Evaluation of Buprenorphine Taper Duration in Primary Prescription Opioid Abusers Confirms What We Know About Relapse After Tx Ends
opiate addiction treatment with emphasis on methadone maintenance and detox; drug policy;drug courts; buprenorphine;suboxone
Hope there are still folks interested in reading. . . . . Bob Newman
The following is an exchange that appeared recently on a international website linking colleagues involved in addiciton treatment:
A comment from a long-term, thoughtful provider of "substitution" treatment in Germany, and one that applies in most countries (most particularly the US): "Wherever we fight for a better treatment of addicted patients, our goal should be the same as the ones we apply to the treatment of all other chronic diseases. Three common violations of this principle:
A decision in Oct. 2010 ruled in favor of a patient whose daily travel to a methadone clinic cost approximately $US 220. Note that there has been political furor over costs born by Pennsylvania for transportation of patients to nearest methadone clinics. Summary (in German)click here.
Buprenorphine maintenance vs. “taper” in chronic pain patients “who also had opioid addiction”. The stated objective of this study with NIH grant support: to test the hypothesis that “… those given steady doses of buprenorphine would be more likely to adhere to the treatment protocol than those given tapering doses.” We won’t kill the suspense by revealing the outcome.
Mother faces life in prison because of accidental methadone death of 3 year old daughter. In this report from Reno, Nevada, the District Attorney notes that the guilty verdict "should send a strong message to every methadone user ... that if you choose to bring this liquid poison into your home, you better make damn sure it's secure... If you fail to, you may be spending the rest of your life in prison.'
The bottom line:
The key conclusions of the Rolleston Committee Report (1926) in UK are worth considering (again, still) today. "[Addiction] in most well-established cases must be regarded as a manifestation of disease and not as a mere form of vicious indulgence. In other words, the drug is taken in such cases not for the purpose obtaining positive pleasure, but in order to relieve a morbid and overpowering craving. ... It is true that there is a certain group who take the drugs in the first instance for the sake of a new and pleasurable sensation ... But even among these a morbid need for the drug is acquired and the use is maintained not so much from the original motive as because of the craving created by its use."
From a fossil fuel expert comes the following: … the question is, does CNG (compressed natural gas] make sense right now or is it to petroleum based fuels what methadone is to heroine [sic!]” The author’s understanding of methadone treatment is surpassed only by his spelling ability. Sadly, his use of this analogy reflects - and also strengthens further - the bias against methadone maintenance as a treatment of unparalleled efficacy in response to a chronic, often fatal, medical condition. See the full article.
Prime Minister Cameron of UK has “suggested taxpayers shouldn’t be paying for drug treatments that don’t really work, especially when they involve the government dispensing even more addictive drugs.” The basis for his conclusion: the very small proportion of patients “able to kick their addictions.” Same criticism, same response: consider applying this orientation to any other chronic illness... Report accessed at: http://reason.com/blog/2010/10/06/cameron-government-shouldnt-gi
The above is the headline of an article in the Tribune-Review of Oct. 1.
"Feetox": a Sept. 2 news report is headlined "Acadia [Healthcare Corp.] cuts free methadone to uninsured" and states some 100 patients will b affected. The Corporation's chief of clinical services is quoted as saying, "... earlier assumptions about methadone are being challenged, including the idea that it is in most cases a lifelong therapy." Let him tell that to a parent whose child has been doing well with methadone treatment and dies of an overdose after being “terminated” from the program because of inability to pay.
US state opioid treatment authorities were surveyed as to their policies and guidelines (Harris et al. J Subst Ab Treatm 2010, 39:58-64). Eight states “stipulate patient discharge for continued alcohol abuse and … four states mandate or recommend patient discharge for continued failure of alcohol tests.”
A physician in Windsor, Ontario, has written about the problem of opioid addiction and the very positive role that methadone maintenance treatment can and does play in addressing it. He describes and corrects some of the major misconceptions that cause so many communities to fight against the establishment and continued operation of methadone treatment services.
A headline (12 Sept) in the Windsor (Ca.) Star reads: “Meth clinic unwelcome in Somers Point”. The lead paragraph: “Fear gripped West Cedar Avenue residents recently after an 89-year-old homeowner was attacked and sexually assaulted in her home.” The next paragraph: “While a 27-year-old Vineland man, Marvin Sherwood, has been arrested and charged in connection with that particular incident, residents are fed up with problems in their neighborhood and are placing blame for recurring issues on a methadone clinic directly across from their homes.” And then the third paragraoph: “The latest incident is not believed to be related to the clinic, but the clinic’s continuing presence angers residents and is prompting city officials to explore ways to force the clinic from the neighborhood.”
Unfortunate that methadone is said to “top the list” of killers in contributing to military deaths, without reference to the fact that it remains the gold standard most effective treatment of dependence. Of course, the fact that until recently FDA was recommending analgesic doses that can be lethal is also not mentioned. Anyway...
"Parents of addicts call for acceptance" is the headline of a piece in the Aug 2010 issue of Drogenkurier, which bills itself as "the magazine of JES - Junkies, former junkies and those receiving substitution treatment". The head of one of the leading parent groups in Germany is quoted: "Of course we'd prefer to have our children clean. But the first goal must be to secure their survival, not their abstinence." Difficult to comprehend how anyone, regardless of therapeutic philosophy, could argue with that sentiment. The man who is quoted lost a son to "the politics of drugs" 18 years ago, a suicide by hanging after a long period of desperate and unsuccessful attempt to get help.
A voice of reason in the drugs discussion: Those who expect yet another diatribe against "maintenance" treatment will be pleasantly surprised by a 1 Sept. article in The Guardian headlined, "Is abstinence the best policy for addiction?". The focus is on an "award-winning advocate of an abstinence-based approach to [drug] rehab," Noreen Oliver, who "... refuses to be drawn into a dispute that, she says, is not only divisive, but misses the point." More specifically, she states that "Any limits on the prescribing of methadone would be the 'antithesis of individualized care and may actually put lives at risk'. There is no need for a fissure in drugs policy, she argues." Complete article: CLICK HERE
An article just published in J subst Ab Treatm (2010, vol. 39, pp22-31) discusses "trends in methadone maintenance treatment ... in British Columbia, Canada. It was found that compliance with "minimally effective dose guidelines" dropped from 2001 to 2006, and that this decline was mirrored in the decline of 12-month retention data. Another "... troubling finding was the low rate of compliance to guidelines on starting doses and dose titration" despite the fact that the risk of fatal methadone overdose during the first two weeks of treatment is estimated to be 6.7 times higher than that of heroin-dependent patients not in treatment and 98 times higher than that of patients on maintenance doses of methadone". Specifically, 47% of patients were started on a daily dose greater than 40 mg.
This reality seems to have been overlooked by authors of a paper that appeared recently (J Psychoact Drugs, 42(2):161-175, 2010). They state: "For reasons not adequately understood, some patients find discontinuation of buprenorphine following long-term use difficult." Indeed, this understates the case! Notwithstanding such claims as "buprenorphine is less addicting," once treatment of addiction ends relapse is the rule rather than the exception, and this applies to buprenorphine no less than to treatment with methadone or various drug-free approaches.
According to a 23 Aug article in The Telegraph “The Coalition is working on proposals to stop the widespread prescription of methadone for heroin users and instead increase the use of ‘cold turkey’ residential treatment programmes.” It is difficult to comprehend, even for the most cynical of observers! Are "cold turkey residential" programmes effective for some? Sure: among the relatively very small percentage of the heroin addicts who seek and enter such programmes there is a small proportion who "graduate" - and of these another small proportion have achieved and will maintain abstinence. Great. But to propose this as national policy in lieu of "widespread prescription of methadone" can only be described as madness. Aside from the (huge!) question of efficacy, a massive residential option could never be implemented for a host of reasons - starting with the financial requirement. Severely curtailing methadone treatment, alas, is possible - and the costs will be high for those dependent on opiates as well as for the general community. Before anyone recognizes what many decades of experience have consistently shown - there's no "cure" for addiction - the damage will have been done, many lives lost, more illness, more incarcerations, greater demand for (and thus inevitably supply of) illicit opiates, etc.
A 1971 paper by Gay and colleagues discuss the US opiate dispensing clinics operating from 1919 to 1923 (there were 44 of them!). they conclude: Today, some 47years later, the time is long overdue to ... reconsider the efficacy of outpatient treatment of addiciton. It seems cler now that (1) institutional programs have failed to establish a broad base of effective treatment, and (2) law enforcement has failed either to stop the flow of drugs or to incarceration all users. We are left with a medical and social problem of staggering dimension." (Int J Addictions 6(2):241-264, June 1971)
"Despite multidisciplinary coordinated antenatal care, women with substance abuse during pregnancy are at significant risk of adverse obstetrical and perinatal outcome ..." Two comments: among the "substance abuse" cohort 66% smoked compared to 2.4% of the controls. Secondly, in the facilities studied "women are always encouraged to reduce their overall drug use (prescribed and illicit) during the pregnancy ..." And indeed this policy - which runs counter to all the evidence on treating opiate dependence with methadone during pregnancy - resulted in an average daily dose at the time of delivery of 35 mg. When providing grossly suboptimal dosages of medication it is hardly surprising that patients (and in this case their offspring) have suboptimal outcomes. It's difficult to comprehend how this practice could be rationalized by the clinicians, and perhaps even more difficult to understand how the investigators could fail to mention this detail in their report. Study: Pinto et al; Eur J ObGyn and Reproductive Biol, 150 (2010) 137-141.
The July 12 CESAR FAX (vol. 19, issue 26) of CSAT reports on a letter to editor of Am J Psych 167(4):473-475, 2010). The authors, Wilson Compton and colleagues, observe that "High rates of DSM-IV substance use disorders among inmates combined with a large inmate population mean that many persons with alcohol and drug use disorders are missed by major US national general population surveys." Hardly anything surprising in that observation - except the fact that this deeply flawed process for making estimates persists. Furthermore, surveys based on "household sampling" miss as well the very sizable population of Americans who are homeless - whose numbers in the US on any given night are estimated at "anywhere from 700,000 to 2 million" (attributed to National Law Center on Homelessness and poverty). When it comes to substance use/misuse, one has to wonder about the relevance of data based on household survey techniques, and worry about the the governmental policy decisions that are based on their findings.
In a nutshell: a man is stopped for a traffic violation, consents (!) to have his car searched. Is found to have a baggie and a scale with trace amounts of amphetamine/cocaine - and also a bottle with "three wafers of methadone" said to weight 5.14 grams (yes, grams). The "wafers" were in a bottle with a label indicating they had been prescribed for an acquaintance - the named acquaintance testified she dropped the medication in defendant's car and forgot to take it with her when she left; this is same story defendant told. Appeal based (as far as I can tell) entirely on the admissability of the trace amts amphetamine/cocaine to indicate to jury defendant's "character" and likelihood that the methadone "contraband" was there knowingly and with criminal intent. Conviction and resulting sentence are for the methadone possession - not the presence of trace amounts amphetamie/cocaine. .
(Tages Anzeiger, Switzerland, 12 Aug):
Candid comments on AA and “rehab” - an article in Washington Post 8 Aug is headlined, “We're addicted to rehab. It doesn't even work”. The author, Dr. B. A. Johnson, is chairman of psychiatry and neurobehavioral sciences at the University of Virginia. Dr. Johnson concludes as follows: “When any other illness causes great suffering, our society devotes time and money and effort to studying it and to developing treatments that are empirically found to work. Alcoholism and drug addiction should be no exception. Recent advances in neuroscience have led to a greater understanding of how alcohol and other drugs affect the brain. They have, in turn, allowed medical researchers, myself included, to begin to approach alcohol dependence as we would any other disease: by searching for effective medicine.”
UK prime minister Cameron "... wants to shift the focus away from the use of methadone as a substitute drug.... [and] press ahead with an expensive shift in treatment for drug addicts, towards residential programmes and away from the use of methadone as a substitute licensed drug." Cameron described methadone as " ... a government authorised form of opium ..." There are today an estimated 150,000 patients in England receiving methadone maintenance treatment. Full story click here (Guardian, 6 Aug)
DEA "diversion program manager" for 5 mid-western states worries about the danger of diversion of methadone posed by the "multiple employees" working in OTPs. "The more people involved, the more it increases the chance for diversion." Wow - that's a new one! Suppose it's time for FDA to demand OTPs get rid of those docs, nurses, counselors and other potential diverters that it currently requires as a sine qua non for approval to operate. The context: praising suboxone as "...a safer option to methadone." Even the manufacturers of buprenorphine couldn't have come up with this "benefit". For full story click here.
That’s the headline of a 26 July opinion piece in The Guardian, UK, written by a London physician whose practice includes many patients receiving methadone or buprenorphine maintenance. Dr. Chris Ford addressed “…the possibility of returning to the outdated and discredited policy of time-limited methadone prescribing” – a policy change stridently demanded by some UK politicians (and also proposed in a recently introduced bill in the state of Pennsylvania). Dr. Ford states, “As a doctor I use methadone and buprenorphine with many patients alongside a variety of psychosocial and other healthcare interventions. Prescribing can last for one week or it can last for 30 years – it is and should be completely patient-driven and dependent on them as individuals. An arbitrary time frame imposed on any patient's medication regime is unacceptable.”
While most reports of the major liberalization initiated in the country 10 years ago have been decidedly positive, and even though Portugal is now looked on as a model by several other countries who are considering emulating their success, the article refers to the negative data of the past decade. It concludes by quoting a senior member of the EMCDDA staff (based in Lisbon) warning that "Now that the epidemic [of drugs] is under control, people start asking ... what is going to happen next? There is a part of the population who do not have the possibility of leaving the treatment." Precisely the same questioning, of course, has been heard in many countries of the world - none more insistently and harshly than Scotland.
The Chief attributes to the new methadone facility, operating out of necessity with essentially no counseling or other support staff, with the dramatic drop in armed robberies there. "Armed robberies in the city are down by more than half since the methadone clinic opened in the city centre last year," according to Chief Bill Ried. He went on: "It's mighty important that we do not have waiting lists - and waiting lists?
A clear, compelling overview of the arguments favoring the establishment of methadone clinics is to be found in an opinion piece published in SalemNews.com, Salem, Mass. Written by columnist Brian Watson, it describes one operating clinic he observed as follows: "I was struck by the diversity of people using the clinic and the universally quiet, focused, businesslike manner with which they arrived, drank their daily dose and left. Young and old, men and women - even people opus hing baby strollers - came to the center." Mr. Watson goes on to ascribe what he heard from the local Police chief: "He said he could not remember so much as a traffic infraction - or any other incident - that stemmed from patients at the clinic or walking in the neighborhoods around it."
According to an article in the July 1 issue of the Pittsburgh Tribune-Review, Pennsylvania lawmakers have called for an "audit" of methadone maintenance programs in the state to help them consider a half-dozen proposed laws to restrict the eligibility for, maximum duration of, and a host of other restrictions to be imposed in methadone treatment for opiate dependence. It is always appropriate for government to audit services for which taxpayers provide the funding, but the article reflects a fundamental misunderstanding when it states, “The review will examine . . . whether methadone is used as part of a treatment plan aimed at recovery or as a maintenance plan.”
A UK headline (The Observer, 11 July) reads: “Anthrax deaths expose addicts' plight …13 deaths in UK since Xmas”. The article quotes a drug treatment worker as saying lives could have been saved "if we could have got people access to methadone or Subutex very quickly … but we were looking at six-month waiting lists and, in some parts of Scotland, a year."
A recent contribution to the Journal of Addiction (105:1311-1313, 2010) describes a survey of opiate substitution treatment (OST) policies and practices in prisons that found "...only 55% of prisons in the US provide methadone to inmates in any [emphasis in original] circumstance, and most provide only to pregnant women". Overall the authors conclude "only a minute fraction of the estimated 200,000 incarcerated individuals with opiate dependence have access to OST [and] the overwhelming majority also do not offer referral to OST providers ... upon release..."
Difficult to understand the dismissal ("what's the point") of medical treatment that is acknowledged to prolong lives but fails to cure the underlying condition. The same (il)logic would lead one to look with contempt on the management of any chronic malady: diabetes, depression, hypertension, etc. It would result in the same "what's the point" contempt for AA and its universally respected role in assisting alcoholics in recovery (but never ever "curing" them of their alcoholism - just ask any AA advocate). And if it were shown that life could be prolonged by nicotine replacement (!) gum or patches that help long-term smokers cut down from two packs to 5 cigarettes a day - would that lead to criticism that one is simply replacing "a queue of people at the pharmacy ... " with one at the tobacconist? As stated at the outset, difficult to understand!
What’s most noteworthy about the prediction is the source: an op ed piece written by Lee Baca, sheriff of LA County and Charlie Beck, LA chief of police. They say cutting $55 million out of the Medi-Cal methadone program “… is tantamount to destroying the lives of 35,000 people, as well as having them return to addiction. The impacts are significant, and go beyond the patients themselves.” Full story in LA Daily News 6 July http://www.dailynews.com/opinions/ci_15445015
In a series of half dozen proposed bills, the PA. Senate is seeking to assume the role of physicians. For example: Sen. Bill 1293 would estaboish a "methadone death and incident review team" - what a label for those who desperately need help to contemplate! The team (mainly non-physicians would be charged with "determining the role that methadone played in each death ..." Isn't that the traditional responsibility of the trained/certified medical examiner? Sen. Bill 1294 would establish "eligibility criteria" (ever hear of eligibility" for a medical treatment ordered by medical doctors?), to include: "inability [of applicant] to stay drug free after at least two substantial attempts at appropriate treatment in drug-free programs." Like telling severely depressed and suicidal patients they must first have two unsuccessful suicide attempts before being "eligible" for anti-depressant medication. And the same bill demands a specific plan to achieve abstinence," imposes urine testing every two weeks forever, and prohibits patients from driving during the first two weeks treatment with methadone (but only if the methadone is given for treatment of dependence - patients getting methadone for pain would be under no constraint whatever).
(Statement of Office of the Director, ONDCP (office of national drug control policy), May 18, 2010) What a sad reflection on our country's policies, priorities and practices! In NYC at the height of the tuberculosis epidemic a few years ago, roughly 3% of all patients were under legal mandate to receive directly observed treatment (source: email correspondence with NYC Health Dept Bureau of Tuberculosis).
At a news conference 16 June LA Police Chief Beck and Sheriff Baca "decried the proposal ... to eliminate state funding for treating heroin addicts [with methadone]". Those against methadone treatment, as well as those who don't care one way or the other as long as it's provided in someone else's backyard, take note! What do top cops know that you might not? Full article: http://www.mercurynews.com/breaking-news/ci_15311225?nclick_check=1
That is the question posed by a recent article in Pain Physician (13:289-293, 2010), and not surprisingly, the answer is an emphatic "yes"! The authors note that "the most socially stigmatized patients are those treated with chronic methadone." While it "is an excellent drug" for pain management, "... the lack of depth of knowledge by pain care providers about the benefits of the medication and societal stigma still play a role as a barrier to treatment." Sadly, of course, precisely the same can be said about methadone in the care of opiate dependence - even after 45 years of consistent evidence of efficacy.
A June 10 Riverdale (NY) Press article reported that for some time now 45 residents of a health care facility for elderly and disabled in the Bronx have been obliged to travel by special bus, most on a daily basis, to obtain their methadone from a maintenance facility in the neighboring town of Yonkers. It has obviously been a great inconvenience to the patients - as well as costly and disruptive (an estimated taxpayer cost of $150,000 yearly, and "loading and unloading the patients, some of whom are in wheelchairs, on the buses backs up traffic..."). So . . .the facility has proposed operating a methadone program on-site under terms that would involve a maximum of four non-facility residents receiving methadone there.