A DRAMATIC LEGAL TURNAROUND:

A South Carolina conviction of manslaughter has been overturned - at last! The charge - and a 12-year sentence without possibility of parole! - was the result of a stillbirth that the prosecutor alleged was due to the use of cocaine during pregnancy. There was nothing to link the stillbirth to the cocaine use, as noted by a host of experts

For the full story on the National Advocates for Pregnant Women Website
Click here

RUSSIA: FLAT-EARTHISM RULES!

The top physician-hygienist and the leader of nation's consumer protection agency, Gennadi Onischtschenko, declared at the end of a conference on AIDS in Eastern Europe and Central Asia that there is as yet no evidence to support the notion that methadone treatment is effective. Go figure(from Ria Novosti, 3 May 08 - more information available in German at http://de.rian.ru/russia/20080503/106442797.html

Special thanks to our Hamburg colleague Hans-Guenter Meyer Thompson for bringing this to our attention

WHY IS ABSTINENCE NOT POSSIBLE FOR SOME

Dole and Nyswander speculated that when people become addicted to heroin there is a physical change in their systems that may or may not be reversed with abstinence, and to the extent it isn't, it could explain the tendency to relapse after abstinence is achieved. Without question, long-time abstinence after dependence on morphine still leaves lab animals "different" - they develop tolerance vastly more quickly than opiate-naive animals though God only knows why or how (same difference in development of tolerance applies to humans, by the way). The other possibility they put forth was that some people are genetically, physiologically, predisposed to react differently to heroin when exposed than are the majority. We know virtually everyone drinks, but only some 15% or so go on to become progressive, self-destructive alcoholics. About the same proportion was found for Vietnam GIs coming homne after having used huge amounts of very pure heroin for a year or more - about 85% promptly quit upon returning to US and the remaining 15% were quickly indistingishable from addicts whose drug experience was entirely domestic. How did the 15% differ from the 85%? To this day no one has the answer.

Many folks dismissed their hypothesis and I remember a very highly respected leader in the field (maybe the MOST respected leader) at a conference pointing to enforced abstinence in a prison setting, for instance, and the total inability to detect any abnormality among inmates who had been using heroin for years and then were incarcerated. But Dole and Nyswander stuck to their guns. And then, when endorphins were discovered, their hypothesis suddenly made great sense. Endorphins are formed by a hormone system, and we know that every hormone system gets screwed up (a non-scientific description, but it'll do) if one introduces from outside a substance that is essentially the same as the hormone. Take steroids long enough and it can be sheer hell to be weaned off them - and some people never can be. Same with thyroid hormone - or any other. So it makes absolutely perfect sense that taking into the body something akin in all respects to endorphins will screw up the endorphin system - maybe forever, maybe for a while, maybe a great deal in some people and hardly at all in others.

Alas, no one has been able to identify - YET - just what that abnormality is and how it can be measured. But the bottom line: it don't make any difference. The fact is that most people who are addicted to heroin can't achieve and maintain abstinence - can't or won't, makes no difference. They will keep using dope and risk their own health and lives and harm others. That's the reality and wishing it were different doesn't help. And then there's methadone, which enables many (not all) people to lead productive, satisfying, reasonably healthy lives and dramatically lessens the danger of dying. So what's not to like? Beats the hell out of me. I've never understood it, and my experience with nicotine patches makes me even more amazed that so many people detest methadone treatment - I smoked 45 years, never went a day without smoking, hated it for decades and would have given anything to be able to quit. And finally with the patch for 2 years I cut down to about 5 a day and then quit. What kind of idiot would say: yeah, but what proves you needed the patch? And then go on, "I have an uncle whose maid quite smoking without anything" - as if that makes the slightest difference.

PEAK-TROUGH TESTING:

We've been copied on correspondence involving a long-time methadone patient who has not been doing well on doses that very slowly and grudgingly were raised to about 80-mg per day. The "clinic" insisted she have peak-trough blood concentration testing done - and pay for it! Based on the results they claim there's no rationale for increasing the dosage and instead are threatening to decrease it. Some comments on peak-trough testing follow:

Tom Payte is the expert on this... My understanding: peak-trough relationship merely indicates that one might have a "fast metabolizer". It's indicated not to determine adequacy of dosage, but to help formulate response to patient discomfort and less than optimal therapeutic results.

If one has a patient not doing well, and there's a big big gap between the peak concentration and the lowest in the course of a day, then it might make much more sense to split the dose rather than "just" increase it. In fact, increasing it in such cases might lead to more discomfort/problems, because there'll be a higher peak, still a very rapid metabolism and thus in the course of the day an even greater gap between the high and low concentrations. Thus: rationale for splitting doses - I've heard Tom Payte talk about some (very few) patients whom he had to give doses six times a day before they responded well.

I see zero rationale ever for decreasing a dose based on P-T levels. Ultimately, I'm a believer in clinical observation rather than fancy and expensive lab tests. Patient's dojng well on a dose, great. If not, and most definitely if patient has been getting dosage that for most is sub-optimal (e.g., less than 80) then of course increase the dose! It's when the dose gets up[ to 150-200 and the patient still reports doing poorly, especially toward end of day, then logic dictates trial of splitting the dose - say half AM and half PM. What counts is how the patient is doing - NOT what a lab test shows (identical reasoning for my disdain for urine tests!).

AA (as in Abstinence Advocates who despise medically-supported treatment of addiction) TAKE NOTE:

Vincent Dole gave a presentation in 1991 to the American Society of Addiction Medicine (reprinted in Clin Exp Res, 1991, 15(5): 749-752), in which he told about being asked in the early 60s to become a "lay" member of the Board of Alcoholics Anonymous - only 7 non-alcoholic trustees are permitted worldwide under the constitution of AA. Vince had just published the initial studies on methadone, demonstrating its unparalleled efficacy in treating heroin dependence, and he couldn't figure out why he was asked to join the board of AA, which had never utilized medication in helping alcoholics.

At the last meeting he attended with Bill W before the AA founder's death it was explained. "[H]e spoke to me of his deep concern for the alcoholics who are not reached by AA, and for those who enter and drop out and never return. Always the good shepherd, he was thinking about the many sheep who are lost in the dark world of alcoholism. He suggested that in my future research I should look for an analogue of methadone, a medicine that would relieve the alcoholic's sometimes irresistible craving and enable him to continue to progress in AA toward social and emotional recovery..."

Bill W was a wise and compassionate man! Hopefully some day soon an "analogue" to methadone indeed will be found - and when it is, one can only pray it will be embraced by those who are committed to helping those afflicted by alcoholism.

BUPRENORPHINE AND METHADONE:

Vastly different requirements - and practices. For methadone treatment of opiate dependence, 6-7 visits each week are mandated for every single patient for several months after treatment begins. For buprenorphine, there are no requirements whatsoever.

According to data presented on Feb. 21, 2008, by the Director of CSAT, SAMHSA, 35% of patients surveyed reported they had NO return visit to the physician for at least 30 days after the very first prescription for buprenorphine was given (no information was provided as to how many returned after the first 30 days). Clearly, this means that during those first 30 days of treatment there was no urinalysis, no assessment of dosage adjustments that might be indicated, no followup of any possible medical or mental co-morbidities, no determining whether "counseling" as needed and, if so, whether it was received and how effective it was, etc. And yet, the Director's presentation also stated that 40% of prescribing physicians believed buprenorphine treatment to be "very effective" for patients receiving treatment for 8-30 days (one must wonder how they knew).

At the very least, the disparities would seem to cry out for a reassessment of the rationale for the extraordinarily onerous and expensive demands that are imposed on patients and providers alike when the medication employed in treating the disease of opiate addiction is methadone rather than buprenorphine.