THE LUCK OF THE DRAW

Mr. David Paterson, newly elevated Governor of NY, recently acknowledged (presumably because he realized it would get out anyway!) that he used cocaine and marijuana in his younger years. Had he been unlucky enough back then to get busted for possession of a single joint, or a trace amount of coke, he'd probably be in jail now, or trying to overcome a "criminal record" and find a job, or perhaps dead. Instead, because he had the good fortune not to have been in the wrong place at the wrong time, he is responsible for governing NY State - and however one judges his likelihood of governing well, no one has suggested for a moment that he's unqualified in the light of his acknowledgment.

Justice should not hinge on luck. Hopefully, the new governor will reconsider our drug policies in light of his own experience. He has long advocated changing the Draconian Rockefeller Law; now he should push for an even more radical change in how we approach drug use in our state and nation. If any political leader can empathize with the real victims of the drug war, he can!

MISLEADING REFERENCES TO DANGERS OF METHADONE:

An article in the International Herald Tribune of March 20 was entitled, “Nine middle school girls get sick from methadone pills.” In the US, “methadone pills” are only provided for the management of pain; for many years Federal regulations have demanded that all methadone used in the treatment of dependence be in dissolved, liquid form. So in this unfortunate case it’s clear that wherever the methadone came from, it was not from comprehensive methadone treatment programs. And yet, the article describes methadone as “a drug commonly used to treat heroin addiction.” Certainly, it is that – and it’s used in treating opiate dependence with unparalleled effectiveness. The message that the average reader of this story will take home, however, is clear: by a miracle nine young girls avoided being killed by methadone, “commonly used to treat addiction.” Inevitably, the article will add to what already is the greatest hurdle that faces patients and providers in their efforts to overcome addiction - misunderstanding and the fear and stigmatization it leads to.

ARTICLE FOLLOWS
INTERNATIONAL HERALD TRIBUNE AMERICAS 20 March 08
9 middle school girls in Missouri are sickened after apparently eating methadone pills The Associated Press Published: March 20, 2008 ST. JOSEPH, Mo.: Nine middle school girls were sickened after apparently eating methadone pills supplied by a 16-year-old boy, police said. The girls were hospitalized Wednesday and being kept for observation at Heartland Regional Medical Center.

"It appears that the students are doing OK," St. Joseph police Capt. Kevin Castle said. The teen suspected of providing the prescription methadone — a drug commonly used to treat heroin addiction — was charged with distributing a controlled substance. Officials are still trying to determine where he got the drugs.

Castle said the Benton High School student is believed to have given the pills to a middle school girl on a school bus. Police believe the girl then distributed the pills to other girls, most or all of them eighth-graders. The girls first complained of feeling nauseous and groggy, and at least one was salivating excessively, school administrators said. Around noon, the girls were crying as they walked to ambulances, and one hysterical girl was taken from the school on a stretcher.

School and police officials said it is unclear whether the girls knew what they were taking. All nine of the Spring Garden Middle School girls face potential sanctions, officials said. District administrator Cheri Patterson sent a letter home with students discussing the situation. It encouraged parents to talk to their children. "Drugs, whether prescription or not prescription, are dangerous drugs. And as some of our students found out, you take a scary risk when you ingest them," Patterson said in the letter.

UNODC, WHO AND UNAIDS SPEAK OUT FOR HARM REDUCTION:

In a statement by the Joint United Nations Programme on HIV/AIDS, 14 March 08 at the meeting in Vienna of the Commission on Narcotic Drugs, “a set of measures for people who use drugs” was recommended. Recommendations number one and two called for needle and syringe programmes, and “opioid substitution therapy.” One can only hope governments are listening, and for none is heeding and implementing the recommendations more imperative than for the United States and the Russian Federation – the former clinging to its “flat-earthist” policy of rejecting the evidence for efficacy of needle/syringe exchange in curtailing spread of the virus, and the latter persisting in its refusal to legalize a form of treatment that has been shown to have unparalleled therapeutic outcomes.

MMT IN CHINA: NEGATIVE ATTITUDES IN FACE OF POSITIVE RESULTS

Does this heading sound familiar? It basically sums up the entire history of MMT worldwide over the past 40 years. Now China: in a brief summary of experience with methadone in recent years (AmJDrugAlcAb 34:127-131, 2008) it's noted that MMT has "reduced injection drug use and criminal behavior and improved social behavior... employment increased ... [and] high-risk consumption patterns like injecting diminished significantly." In short, "MMT programs have successfully mitigated harm related to heroin abuse." And yet, "... objections to MMT from general health care providers and the public about substituting one addiction for another ..." persist.

A NEW LOW IN UNINFORMED REMARKS ABOUT METHADONE TREATMENT:

Bill Aitken, a "senior Tory politician," told BBC-Scotland, "We have a very high proportion of the drug-abusing population sitting fat, dumb and happy on methadone," The barrier of stigma and prejudice facing patients receiving methadone in the hopes of leading a reasonably self-fulfilling, productive life in society has just been made higher. Scotland has no corner on the market of stupid politicians, God knows, but this example of stupidity is mighty bad. For BBC story,

http://news.bbc.co.uk/go/em/fr/-/2/hi/uk_news/scotland/7299452.stm

UN INCB CALLS TO SHUT DOWN CANADIAN DRUG INJECTION SITES:

According to an article in "The Citizen" (western Canada) The UN INCB has recommended that Canada “shut drug injection sites” (March 5). One has to wonder what the folks at the UN Narcotics Control Agency have been smoking. First, to the extent Canada is violating any UN conventions with supervised injection facilities and distribution of “handouts of paraphernalia” it is in very good company; injection sites have been widely available in Switzerland, Germany and The Netherlands, for example, for years, and needle/syringe exchange programs operate in countries throughout the world (yes, even in the USA, where the Federal government has a rigid flat-earth view of harm reduction). If the UN body has evidence that these services “enable” illicit use, as it claims, it’s keeping it close to the chest, since no credible reports of such adverse effects have been published. To the contrary: experience – including that of Canada - has consistently proven that these measures add to the safety of drug users as well as the general community, and actually facilitate referral to long-term treatment. And one would expect no less, since the alternative is abandonment. Go Canada!

STRATEGIES TO CONTROL BUPRENORPHINE ABUSE:

On Feb 23rd the Baltimore Sun published the following article.

I wrote to seek clarification from Dr. Fiellin's reference to Physician Clinical Support System's (PCSS) role in physician compliance with buprenorphine prescribing guidelines

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LETTER TO DR. DAVID FIELLIN
RE BALTIMORE SUN FEB 23 ARTICLE
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March 7, 2008

Dear David:

The comments attributed to you by the Baltimore Sun in its Feb. 23 article on “strategies to control bupe abuse” are of concern. Specifically: “’There is not an active surveillance system in place to identify physicians who are practicing outside the guidelines,’ Fiellin said. When they are found, he said, his group will work to report them.”

Which guidelines? All those contained in the 198-page publication, “Clinical guidelines for the use of buprenorphine” – to which you contributed as member of the “buprenorphine expert panel”? Or are there guidelines of particular concern based on evidence that they are causing misuse/abuse/diversion?

What is the plan for “finding” doctors who deviate from the guidelines?

To whom is the ASAM “group” planning to report the doctors it identifies?

It may well be that you were misquoted and/or that your remarks were distorted by being taken out of context. As they stand, however, they surely will dampen the already quite limited enthusiasm of physicians to obtain and utilize the authority to prescribe. I also worry that your sentiments will give impetus to pressure to impose on buprenorphine many of the same demands and restrictions that for decades have served to exclude office-based physicians from caring for opiate-dependent patients with methadone. In any event, physicians prescribing or thinking of prescribing buprenorphine have a right to know what to expect: the practices ASAM plans to monitor and how, and to whom non-compliance will be reported. Notification to all waivered physicians of ASAM’s intentions should be easy to arrange. I urge you and ASAM to do so.

Sincerely
Bob Newman, MD

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RESPONSE BY DR. DAVID FIELLIN:
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Bob,

Thank you for your letter.

I spoke at this press conference as Medical Director of the PCSS, not as an employee or member of ASAM.

As you have suggested, I was indeed misquoted. I am also disappointed that the Baltimore Sun choose not to print my letter to the editor regarding their series on buprenorphine.

The guidelines that I referred to include the CSAT TIP #40 and the Guidance produced by the Federation of State Medical Boards.

Both of these documents recommend that stabilized patients be seen on a regular basis (e.g. monthly) and that patients who are early on in the recovery process be seen more frequently and have access to physician and counseling services.

The PCSS has no role in active surveillance of physicians but exists primarily as an educational resource to assist clinicians in providing quality care to opioid dependent patients. To help them get over the reticence that you discuss.

My statement was that the PCSS mentors are encouraged to work with state medical societies if there are concerns about inappropriate prescribing behaviors. We have occasionally received reports about physicians who do not have a modified DEA registration who are prescribing large quantities of buprenorphine, offering no office or counseling services and the like. My hope is that the medical societies and the medical profession can work to limit these events and respond within our profession so that we do not end up with significant restrictions, from federal agencies, that limit the availability of office-based treatment of opioid dependence.

I hope you agree. Thanks,

David

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COMMENT BY DR. MIKE MILLER,
PRESIDENT AND BOARD CHAIR, ASAM
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David:

1. Thanks for your leadership of PCSS.
2. Thanks for your excellent letter to the Baltimore Sun. I agree, it's a shame they didn't publish it.
3. Thanks for your reply to Bob.

Bob: Thanks for bringing this to our attention. You are surely not the only ASAM member, or patient of an ASAM member, who has seen the article, on the web or even on their news stand in Baltimore, and wondered, 'Huh??'

This is such a delicate topic: it occurs to me, David, that your response to Bob, or something like it, could be posted on the ASAM website, and published in ASAM News. ASAM has no role, and CSAT's PCSS, administered by ASAM, has no role, in monitoring physician practice, cataloging deviatiations from standards of care, or reporting physicians to regulatory or licensing agencies. Individual physicans are bound by our code of ethics, however, to report egregious physician behavior when we are aware of it.

This really is a delicate topic, and shining light on it is warranted especially in the current environment, stirred up by the editorial board of the Baltimore Sun, in which partial truths, misquotes, and other misinformation is harming the ability to expand an incredibly successful public health intervention to more patients in need. Plants need light and mud to grow; in this case, more light and less mud would be a good thing.

Mike

--
Michael M. Miller, MD, FASAM, FAPA
President and Board Chair, ASAM

NEWSWEEK: WHAT ADDICTS NEED

An Unpublished letter to the editor that needs to be heard...

TO THE EDITOR: Addiction indeed is an illness, a “chronic, relapsing brain disorder,” as your article notes (Feb 23).You also correctly point out that this has been recognized (e.g., by the AMA) for over 50 years. Furthermore, it’s a disease that – where narcotics are concerned – has been treated with great effectiveness with medicines (especially methadone) for more than four decades. Accordingly, it is difficult to understand the quote you attribute to Dr. Nora Volkow, the Director of NIDA, “The future is clear. In 10 years we will be treating addiction as a disease, and that means with medicine.” Obviously, this is not a prediction of the future, but a concise recap of the knowledge and practice of the past.

RGN

GOOD NEWS METHADONE ARTICLE – WITH A TWIST...

A seemingly positive story about “methadone clinics treating hundreds around area,” in the Mar 9 Cumberland (W. Va.) Times-News, includes no community attacks, no claims of problems in or around the clinics, and thus would seem welcome news. Unfortunately, the story on balance is probably going to reinforce the stigma against patients and the treatment in an area generally, and ironically the negative vibes emanate from those who run these clinics.

One administrator acknowledges that “addiction is a lifelong disease,” but also states that “what we have here is a methadone-to-abstinence program.” Worse, he claims that there’s an 80% “success rate for people enrolled in maintenance drug-based program more than 11 months. Typically, after 12 months of treatment, patients use the next six months for detoxification” followed by “counseling for six months.” The figures would be radically different from those of every study published in the past 40-plus years, and give the impression that the great majority of patients can discontinue methadone after a relatively short period of time. Ultimately even a positive spin is very harmful when it surrounds misinformation and cites outcomes that are unachievable.

THE GOOD – AND THE UGLY: A NEW JERSEY EDITORIAL

The Courier-Post (NJ) on February 24th noted, correctly, the tragedy of New Jersey’s needle exchange program being “hobbled by lack of funding.” Sadly, the editorial also merits condemnation for lumping together “methadone clinics, poverty and drug markets” as being a “magnet for drug users.” It is distressing to note the inability to distinguish the problem, from legitimate, time-tested, highly effective interventions that dramatically lessen the harm with which it is associated – and when it comes to narcotic dependence, no intervention has been proven to be more effective than methadone maintenance treatment.

Precisely this muddled thinking, and the erroneous assumptions it reflects, underlie the hurdles facing needle exchange programs as well as treatment services as they seek the support they – and their clients and patients and the community at large – so desperately need.