NY TIMES LETTER TO EDITOR: “Revolving Door For Addicts”

Re: “Revolving Door For Addicts” (April 17), it has long been accepted that addiction is a chronic, relapsing illness, and when relapse occurs – as it so commonly does after even the very best of treatments – one can only applaud when patients return for additional episodes of care. The fact that “many patients do cont fully recover from their addictions” merely reflects the complexity of the problem.

The “revolving door” can be and often is a life-saver in every sense of the word. Consider a member of the cabinet of former Governor Carey. In an interview reported by The New York Times (December 20, 1978) Commissioner Julio Martinez acknowledged a long history of heroin addiction and “about fifteen” admissions for what you describe as “the most expensive kind of inpatient detoxification.” Would anyone deny that the investment of Medicaid dollars was worthwhile?

Robert G. Newman, MD
Director,
Baron Edmond de Rothschild Chemical Dependency Institute
of Beth Israel Medical Center, NYC

This letter was not published

OBJECTIVE ASSESSMENT OF DRUG POLICIES AND THEIR IMPACT

ANALYSIS OF UK DRUG POLICY was released on April 18, 2007, by the UK Drug Policy Commission. The full report and executive summary are available at: http://www.ukdrugpolicycommission.org.uk/reports.shtml.

Some data from the executive summary:
* the number of "dependent heroin users" in UK estimated at 5,000 in 1975, today 281,000;
* between 1998 and 2004/5 "Government has successfully increased the number of drug dependent users entering treatment . . . .from 85,000 in 1998 to 181,000 in 2004/5 [leading to] ... substantial reductions in drug use, crime and health problems...";
* "the majority of this treatment involves the prescription of heroin substitution drugs (mostly methadone)";
* more than half of the estimated problem drug users are now in contact with structured treatment each year;

The report is important not only in what it tells us about the response to the drug problem in UK; it also raises questions about what comparable data exist elsewhere that would permit an objective assessment of drug polices and their impact. For instance, is there in the US at national or state levels information on the extent to which "Government has successfully increased" enrollment in addiction treatment in recent years, and the proportion of "problem drug users [that] are now in contact with structured treatment each year"?
Anyone know of efforts currently under way to obtain such data?

Not rhetorical questions - would welcome posting of comments/responses.

WHY USE SUBUTEX WHEN YOU HAVE SUBOXONE?

Extremely widespread illicit IV use of Subutex in the former Soviet nation of Georgia was recently reported in a German newspaper. The question: since Suboxone is said (rightly or wrongly - we've seen no comparative data to support the theoretical advantage) to be significantly less liable to misuse by injection, and since both preparations are believed (again, with no reported evidence as far as we know) to have equal effectiveness, why is Subutex used at all? There are claims that Subutex is "better" at the start of treatment and perhaps (!) safer in pregnant patients - but if there's supporting evidence, then why doesn't FDA in USA and counterpart agencies elsewhere state unequivocally that Suboxone SHALL be prescribed unless there's a documented rationale for not doing so - and then, for some of us dummies, specify the key reasons for exceptions and the reported evidence on which they are based? Comments welcomed!

(For the record, no one at ICAAT has any relationship with the manufacturer of Subutex or Suboxone and zero interest in advocating the latter, trade-mark protected, formulation.)

A CALL FOR PERSPECTIVE IN METHADONE DISCUSSION:

from Maine comes a call to "consider methadone treatment's successes." Brent Scobie of The Acadia Hospital urges those who engage in "passionate debate for and against medication-assisted treatments of opioid addiction ... to consult the science and the data behind all the approaches." Yes indeed - passion is good, but evidence-based medicine must be the underlying guide.

Appeared in the Bangor Daily News, 12 April 2007

"OPIUM FOR THE PEOPLE"

Tony Blair reportedly "is considering calls to legalise poppy production ... [to] cut medical shortages of opiates worldwide, curb smuggling - and hit the insurgents" (The Independent - U.K., April 1). Discussion of any change in long-standing, dismally ineffective, drug-war policies is welcome. The problem here, however, is the continuing focus on illegal supply while ignoring demand. As long as millions of people worldwide seek opiates that are not indicated for pain control, there'll be an illicit traffic to meet that demand. And when it comes to purchasing the opium crop from Afghan farmers, there's no way legitimate businesses supplying physicians and their patients will be able to compete with those whose intended consumers are obliged to patronize the black market.

There is a more promising approach: rather than just legalize production, legalize the use by and prescribing to those dependent on opiates.

NY TIMES READERS COMMENTS (April 3) ON "TRAFFICKER OR HEALER":

The article (March 27) concerning opiates prescribed for analgesia is worth reading. One conveys the perspective of a physician who acknowledges having been focused more on identifying the "drug seeking" patient than on responding optimally to those whose pain demands treatment. The other letter is from a chronic pain patient who laments "... the constant unwarranted suspicion" and the questioning of her motives and personality, and the stripping away of her dignity and integrity.

METHADONE FOR PAIN: KEEPING PERSPECTIVE:

Though the focus of this website is treatment of addiction (particularly with methadone), the extraordinary media attention given in recent weeks and months to complications associated with methadone prescribed for pain should also be put in perspective. Clearly, every death associated with any medication, whatever the contributing factors and regardless how the medication was prescribed and/or otherwise obtained, is an absolute tragedy! We must not lose sight of the fact, however, that methadone can offer unique long-term relief for patients with chronic and debilitating pain. An article in the Salisbury, NC, Post on March 27 describes a case in point, and the headline says it all:

"Methadone only thing that makes life bearable for arthritis sufferer."
Full story: http://www.salisburypost.com/area/357243898133166.php

GOOD “PILOTS” OR BAD:

Depends on where they’re heading. The Xinhua News Agency Mar 26 reports that a “methadone pilot” is being launched in Vietnam. Sounds good – until one looks at the details. First, it targets 700 patients – in a nation that estimates over 160,000 opiate dependent people. Second, the “pilot” is to last almost two years – until Dec. 2008; the premise seems to be that it will take that long before data are in hand on which the government will rely to determine the future role of methadone in Vietnam. And finally, the report describes the project” as “…giving oral methadone to patients instead of heroin and eventually weaning them off methadone.”

Comment: over 40 years of experience with methadone maintenance around the world – including Asia – have demonstrated the efficacy of this treatment of addiction; the very concept of a “pilot” for such a proven therapeutic regimen is impossible to justify.

The corollary of “700 patients” to be enrolled in the project is that over 99.5% (sic!) of those who might be helped by methadone treatment will be abandoned – presumably for the next two years or so.

And perhaps most damning of all, the “pilot” embraces and implicitly endorses the unequivocally incorrect assumption that persistent abstinence following discontinuation of methadone maintenance is an appropriate and realistic program objective.

While USAID and its British counterpart surely have the very best intentions, one has to wonder if this particular effort will not be decidedly harmful to vast numbers of people who desperately want and need help - people for whom we know, unequivocally, help could be provided promptly and effectively without any “pilots.”