Providers Ignoring the Evidence - Difficult to Comprehend!

An article just published in J subst Ab Treatm (2010, vol. 39, pp22-31) discusses "trends in methadone maintenance treatment ... in British Columbia, Canada. It was found that compliance with "minimally effective dose guidelines" dropped from 2001 to 2006, and that this decline was mirrored in the decline of 12-month retention data. Another "... troubling finding was the low rate of compliance to guidelines on starting doses and dose titration" despite the fact that the risk of fatal methadone overdose during the first two weeks of treatment is estimated to be 6.7 times higher than that of heroin-dependent patients not in treatment and 98 times higher than that of patients on maintenance doses of methadone". Specifically, 47% of patients were started on a daily dose greater than 40 mg.

What could the clinicians possibly be thinking, and how many lives have been lost as a result of their refusal to comply with guidelines? When patients are non-compliant they generally are threatened with a host of sanctions, including termination of care. Providers of treatment seem to be immune to sanctions of any kind. Tough to figure!

Opioid Dependence Remains an Incurable Condition

This reality seems to have been overlooked by authors of a paper that appeared recently (J Psychoact Drugs, 42(2):161-175, 2010). They state: "For reasons not adequately understood, some patients find discontinuation of buprenorphine following long-term use difficult." Indeed, this understates the case! Notwithstanding such claims as "buprenorphine is less addicting," once treatment of addiction ends relapse is the rule rather than the exception, and this applies to buprenorphine no less than to treatment with methadone or various drug-free approaches.

UK Government Determined to “Push Ahead With 'Cold Turkey' Drug Policy”:

According to a 23 Aug article in The Telegraph “The Coalition is working on proposals to stop the widespread prescription of methadone for heroin users and instead increase the use of ‘cold turkey’ residential treatment programmes.” It is difficult to comprehend, even for the most cynical of observers! Are "cold turkey residential" programmes effective for some? Sure: among the relatively very small percentage of the heroin addicts who seek and enter such programmes there is a small proportion who "graduate" - and of these another small proportion have achieved and will maintain abstinence. Great. But to propose this as national policy in lieu of "widespread prescription of methadone" can only be described as madness. Aside from the (huge!) question of efficacy, a massive residential option could never be implemented for a host of reasons - starting with the financial requirement. Severely curtailing methadone treatment, alas, is possible - and the costs will be high for those dependent on opiates as well as for the general community. Before anyone recognizes what many decades of experience have consistently shown - there's no "cure" for addiction - the damage will have been done, many lives lost, more illness, more incarcerations, greater demand for (and thus inevitably supply of) illicit opiates, etc.


For full story click here

Plus ça change - Ambulatory Clinics Providing Opiate Agonists:

A 1971 paper by Gay and colleagues discuss the US opiate dispensing clinics operating from 1919 to 1923 (there were 44 of them!). they conclude: Today, some 47years later, the time is long overdue to ... reconsider the efficacy of outpatient treatment of addiciton. It seems cler now that (1) institutional programs have failed to establish a broad base of effective treatment, and (2) law enforcement has failed either to stop the flow of drugs or to incarceration all users. We are left with a medical and social problem of staggering dimension." (Int J Addictions 6(2):241-264, June 1971)

And where are we almost 40 years after that assessment? Russia refusing to offer opiate agonist treatment to its estimated 2-3 million addicts; long waiting oists for methadone programs in most of the country where it is legal to provide it; a UK government whose stated aim it is "to stop the widespread prescribing of methadone" and to rely instead on "the use of ‘cold turkey’ residential treatment programmes".

Retrospective Study of Substance Abuse During Pregnancy Concludes:

"Despite multidisciplinary coordinated antenatal care, women with substance abuse during pregnancy are at significant risk of adverse obstetrical and perinatal outcome ..." Two comments: among the "substance abuse" cohort 66% smoked compared to 2.4% of the controls. Secondly, in the facilities studied "women are always encouraged to reduce their overall drug use (prescribed and illicit) during the pregnancy ..." And indeed this policy - which runs counter to all the evidence on treating opiate dependence with methadone during pregnancy - resulted in an average daily dose at the time of delivery of 35 mg. When providing grossly suboptimal dosages of medication it is hardly surprising that patients (and in this case their offspring) have suboptimal outcomes. It's difficult to comprehend how this practice could be rationalized by the clinicians, and perhaps even more difficult to understand how the investigators could fail to mention this detail in their report. Study: Pinto et al; Eur J ObGyn and Reproductive Biol, 150 (2010) 137-141.

This blog was sent to the senior author of the paper who asked that the following reponse be added:

We note the rather unsubstantiated comment above. There are a wide range of management options for methadone maintenance during pregnancy and for the management of illicit drugs during pregnancy, as we assume the author of the blog entry is aware. These even include withdrawal therapy. The inference that higher doses of methadone plus allowing unrestricted and unadvised illicit use of any drug during pregnancy could lead to better outcomes needs no real rebuttal, as it is self evidently wrong. Most would regard such an approach as poor care.

In our population women are stabilised on methadone if necessary and incremental dosage reduction attempted where feasible. This is a well recognised practice. Removing the risks of illicit drug use is a priority in most services.'
Pinto Shanthi (RBT) Mid Cheshire Tr

Ignoring Populations Most at Risk When Estimating Prevalence of Drug Use Disorders:

The July 12 CESAR FAX (vol. 19, issue 26) of CSAT reports on a letter to editor of Am J Psych 167(4):473-475, 2010). The authors, Wilson Compton and colleagues, observe that "High rates of DSM-IV substance use disorders among inmates combined with a large inmate population mean that many persons with alcohol and drug use disorders are missed by major US national general population surveys." Hardly anything surprising in that observation - except the fact that this deeply flawed process for making estimates persists. Furthermore, surveys based on "household sampling" miss as well the very sizable population of Americans who are homeless - whose numbers in the US on any given night are estimated at "anywhere from 700,000 to 2 million" (attributed to National Law Center on Homelessness and poverty). When it comes to substance use/misuse, one has to wonder about the relevance of data based on household survey techniques, and worry about the the governmental policy decisions that are based on their findings.

To read more click here.

Methadone Possession Results in 40 Year Sentence:

In a nutshell: a man is stopped for a traffic violation, consents (!) to have his car searched. Is found to have a baggie and a scale with trace amounts of amphetamine/cocaine - and also a bottle with "three wafers of methadone" said to weight 5.14 grams (yes, grams). The "wafers" were in a bottle with a label indicating they had been prescribed for an acquaintance - the named acquaintance testified she dropped the medication in defendant's car and forgot to take it with her when she left; this is same story defendant told. Appeal based (as far as I can tell) entirely on the admissability of the trace amts amphetamine/cocaine to indicate to jury defendant's "character" and likelihood that the methadone "contraband" was there knowingly and with criminal intent. Conviction and resulting sentence are for the methadone possession - not the presence of trace amounts amphetamie/cocaine. .

First: no way in hell three "wafers" in one medication bottle can weight 5.14 grams -that's 5,140 mg, or roughly 100 days' of average dose medication. Presumably they made mistake - off 1000-fold on weight.

Second, the reason the medication was in car was perfectly reasonable according to defendant and corroborated by the person to whom the medication was legitimately given.

Third, bolstering with the finding of "trace amounts" of amphetamine/cocaine the preposterous notion that - in the face of the evidence - these three wafers were "contraband" and thus merited a prison sentence seems incredible.

And finally, even if the methadone were indeed "contraband" and had been acquired illegally for some nefarious purpose, and even if one gives great significance to the finding of "trace amounts" of other substances and what it might say about the defendant, and even assuming presence of that trace amount (which resulted in no criminal charge) was/is admissable...a 40 year prison sentence??? For three "wafers" of methadone - i.e., three days' supply?

Anything anyone can do for this poor guy? It seems absolutely outrageous - and the people of Texas will be paying for the man's incarceration for many decades. What a disgraceful indictment of our "war" on drugs...(and anyone wanna bet on the defendant's race?) Suggestions.

To read this story click here

Swiss Parliamentarian Wants Drug Legalization - Everywhere:

(Tages Anzeiger, Switzerland, 12 Aug):
According to Dick Marty prohibition has been a total failure and "... has lead to high prices and big profits for the drug mafia, without lessening availability." Marty, who is known for having exposed the secret CIA prison camps, was involved with the drug war as prosecutor for 15 years. He explained his new orientation by noting it was always the small-time dealers that were prosecuted - and that it's never been easier to obtain illicit drugs.

Marty wants to see the money now spent on enforcement to be used for prevention instead, and have drug use controlled in future through taxation as in the case of alcohol and tobacco. However, he acknowledged skepticism regarding his own proposal, saying legalization could only be achieved on an international basis and that this probably would not be achieved during his lifetime. On the other hand, "Mafia states" such as in Latin America could expedite reconsideration of current policies, pointing to former Mexican President Vicente Fox who, with 28,000 drug-related deaths in a single year, has called for legalization.

For full story in German click here.

Candid Comments on AA and “Rehab”

Candid comments on AA and “rehab” - an article in Washington Post 8 Aug is headlined, “We're addicted to rehab. It doesn't even work”. The author, Dr. B. A. Johnson, is chairman of psychiatry and neurobehavioral sciences at the University of Virginia. Dr. Johnson concludes as follows: “When any other illness causes great suffering, our society devotes time and money and effort to studying it and to developing treatments that are empirically found to work. Alcoholism and drug addiction should be no exception. Recent advances in neuroscience have led to a greater understanding of how alcohol and other drugs affect the brain. They have, in turn, allowed medical researchers, myself included, to begin to approach alcohol dependence as we would any other disease: by searching for effective medicine.”

For the full story click here

(Dr. Johnson states by way of disclosure that he has "served as a paid consultant to pharmaceutical companies developing medications to treat alcoholism")

This is a thought-provoking (and courageous!) article. Alas, it is sobering (!) to note that even when “effective medicine” for dependence has been identified it is all too often rejected by medical professionals and the general society alike. Methadone for the maintenance treatment of opiate dependence is a case in point.

UK Prime Minister Cameron "... wants to shift the focus away from the use of methadone as a substitute drug..."

UK prime minister Cameron "... wants to shift the focus away from the use of methadone as a substitute drug.... [and] press ahead with an expensive shift in treatment for drug addicts, towards residential programmes and away from the use of methadone as a substitute licensed drug." Cameron described methadone as " ... a government authorised form of opium ..." There are today an estimated 150,000 patients in England receiving methadone maintenance treatment. Full story click here (Guardian, 6 Aug)

A DEA Manager's View: Diversion a Consequence of Too Many Staff in OTPs

DEA "diversion program manager" for 5 mid-western states worries about the danger of diversion of methadone posed by the "multiple employees" working in OTPs. "The more people involved, the more it increases the chance for diversion." Wow - that's a new one! Suppose it's time for FDA to demand OTPs get rid of those docs, nurses, counselors and other potential diverters that it currently requires as a sine qua non for approval to operate. The context: praising suboxone as "...a safer option to methadone." Even the manufacturers of buprenorphine couldn't have come up with this "benefit". For full story click here.