PERSISTENT REJECTION OF EVIDENCE-BASED MEDICINE WHEN IT COMES TO MAINTENANCE TREATMENT OF ADDICTION:

in a "Comment" in this week's Lancet (Aug. 18, vol. 370, pp 550-553) that focuses primarily on a possible role for codeine in treatment of opiate dependence, the authors note that notwithstanding the clear and overwhelming evidence that one is dealing with a chronic medical condition, "...politically the popular treatments are those that aim to achieve abstinence within weeks to months."

By contrast, the statement goes on to note that, reflecting evidence-based medicine, "The aim of [maintenance] treatment is long-term retention in the programme and normalisation of psychosocial functioning, rather than abstinence from all opioids."

So . . . the problem of the past 40 years remains: how to overcome the political dogma that continues to shape the policies and practices governing treatment of addiction?

AFGHANISTAN OPIUM PRICES DROP SHARPLY:

UNODC has determined the trend of "farm gate prices" of Afghani opium through July 2007. Since July of 2005, the per-kilo price dropped from $ US 167 to $US 105 - a whopping 37%. In just the past twelve months it dropped from $ US 140 - 25%. Says a lot about the "other" war - the war on drugs, and bodes ill for the impact on price and purity in consuming nations around the world.

COMMUNITY SUPPORT FOR NEW METHADONE CLINIC:

In an all-too-seldom good news story, Hazleton, PA, officials backed establishment of a methadone clinic. No one at a City Council meeting spoke against the proposal and the Mayor as well as Chief of Police endorsed it. The later stated, "I think we'd see a decrease in crime if we had an in-town treatment center," adding that patients could “hold jobs they otherwise might not be able to hold and become productive to society again.”
Full story:

ATTACK HEROIN NOT METHADONE

I am posting below a brilliant letter by Alex Wodak, MD submitted for editorial to The Times.

Wed, 25 Jul 2007

Subject: Attack heroin not methadone

Dear Sir,

The recent report (The Times, 23 July 2007, Services failing the children of 7,000 drug addict parents, Charlene Sweeney) into treatment services for drug dependent parents in Scotland attacks the most effective response rather than focusing on the real problem. If Ms Annabel Goldie really wants to listen to experts, she should read the 2005 joint
endorsement of methadone by the United Nations Drug Control Programme, the World Health Organisation and UNAIDS. In 2005, WHO added methadone to its list of Essential Medicines. Methadone and buprenorphine treatment are remarkable for their ability to attract, retain and benefit large numbers of heroin users.

Abundant research confirms that methadone substantially reduces deaths, heroin use, crime and HIV infections. In a 2006 study published in The Lancet, methadone treatment in Zurich reduced the number of new heroin injectors from 850 in 1990 to 150 in 2002 with a large decrease in deaths, crime, HIV infections and heroin seizures.

Supervision of methadone treatment reduces diversion to the black market while inadequate methadone treatment increases the black market. All over the world, methadone treatment is grossly under funded. Consequently, programs have insufficient capacity and quality. Residential treatment programs for heroin users attract few, retain even fewer and are expensive. Finding evidence of benefit is very difficult. Yet they have their place as some drug users will always reject or not receive benefit from methadone treatment.

Yours sincerely,

Dr. Alex Wodak,
Director, Alcohol and Drug Service,
St. Vincent's Hospital,
Darlinghurst, NSW, 2010,
AUSTRALIA

WHEN POLICE PROCLAIM TREATMENT AS THE KEY TO THEIR ANTI-DRUGS STRATEGY, WATCH OUT!

Iran has in recent years been a splendid model of response to opiate addiction for other countries. It has had an avowed commitment to massive treatment expansion, with primary reliance on methadone maintenance - in the community and in prison. Treatment has been coupled with harm reduction measures such as needle and syringe exchange and condom distribution, as well as continued focus on lessening the flow of opiates across its porous borders.

Unfortunately, a report on 13 August by BBC Monitoring International quotes the head of the anti-narcotics police force as saying, "All injecting addicts will receive treatment by year-end ... even mandatory treatment." To achieve this goal the Police will conduct a "roundup of the most dangerous drug addicts" in the country.

"Mandatory treatment" is an oxymoron. One can readily imagine what action the Police will take when a "patient" fails to respond as well as they would like, and shows signs of the condition being "treated". It is particularly tragic to note that this approach may well prove to be the death knell for the successful voluntary services offered on a rapidly expanding basis to date.

IN US AND OVERSEAS, BIG TOWNS AND SMALL, WHEN IT COMES TO ADDICTION AND METHADONE THEY JUST DON'T GET IT:

The Clanton (Alabama) Advertiser on 13 Aug reported a local ruling that disallows establishment of a methadone clinic there. Part of the rationale: there's another clinic that is within 30 minutes drive from all parts of the county (i.e., pursuant to "pickup" regulations, every patient would face a one-hour daily roundtrip to be medicated!). The local District Attorney commended the mayor and council for their opposition to the proposed methadone clinic," stating: "If you are going to open a methadone clinic here, you might as well open a clinic next it to that will help get people off methadone."

Meanwhile, new Swiss guidelines and recommendations concerning "substitution" treatment of addiction were attacked in the press because they were interpreted as discouraging "abstinence" as a therapeutic goal (for example, see Tagesanzeiger, Aug 12, http://www.tagesanzeiger.ch/dyn/news/schweiz/780252.html)
In response, the Swiss Society for Addiction Medicine issued a statement noting the obvious: "It's a worldwide reality that only a minority of those who are dependent manage to achieve and maintain abstinence."

Clearly, there's been a very widespread - near-universal - failure of providers, professional organizations and government authorities to achieve an understanding of the chronic disease of opiate addiction and its treatment with methadone.

ATTACKING STRAWMEN IN SWITZERLAND:

Two news articles (Tageszeitung 12 Aug and Blick 13 Aug) have claimed that recently released guidelines and recommendations concerning "substitution treatment" of opiate addiction damn the goal of abstinence and instead hold up methadone as a "cure-all." Absolutely not the case. The guidelines, prepared by a number of organizations, including the Swiss Society of Addiciton Medicine, tell it like it is, acknowledging limitations of any and all forms of treatment and pointing out that after treatment (with methadone or any other modality) relapse and its potentially life-threatening consequences is the rule rather than the exception. Full stories (in German):
link 1 and link 2

UN SECRETARY GENERAL: ADDICTION IS A DISEASE AND DEMANDS POLITICAL LEADERSHIP TO IMPROVE ITS TREATMENT:

that in a nutshell was the message by UN Secretary General Ban Ki-moon on the occasion of World AIDS Day on 26 June 2007. He went on to say that "the greatest challenge in global drug control is reducing demand . . . [and] for those who are grappling with addiction, effective treatment is essential." Right, but a bit depressing that this statement seems to have gotten very little attention from the world's media.

SAFER DISPOSAL OF SYRINGES: ONE APPROACH

An article in the San Francisco Chronicle (July 29, 2007) reports there are lots of used needles and syringes littering Golden Gate Park in areas drug users frequent. No serious advocate of needle and syringe exchange ever claimed it would be a panacea, but we know from experience with such programs throughout the world that they indeed cut down considerably the spread of HIV among intravenous drug users. As for safer disposal, one approach is – as the Homeless Youth Coalition has suggested – utilization of strategically placed biohazard boxes. They too are not a perfect solution, but they help. As an illustration of how widespread their use is, such boxes have been located in QANTAS business class(!) lounge toilets, and on the British Columbia Ferries fleet.

FROM RUSSIA - WITH LOVE?

Moscow Mayor Luzhkov's proposal of mandatory testing of students for illicit drugs has now been endorsed by "Russia's chief sanitary doctor," Gennady Orishchenko. Whatever rationale might be offered for this approach in societies that make treatment for drug dependence available to those who want and need it does not apply in Russia, where there's essentially no addiction treatment for anyone. Locked-ward cold turkey detoxification is about as close to "treatment" as one finds in that country, where the prevalence of opiate dependence is estimated to be as high as two million. (RIA Novosti, 27 July 07)