REPORTED PREFERENCE OF IVDUs FOR BUPRENORPHINE OVER METHADONE:

A colleague has advise that in Australia there is an extremely high preference for buprenorphine over methadone among potential patients - 9:1! I'm a firm believer in ensuring availability of ANYTHING that offers help and hope to those who want it, which is why I have been enthusiastic in praise of France bringing some 100,000 people into treatment - overwhelmingly with buprenorphine - in precisely the way I've been ecstatic about Germany achieving much the same with methadone. If Russia (estimated opiate dependent population in the millions, essentially zero treatment of any kind available!) were some day to boast a few hundred thousand ivdu's in treatment I could care less if it was with one medication or the other.

BUT I do have concerns over what underlies the preference, and if it is a false expectation, then sooner or later it will haunt us. Specifically, if heroin addicts (and doctors, and politicians, and the voting public) see in buprenorphine a medication that "cures" - that can be taken for a while and then stopped and lasting asbtinence subsequently be the rule rather than exception, it's only a matter of time ...(I say this based on my belief that there's never been a study of post-buprenorphine sustained abstinence - I may have overlooked something).

I am painfully reminded of the first public media discussion of methadone in late 60s (just before my time) where it was described as the "Cinderalla drug" and heralded as a magic panacea that would end addiction in our time (only a tiny bit over-stated). Could probably find the reference if someone wanted it.

Anyone consider a disinterested party doing a focus group and reporting what heroin users prefer, and why . . . ? Would be fascinating, especially if comparing land of Oz with US, Canada, France, etc.

HEROIN TRIAL REVIEWS

A colleague recently asked about review articles on heroin precribing for opiate addiction. The following response was sent, BUT ADDITIONAL REVIEW ARTICLES WOULD BE WELCOMED - please post.

There are various national trials that have been described - Netherlands, Germany, Switzerland, but the most objective overviews of everything available in the field comes from the Cochrane reviews, and there I find two references. One very recent, 2006, and I find nothing yet available except the abstract but maybe you can do better. Conclusion from abstract reads ( found at http://www.cochrane.org/reviews/en/ab003410.html)

Authors' conclusions No definitive conclusions about the overall effectiveness of heroin prescription is possible. Results favouring heroin treatment come from studies conducted in countries where easily accessible Methadone Maintenance Treatment at effective dosages is available. In those studies heroin prescription was addressed to patients who had failed previous methadone treatments. The present review contains information about ongoing trials which results will be integrated as soon as available.
Second review is 2 yrs old, and conclusion is: (found at http://www.cochrane.org/colloquia/abstracts/ottawa/P-004.htm)

Conclusions: Data from systematic reviews show MMT at appropriate doses the most effective in retaining patients in treatment and suppressing heroin use. The available evidence calls for two different actions in terms of clinical practice and research. On one side, proper methadone therapy should be offered to patients but on the other side future clinical trials should select clinically relevant alternative interventions to compare, include a diverse population of study participants, recruit participants from heterogeneous practice settings and heterogeneous social contexts, and collect data on a broad range of health outcomes.

DRUGS IN IRAQ:

It was inevitable, of course - but now an AP report (July 17, by Sinan Salaheddin) confirms that "Iraqis turn to drugs to escape violence." Noting the shift from the days of Saddam Hussein, the point is made that "the abuse of prescription and illegal drugs has become more widespread than alcoholism." No numbers are given, and heroin dependence is not singled out for mention - though street "lingo" is said to have developed for valium, tegretol and methadone ("the opiate that's medically prescribed for treating heroin addiction but also can be abused").

Anyone have any information about heroin/opium use in Iraq? Any data on opiate and/or other drug problems among "coalition" troops in Iraq or Afghanistan?

"METHADONE TREATMENT" AND FATALITIES: THE NEED TO BE SPECIFIC

In the Bangor (Maine) Daily News of 18 May an article was headlined, "Methaodne treatment exacts too high a cost." No one could disagree with the statement that “even one methadone-related death is one too many.” It should be noted, however, that the tragedy in the particular case which prompted this story was most likely due to the inadequate availability of methadone treatment for opiate dependence, and not to its limitations. Reportedly the deceased woman had been desperately motivated to give up her addiction, which before she reached the age of 20 had progressed to intravenous use of heroin. “She tried to quit,” the story said, but even with the encouragement of her family her attempts failed. We are further told, “At one point she was on the waiting list at a methadone maintenance program, but she died before she could be enrolled.” The reporter's reasonable conclusion: the deceased “was probably trying to control her cravings by self-medicating.”

Clearly, nothing can possibly make up for this terrible loss of life or ease the grief that it has caused. But to save the lives of others it seems vital to ensure that “waiting lists” – for methadone as well as for any and all other forms of care for addiciton - be eliminated, and that those who want and need help in overcoming their dependence can get it promptly.

OVERVIEW OF THE US FAILED 35-YEAR WAR ON DRUGS

This appeared as an op ed piece in the Boston Globe, 27 June. In sum, the war "... has failed for many reasons. Our leaders refuse to accept the facts on the ground. Their strategies are shaped more by punitive ideology than by pragmatism and compassion. And too many Americans still believe that drug addiction is someone else's problem. As a result, our government's wrongheaded policies have gone unchecked -- with countless lives lost, families wrecked, and victims more cruelly marginalized than in other developed nations." Less than a quarter of the Bush administration drug-related budget goes for treatment; when Nixon launched "the war" over half was ear-marked for rehabilitation services.

The authors quote two respected observers of the drug wars: "The problem is not that the United States has failed to do the impossible, but that it has failed to do things that could readily be done." To that one can only add: The US has failed to consider - and has refused to permit even the discussion of - any alternatives to the policies and practices that have been such a dismal failure for decades.

UN Drug Czar … Countries "Get the Drug Problem They Deserve"

The head of the UN anti-drugs department is quoted (June 27) as saying "the harmful characteristics of cannabis are no longer that different from those of . . . cocaine and heroin." His statement would have been more credible if he stated he prepared these comments while smoking pot! Does any - sober - professional or lay-person really believe there's essentially no distinction in the harm associated with marijuana and the other drugs?

As for the UN drug czar's statement that countries "get the drug problem they deserve," it should be noted his condemnation was directed at Britain and its decision to downgrade cannabis, and not at countries like Russia, where an estimated 2 million heroin addicts have absolutely no treatment whatsoever.