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
posted by RGNewman, MD @ 8:59 AM
5 comments
5 Comments:
Bijan's clinic in South Tehran has two queues [lines]
One is for methadone maintenance treatment - The other is for the needle syringe programme -
Well worth seeing next time you're in Tehran
We have both NSEP & MMT at the same centre for around 2 years. This is the story: We started Sept. 2002 with NSEP both in drop in & in outreach. Very soon clients stated that they need some more advanced form of care. They were sure that abstinence is not the next step or desired choice at that time but asked us eagerly & frequently for some alternative to NSEP & abstinence. We requested to have 15 cases on MMT, we then increased the cases as project progressed & got rid of pilot project & now we have 500 MMT clients in 2 centres; both have NSEP/MMT at the same space &
same time.
But let me comment on the idea of 30 mg methadone & "having some brief break". I afraid that I am not fully agree with that because in practice we have either NSEP
or MMT. For sure in the induction phase less or more we offer NSEP to the MMT client but it is descending pace means as methadone dose goes up & up the NSEP frequency goes down & down & usually after 3 months majority of MMT cases do not request for NSEP services. Also there are some cases who switch from NSEP to MMT & vice versa but it is very
rare & not encouraged at all.
The reason is: If we define MMT (this is the only relevant term when methadone comes to my mind) as a method for treating users (IDU or DU) with more than 30 years of history for improving
guidelines it only works if we
complete the courses of treatment & it maybe last for whole life.
The big mistake for using methadone in this way (especially
from advocacy point of view) is introducing methadone both to public & users as a tranquilizer as
majority of policy makers do. They
always say: By offering methadone
you just only give some break that is superficial & dose not apply term "Treatment". I do not know if anybody in the world has piloted on & off agonist for regular NSEP clients but hardly believe that it can bring any change to the life of drug users.
Usual story for our service is we have NSEP for all IDUs without any push or judgment that you have to go to MMT but automatically after 2-6 months NSEP guys witness the huge improvement of MMT people
& request us to place them on that. Unfortunately because there is huge demand & few resource we cannot answer to lot of them because MOH cannot offer MMT free of charge any more but ideally if there is good support you can
see that this combination is an effective model in harm reduction to offer a choice for client & not
impose on them only the services we have. As a rule of thumb from 10 people who comes to NSEP service in our centres %50-%70 request to go to MMT after several months not just for beak but for real shift in services they need.
Adding MMT outlet to NSEP services around the world can show this bridging effect I stress again NSEP/MMT at the same side as the idea of referral cannot be trusted all the time & usually the low threshold services of NSEP dose not match nicely with majority of MMT sites that have been built in high threshold setting.
Bases on survey we had around %70 of our client remain in MMT treatment (that is a low threshold service) after one year. For the remaining %30 the major reason for drop out is police arrest (>%90)!
Thus I want to criticise the high threshold costly services of MMT &
advocate for low threshold MMT services especially for street homeless users & especially in beginner countries because the high threshold systems can only work for less than %10 of needy people & I doubt if it is as
nice/humane as low threshold service of MMT.
Here is a recent story of our
centre at:
http://www.washingtonprism.org/eng/showarticle.cfm?id=36
I see a few problems with this. First of all, is there any control put in place for the person receiving the 30mgs of methadone for a day or two, to not use other opiates? It would be quite easy for someone to say they wanted 30mgs of methadone today because they don't want to go and score, and then go and score after anyway. At a dosage such as 30mg to 40mg (obviously in most cases it wouldn't be safe to use higher doses) there is no blockade effect. Even at dosages high enough to produce the so called blockade effect, taking methadone only once or twice a week causes no blockade no matter what the dosage. My point being what I mentioned above. Using methadone in this way, one could easily take heroin after and the methadone would simply add to the heroin's effect. Say an addict has only enough money to score an amount of heroin that would just curtail withdrawals,(even then for only part of the day) but produce no euphoria, which is often the case. It would be an attractive proposition in many cases to use the methadone not as a break, but as an adjunct to other opiate use. To prolong the time before wd's kick in , or to cause euphoria because the dose of street opiate by itself is insufficient to do so.
I think I understand your reasons for suggesting this type of service, and they are commendable. Personally, I wouldn't have a problem with this type of program, even if there was abuse, but then I think addicts should be given their choice of opiates anyway. I think opiates should be legalized for people who are already addicted to them.
The thing is, with all the NIMBY problems, anti-methadone politicians and other negative press that MT receives, abuse of a program such as this would just add to the negative publicity. It would give the anti-methadone side fuel for their fire.
I should add to my previous comments regarding the potential problems with a program such as this.
Obviously there would be positives to a program such as this. Potential reduction of crime and a big one, it could influence more people to get into MMT.
no, as a patient (but not a heroin user) in MMT, I don't think that it would really help, I think it should be something that helps people who want to stop using. What I feel is different--like you I think it should be legal or at least available from your doctor! very cool that the clinics are trying to do it, but I think it should be offered as an alternative to using drugs recreationally--that way people, and hopefully someday the public, can see it for what it's been to me for the last ten years--permission to live a normal life & not be looking for drugs. And to reduce the fear of stopping the drugs/fear of withdrawal when we do make a bad choice. Thanks to those who support these programs--MMT works.
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