A.T.F. Volume VI, #4. Fall 1997

Coke Confounds MMT
Patients' Perspective
From the Editor
Events to Note
Current Comments
Reader Survey Responses
Where to Get Info
Case Challenge

Events to Note

For additional postings & information, see: www.atforum.com

OCTOBER 1997

10th National Conference on Nicotine Dependence
October 16-19, 1997
Minneapolis, Minnesota
Sponsored by American Society
of Addiction Medicine
Contact: 301-656-3920;
Fax 301-656-3815
E-mail: asamoffice@aol.com

State of the Art in Addiction Medicine
October 23-25, 1997
Washington, DC
Sponsored by American Society of Addiction Medicine
Contact: Phone 301-656-3920;
Fax 301-656-3815
E-mail: asamoffice@aol.com

NOVEMBER 1997

14th Annual Gulf Coast Conference on Alcohol and Drug Abuse
November 6-7, 1997
Adam's Mark Hotel, Mobile Alabama
Sponsored by University of South Alabama School of Continuing Education/College of Medicine and the Drug Education Council
Contact: Debbie Clolinger 334/431-6411; Fax 334/431-6408
E-mail: usabestcourse@usouthal.campus.mci.net

Medical Review Officer Training Seminar
November 14-16, 1997
The Seattle Hilton, Seattle, WA
Sponsored by The American Society of Addiction Medicine
Contact: 310/656-3920; Fax 301/656-3815

DECEMBER 1997

SECAD/97
An International Conference for Alcohol & Drug Addiction Professionals
December 3-6,1997
The Marriott Marquis, Atlanta Georgia
Sponsored by Magellan Health Services
Contact: 1-800/845-1567 (Outside US; 404/814-5877); Fax 404/814-5877
Web Site: www.charterbehavioral.com/secad97


8th Annual Meeting and Symposium of the American Academy of Addiction Psychiatry
December 4-7,1997
San Antonio Convention Center, San Antonio, Texas
Sponsored by AAAP
Contact: Carmela J. Cannova 913/262-6161
E-mail: addicpsyc@aol.com

JANUARY 1998

Eighth International Conference on Treatment of Addictive Behaviors
January 11-15, 1998
The Eldorado Hotel, Santa Fe, New Mexico, USA
Sponsored by University of New Mexico CASAA and Harvard Families and Addiction Program
Contact: Delilah Yao 505/277-2805; Fax 505/277-6620
E-mail: dyao@unm.edu

Second Annual Conference on Pain Management & Chemical Dependency: Evolving Connections
January 15-17, 1998
New York City; Sheraton Hotel & Tower
Sponsered by NIDA, ASAM, NY State OSASAS
Contact: Imedex 770/251-7332; Fax: 770/751-7334

(To post your event announcement in A.T. Forum and/or our Web site, fax the information to: 847/413-0526 or submit it via e-mail from: http://www.atforum.com)

Current Comments

Determining Adequate Methadose Dose
Andrew Byrne, MD ­ a drug and alcohol medicine specialist in Redfern, New South Wales, Australia ­ comments on a statement by Vincent P. Dole, MD, the "father of MMT," that with appropriate methadone treatment opiate injecting should be eliminated in close to 95% of addicted patients. Since HIV and hepatitis are so prevalent today, this goal is still of the highest priority. Yet it often remains illusory. Why?

Dr. Byrne writes:

"Dole's original 1965 description of methadone treatment involved 22 patients who were prescribed high doses by today's standards. The average was over 100 mg with several as high as

180 mg daily, and the reported results were extraordinarily favorable by any standards.

"Doses prescribed in more recent times have been less than half this level and outcomes generally less favorable. Toxicity in regular maintenance patients is almost unknown and the drug seems to have no significant long term side effects. However, many clinics still use arbitrary dose ceilings, often determined by administrators with no regard for the medical literature.

Dose Ceilings

"Sometimes this cut-off was determined by requirements for further paperwork at certain levels. This may have suited some people with no understanding of addiction and who had an obsession with 'dose minimization' in the misguided belief that this speeded 'recovery.'

"However, it is not advisable for methadone reductions to commence until stability has been achieved and there has been a major change of focus in the patient's life. It would be unreasonable for arbitrary limits to be placed on other medications, such as insulin, cortisone, or warfarin; all of which are prescribed according to individual clinical circumstances.

"It should be stressed that new patient dosing in the first two weeks is a quite separate issue. The starting methadone dose should not be more than 30 mg/day and early increases should only be allowed in patients with demonstrated abstinence syndrome.

Blood Plasma Levels

"A study by Forrest Tennant MD selected a number of regular methadone patients who were all taking 80 mg daily and were considered unstable by clinic staff. All were found to have low or undetectable levels of methadone 24 hours after supervised dosing. Consistent with increasing blood levels, drug use outcomes improved substantially after a graduated dose increase to 100 mg/d.

"This same study could apply to any patient who is using supplementary drugs. If the trough plasma level is low then a dose increase may be indicated. Doctors are familiar with a similar rationale with other drug therapies such as digoxin, lithium, or phenytoin. In these cases, what might be a lethal dose in one patient may be an inadequate dose in another.

"Clinical factors are still paramount in determining methadone dose. Patients who are taking low doses and who arrive early in the morning with insomnia and large pupils will usually benefit from a graduated dose increase. In principle, the methadone dose should be sufficient to take away cravings and enable the person to function normally without unacceptable side effects.

Higher Dose/Better Outcomes

"Studies have consistently shown better outcomes for patients on higher doses of methadone. Most of these studies have looked at narrow ranges, but there are reports of patients taking as high as

350 mg daily before becoming stable.

"Patients who request dose increases should always be given a good hearing. Research indicates that even when patients are given freedom to choose dose levels, they do not increase the average dose substantially.

"Where there is any question of toxicity, or if the dose is at a level with which the prescriber is uncomfortable, there are two diagnostic approaches to consider: 1. Examination of the pupils, physical, and mental state three hours after witnessed dosing can ensure that patients are not being overdosed; 2. A blood test at either peak or trough times can also be helpful.

"Peak blood levels taken three hours after dosing are generally double the trough levels at twenty four hours. Trough levels are probably the more relevant, since they reflect the amount of drug present just before the next dose is to be given.

"The 'half-life' of methadone is usually longer than one day. Dole believes that to avoid narcotic cravings the trough level should not fall below 0.2mg/L (200ng/mL).

"One pathologist has quoted a maximum upper range of 1.0mg/L (1000ng/mL). A recent report in the British Medical Journal quoted lethal blood levels of 2.7mg/L in habituated patients and 1.1mg/L in the 'opiate naïve.'

"As long as patients remain under dosed, they will feel uncomfortable for part of the day and they may not sleep at night. They may then be tempted to use heroin, purchase illicit methadone, inject take-home doses, and/or consume sedatives or excess alcohol.

"MMT practices with mean doses below 60mg/d should look hard at their patient groups. This is still far below Dole's mean dose of 100mg/d-plus with its enviable 'success' rate.

"A most fundamental job of physicians is to prescribe safe, effective doses of appropriate medications to their patients. In the case of methadone, many clinicians have been unwittingly under dosing a proportion of patients over the years."

[In separate correspondence, Dr. Byrne described to us a study in his own medical practice. Ten methadone patients who had continued heroin use or cravings were prescribed between 150 to 350 mg/day based on serum level evaluations. As a result, the high dose patients, possible fast metabolizers of methadone, appeared to virtually cease all heroin use as shown by consistently clean, supervised urine tests. ­ Ed.]

Reader Survey Responses

Does Change Beget Chaos?
The last issue of A.T. Forum explored the impact of changes in MMT clinic policies or procedures. It was noted that disruptions anticipated by patients and staff can become self-fulfilling prophesies leading to stress and patient problems. Certain groups of patients were found to be more "change intolerant" than others.

Readers were surveyed regarding their own experiences:

• A majority (80%) of those responding indicated that their clinics experienced increased stress among patients as a result of some change in overall policies or procedures.
• Nearly half of respondents (47%) said there were increased rates of patient relapses or aberrant behavior as a result of stress.
• Over a third (37%) of those responding indicated that some patients left their respective MMT programs due to anxiety-provoking changes.

There were a few comments sent in by readers to indicate the sources of stress:

• A clinic nurse from Stockton, California said changes in Medicaid and SSI benefits caused some patients to detox due to inadequate financial support. As a result, she claimed, 90% of them returned to illicit drug use.
• One patient indicated that many patients complained of feeling sick when his clinic switched to a different brand of methadone.
• There were several comments regarding government agencies imposing overly stringent regulations that had perceived negative impacts on patients and staff.
• In one example, several staff members left a clinic in response to new medical regulations.
• Inadequate methadone doses leading to patient relapses and tighter, stress-producing, controls imposed by clinics was mentioned by a few patients.

One counselor in Massachusetts summed up the situation: "Change is hard for everyone, but especially for addicts who seem to need more consistency and comfort in their lives to reduce stress. Sometimes, patients equate any change at all with punishment."

As the survey revealed, changes leading to stress and anxiety are very common in methadone clinics, and frequently lead to patient relapses or behavioral disruptions. As the informal survey also discovered, a relatively high percentage of patients leave treatment under those circumstances. And, it might be assumed that those drop outs are at premature stages of patient recovery.

There appears to be a need for MMT clinics to more adequately anticipate possible adverse consequences and develop appropriate strategies for meeting the challenges of change.

Where to Get Info

Contacting Advocate Groups

The following groups are mentioned in the accompanying article. (Information was current as of August 1997.)

ABATE (Advocates for the Betterment of Addiction Treatement and Education)

Antony Scro, Co-Founder

tonycold@AOL

www.nordexcent.com/abate/

BAM (Baltimore. Advocates for Methadone)

Jessica Durnin, President,

BAM; 3 Brucetown Court; Baltimore. MD 21228.

Jess2day@aol.com

Shot Of Hope, monthly newsletter; $10.00/year.

Danish Drugs Users Union; Brugerforeningen

Jørgen Kjaer, Vice President

20 Noerrebrogade - 2200 Copenhagen N.- DK Denmark.

Phone: 0045-3536-0150

bf@cybernet.dk

www.cybernet.dk/brugerforeningen/

DONT (Detroit Organizational Needs in Treatment)

Beth Francisco, Executive V.P.

P.O. Box 164, Davison, MI 48423-0164

yourtype@tir.com

www.tir.com/~yourtype

Methadone Today, monthly newsletter; $10/year.

NAMA (National Alliance of Methadone Advocates)

Joycelyn Woods, Executive Vice President

435 Second Ave.; New York, NY 10010

212/595-NAMA

nama@interport.net

www.methadone.org

Individual membership is $10 (includes The Ombudsman newsletter); or,

$50 for institutions.

Also available: Education papers, policy statements, various special

packages of information.

NAMA Philadelphia Chapter

Katherine Bolton

617 Pine Street, # 2, Philadelphia, PA 19106

215/629-1510

KB4MA@aol.com

Methadone Awareness, monthly newsletter; $10/year

SOMA (Southern Oregon Methadone Advocacy)

Ed Barios, Secretary

c/o JCMH; 338 N. Front St.

Medford, OR 97501

eddibarr@jeffnet.org

The Advocate, bimonthly newsletter; free.

Tennessee Methadone Advocates Coalition

Robin Robinette, Acting Director,

PO Box 422; Georgetown, TN 37336

423/265-3122

Rrobinette@aol.com

NOTE: The above is not inclusive of all advocate groups or publications currently available. Also, according to the persons contacted, nobody is denied access to their newsletters due to inability to pay ­ contact the individual group for details.

Case Challenge

Dealing with Difficult MMT Patients

A.T. Forum received the following query from Elizabeth Imeson, MD, medical director of Southland Counseling Center in Michigan. Readers are invited to contribute their advice, which will appear in our next edition. Mail, fax, or e-mail your responses ­ see contact info at end of the "From the editor... " column.

"Usually, establishing a maintenance dose for the majority of methadone patients is an open, congenial process. The patients I find difficult are those who consider opioid dependence a minor problem for which they need only a low dose of methadone for just a few weeks or months, and then they will be 'cured.'

"Pressure may be coming from families, employers, or spiritual advisors, as well as from the patients themselves. The patients refuse to give up control of their treatment or to accept education allowing them to participate effectively in decisions regarding their care. They often view methadone on a par with illicit substances of abuse and, so, 'can't wait to get off this junk.'

"The patients typically continue some abuse of opioids while in treatment, with increasing abuse as the methadone dose decreases. Hence, they are soon in their pre-treatment circumstances or worse.

"I would appreciate learning of others' experiences that might be helpful in dealing with such difficult situations."