A.T.F. Volume VI, #3. Summer, 1997

High Dose Best Dose for Many
Managing Clinic Growth
From the Editor
Events to Note
Change as a Challenge
Reader Survey Responses
Where to Get Info

Events to Note

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

August 1997

Summer Clinical Institute in Addiction Studies
August 4-7, 1997
University of California,
San Diego Campus, La Jolla
Sponsored by U. of C., San Diego,
School of Medicine.
Contact Michael Ki: 619-551-2953

Intro to Drug Prevention & Demand Reduction
August 24-29, 1997
Hartford, Connecticut
Contact Steve Morgan: 805-782-6740

October 1997

10th National Conference on Addiction Medicine
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

(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)

Change as a Challenge

Shifting From Solid to Liquid Methadone
"Most of us are about as eager to be changed as we were to be born, and go through our changes in a similar state of shock."

Those words, by American author James Baldwin, might also apply when it comes to changes made by methadone maintenance programs. Of special importance, changes in methadone formulations - from tablets to diskettes to liquids - have sometimes been troublesome. Why?

A recently reported study[1] by two Harvard Medical School researchers sought to identify individuals most likely to have difficulty adjusting to changes in methadone formulations (or other treatment changes), and to help develop strategies and interventions for reducing any adverse consequences or disruptions in clinic operations.

This study was conducted at a Massachusetts-based MMTP that switched methadone formulations from tablets and diskettes to a computer-dispensed liquid. A total of 177 patients were included in the investigation over a seven month period. The study group was about two-thirds male and 86% Caucasian with an average age of 40.

The staff developed a transition plan beginning a month prior to the changeover. Printed information was provided to patients, and special meetings and counseling sessions focused on the need for the change. Patients were assured that dosage increases would be allowed if they experienced any difficulties. However, despite such reassurances, many patients fought the change; anticipating that the computer system would "cheat" them or the new formulation "would not hold." Such thoughts spread quickly among the clinic population creating a stressful environment.

The Intolerance Dilemma

Soon after the formulation changeover, the study population self-divided into two groups:

*Change-Intolerant (CI) - met withdrawal criteria: 1. requested formal medical assessment; 2. had observable narcotic abstinence symptoms; 3. were medically recommended increased doses above the their previous dosage ceilings.

*Change Tolerant (CT) - did not experience any withdrawal or meet the above criteria.

A quarter of the patients (45) were in the CI group; the remainder were change tolerant (CT). By the end of the seven month study period, average methadone dosage increased significantly by about 28 mg/d for the CI group. Conversely, the CT patients decreased their average dose 3.4 mg below the group's beginning level (average 76.5 mg/d).

At the outset and throughout the study, CI patients complained about withdrawal symptoms. However, the authors claim psychological stress might have been the primary cause for such distress, "independent of any biological factors." In explaining this, they note that stress can lower urinary pH in ways that accelerate the systemic excretion of methadone, thus lowering plasma levels. Stress might also have increased patients' uses of prescribed drugs for psychiatric illness, which could have also lowered methadone plasma levels.

Data analyses found that change intolerant patients were more likely to be female, with more serious psychiatric problems (often dual diagnosed with addiction and psychiatric problems). CI patients were also more likely to have spent a longer time in MMTPs than CT patients prior to the changeover in formulation.

During the course of the study, as more and more patients complained of the new dose "not holding," there were significant disruptions of the treatment environment. Staff members became anxious themselves, not knowing how many patients would be affected or how long the situation would continue. There was also uncertainty about whether outside drug use or behavioral problems could be attributed to the formulation change. The authors note that, "the instability of the clinic environment created additional stress in the patients' treatment environment. Chaos within the program may have contributed to and helped sustain patients' subjective experiences of narcotic withdrawal."

The researchers conclude that being forewarned as to which patients are most likely to be intolerant of change can help staff develop specific treatment plans for overcoming any difficulties. Once identified, those patients might receive more intensive therapy to help them deal with existing psychiatric diagnoses and/or the increased anxiety resulting from changes in the clinical setting.

The Beth Israel Experience

In 1992, Beth Israel Medical Center developed a pilot project implementing a computer-assisted system for dispensing liquid methadone in two of their 23 MMT clinics.[2] Prior to this, all clinics had been using a tablet formulation since 1976. A key motivation for the changeover was gaining greater efficiencies in clinic operations, allowing more time for patient care and health teaching.

The two clinics selected for the test program served a total of 650 patients. Focus group meetings were held with staff and patients prior to implementing the new system to learn of and respond to their questions and concerns. Similar sessions were held following the changeover.

While this study did not gather quantitative data regarding patient response, it did note a number of patient comments. "It takes a while to adjust but now it's better." "Others are saying this [liquid] isn't as strong, but I don't think it's true." "The (dosing)line goes fast. It's a good system."

On the negative side, "some patients felt that the liquid methadone metabolized faster, and reported that they were waking up at night. They found the liquid not as strong as the tablet methadone. The medication dosage was increased for these patients until they were comfortable." Blood serum methadone level analyses were not a part of this study.

Administrative staff had anticipated that any change in the work routine of clinic staff and the medical regimen of patients would engender some anxiety. The careful approach to this pilot program, including frequent and open communication with staff and patients, was successfully designed to allay such concerns. Consequently, despite initial fears and reservations, "staff clearly preferred the automated system overall. Patients maintained confidence in the treatment program, with many praising the new system although some still voiced reservations."

(According to the lead author, Nina Peyser, all Beth Israel MMT clinics subsequently changed over to the automated liquid dispensing system. She notes also that there is a policy of providing any patient with a methadone dose increase upon request (in accordance with appropriate medical judgment and regulatory standards), and this was an important factor in overcoming resistance to the new liquid formulation. - Ed.)

Chaos in the UK

In 1989 a small MMTP clinic in Nottingham, England [3] tried unsuccessfully to switch half of the patient population from methadone tablets to liquid. Sixty-one of the clinic's 127 patients were already taking a liquid formulation and the other 66 were to take part in the changeover; they were so notified two weeks in advance by letter.

Seventy-two percent of the clinic population were males with an average age of 33. The average methadone dose was 44 mg/d.

Sixteen of the 66 slated for changeover immediately objected and were allowed to remain on tablets. Of the 50 who did change to liquid methadone, nearly three-quarters (37) were allowed to switch back to tablets during the first three months. This left 13 patients, merely 20% of the original changeover group, fully tolerant of the change.

Those patients who initially refused to make the change on average were older, had the longest term in MMT (similar to the Harvard study), and were receiving the highest methadone doses. The staff was concerned that those patients would leave treatment rather than change to the liquid formulation.

Conversely, the 13 patients most accepting of the changeover had been in methadone treatment for the shortest time. Those who started on the liquid and then changed back to tablets were younger and had more months in treatment than their fellows who stuck with the liquid. The most frequent patient complaint was nausea and vomiting, but the staff found no objective evidence of any physical reactions to the liquid.

Of special note, the study's authors reported an increase in crime during the three month period of the study, including one break-in at the pharmacy that emptied the entire drug cabinet except for a large container of liquid methadone left behind as a blatant gesture of protest. There was also threatening behavior toward the staff.

The Nottingham researchers concluded that the deteriorations in behavior and functioning of a significant number of patients during treatment changes were due to psychological factors and an intense resistance to change; it was not directly related to the prescribed formulation. "Physical complications of methadone mixture occurred in very few," they wrote.

Self-fulfilling Prophesies

As the Nottingham group noted, "The destabilization predicted by the patients prior to the change actually occurred in many of those who received the [liquid] against their wishes - a self-fulfilling prophesy!" One might also consider that some of the reactions may have taken on qualities of a mass hysteria spreading through the patient population and leading to a revolt that the staff could not control. There was no mention in this study of patients being offered increases in methadone dose, if needed, and the clinic's average dose was lower than what most practitioners would consider optimal.

There was no mention of an impact on retention rates in any of the studies. Furthermore, the studies did not report on positive urine tests, so it is unknown to what extent, if any, those patients who appeared to be change tolerant might have been using illicit drugs to deal with their stress or perceived withdrawal symptoms.

The results of the Beth Israel study were certainly quite different from the Nottingham fiasco. At Beth Israel some patients did express dissatisfaction, although many took a neutral or wait-and-see posture and others "voiced enthusiasm about the benefits of the new dispensing system." Still, the study authors emphasize that the initial caution of the administration was warranted, and first introducing the new approach in a pilot program was wise.

The authors also note, "While certain specific worries were expressed by staff and by patients, few of these potential problems actually materialized. Both staff and patients realized benefits of the new system and remaining concerns were handled sensitively and individually." Hence, prophesies of doom in the face of change need not become fulfilled.

1. Silver JS, Shaffer, HJ. Change intolerance to shifts in methadone formulation: A preliminary investigation. Journal of Substance Abuse Treatment. 1996;13(4):331-339.

2. Peyser NP, Friedman P, Damiani S, Goldsmith DS, Petty WG. Evaluation study of a computer-assisted pump used for liquid methadone dispensing. Journal of Maintenance in the Addictions. 1997;1(1):25-47.

3. Steels MD, Hamilton M, McLean PC. The consequences of a change in formulation of methadone prescribed in a drug clinic. British Journal of Addictions. 1992;87:1549-1554.

(What have been your experiences with change? Respond to the A. T. Forum survey on the feedback card in this issue. - Ed.)

Reader Survey Responses

The Heroin Crisis - Smack is Back
In the last edition of A.T. Forum, and at our Web site - www.atforum.com - readers were asked to respond to three questions:

· Over the past year, has there been a change in heroin addiction in the area served by your clinic?

increasing	same	decreasing
80	18	2

· Compared to past years, has there been a change in the age of heroin users coming in to MMT programs today?

younger users	no change	older users
70	27	3

· Is funding adequate to meet needs for new treatment slots?

funding inadequate	not sure	funding sufficient
75	17	8

While few written comments were received from readers, check-off responses to the questions were quite in line with our article - "Smack is Back - Big Time" - that discussed the issues.

In brief, A.T. Forum readers overwhelmingly believe that heroin addiction is on the rise, among younger users, and that funding is inadequate for new treatment slots.

Eighty percent of those responding believe heroin addiction has increased in the areas served by their clinics. Only 18 percent feel it is about the same, while two percent claim it has decreased.

About 70 percent of readers indicated users coming into MMTPs are younger than in the past. Only three percent believe patients are older than before.

Three quarters of those responding believe funding is inadequate to meet needs for new treatment slots, while 17 percent aren't sure. Only eight percent said

funding is sufficient or additional slots aren't needed.

The results of our informal, straw vote survey are consistent with all other reports, and further research has produced additional information:

· A Newsweek magazine cover story in August 1996 reported heroin use increased throughout the United States.

· The New York Times published a story in October 1996 bemoaning the surge of cheaper, purer heroin in that city and

surrounding areas. More users were becoming addicted by snorting the drug than injecting it.

· A study by the Partnership for a Drug Free America in 1995 found that 2.3 percent of eighth graders had tried heroin, double the rate of 1991. Only half of those 12 to 17 years of age thought there was a "great risk" in trying heroin. [Indeed, one A.T. Forum reader responded on our survey, "Younger users entering our program appear to have no concept of the addictiveness of heroin."]

· That same federal study indicated that between 1991 and '94 there was a 193 percent increase in heroin deaths in Newark, over a 100 percent increase in San Francisco, and a 71 percent increase in Chicago. So, the trend seems to blanket America from coast to coast.

In the fall of 1996 the New York Times presented disturbing findings that heroin was being used by a generation of younger persons influenced by the entertainment and fashion industries. Recently, president Clinton lambasted the fashion industry in a speech May 21, 1997 proclaiming, "The glorification of heroin is not creative, it's destructive."

Clinton said some fashion leaders flat-out admitted that fashion photos in the last few years have made heroin addiction seem glamorous, sexy, and cool. His attack was prompted by a New York Times article the prior week berating the "heroin-chic" style of fashion photography. "You do not need to glamorize addiction to sell clothes," he commented. " this is not about art, it's about life and death. And glorifying death is not good for any society."

Survey Results:

80% of Readers Say Heroin Addiction is on the Rise

70% of Readers Say Heroin Users are Entering MMT Programs at a Younger Age

75% of Readers Say Funding for New Treatment Slots is Inadequate

Where to Get Info

New Journal Targets MMT

The Haworth Medical Press has published the premier edition (Vol. 1, No. 1; 1997) of the Journal of Maintenance in the Addictions focusing on innovations in research, theory, and practice surrounding opiate addiction and methadone treatment. Edited by J. Thomas Payte, MD, the 140 page journal features reports of new and original scientific investigations, book reviews, policy position statements, and practical clinical suggestions.

Among the topics presented in this first edition are: Quality assurance in MMT; efficacy and cost-savings of computer-assisted liquid methadone dispensing; increasing early engagement of patients in treatment; patient retention in treatment; therapy for treating refractory patients.

Inquiries from the field regarding submitting articles for publication in future editions are welcome.

For further information, to subscribe, or to request a sample copy (treatment professionals only), contact Haworth Press at:

1-800-HAWORTH
(Outside US/Canada: + 607-722-5857)
FAX: 1-800-895-0582
(Outside US/Canada: + 607-771-0012)
Email: getinfo@haworth.com

Dynamic Duo from Down-Under

A pair of very reasonably priced books by Australian addiction treatment specialist Andrew Byrne, MD offers much of value for professional and lay audiences:

Methadone in the Treatment of Narcotic Addiction - is a good read for physicians and other health care workers interested in a broad understanding of addiction and methadone maintenance. Byrne presents his experiences gathered from over a decade of practice in the field in a straightforward, fact-filled manner. [96 pages; $14 US, includes postage]

Addict in the Family - is a reference for persons addicted to substances of abuse, and for their relatives and friends. It provides a practical, no nonsense guide for better understanding drug abuse and the various treatment options available. (88 pages; $9 US, includes postage)

Send check or credit card details to:
Tosca Press; 75 Redfern St.; Redfern,
NSW, 2016, Australia
Fax: 61 2 9318 0631
Email: ajbyrne@ozemail.com.au