Thursday, February 25, 2010

Crisis and Complacency . . .

A 22 Feb news report from Scotland is headlined “Waiting list crisis for drug treatments” describes the desperation to obtain methadone treatment so great that some are committing crimes in order to be incarcerated and have easier access to methadone behind bars. The immediate cause of the desperation is attributed to fear of anthrax, which has claimed nine lives recently as a result of contaminated heroin.

"A spokeswoman for the Scottish Government said NHS Scotland targets were in place to ensure that by March 2013, 90% of people who need treatment for their drug problem receive it within three weeks." Three years to be able to offer admission within three weeks? Difficult to comprehend!

For full story click here

“Walking proof that methadone ‘is failing’ after 20 years on treatment”

A 12 Feb article in News.Scotsman was headlined: “Walking proof that methadone ‘is failing’ after 20 years on treatment”. the article reports the latest harsh criticism of methadone maintenance by "one of Scotland's leading experts on drugs," Prof. McKeganey. The man referred to in the headline has been dependent on opiates since a teenager, and in Scotland – even more than most countries of the world – untreated heroin use with tragic frequency ends in death. It is difficult to imagine anyone positing that the methadone prescribed in this case did not contribute in a major way to survival. And if survival of a frequently fatal condition is not proof positive of a treatment’s efficacy, then what is?

Monday, February 22, 2010

GUEST VIEW: Clinics' 'Red Tape' Not the Problem

The following comment was prompted in response to “GUEST VIEW: Clinics' 'red tape' not the problem” – by Delia Brennan, 20 Feb 2010,

Regarding the stated practice: "[Methadone maintenance patients] will be disciplined through a series of contracts, but not discharged. If, for instance, a client has multiple positive drug screens, and misses counseling and groups regularly, then perhaps a discharge hearing will occur." Can one imagine anything remotely similar for clinics treating diabetics, in response to blood sugar levels remaining out of control, patients failing to keep appointments with nutritionist, patients seen eating a Twinkie outside the clinic . . . .? The fact that a patient continues to come to the methadone clinic clearly indicates a need and desire for help. Discharge can mean death.

Clinics with such practices would do well to consider AA and its approach to alcoholics... AA NEVER denies access to those who "slip," who are inconsistent with meeting attendance, etc.

Tuesday, February 16, 2010

Deterrents to Methadone Treatment Enrollment:

An important study addresses the question: "Why don't out-of-treatment individuals enter methadone treatment" (Int J Drug Policy 2010; 21(1):36-42). The major reasons given by a small (n=26) cohort of subjects in Baltimore were: waiting lists, financial barriers and requirement to carry photo ID. Another reason given: unwillingness to commit to long-term maintenance, "but would have accepted shorter time-limited methadone treatment". Some of these barriers could, presumably, be removed promptly and at no cost: e.g., accepting driver's licenses or other ID in lieu of "program" ID, and publicizing availability of short-term maintenance or even shorter-term detoxification. We can only hope these research findings will be translated into practice.

Sunday, February 14, 2010

Try Substituting Methadone for Aspirin ...

A recent study published in Substance Withdrawal Syndrome (Eds. Rees and Woodhouse, 2009, pp. 93-112) concluded as follows: "This systematic overview suggests that aspirin withdrawal has ominous prognostic implication in subjects with or at moderate-to-high risk for coronary artery disease. Such information should be borne in mind when advising patients under such treatment, and aspirin discontinuation should be advocated only when the risk of ... adverse effects clearly overwhelms that of cardiovascular atherothrombotic events."

Change a few words and this admonition applies - in spades! - to opiate maintenance treatment of dependence. "Advising patients" of the "ominous prognostic implication" of discontinuing maintenance treatment should be considered absolutely essential before any "tapering" begins. Indeed, ethical medical practice (and logic) would seem to demand that a written informed consent be obtained before beginning withdrawal. Clearly, the risk associated with discontinuing maintenance treatment is vastly greater than that associated with its commencement.

Thursday, February 11, 2010

Subutex v. Suboxone Abuse Liability:

A study by investigators at Columbia University that seems to have received inadequate attention appeared in 2002. Bottom line: “... results demonstrate that both [Subutex and Suboxone] served as re-inforcers … and that they may have similar [intravenous] abuse liability in recently detoxified individuals who abuse heroin.” (Comer and Collins. 2002. J Pharmac Exp Therap 303(2):695-703)

We’re unaware of any data in the USA regarding the actual parenteral misuse of either medication (or, for that matter, misuse by oral consumption), but these findings would suggest that the primary consideration in deciding whether to use Subutex or Suboxone should be price.

Monday, February 08, 2010

Memorable and Still Relevant Quotes:

"The drug treatment field is unusually contentious. the gold standard pharmacological therapy for heroin dependence, methadone maintenance treatment, is attacked relentlessly despite compelling evidence of benefit and safety."
Alex Wodak, 2005
Expert Opinion Drug Saf. 4(5):815-819

"Methadone maintenance is a treatment method that does restore a substantial portion of those treated to socially productive activities. Thus, as community groups fight the establishment of new clinics ... the necessity is to compare the results with what else is available rather than with generally unrealistic expectations."
Oct 1, 1975
NY Times Editorial

Thursday, February 04, 2010

Yes, Semantics Clearly Do Seem to Make a Difference

A study that as yet is available on-line only assessed the impact of two "commonly used terms" applied to individuals with substance-related conditions. The conclusion: "Even among highly trained mental health professionals, exposure to these two commonly used terms ["a substance abuser" and "having a substance use disorder"] evokes systematically different judgments. The commonly used 'substance abuser' term may perpetuate stigmatizing attitudes." Kelly JF and Westerhoff CM. Int J Drug Pol (2009), doi:10.1016/j.drugpo.2009.10.010

"Methadone Maintenance: It Ain't What it Used to Be":

That was the title of a presentation made in April 1974 (and published 2 years later), lamenting the overwhelming focus on providing the lowest dose of methadone and discontinuing it altogether as soon as possible (or sooner!). Alas, the preoccupation of politicians, the public at large and - tragically - even most providers is at least as great today as it was 36 years ago, in America and throughout the world. Source: Newman RG, Br J Addict 1976, 71:183-186.

Wednesday, February 03, 2010

In Defense of UK Prison Drug Policies/Practices

Responding to harsh criticism that methadone is used to "control" prisoners and that "treatment" is denied, the chief executive of the National Treatment Agency for Substance Misuse notes that "... the voices of users are heard - a key driver for making methadone more widely available was the class action taken by almost 200 ex-prisoners a few years ago [who ...said their human rights were breached because they could not access the same treatment in prison that they had outside." The Chief Exec went on to note: "Good clinical practice will either continue the treatment the prisoner had before arrest, or prepare them for the treatment they will receive on the outside. Otherwise individuals would be vulnerable to suicide while they were in custody, and to overdose on release." For the Full story click here

The Guardian ( London ) 3 Feb 2010

Monday, February 01, 2010

Catholicism and Common Sense:

From Albany, NY, report of a decision by Catholic Charities to provide sterile needles and syringes to all IV drug users. The following quote seems to say it all: "I understand there will be questions, but this is common sense," said Sister Maureen Joyce, CEO of Catholic Charities. "I strongly believe in this. It will save lives." From Albany Times-Union, 29 Jan.