Afghanistan's new policy - encourage narcotics trade profits to be invested for benefit of impoverished nation

A few weeks ago an AP release (picked up by Monterey Herald, for one - March 15) reported on Afghanistan's new policy to encourage some of the "booming narcotics trade" profits to be invested for the benefit of that impoverished nation. Sounds like a pretty brilliant idea, and one that is no less applicable in the wealthiest nation of the world (indeed, the pot is vastly greater in our country of drug consumers than in places where opium is grown). Think of the impact if instead of our woefully unsuccessful "zero tolerance," for which American taxpayers have been paying tens of billions of dollars anually, we adopted some form of "tolerate and tax." Even a tiny percent of the drug industry profits would yield phenomenal benefits in areas like health care, education, housing, etc.!

DILEMMA OF DRUG COURTS

Most proponents and providers of methadone maintenance are outraged that this form of treatment, shown for 40 years to be without parallel in efficacy, is generally denied defendants by judges and prosecutors in "drug courts," even those defendants who are already receiving methadone and responding well to the treatment.

Sure - it's indeed outrageous that the courts presume to overrule physicians and dictate what medical treatment is and is not permissable. But it's almost as troubling when physicians accept patients who are sent to them under circumstances that are diametrically opposed to the concept of "voluntarism." It's also distressing, to say the least, for the doctor to accept a situation in which patients will be punished by imprisonment simply because the treatment they received was less than optimally effective - ie, when illicit drug use persists.

Drug court defenders say no one is really "forced" to participate; but it's clearly disingenuous in the extreme to suggest that "Hey, it's a free country; the defendant is always able to choose the option of going to prison instead of to the methadone program." In any event, this obvious absurdity is little comfort to the physician who participates in a system that everyone knows is - and is intended to be - a way to blackmail people into accepting treatment.

No easy answers - but worth thinking about.

QUESTION POSED BY A COLLEAGUE: What is the best starting dose for methadone...

What is the best starting dose for methadone, and what rate of dosage increase should be used when raising a patient to a maintenance (“blockade”) dose? And what happens when a patient is not comfortable, and the discomfort lasts not for just a few days but for weeks, and it is considered due to the dosage regimen? Are there exceptions to the usual policies that are considered optimal in most cases?

RESPONSE: Good questions, but tough to answer beyond the fundamental generalization that always applies: one must individualize dosages based on assessment of physician, who in turn must give major weight to the subjective report of the patient.

IN GENERAL: the rule of “start low – go slow” (coined, we believe, by colleagues at the Ontario College of Physicians and Surgeons) applies – as does the addendum, “aim high”. The starting dose generally shouldn't be more than start at more than 40mg (30 is safer), and after an initial 10mg MAX increase the following day increases should be no more than 10 mg every 2-3 days. Starting higher runs the risk (whether high or low is open to debate) of possible overdose. As for increasing too rapidly, there’s an additional problem: the possibility of persistent agonist effects because tolerance can't catch up to the dose being given. Then, when one ultimately tries to level off at a "stable" dose, the patient perceives the absence of those agonist effects and concludes the methadone "isn't holding."

All this may sound logical, but there are also dangers associated with too low a start and/or too slow a buildup. Withdrawal/craving can lead to the patient shooting heroin and that, especially with the relatively lower level of tolerance at the earlier, lower doses of methadone, can also have fatal outcome.

What is key is to be candid with the patient and try to ensure s/he understands what to expect. Specifically, that the body may take a while to adjust to a once-daily oral dose of methadone after prolonged use of short-acting, parenterally administered heroin (or whatever). Withdrawal symptoms (or discomfort, however described) often occur in the initial couple of weeks of treatment regardless what policies are employed. Aiming for - and leading patients to expect - total absence of any discomfort is inappropriate, I believe, and sets the stage for poor therapeutic outcome.

One might wish for a more definitive answer to the critically important question of starting dosages and build-up. In fact, however, as in the case of management of all other chronic medical conditions, treatment of addiction defies the establishment of absolute rules. One must be aware of the benefits and risks of every possible course, explain these to patients, and make the best judgment possible in each case.

DIFFERENT VIEWPOINTS WELCOMED!

IN GERMANY, FAVORABLE HEROIN TRIAL RESULTS, UNFORTUNATE AND UNWARRANTED COMPARISON TO METHADONE TREATMENT

Favorable results of the multi-year, seven-city pilot project that provided heroin to long-term opiate addicted individuals have led the city government of Frankfurt to overwhelmingly approve continuation of heroin maintenance, and to push for federal approval to legalize prescribing of heroin. What is unfortunate is that the pilot study chose as a “control” group subjects who were given methadone – even though, as required by the eligibility criteria, virtually all had failed to achieve positive outcomes with methadone maintenance in the past.

First, this amounts to testing one regimen whose outcomes are not known, to another that has a proven record of failure with the subjects studied. Secondly, virtually all those who volunteered to participate were surely motivated by the desire to obtain heroin, rather than the medication that had previously been ineffective. Whatever the groups randomly assigned to the two “arms” of the study may have had in common, their desire for and expectations of heroin as opposed to methadone could not have been more different. The results of the comparison were inevitable. Thus, the recent (March 11, 2006 – redaktion rhein-main) press report noted the success of heroin compared to methadone in improving drug use, health and social status.

So will there be immediate adverse consequences of the findings, as reported, of the German trial, stating that heroin is “more effective” than methadone? Hopefully not, but it will certainly lend support to those who already hold a strongly pejorative view of the latter in many countries of the world. .

ADDICTION PODCASTING: WHO'S ON TOP? THE FOLKS DOWN UNDER! (click here for link)

For those into the explosively growing medium of podcasting, 2GB PLUS in Australia has just made available the first of six programs on addiction - this one dealing (exceedingly well!) with heroin dependence and methadone treatment. The physician in charge of the Kings Cross Injection Centre, Dr. Ingrid van Beek, and a methadone patient, "Susan," are interviewed. Well worth listening to.

IDAHO LAW WOULD PUNISH (BY UP TO 5 YEARS IN PRISON) ANY ILLICIT DRUG USE BY PREGNANT WOMEN

Lewiston (ID) Morning Trib, Mar 1): the inevitable consequence of such a bill, which passed Idaho State Senate by vote of 18:16, would result in pregnant women shunning not only addiction treatment services, but prenatal care.

It doesn't take much imagination to recognize the real agenda behind such a bill - setting the precedent that a woman who - ostensibly! - harms her unborn fetus is guilty of a serious crime demanding serious punishment. And when that has become an established part of our legal system, it is inevitable that those women who cause the "ultimate harm" - aborting their fetus - will be prosecuted for the "ultimate crime" - murder - and subjected to the ultimate sanction.

Never has the link between women's rights, the right to choice, and our probihitionist drug policies been clearer, and the need to join forces in fighting the trend more overwhelmingly compelling.

A manifesto: NOTHING ABOUT US WITHOUT US

The Canadian HIV/AIDS Legal Network recently announced publication of new resources - in French and in English. Of particular note: "a manifesto by people who use illegal drugs demanding greater involvement" with the brilliant title: "Nothing about us without us" (in French, "Rien a notre sujet sans nous")

Absolutely worth checking out.
Available in English


Available in French

NEED FOR BASIC BUPRENORPHINE DATA

In a recent bimonthly news update of AT Forum the hope is expressed that a "sufficiently large study finally will be conducted to provide more authoritative guidance regarding if, when, and in whom buprenorphine might be preferred over methadone in pregnant women." True, but precisely the same hope applies with regard to every applicant for treatment or opiate dependence.

It is essential that evidence is sought and reported to support or to lay to rest such commonly expressed views regarding one medication being "better" for the more recently addicted and another for the more "hard-core;" one being "easier to get off" than the other (however that term may be defined); and the belief that one leaves patients "more clear-headed" than the other. For all these issues, and many more, it's high time for "authoritative guidance" to replace dogma.

unused MTP capacity

HELP MAY BE AVAILABLE BUT . . . there appears to be a fair amount of unused capacity in MMT in Manhattan and Bronx - maybe elsewhere. And one can imagine lots of reasons why this is so. The immediate question is: what are programs doing about it? Anyone see any ads in Daily News (or WSJ)? Anyone see any public service announcements by NYC govt, by State (OASAS, DofH), by our fedeal govt servants in CSAT, VA or whatever? There seem to be fair number of ads for knee replacement surgery, for diabetes care, for smoking cessation programs, etc etc - but opiate addoiciton? And for methadone treatment in particular?

I just this morning called nyc 311 helpline - I asked the very pleasant man who answered how I could find a MTP in upper Manhattan. He checked and after a minute or so told me that I'd have to ask the OASAS referral line - and then offered to transfer me. So far, pretty good (though it would be nice to have the City help-line have the info). But after he transferred me the line rang a dozen or so times and I was disconnected. It's easier to buy a bag of dope. rgn