The following open letter was emailed to leading Maine political leaders who represent the state in Congress… comments welcome

Congratulations on your letter to SAMSHA urging that HHS Secretary exercise authority to waive 30-patient limit on prescribers of BUPRENORPHINE. I wonder, though, if your office has assessed impact of the recent congressional bill (109-56) waiving the 30 patient per GROUP limit. Hopefully it's expanded patient access to care, but has it?

As a fervent advocate of opiate agonist treatment I applauded 109-56 and also your current effort to remove individual doctor limit as well. But would this really make much difference? You estimate Maine would need additional 667 certified docs to meet the need - I guess roughly 20,000 opiate dependent citizens. There are 33 Maine physicians now certified - to meet even a quarter of the addicted population, these 33 would have to prescribe to roughly 150 patients each - clearly unlikely. So what would the expected impact be of removing the individual physician limits?

More is needed than lifting the physician-patient limit. I urge you to demand of Federal government that it explore promptly what alternatives exist, and move to implement those that are promising. Much can be done - France was able to increase patients in treatment from 0 to over 85,000 in about 7 years - overwhelmingly through generalist community-based practitioners. Community docs also are the primary source of care to some 65,000 methadone- and buprenorphine-maintenance patients. Why can't USA achieve similar expansion?

Thank you. Robert Newman MD, MPH

First Scotland now Australia: Politicians against Methadone

Australian Health Minister Abbott announced his intention of encouraging "the growing number of people in long-term treatment with methadone ... to kick their drug addiction completely" (Dec 3, Sydney Morning Herald): Anarray of treatment options helps to enhance and extend life for those who are opiate-dependent. One of the most effective treatments is methadone maintenance; one of the least effective, to date, has been naltrexone. But one thing these two medications and all other therapeutic approaches to opiate addiction have in common: they do not offer "cure," any more than Alcoholics Anonymous pretends to cure alcoholism, cardiac medications cure coronary artery disease, etc.

Given the costs in dollars and in human suffering associated with illicit heroin use, treatment is a great bargain, and community leaders should applaud the steady increase in the number of Australians receiving care. All efforts for which evidence of effectiveness exists should be supported maximally, but none has been shown more effective, for more people, than methadone maintenance. An "exit strategy," however, while a useful metaphor when applied to wars, is not a useful concept when it implies termination of effective medication for a chronic medical condition.

METHADONE MAINTENANCE DOSE AND RATE OF "INDUCTION

A study by Brady and co-workers (J Addict Diseases, 24(3):2005) found that two weeks after admission "more than two-thirds of methadone clients nationally were receiving below 60 mg/day [of methadone] ." Reference is made to the long-standing knowledge - reaffirmed by a consensus statement of an NIH expert panel in 1997 - that maintenance doses below 60mg are suboptimal for the majority of patients.

A question not addressed by this study, which may invalidate the criticism of maintenance dose practices, is the appropriate and safe starting dose and rate of increase. It would not be unreasonable to have a starting dose of 30 mg, and to prescribe increases of no more than 5-10 mg twice weekly. With such policies the dose after two weeks might still be rising and permit no conclusions regarding what providers ultimately aim for and achieve with respect to "maintenance" levels. Furthermore, the only outcome measure reported here - retention - did not show any consistent dose effect: retention was lower in patients receiving 41-60 mg after two weeks than those receiving only 21-40, and patients who were getting over 80mg had the lowest retention rate of all. NOTE: The Province of Ontario's methadone guidelines should be kept in mind: START LOW, GO SLOW (to which one should add, "AIM HIGH").

Needle Exchange Programs (NEPs) & Methadone- different strokes for some of same folks

Why don't NEPs offer methadone to those who want it, one day at a time? NEPs do a great job already, but suppose a "client" states s/he wants a brief break from shooting dope, and/or doing what has to be done to get the next fix of heroin? At the moment, the response is: tough! Just go inject some heroin, but try to be careful please.

Anyone know of any exchange facility in the world that offers the option of 30mg methadone po, a dose that is associated with no hazard, would preclude diversion is given only in the facility, and will obviate withdrawal in most heroin-dependent individuals for 24 hrs? And additional 30 mg on subsequent days upon request?

Sure, there are issues to be resolved: probably need a physician for at least a brief period on days when methadone option will be available; regulatory constraints will have to be identified and waivers requested; minimizing likelihood of multiple doses being given on a given day in unrelated NEPs in same city; etc. Conceivably community/political opposition, but a service that has overcome such opposition and already gives heroin users sterile needles/syringes should, logically, be able to make the case that it's better yet for all concerned to offer a daily dose of methadone. Has any NEP, anywhere, even considered the question?

If not, why not? Why settle for a service - as great as it is - that denies safe and effective medication to those who, for whatever reason(s), opt on any given day to forgo heroin injection, rather than to simply request assistance in lessening the harm associated with such use?RGN

US GOVT'S BIAS AGAINST PRIVATE SECTOR MEDICINE - GO FIGURE. . . .

Federal regulations authorize "interim maintenance treatment" (methadone with minimal services for applicants on waiting lists) - 42CFR, Part8. The authorization, however, is limited to "program sponsor[s] of a public or nonprofit private [program]," and eligibility is limited to applicants "who cannot be placed in a public or nonprofit private comprehensive program . . . " How to explain this exclusion of for-profit programs and eligible applicants who seek their care? Why has the AMA not denounced this unprecedented _expression of hostility by the US government toward the profit-based practice (and the profit-oriented practitioners!) that overwhelmingly characterize medical care in America? Comments welcomed! RGN