HIV RISK BEHAVIOR COMPARED AMONG THOSE ASSIGNED TO VARIOUS AGONIST MEDICATIONS FOR OPIATE DEPENDENCE

The letter below was submitted to the Editor of the Journal Substance Abuse Treatment some 3-4 months ago, with a follow-up request for response - but no acknowledgement was forthcoming. It's blogged at this time for the possible interest of blog viewers.

The article by Lott and co-authors (1) presents data from a study carried out in 1996-97 in which HIV risk behaviors were compared among subjects assigned to various agonist medications for opiate dependence. One out of four subjects was given “…a fixed daily dose of 20 mg of METH [i.e., methadone] and served as a control group.” Seven years before the trial commenced the then-Director of the National Institute on Drug Abuse had stated, "...in this age of AIDS, a low dose policy is not simply inappropriate, but can be fatal to the IV drug abuser in treatment as well as his or her sexual partners and children." (2) It is difficult to comprehend the rationale for unnecessarily subjecting people to a potentially fatal outcome, even during the course of a study of limited duration and even with provision (when it’s not too late!) for “therapeutic rescue.”

References

1. Lott, D.C., Strain, E.C., Brooner, R.K., Bigelow, G.E. & Johnson, R.E. (2006). HIV risk behaviors during pharmacologic treatmenty for opioid dependence: A comparison of leomethadyl acetate hydrochloride, buprenorphine, and methadone. J Subst Ab Treatm 31, 187-194

2. Schuster, C.R. (1989). Methadone Maintenance - An adequate dose is vital in checking the spread of AIDS. NIDA Notes. Spring/Summer, p. 3

JUDGES ARGUE ABOUT WHAT “TREATMENT” SHOULD BE IMPOSED ON DEFENDANTS

The Wall Street Journal of Jan. 19 reported at length on a dispute between judges in New Mexico over whether defendants should be sentenced to an addiction “treatment program” founded by a Scientologist and former real-estate developer. One judge doesn’t want his colleagues to sentence inmates to the program, Second Chance, while another is paid “…to convince judges to do just that.”

The issue here has nothing to do with the specifics of this particular program, where “patients” stay a minimum of six months. Rather, what in the world are judges doing making decisions over treatment for the medical problem of drug dependence? How can they consider themselves qualified to determine for any defendant coming before them which program or modality is most appropriate? It's good that they accept the now widespread view that addiction is an illness, but surely diagnosis and therapy are matters that should be left to clinicians, as in every other field of medicine.

And then, of course, there’s the ultimate irony that is fundamental to all “treatment in lieu of prison” approaches: when the therapy and those that provide it fail – i.e., the outcome is less than hoped for – it’s the hapless “patient” who pays the price by being sent to prison.

MAINTENANCE VS. DETOX EMPHASIS WITH METHADONE AND BUPRENORPHINE:

According to Drug and Alcohol Services Information System (DASIS, Office of Applied Studies, SAMHSA), publication issue 36 (2006), and information received from DASIS directly, "clients" receiving methadone on 31 March 2005 were enrolled in opioid treatment programs self-identified as follows: 95,058 in maintenance programs, 2,131 in detoxification programs and 138,647 in programs offering services with both goals. In percentage terms, 59% were in programs pursuing both goals, and of the remaining 41% whose programs had one therapeutic goal or the other, only 2% were in detoxification programs.

The corresponding information for buprenorphine recipients was as follows: 288 were in maintenance programs, 112 in detoxification services and 765 (66% of the total) were in programs offering both. Of the 34% in programs with one or the other defined goal, 28% were being detoxified.

Unfortunately, DASIS states it has no information on any office-based (non-"program") providers or patients, and has no way of breaking down maintenance vs. detoxification recipients in programs offering both services. However, it is striking that for those individuals enrolled in programs with defined goals, 14 times as many buprenorphine recipients were in detoxification compared to those who received methadone.

Sure, there are lots of unknowns here, but the data obviously are considered meaningful enough to be collected, analysed and reported to the public. So . . . what do these strikingly different proportions of maintenance vs. detoxification mean, and is there any evidence in the world-wide literature that would support such a disparity?

Comments welcomed.

DRUG ABUSE A "MEDICAL ISSUE,"

According to two-thirds of Canadians in a national poll. This was the headline of an article Jan 16 in the Vancouver Sun. Not sure what the comparable vote tally would be in US, but certainly America's elected officials don't see it that way, as the annual budget allocations for law enforcement vs. prevention/treatment demonstrate.

MORTALITY ASSOCIATED WITH COMMENCEMENT OF METHADONE TREATMENT:

A concise but well-referenced and compelling overview of “iatrogenic methadone toxicity” associated with initial dosage of methadone was published in 2004 by Ralf Gerlach (German, reference upon request). The conclusion: “Based on the evidence presented, the initial dose of methadone should not exceed 30 mg.”

THE NEED TO RETHINK THE STRATEGY ON MAKING BUPRENORPHINE AVAILABLE TO THOSE IN NEED:

The Spokesman-Review (Washington) reported Jan 3 that there's not one physician in Spokane willing to prescribe buprenorphine, and only one within a 100-mile radius. So . . .is anyone re-thinking how to make the much-heralded promise of this medication reality for more than the tiny handful of patients who get it? For sure, one can imagine the manufacturer is giving this a lot of thought - but what of those whose responsibility and mission are to provide medical care to those who want and need it, and all too often die without it? The Federal authorities, and state agencies? Medical societies? And is anyone re-thinking the policies and practices that limit methadone maintenance to no more than about 20% of the estimated heroin-dependent Americans (in addition to the substantial number of Americans dependent on prescription pain-killers)?

Timothy Lepak wrote as a incidental side note

I’ve been in touch with the reporter in Spokane to mention that after some research I found that there are actually 11 certified physicians within the 100 mile radius, with only 5 on the SAMHSA list.

But the opposite is true in other parts of the country. "Almost daily I have physicians calling me with treatment openings and no patients." In areas such as Boston, we have patients contacting us who are unable to find treatment despite numerous certified and participating physicians. Since the launch of the matching system on Sept 1st., 1,239 (60%) have been successfully matched to a physician, As of today there are 322 patients on the list looking for treatment.

We (NAABT) have patients that have registered to be matched with a physician in the Spokane area, however currently there are no physicians within range participating in our program. One thing we are doing is sending a postcard to the certified doctors, http://www.naabt.org/tl/postcard.pdf we notify the physicians how many patients are currently seeking treatment near them in hopes it will prompt them to treat the people in need in their community. To date it has prompted 20 physicians to participate in the program. I’m amazed that after 4 years so many are still unaware of the treatment. Almost daily I have physicians calling me with treatment openings and no patients.

ALMOST 4000 "METHADONE-RELATED" DEATHS IN 2004 - OVERWHELMINGLY ASSOCIATED WITH PRESCRIPTIONS FOR PAIN MANAGEMENT

The death toll was reported in the Charleston (W.Va.) Gazette on 31 Dec 06; West Virginia is said to lead the nation in this regard, with 99 fatalities. SAMHSA and CDC determined several years ago that methadone-related deaths are overwhelmingly associated with pain management and occurred largely in individuals for whom the medication was prescribed. Two months ago FDA changed the "recommended usual dose" for analgesic use from a range of up to 80 mg daily (correctly described in the Gazette article to be "potentially fatal") to 30 mg - but this radical (and long-overdue) change was not mentioned in the "advisory" or "alert" or "patient information notice" that was publicized. So how are physicians and patients to know?