Veteran's Administration Buprenorphine Criteria

Veteran's Administration (VA)criteria/directive of June 2003 (apparently not modified since) re buprenorphine for opiate dependence. Some highlights:

"In general, methadone should remain the substitution treatment of choice."

"... in the the VA, the limit of 30 patients applies only to individual physicians. There is no limit on the number of patients that can be treated with buprenorphine for group practices."

"The criteria for . . . buprenorphine require that a patient have a documented severe, uncontrollable adverse effect or true hypersensitivity to methadone or LAAM before the physician considers switching to buprenorphine. Patients who are stable on methadone or LAAM maintenance and who do not have a compelling reason to switch therapy should continue maintenance on methadone or LAAM."

Cost paid by the VA system for one month buprenorphine/naloxone tab, 16mg/d, is $176; for methadone, 80 mg = $10/mon if purchased as tablets, $8 if purchased as concentrate

Drug Testing in High School

Today's blog contains a relevant Letter-to-the-Editor, that was never published nor answered...

"THE ARTICLE"
An article appeared in the Marion Star Newspaper (Ohio) concerning drug testing in high school. The article stated that random drug testing could be done more than once a year in upwards of 25 percent of extracurricular participants. Testing would include alcohol, amphetamines, anabolic steroids, barbiturates, cocaine, LSD, marijuana, methadone, MDMA (ecstasy), nicotine, opiates…. Those who refuse to submit to testing would not be allowed to participate in their extracurricular activity, those failing a random test would be subject to disciplinary action including counseling and suspension from their activity.

"THE LETTER"

The rationale for subjecting students to drug testing would be a bit more persuasive if tests were administered as well to all teachers and school administrators – and to parents. Surely the consequence of drug use on the kids and the community is far greater when it exists in those folks than among students.
- RGN

SUBOPTIMAL DOSAGES (still)

A colleague from Australia, Andrew Byrne, calls attention to an article in the current Brit J Gen Practice (June 05) by Strang et al. The authors surveyed private physicians in UK who prescribe methadone maintenance, and found a mean daily dose of 36.9. It's been shown consistently (no exceptions, I believe!) for many years that for the great majority of patients doses under 60 are sub-optimal, and that many patients require daily doses of at least 100mg (any many a great deal higher). It's difficult to comprehend such apparent bias against reliance on dosages that will, predictably, be associated with persistent illicit opiate use and the substantial risk of illness and death. Sure - the refusal of methadone providers to practice evidence-based medicine is almost universal, but one might have expected better from the UK, where over 50% of GPs reported treating "at least one opiate dependent person" - presumably with methadone.

So . . . anyone offer an explanation? Anyone have suggestions regarding how to address a problem that has been associated with methadone treatment for many decades despite uncontested evidence that it is wrong? rnewman

PHENOBARB FOR OPIATE WITHDRAWAL RX???

J Addict Dis 2005; 24(2):135 has an abstract from the Betty Ford Center describing a comparison trial of inpatient detox using buprenorphine vs. "a standard phenobarbital protocol." Anyone out there know of any current theoretical, pharmacological or empirical basis for using phenobarb for the "standard" detoxification of opiate-dependent individuals?

singing for support

LIVE EIGHT has been a magnificent effort to generate support for the impoverished in Africa. Question: how come no one is singing for opiate-dependent people around the world who desperately want and need help, and for whom effective help (especiallyopiate agonist treatment) is known to exist, but who have no access? Sure, untreated heroin addicts in Hanoi, Delhi, Kazan, Kiev - AND New York - are not very sympathetic in the eyes on the general public, but heightening awareness and generating support where none has existed is precisely what international events like Live Eight are designed to generate. So . . . where's the support, in song or in words, for opiate-addicted persons who currently have no prospect of help or hope? rnewman