Thursday, February 22, 2007


This Letter to the Editor Appeared in the Charleston Gazette (West Virginia)February 20, 2007, Tuesday

LETTER TO EDITOR Methadone isn't devil you say it is. I have read with great distress the articles this paper has written On methadone. I am a 51-year-old married woman who happens to be a heroin addict. I did the 12 steps; they didn't work for me. The bottom line is, I have been on methadone maintenance for some time now, and it has saved my life. I am on 175 grams a day, and if you saw me, you couldn't tell I am on a lifesaving medication.

Methadone has been the most successful treatment for heroin addicts. I have been clean from all illegal drugs for a long time, and if it weren't for methadone, I would be dead, in a nut house or in prison.

There is a group of women who want to ban methadone because their loved ones died from methadone and other drugs. Methadone doesn't kill people. It is people who take it with other drugs. I have been to over 20 funerals of friends who died of overdoses, and not one was a methadone death. The friends that I have who are on methadone for pain do not take more than 40 milligrams a day.

Methadone is my lifesaver. Please don't let a few zealots tell you it is the devil.


Wednesday, February 21, 2007


In the 2006 annual rreport of the travel advisory program of INDRO (Muenster, Germany) the number of patients receiving opiate agonist treatment is broken down by medication. Between 2003 and 2005 the number of methadone recipients increased slightly from 48,216 to 50,020, while the relatively few receiving codeine preparations dropped from 896 to 488. But the number receiving buprenorphine increased from 6888 to almost 10,500. It's good to see this recently introduced medication add substantially to the number of persons in treatment. Alas, in the US I'm not sure anyone is even collecting such data, and when one hears numbers related to buprenorphine "prescriptions" here it's not clear how many are for detoxification vs. maintenance (the German data are point in time, maintenance patients). Full report (in German) at

Sunday, February 18, 2007


in what is described as an impending "return to the stone age of drug politics," federal political leaders in Germany are remaining adamant in their refusal to permit routine availability of heroin for the very hard-core individuals who have not been helped by "traditional" treatments.The article concludes: "There are no medical or ethical grounds for arguing against the availability of heroin treatment." The full story (in German): (Thanks to colleague Hans-Guenter Meyer-Thompson for bringing this to our attention)


A literature review published in 2005 analyzed reported abstinence rates AFTER detoxification form methadone maintenance. It found that, collectively, only 32% of some 1900 patients were defined as “abstinent” after an average period of observation of 27 months. It should also be noted that some definitions of “abstinence” were very loose: one defined it as including “at least one month during the follow-up period with no intense use.” One can only hope that patients considering detoxification from successful methadone maintenance treatment are being advised up front of these very gloomy results. As for treatment providers who encourage (or force) patients to detoxify, one has to wonder about their clinical and ethical judgment. The review: Kornor H and Waal H: From opioid maintenance to abstinence: a literature review.” Drug and Alc Rev 24:267-274, 2005

FROM HERMAN JOSEPH, NYC, THE FOLLOWING COMMENT (blogged with permission) : That study seems to fall into the work that I did with Dole and the review in the MT Sinai journal of medicine which i commissioned from Magura and Rosenblum who did an article on the subject when i was guest editor--They did the classic Leaving methadone lessons learned lessons forgotten--By the way he should also include excessive use of other drugs such as alcohol since patients abstained from heroin only to drink excessively and eventually die from alcoholism--The Magura article is in volume 68 number 1 January 2001 of the Mount Sinai Journal of medicine--Also see the article causes of death in Vol 67 number 5&6 Oct /Nov 2000 by Appel, Joseph and Richman--Both articles are in the issues that I edited and can be downloaded free from the Internet by going to the web site of the Mount Sinai Journal of Medicine and clicking on past issues You can google it --very simple

Friday, February 09, 2007


On Jan. 25 the San Francisco Chronicle reported that a 20 year old was sentenced to nine years in prison for selling 8 ecstasy pills to a 16 year-old high school student who subsequently tried to kill herself by overdosing on theese pills. The defendant is said to have had no prior drug convictions, was addicted to narcotics and "had cooperated with police . . . "

What possible good can come of this sentence - and for whom? What will the public get in return for a destroyed life and the many hundreds of thousands of dollars it will cost to lock up the seller for almost a decade? Can anyone believe there will be any "deterrence," any reduction in buying or selling or using illicit substances? Isn't it time to rethink the laws that are applied in situations like this - if not for humanitarian reasons, than strictly from the perspective of what makes sense for the general community?


The following letter was emailed to the well-known and widely respected medical ethicist Dr. Arthur Caplan of the University of Pennsylvania. Dr. Caplan has been invited to respond – and assured that if he does so his response will be posted on this blog with no edits. To date he has not accepted this offer to have the last word.


Dear Dr. Caplan:

Regarding your recent article endorsing coercion of opiate dependent persons to accept naltrexone implants in lieu of incarceration (“Ethical issues surrounding forced, mandated, or coerced treatment,” J Subst Ab Treat, 31:117-120, 2006):

You state at the outset that it is your goal to suggest “a way in which self-determination may not conflict so strongly with the compulsory use of drugs for prisoners.” I believe it is not appropriate for ethicists to help researchers and clinicians climb what you describe as “a very steep ethical hill” by suggesting rationalizations to overcome “… the emphasis that has been placed in American bioethics on the values of personal autonomy and respect for patient self-determination.”

A number of aspects of the proposal to implant “depot naltrexone” through coercion applied by the Criminal Justice System (CJS) are of particular concern:

1. It seeks to force individuals to accept treatment for the explicit reason that it has such limited attraction on a voluntary basis.
2. It would employ a medication whose efficacy is unimpressive, to say the least, even for the limited number of patients who accept it without coercion (and thus, presumably, have some genuine motivation).
3. It would utilize a “delivery system” – implantation of a drug whose pharmacological action persists for months – for the specific purpose of rendering patients incapable of opting out, regardless of the subjective response(s) they may have to the medication.
4. It relies heavily on the CJS (parole and probation officers, and perhaps also judges and prosecutors) to decide who is “sick” and thus qualifies for and needs “treatment” – and this pharmacological treatment in particular. Not only do the criminal justice gatekeepers lack the qualifications needed to make such clinical decisions, the interests they are sworn to represent are first and foremost those of the general society, and not the “patients” (or “subjects”).
5. There is an inherent illogic in this as in all forms of coercion involving the “choice of prison vs treatment.” When clinicians and the care they provide are unsuccessful, it is the subject who pays the price! Ironically, evidence of drug use per se, which merely confirms the existence of the clinical condition being “treated,” is generally what triggers the process leading to incarceration or reincarceration.

Regarding some of the key assumptions underlying your conclusions, you are simply misinformed. Your concept of drug dependent persons being individuals “in the throes of addiction and who [therefore] cannot choose anything . . .” is wrong, as is the implication of the rhetorical question you pose, “Can drug addicted individuals be autonomous when they are addicted . . .?” First, drug dependent people do make decisions all the time – including decisions without legal duress to seek and accept a broad spectrum of treatment services. In fact, lack of treatment availability is probably a far greater deterrent to delivery of care than lack of motivation or decision-making capability on the part of drug users. Furthermore, whatever constraints on autonomy addiction imposes, they are not eliminated by a period of abstinence, whether enforced or voluntary. “Addiction” and the clinical challenge of craving are as much a reality after six months of abstinence (with or without naltrexone) as when an individual is on the streets shooting up with heroin several times a day. Ironically, the undisputed fact is that naltrexone, whatever its degree of efficacy, has no effect whatsoever on the critical phenomenon of craving.

I will not comment on your views concerning methadone, which you contrast with naltrexone by stating, “Breaking the back of addiction is a better moral choice than maintaining addiction at a lower cost,” and your contention that “many [supporters of opiate maintenance] believe that it is better to use substitute drugs that are not as expensive as heroin . . .” I respectfully suggest, however, that you review with some objective experts in the field your perception of addiction treatment that includes the medication methadone.

And finally, an observation concerning one of the premises of your paper - that forcing treatment on people against their will is defensible because it allows them to make choices following “adaptation to the new state of affairs.” Such thinking would allow one to ignore almost any decisions made by patients. Thus, the adamant refusal to have amputation of a gangrenous limb could be overruled with the rationalization that the patient should have the surgery and then be “allowed to adapt” to a prosthesis, with the option of suicide available if adaptation is unsuccessful.

Robert Newman, MD, MPH

Thursday, February 01, 2007


In a recent exchange a colleague from Europe asked about switching from methadone to buprenorphine maintenance – and vice versa. Regarding the former, the common wisdom is that patients should be “tapered” to no more than 30 mg or so of methadone because of concern over precipitated withdrawal. However, some clinicians have advised that they switch medications even when patients are receiving as much as 70 mg methadone without significant problems reported by the patients.

But there’s the other side of the coin: what if any evidence-based guidelines are there for patients moving from buprenorphine maintenance to methadone? Any special cautions, side effects to anticipate, issues to which patients should be alerted? And regardless of anecdotal reports of “in my experience . . . “(which often translates to: in the one case I treated), or “in my series of patients” (which often means in those 2 or 3 patients I’ve observed), are there data supporting one approach over another for most patients?

As someone with as much experience in the field of methadone as anyone, it suddenly occurred to me – as a shock! – that I can’t think of a single controlled trial that compared different induction regimens for methadone maintenance either - after 40plus years! We (and for sure, I include myself!) speak of rules of thumb- “start low, go slow” – and make pronouncements that “starting doses over 30-40 mg can be lethal,” and state with conviction that increments of 5 mg every 2-3 days, or 10 mg every other day, or whatever . . . are optimal for most patients. But are there studies supporting one protocol over another?

A practical illustration of the problem of lacking data: a central Asian colleague asked recently whether 5 mg tablets of methadone were essential. Having this dosage (in addition to others) available would increase cost, could lead to far greater number tablets being administered/dispensed to patients, more difficulty in places where law requires the solid tablets to be crushed and dissolved before administration, etc. What evidence guides the answer? 35 years ago the NYC MMTP admitted roughly 15,000 patients to maintenance, and about 25,000 (!!) for ambulatory detoxification before dosages of 5 mg were available - and it seemed to work just fine (as Vince Dole used to say, “patients vote with their feet”, and they sure voted emphatically that these were programs they liked!).

So - can anyone suggest reasonably solid studies that allow us to go beyond the anecdotal to true evidence-based recommendations on induction (let’s stick to induction for now, and perhaps when we’ve solved that issue we can go to the withdrawal protocols)?

AND THEN THERE'S A MORE FUNDAMENTAL QUESTION, just pointed out to me by a colleague in Pittsburgh - do we really want to go down this path? "Guidelines" tend - especially when it comes to addiction medicine - to rapidly become transformed into rigid demands that preclude individual clinical judgment. Nothing's easy!

Comments and references will be appreciated greatly.


from our friend and colleague down under, Alex Wodak, come the following observations (as always, comments and opposing views welcomed):

Annual AIDS incidence (number of new AIDS cases ayear) in the USA is 14.7 per 100,000 ; that is the highest (by a factor of 3-5) in the developed world; the comparable figure forAustralia is 1.2 per 100,000

The USA (population 300 million) provides 25 million needles and syringes a year; Australia (population 20 million) provides 32 million needles and syringes a year

At least 1/3 of new AIDS cases in the USA are injecting drug users; less than 5% of of new AIDS cases in Australia are injecting drug users

Fortunately, saving lives is considered even more important in Australia than 'sending the right message'. But the US has helped many other countries to work out what HIV prevention policies to follow by allowing its people to be used as a negative control.