Thursday, June 30, 2005

Could Have Extraordinary Implications & Affect Harm Reduction Services For Many

The decision pending in Malaysia (see below) seems to me to have the most extraordinary implications not only for that country, but for many countries throughout the world and could affect the harm reduction services for many, many hundreds of thousands of people! It bears close watching. I imagine there's nothing to do to influence this - except maybe to pray (?).

The Malaysian National News Agency (June 25’2005)
The government will make a final decision on the pioneer programme to give needles, condoms and methadone substitution drugs to addicts in a move to reduce the spread of HIV/AIDS after getting an official edict from the National Fatwa Council.

Tuesday, June 28, 2005

drug testing - process v. purpose

Urine toxicology tests for methadone maintenance patients (but apparently not for buprenorphine patients) is a universal practice, and generally continues for even the most stable patients who have been in treatment for decades. To minimize likelihood of "cheating" many programs directly observe the act of urination, or use closed circuit video monitors, test for temperature, etc. To accommodate those who consider these techniques to be undignified, different testing approaches have been introduced over the years: hair samples, saliva specimens, "markers" given to patients before testing that can be identified in the urine specimens, etc. The use to which the test results are put will determine whether and at what lengths steps are needed to lessen the likelihood of "cheating". The more heroic measures to counter patient deception will be employed by those providers who impose the greatest "punishment" for positive toxicology results: reduced "take-home privileges," reduced dosage (despite the illogic of such a response), termination of treatment (and incarceration for patients under some kind of criminal justice system order), etc .

QUESTION: is the challenge the enhanceent of the PROCESS of specimen collection and testing, or is it the need to reconsider the PURPOSE of testing?

And whatever the rationale used to justify on-going testing of all patients, would the same rationale perhaps suggest that every caregiver - doctor, nurse, "counselor" etc - also be tested under identical conditions and, where relevant, with the same consequences (e.g., terminaiton from the program or the practice)?

Bottom line: does the field of addiction treatment need a better mousetrap, or should it be reconsidering just why it is so intent to catch mice in the first place? COMMENTS WELCOME.

Thursday, June 23, 2005

Why in Canada and Not in the US?

A new methadone clinic has opened in Miramichi, and more are planned in Moncton, St. Johns and Fredericton. The combined capacity will be 600 patients. The Miramichi (population 16,500!) facility opened recently and already has 114 patients and another 140 on the waiting list. (The Canadian Press, June 20). At the same time, cities throughout the United States bitterly fight the establishment of clinics "in their backyards," and - tragically - usually succeed in keeping out treatment that can spell the difference between life and death.

Monday, June 20, 2005


Previous blogs have referred to a Twin Cities news article on the attractiveness of buprenorphine as a medication for opiate addiction treatment. That article refers to a hypothetical "suburban housewife” who places a methadone program last on her list of providers of choice. But that's not only true of the stereotypical "suburban housewife"! The regulations imposed on methadone programs, and the common (but not universal) attitudes of staff and the community at large, make many of them awful places to seek health care. Patients are forever subject to “urine controls” (in most programs, under direct observation), always having to ask permission to go on vacations, dealing with child welfare bureaucrats who view appropriately prescribed methadone as no less an evil than street heroin – and equal grounds for denying custody, etc. What’s amazing is that a couple of hundred thousand American opiate dependent individuals are so desperately motivated for help that they seek and enter such programs notwithstanding the rules, patronization, stigma, etc. Also amazing - and distressing - is that so few physicians are willing to take the minimal steps needed to gain authorization to prescribe buprenorphine to those patients who need and want it.

The fundamental question is why addiction is not treated – and treatable – like all other chronic illnesses. Why limit methadone to "comprehensive treatment programs"? We don’t we demand “community approval” to open a radiology imaging center, or a sexual health practice where Viagra is prescribed, or a facility that treats Downs syndrome children and offers support to their parents, or smoking cessation programs or facilities where AA holds its meetings. For buprenorphine, why demand special training? Why patient limits?

Thursday, June 16, 2005


Denial of Buprenorphine to those who want and need it is said to be analogous to “telling diabetics that we have insulin, but they can’t have it.” But hey - this is absolutely what we’ve been telling opiate-dependent people desperately seeking methadone for the past 40 years! The frustration – and outrage– should be the same. So how come the medical community has never expressed such outrage?

Tuesday, June 14, 2005

More on Buprenorphine vs. Methadone Comparisons (or lack of same):

I believe no study has ever compared POST-treatment abstinence results for buprenorphine versus methadone maintenance or detoxification. In other words, when reference is made to patients finding it "easier to withdraw" from one or the other, the implication that abstinence is easier to attain AND MAINTAIN after buprenorphine is, I believe, unsupported by any evidence. No study casts doubt on the conclusion that chronic, relapsing opiate dependence is a treatable but as yet incurable disease. Right?

Monday, June 13, 2005


A recent article in a Twin-Cities newspaper quotes one medical authority as suggesting that buprenorphine is – compared to methadone – “well-suited for the growing number of people . . . who abuse prescription pain medications, and for those who are not seriously dependent,” and that methadone is “better for people who are severely addicted and who have powerful withdrawal symptoms.” One or both of these statements may be true - but does anyone out there know of any controlled trials that support either conclusion?