Bob Newman, MD

***************************************************************
RESPONSE BY DR. DAVID FIELLIN:
***************************************************************
Bob,

Thank you for your letter.

I spoke at this press conference as Medical Director of the PCSS, not as an employee or member of ASAM.

As you have suggested, I was indeed misquoted. I am also disappointed that the Baltimore Sun choose not to print my letter to the editor regarding their series on buprenorphine.

The guidelines that I referred to include the CSAT TIP #40 and the Guidance produced by the Federation of State Medical Boards.

Both of these documents recommend that stabilized patients be seen on a regular basis (e.g. monthly) and that patients who are early on in the recovery process be seen more frequently and have access to physician and counseling services.

The PCSS has no role in active surveillance of physicians but exists primarily as an educational resource to assist clinicians in providing quality care to opioid dependent patients. To help them get over the reticence that you discuss.

My statement was that the PCSS mentors are encouraged to work with state medical societies if there are concerns about inappropriate prescribing behaviors. We have occasionally received reports about physicians who do not have a modified DEA registration who are prescribing large quantities of buprenorphine, offering no office or counseling services and the like. My hope is that the medical societies and the medical profession can work to limit these events and respond within our profession so that we do not end up with significant restrictions, from federal agencies, that limit the availability of office-based treatment of opioid dependence.

I hope you agree. Thanks,

David

*********************************************************************
COMMENT BY DR. MIKE MILLER,
PRESIDENT AND BOARD CHAIR, ASAM
*********************************************************************

David:

1. Thanks for your leadership of PCSS.
2. Thanks for your excellent letter to the Baltimore Sun. I agree, it's a shame they didn't publish it.
3. Thanks for your reply to Bob.

Bob: Thanks for bringing this to our attention. You are surely not the only ASAM member, or patient of an ASAM member, who has seen the article, on the web or even on their news stand in Baltimore, and wondered, 'Huh??'

This is such a delicate topic: it occurs to me, David, that your response to Bob, or something like it, could be posted on the ASAM website, and published in ASAM News. ASAM has no role, and CSAT's PCSS, administered by ASAM, has no role, in monitoring physician practice, cataloging deviatiations from standards of care, or reporting physicians to regulatory or licensing agencies. Individual physicans are bound by our code of ethics, however, to report egregious physician behavior when we are aware of it.

This really is a delicate topic, and shining light on it is warranted especially in the current environment, stirred up by the editorial board of the Baltimore Sun, in which partial truths, misquotes, and other misinformation is harming the ability to expand an incredibly successful public health intervention to more patients in need. Plants need light and mud to grow; in this case, more light and less mud would be a good thing.

Mike

--
Michael M. Miller, MD, FASAM, FAPA
President and Board Chair, ASAM

NEWSWEEK: WHAT ADDICTS NEED

An Unpublished letter to the editor that needs to be heard...

TO THE EDITOR: Addiction indeed is an illness, a “chronic, relapsing brain disorder,” as your article notes (Feb 23).You also correctly point out that this has been recognized (e.g., by the AMA) for over 50 years. Furthermore, it’s a disease that – where narcotics are concerned – has been treated with great effectiveness with medicines (especially methadone) for more than four decades. Accordingly, it is difficult to understand the quote you attribute to Dr. Nora Volkow, the Director of NIDA, “The future is clear. In 10 years we will be treating addiction as a disease, and that means with medicine.” Obviously, this is not a prediction of the future, but a concise recap of the knowledge and practice of the past.

RGN

GOOD NEWS METHADONE ARTICLE – WITH A TWIST...

A seemingly positive story about “methadone clinics treating hundreds around area,” in the Mar 9 Cumberland (W. Va.) Times-News, includes no community attacks, no claims of problems in or around the clinics, and thus would seem welcome news. Unfortunately, the story on balance is probably going to reinforce the stigma against patients and the treatment in an area generally, and ironically the negative vibes emanate from those who run these clinics.

One administrator acknowledges that “addiction is a lifelong disease,” but also states that “what we have here is a methadone-to-abstinence program.” Worse, he claims that there’s an 80% “success rate for people enrolled in maintenance drug-based program more than 11 months. Typically, after 12 months of treatment, patients use the next six months for detoxification” followed by “counseling for six months.” The figures would be radically different from those of every study published in the past 40-plus years, and give the impression that the great majority of patients can discontinue methadone after a relatively short period of time. Ultimately even a positive spin is very harmful when it surrounds misinformation and cites outcomes that are unachievable.

THE GOOD – AND THE UGLY: A NEW JERSEY EDITORIAL

The Courier-Post (NJ) on February 24th noted, correctly, the tragedy of New Jersey’s needle exchange program being “hobbled by lack of funding.” Sadly, the editorial also merits condemnation for lumping together “methadone clinics, poverty and drug markets” as being a “magnet for drug users.” It is distressing to note the inability to distinguish the problem, from legitimate, time-tested, highly effective interventions that dramatically lessen the harm with which it is associated – and when it comes to narcotic dependence, no intervention has been proven to be more effective than methadone maintenance treatment.

Precisely this muddled thinking, and the erroneous assumptions it reflects, underlie the hurdles facing needle exchange programs as well as treatment services as they seek the support they – and their clients and patients and the community at large – so desperately need.

PARENTS WITH A DRUG PROBLEM:

The following was an unpublished Letter to the Editor:
Dear Editor,
You imply that the 7000 patients being treated medically with the medication methadone fall under the rubric "parent with a drug problem" (Feb.19). This does a terrible disservice to patients and providers of medical care that has for over 40 years been demonstrated to be uniquely effective in permitting opiate dependent people to lead healthy, productive, responsible lives. To the extent you suggest society should give up on efforts to help these 7000 (there are no alternatives for the vast majority!), you help to perpetuate and aggravate the problems faced by the children you wish to protect.

CLEAR THINKING ON DRUGS:

This is from university students... An editorial in the Daily Targum, Rutgers University, of Feb. 26 is headlined, “End the war on drugs.” It goes on to explain why, citing some 40 billion dollars yearly in federal and state expenditures in support of a “hopelessly outdated and Draconian policty ... [that has] has done little, if anything, to curb the flow of these substances into, and throughout, our nation.” With students like this there’s hope for a better tomorrow!

LAMENTING STIGMA, BUT REINFORCING IT:

A report in Citizens' Voice (Feb. 13, Wilkes-Barre, Pa.) discusses the unwillingness of the vast majority of physicians to seek and utilize permission to prescribe buprenorphine in the treatment of opiate dependency.

It's not going to help matters when one reads in this story of a physician who states that his own patients "look normal to you or me," but then goes on to make the horrendously negative generalization that addicts “are very difficult patients. They’re highly manipulative. They lie, they cheat, they steal. … They also may present an unkempt appearance in the office.”

This physician apparently believes that there's something unique about him, his treatment, or his office. The fact is that patients who "look normal" are the rule rather than the exception in all practices that provide maintenance treatment - be it with buprenorphine or methadone. The physician cited in this article does a disservice to those who receive care, and the vastly greater numbers who, as this article notes, cannot find providers because of the stigma that is applied to them.

STIGMATIZING METHADONE TREATMENT:

A battle won, but the war continues unabated. The Baltimore Sun (Feb 24) headline said it all: "Drug clinic limits stand," despite a federal Appeals Court ruling that a specific clinic may remain open. The precise wording of the article as it relates to the bottom line:

"With a less-than-definitive opinion from a federal appeals court, Baltimore County officials say they have no intention of scrapping their restrictions on the location of methadone clinics."

SUBOXONE:

"...works better with addicts who used opiates for two years or less, while methadone is preferred for long-term users." This is the statement in the Times-Tribune story of 13 Feb. entitled, "Treatment still facing hurdles in regulation." The quote reflects what is frequently heard and read. The question is: is there any evidence to support either the "better" effect of buprenorphine on relatively recent users, or the "better" outcomes of methadone with longer-term users of opiates? I don't think so - but would welcome citations on the point.

Click for Link

A NEW LOW IN PATRONIZING, DEMEANING RULES GOVERNING LIVES OF METHADONE PATIENTS

Charleston Treatment Program (W. Virginia) has the following notice posted:
"If you have completed the take home justification to receive take homes, do not ask your counselor where your paperwork is located or who needs to sign your papers next. If you ask for take home privileges or ask questions about your take home paperwork, your take home privileges will be delayed by two weeks." Reminds me of a scene with my son and grand-daughter a few days ago: "If you ask one more time to watch that TV program you won't watch any TV for 2 days." But my grand-daughter is 5 years old. Patients do not deserve to be treated like 5 year-olds. It's amazing - and a testimony to true motivation! - that patients enter and stay in treatment where staff treat them like kindergarden kids.

BAD TIMES LOOM FOR PATIENTS GETTING/NEEDING METHADONE IN SCOTLAND

BBC NEWS (5 Feb) headlined - "


MSPs agree on drugs policy revamp. The SNP and the Tories have reached a deal ...
to draft a new strategy involving less reliance on methadone and a potentially greater stress on promoting abstinence." Scotland's parliamentarians apparently refuse to accept the consistent experience of many decades: a large majority of opiate-dependent individuals is simply jnable - for whatever constellation of reasons - to achieve and maintain abstience! How many Scots must die before this reality sinks in?

METHADONE TREATMENT IN IRELAND: WHAT'S TO COMPLAIN ABOUT??

The Irish Independent (Jan 27) quotes a medical officer at a local prison as claiming methadone “basically substitutes one addiction for another, legal for illegal.” Overlooked is the fact – confirmed by consistent outcome studies published in the worldwide literature for over 4 decades – that methadone allows many patients to resume healthy and productive lives, reduces spread of HIV-AIDS, lowers mortality, etc. Some 9,200 patients are said to be receiving methadone in Dublin alone - can anyone possibly suggest that these people would be better off – and community better served – if methadone were denied?

STOPPING DRUG VIOLENCE

LTE to Washington Post, Feb. 2nd, 2008

Craig Wolf, president of the Wine & Spirits Wholesalers of America, wrote that unlicensed, unregulated alcohol kills [letters, Jan. 17]. He noted the deaths of people in other countries from alcohol that is homemade, counterfeit or tainted, offering a contrast with the situation in the United States, where alcohol has been regulated since Prohibition ended in 1933.

Another lifesaving benefit of regulation that Mr. Wolf did not mention is the end of violence related to alcohol prohibition. When alcohol consumption was illegal in this country we had Al Capone and shootouts in the streets. Today, no one dies over the sale of Budweiser.

The failure and harms of alcohol prohibition are clear. Why have we not learned our lessons when it comes to other drugs, such as marijuana? Tainted drugs, mass incarceration and rampant violence are not a byproduct of the cannabis plant but of the prohibition that creates a profit motive people are willing to kill for.

TONY NEWMAN
Director of Media Relations
Drug Policy Alliance
New York

PROPOSED MORTALITY REPORTING TO SAMHSA BY OPIOID TREATMENT PROGRAMS (OTP): Need Answers Before Being Able to Comment...

The following was sent to SAMHSA in response to its request for comments on the proposed new reporting system.

Re: OTP MORTALITY REPORTING PROPOSAL (Fed Reg 2 Jan 08, vo.73, no.1)

Before being able to comment a bit more information is important:

1. To your knowledge, is anything comparable being considered by FDA, which as you note has authority over methadone prescribing for pain? It's been consistently reported by SAMHSA, CDC, national panels of experts and others that the majority of methadone-related deaths do not, in fact, involve patients, providers or medication associated with OTPs. While recognizing and respecting different responsibilities and lines of authority, one would certainly expect that two parts of the same Federal Department would very closely coordinate their efforts in this important matter. Is that happening? (The same question applies to patients receiving buprenorphine for addiction treatment from non-OTP sources - apparently the vast majority of the total buprenorphine-for-addiction recipients - and those receiving it for analgesia).

2. Your "estimated annual reporting requirement burden" indicates two "responses per facility," and shows nationwide a total of 1150 such facilities. Do I correctly infer that SAMHSA/CSAT anticipates approximately 2300 deaths yearly of patients enrolled in OTP methadone facilities? If so, I imagine you must be seeking reports on every death, regardless of cause – e.g., patients known to have had AIDS unresponsive to treatment, terminal cancer, victims of homicide, etc. Is that the case? Not criticizing – just seeking clarification.

3. It is difficult to comment on the proposed reporting system without seeing even a draft form that reflects the data elements to be captured and analyzed. Can you provide such a draft form?

4. The relevance of data is to a large extent determined by their timeliness. Have you considered the system for collecting and analyzing the information submitted, and do you have estimates of how much time - for instance - between the end of a calendar year and the public release of the findings?

5. Finally, given the importance of this effort (even though it is directed at patients and providers clearly identified as NOT being the primary contributors to the marked increase in reported methadone-deaths), why is SAMHSA proposing to make this reporting system voluntary? The data are deemed important, and the reporting process is estimated by you to involve a "burden" of no more than a half hour per mortality. So why leave it up to each OTP to decide whether or not to report? Government – at all levels – has shown very little reluctance over the course of the past 40 years to demand, as a prerequisite of continued license to operate, compliance with myriad rules and regulations.

Thank you for considering these questions (I am taking the liberty of also sharing these questions with readers of our website - www.opiateaddictionrx.info; hopefully it will serve your goal of getting more comments and suggestions regarding your proposed reporting system - and if you wish us to post your response, we'll be happy to do that, with no editing of whatever you wish us to post)

robert newman, MD, MPH (NYC)

PREVALENCE OF BUPRENORPHINE “ABUSE” – IT’S ALL IN THE DEFINITION:

A recent article entitled, “Abuse of Buprenorphine in the US: 2003-2005” did not consider any indicators of the extent of abuse, but merely tabulated those instances in which the “abuse” caused adverse reactions severe enough to lead someone to contact a poison control center. This would seem to be a particularly misleading approach in dealing with buprenorphine, whose key appeal to regulators and clinicians alike is the high degree of safety attributed to its “ceiling effect.” Smith et al. J Addict Dis 2007; 26(3):107-111.

WAR ON MARIJUANA:

Dollars and lives going up in smoke! A Jan. 9 article in the Wisconsin State Journal quotes FBI sources as stating some 2,200 people are arrested every single day in the US for “marijuana violations” - almost 90% for possession alone. In the state of Wisconsin, over 14,000 arrests were for possession of marijuana in 2003 - and $83 million was spent by the state in "imprisoning such offenders... ". It is difficult to comprehend fully the impact that this has on lives of individuals and families, and costs for the community as a whole. Surely there is a better way!

METHADONE AND CARDIAC ARRHYTHMIAS – THERE’S CAUSE FOR FEARING FEAR ITSELF!

What do we really know about the cardiac “risks” of methadone maintenance? There have been many reports of prolonged QT intervals on electrocardiograms – but what does this mean? Consider a very recent report in the French Revue de Medicine Interne (vol 28, 2007, pages 709-710), which describes a single case – a 51 year-old man who had been on methadone maintenance for nine years and on hospitalized for alcohol-induced cirrhosis and complications, but apparently without cardiac symptoms of any kind. He was found to have a prolonged QT interval on admission, which appears t have necessitated no treatment, and did not prompt change in the methadone regimen.

One of the references cited in the paper also deserves mention – a 2003 report in the form of a letter published by Annals of Internal Medicine (vol. 139, no. 2, pages 154-155). That publication described a study of 132 patients for two months following induction on methadone maintenance. They demonstrated prolonged QT intervals, but there was no mention of any signs or symptoms of cardiac illness, and none of the patients apparently had the treatment plan modified as a result of the EKG changes. The authors concluded by noting that “A critical question . . . is whether the QTc prolongation is clinically significant … [and] whether changes in QTc interval in patients receiving methadone are in fact associated with adverse cardiac outcomes.” Yes indeed – those are the questions! And while they are being considered and answers sought, we must keep in mind the caution of the authors of the 2003 paper: “Any potential risk associated with [methadone’s] use must be weighed against its substantial demonstrated benefits.”

DWI LEADS TO ABRUPT DISCONTINUATION OF METHADONE TREATMENT

An article in The Olympian (Washington State) on 01 Jan stated that a woman with a 3-year old child in the car was cited for drunk driving while on her way to her methadone clinic. The clinic "told her she had to find someplace else for treatment soon." A social worker has been trying in vain to find an alternative provider and indicates that if she's not successful soon the woman will have to "go cold turkey."

Can one imagine any other medical care provider abruptly discontinuing treatment - especially treatment for a condition known to have a significant risk of death - because s/he was cited for drunk driving? Would a diabetes clinic tell a patient on insulin s/he had to find another provider or else simply do without insulin? Or a provider of care for cardiac disease or hypertension or prenatal care or . . .? Unthinkable, and if a provider for whatever reasons were to threaten to do that it would be deemed therapeutic abandonment and subject the physician in charge to possible revocation of medical licenses as well as God knows what civil actions. How incredibly ironic that this particular medical care provider, whose raison d'etre is caring for chemical dependence, should have such policies and practices!

An additional issue raised by the article: narcotic dependence is a medical condition with the most severe consequences for the individual and the community. For the former there is the risk of getting and spreading HIV, hepatitis and other illnesses, arrest and incarceration and loss of child custody, and death from overdose. For the community, there are enormous social and also financial costs. While to date no one has been able to make a credible claim for a cure for narcotic addiction, effective treatment exists - and no form of treatment is recognized as being as effective as methadone maintenance. So . . . shouldn't some voices be raised demanding the State explain what is being done to eliminate the irrationality and inhumanity of requiring those seeking help to languish on waiting lists? The social worker quoted in this article reports that waiting times routinely are 1-1.5 months. Indeed, someone should be demanding to know what consideration is being given to increasing capacity sufficiently to allow the state to take the initiative with public service announcements urging more narcotic dependent people to seek help.

STRONG CRITICISMS REGARDING CHOICE OF WORDS USED IN DISCUSSION OF ADDICTION TREATMENT:

Two specific words that have been criticized are "blockade" and "substitution." Here are some thoughts - and comments are welcomed as always.

Over the years many have made the same observation that "blockade" is an unfortunate term (so is "antinarcotic agent" which dole and nyswander also used in a paper presented in London in 1967 and reprinted in Br J Adict, 1968, vol. 63, pp55-57. Blockade is not an action of methadone; it is an unscientific (and probably misleading) term that simply refers to tolerance, a phenomenon that any 1st or 2nd year med student understands and virtually all physicians have experienced to their frustration and their patients' pain.

As for "substitution" - D and N criticize in the paper cited the term in a very specific sense: "...it needs to be well understood that methadone can be used as an antinarcotic agent, blocking the euphorigenic action of narcotic drugs rather than substituting for them." So certainly, they condemned the notion that methadone treatment provided a substitute high I doubt, though, that D or N would have cared in the least (they almost certainly would have applauded) advocates who shouted from the rooftops that methadone maintenance substituted a legal medication that enhances and prolongs life for an illegal substance that is associated with horrendous costs of suffering, sickness and death (as well as terrible consequences for the community).

I know it's presumptuous of me, but based on my long-standing and close relationship with D and N I am convinced they would focus on practical issues: they'd be thrilled that in Germany and Switzerland, for example, care is available to all who need it, from community-based generalists as well as "programs," with relatively modest constraints - even though in those countries the term "substitution" is almost universally used. By the same token, i'm convinced their horror over the therapeutic tyranny practiced in so very many USA "programs," and the severe limitations on access to humane and respectful community-based treatment, would not have been mitigated in the slightest by virtue of the strong and indignant campaign to get rid of the term "substitution."

Sure, in the best of all worlds where we had no major concerns except semantics, we could all push for the most correct and precise terminology. But in USA, with virtually no one seemingly giving much of a damn about the fate of the estimated 80% of heroin dependent folks having no access to care, I feel a semantic preoccupation is a diversion. And the other 20% who do receive methadone treatment have far far more serious problems - problems associated with the exercise of power by "program" staff who all too often demand they accept "contracts," make medication a function of meeting "contingencies," videotape their urination and terminate patients whose urines are "dirty" - etc. Don't mean to generalize - but God knows these are not issues to trivialize either. And I do respectfully suggest they should be far, far higher on the list of priorities to criticize than semantics.

HEROIN TREATMENT - THERE ARE TWO SIDES TO EVEN THE THINNEST PANCAKE ...

And so it is with the following bottom line of a position statement of the Italian Society of Addiction Medicine (Heroin Addiction and Related Clinical Problems, 9(2):June 2007, 5-10): "Effective treatment is far from being actually available to all those who apply for it, let alone those who may benefit from it. The first step . . . [must be] to spread and enhance resources to grant patients with correct and powerful application of effective techniques, methadone/buprenorphine maintenance being regarded as the gold and first-line standard for the average addict. If that will ever be the case, as we hope, we would need to provide patients identified as refractory with a salvage option, along the concept of harm reduction. In any other context, the intrduction of heroin administration programs would rather reduce the benefit than the harm." We welcome comments.

ADDICTION RECOVERY:

A recent article discusses "addiction recovery: its definition and conceptual boundaries" (J Subst Ab Treatm 2007; 33:229-241). Among the various perspectives cited is that of ASAM, which defines recovery as a "process of overcoming both physical and psychological dependence on a psychoactive drug with a commitment to abstinence-based sobriety". Also cited is Narcotics Anonymous World Services, whose Board of Trustees "affirms the right of NA meetings to refuse to allow those using medically prescribed methadone as 'drug replacement therapy' to speak at meetings and refers to such individuals as 'under the influence of a drug,' 'still using,' and 'not clean.'" The reference for the ASAM position is 1998, and that of NA's Board is 1996. However, we're unaware of any publicized change of position of either.

Clearly, we have a long way to way to go - still! - before narcotic addiction is recognized as a chronic medical problem for which medication can be not only appropriate but life-saving. The challenge of gaining acceptance for this view, put forth originally 42 years ago by Dole and Nyswander, is greatest among our colleagues in the field of addiction treatment.