DEA "MONITORING" OF BUPRENORPHINE-WAIVERED PHYSICIANS:

From the Am Soc Addict Med comes this notice:

"It appears the DEA plans to increase its efforts to monitor physician prescribing [of buprenorphine] under DATA 2000." To let docs know what's in store for them, ASAM comments as follows on past DEA "monitoring" - "Investigations usually last one to two hours . . . [and] In 52% of the 425 physicians inspected up to 12/07, no problems were noted. . . " One can imagine the eagerness with which physicians will be seeking to exercise their "waivers" to treat opiate addicts, and the demand by other prqctitioners to join the ranks of those who enjoy the privilege of prescribing buprenorphine!

COULD THERE BE AN AFGHANI POPPY GROWERS’ LOBBYIST IN WASHINGTON?

According to Join Together (30 July), “… the Obama administration is considering paying local farmers to cease planting poppies, the Associated Press reported July 21”. The possible influence of powerful lobbyists is one of the more generous possible explanations. Regardless how many hundreds of millions of US taxpayer dollars are given to Afghan farmers, can anyone doubt how they will respond when the Taliban make them “an offer they can’t refuse,” offering MORE money with one hand, and holding an AK-47 in the other? Scary! The Join Together story

TRAGEDY OF INACCESSIBLE AND/OR IRRATIONAL TREATMENT OPTIONS FOR ADDICTS:HUGE “REWARDS” WON’T WIN THE DRUG WAR

Miami Herald on 20 July reported that the US is offering $50 million in rewards for information leading to the arrest of “10 top Mexican drug suspects.” Does anyone believe that even if this phenomenally generous reward (paid for by US taxpayers) leads to the arrest and conviction of these bad guys it would have the slightest impact on availability of drugs in our streets or the number of American drug users? The money would be far better spent supporting treatment for the many drug-dependent Americans who need and desperately want help.
Click to Read the Article

FACTORS ASSOCIATED WITH BUPRENORPHINE VS METHADONE FOR OPIATE DEPENDENCE:

A UK study has just appeared that assesses factors involved with the choice of opiates for maintenance and detoxification. Although both providers and patients are said to contribute to the decision, a stated preference for buprenorphine was more likely to be honored than a preference for methadone. In any event, patients generally rated the medication they received in this study as the “most helpful” in their previous treatment experiences. The authors’ conclusion: “The results . . . suggest that patient preferences and beliefs about opioid agonist treatments can serve as important influences upon clinical prescribing practices.” And indeed, they should; in the absence of data allowing reliable predictions regarding which patients might expect to do better with one or another opioid medication, one must wonder why patient preference is not always respected.

Article: Ridge G et al. J Subst Ab Treatm 37 (2009) 95-100.

IGNORING EXPERIENCE - REPEATING FAILURE: ILLUSTRATION FROM ITALY:

In 2006 a bill known as the Fini-Giovanardi Law was passed in Italy, “heralding the mass criminalization of drug users in spite of the success of a 1993 referendum to de-penalize the personal use of drugs.” The result: in less than three years prison overcrowding has reached record levels – some 40% above official “capacity”. There has been a 7.45% increase in arrests, and/but “confiscation of drugs has fallen by 10.5%.” The estimate of addicts behind bars in Italy has risen from 8,363 in December 2006, to 14,743 by Jan 30, 2008. When will they ever learn...
Full story (in Italian)

MORE OF THE SAME: “JUST SAYING NO” TO REALITY...

The reality that opiate addiction remains a chronic medical condition for which, at the moment, there is no known “cure.” Thus the following in a UK Press Association article of 20 July referring to opposition party of England and Wales: “Conservatives have called for an ‘abstinence-based’ approach to drug rehabilitation, after uncovering figures showing that fewer than 4% of addicts undergoing treatment become drug-free each year.” Would the Conservatives deny diabetics continued insulin based on the same criterion? Or epileptic patients their anti-seizure medication? Or...?

METHADONE TREATMENT PARADOXES

An article on addiction treatment policies in National Journal April 18 ’09 noted the following: “The treatment protocol demands at patients behave like grownups while they are monitored like children. The clinic is licit but stays semi-underground, fearing that even a sign of the door would stigmatize patients or annoy the neighbors. The medication is one of the safest known to science but is regulated as if it were one of the most dangerous.” Go figure . . .

"YOKELS BREEDING INTOLERANCE":

The headline "Yokels Breeding Intolerance" from a column in the Edmonton (Canada) Sun, 14 July, describes the "fine line between grassroots protest and a lynch mob." It goes on to give an example of each. The "lynch mob" is exemplified by the case of a Calgary methadone clinic that was "literally run out of town" earlier this month in the face of threats to the facility and its staff. The "grass roots" protest that is described involved a concerted effort to ensure "proper processes and protocols are in place to keep everyone safe" in a neighborhood in which a group home for deeply troubled teens is located; two residents of the home had been charged recently with murdering a local couple. The contrast is well written and compelling. click here to read the article

MR HANON: My congratulations on recognizing the distinction, and expressing it so eloquently. As you see, we're taking the liberty of posting a blog referring to your column on our website - www.opiateaddictionrx.info

CALGARY (CANADA) METHADONE CLINIC CLOSURE:

As noted in previous postings a clinic has been forced to give up the battle to continue operations. An editorial 11 July in the Calgary Herald is a voice of reason, though perhaps too late to avoid the therapeutic abandonment facing the more than 500 patients now receiving treatment. Some excerpts:

“The loss of Second Chance Recovery is a blow to both drug addicts seeking treatment and to the city's reputation. The closure of the methadone clinic could have been avoided had aldermen shown a willingness to address residents' concerns with facts, or seek another solution, such as changing the zoning law to allow the clinic in an industrial park.

“Now Calgary looks like a city that would rather deny the existence of social problems than deal with them... The problem is a lack of leadership. The clinic's operators are tired of fighting City Hall, and who can blame them. They've been shut down three times in six years, and have reasonably concluded Calgary will not support the clinic.

“Police say they have never recorded increased crime rates where clinics have been located, and are more concerned about the impact the closure will have on the city.”

For full editorial click here

PUTTING NIMBY INTO PERSPECTIVE:

A letter to the editor appeared on July 11 in the Calgary (Canada) Herald. It is entitled, “Here goes the neighbourhood” – a commentary on an article 2 days earlier reporting that a methadone clinic has been forced to close, leaving the fate of over 500 patients in severe jeopardy. The letter can be found by clicking here.

CONTINUED SHARP DROP IN DRUG-RELATED DEATHS IN BALTIMORE ATTRIBUTED TO TREATMENT AND HARM REDUCTION MEASURES:

The Baltimore Sun 1 July reported that the number of drug-related deaths in the city dropped by a third between 2007 an 2008, from 281 to 176. “'Short and sweet: Treatment works,'" said Gregory Warren, executive director of Baltimore Substance Abuse Systems. 'There are literally hundreds of people alive today because of what's happening.'" He also credited a variety of harm reduction measures, including teaching drug users to reverse opiate overdose by administering Narcan.

But there’s also a decidedly negative side to the story: “Some 74,000 people needed substance abuse treatment last year, according to state estimates, but Warren's organization was only able to reach 16,000 of them …” Full story

TREATMENT ON DEMAND: AN OLD CRY, STILL UNANSWERED

In 1988 the Presidential Commission on the Human Immunodeficiency Virus issued its report. Among other things it called for “…greatly expanded [addiction] treatment capacity, with the goal of treatment on demand...“ (page XVIII). So...how does one measure the adequacy of the treatment capacity for opiate-dependent individuals? Very simply: by the ability to publicize that treatment on demand exists, and by doing everything possible to encourage those who need help to seek it. And where in the United States does one see public service announcements to this effect? Cynics might well conclude that no one gives a damn. Meanwhile the common-sense conclusion of the Commission more than two decades ago continues to be ignored.

PATIENT BELIEFS ABOUT METHADONE MAINTENANCE:

A study that is 7 years old but still of vital importance describes the results of a survey of patient beliefs about methadone maintenance – which, on average, the 315 respondents had been receiving for seven years in a public clinic in NYC. Among the findings:

. although 79% agreed that “methadone has helped me change my life in a good way,”
the negative beliefs that were expressed were distressing.
. 47% believed methadone “is bad for your health (additional 32% “not sure”)
. 39% believed higher doses “are less healthy than lower doses” (30% unsure)
. 71% (!) believed “methadone gets into your bones” (19% unsure)
. 80% believed “people should try to get off methadone” (11% unsure)

There is no reason to believe that in the intervening years since this study was done much has changed (certainly the public’s perception does not seem to have become more favorable, so there’s presumably no cause for optimism regarding a change among recipients of care). The responses can be interpreted in only one way: the clinic staff have been woefully ineffective at educating their patients about the medication that is fundamental to the care provided. Even more distressing is the possibility that many patients may be mirroring the attitudes and beliefs of staff members.

It is difficult to imagine that treatment will be optimally effective when patients believe the medication they receive is injurious to their health and should be given in doses that may be inadequate. Patients who believe one should aim to discontinue treatment will be likely to do so - notwithstanding the high rate of recidivism and all the concomitant risks (including, very specifically, the risk of death).

Surely patient knowledge about their treatment is a most important parameter of quality care. Is anyone aware of programs that focus on this treatment imperative? Do the accreditation bodies assess the process and outcome of this aspect of care?

Comments welcomed.
Citation: Stancliff S, Myers JE, Steiner S and Drucker. Beliefs about methadone in an inner city methadone clinic. 2002. Bull NY Acad Med. 79(4):571-578.