Straight Talk… from
the Editor
Drug Monitoring:
Therapy or Tyranny?
New Survey:
Drug Monitoring in MMT?
Wide Reach of AT
Forum
www.ATForum.com Updated
Clinical
Concepts: Substance-Abuse Monitoring in MMT
Research Update: Pregnancy & MMT
MMT Pioneers: Marie Nyswander,
MD – Listening
to Patients
Does Age Matter in MMT?
Survey Results: Sleep Disorders
Events to Note
Straight Talk… from the Editor
Drug Monitoring: Therapy or Tyranny?
Drug screening and testing – “substance-abuse monitoring” – is
a challenging and difficult aspect of methadone maintenance treatment
(MMT).
Studies have found persistent substance abuse in 20% of patients
during MMT, with half of those persons also continuing to use illicit
opioids. A prior AT Forum survey (Spring 2004) found that
up to a third of patients may experience full-blown relapses, with
most cases occurring within 6 months of entering treatment. However,
there is an ever-present danger of drug lapses or relapses even
in the most abstinent and stable patients.
If any level of substance abuse can be detected sooner rather
than later, more effective and timely interventions might be implemented
to stem relapses and prevent treatment dropouts. Substance-abuse
monitoring can play an important role, as part of an overall therapeutic
strategy, for achieving those objectives.
Do It Right, Or Pay A Price?
As our interview with Greg Carlson in this edition makes clear,
the federally-mandated 8 substance-abuse assessments per year can
make an MMT program look good, because a great deal of drug use
will go unrecorded. But this is ineffective for providing better
patient care.
Realistically, a greater frequency of monitoring can create a
burden in terms of added staff time and expense. However, as Carlson
suggests, unless drug screening is done often enough it has little
value; so either do it right or the money might be wasted.
There are additional cost issues: What is the cost of formerly
stable patients relapsing without it being recognized and contracting
HIV or hepatitis? What is the cost to an MMT program when patients
leave treatment prematurely due to continuing substance abuse that
wasn’t detected?
Who Is Accountable?
Unfortunately, urinalyses are used too often to identify and
punish offending MMT patients. Such practices might be characterized
as “therapeutic tyranny” (recently noted by Robert
Newman, MD, in European Addiction Research [2005;11, p.12]).
Rather than contributing to the therapeutic process, as effective
monitoring should do, it ends up creating a hostile environment
of antagonism, distrust, and dishonesty.
However, it seems unfair to hold MMT programs solely accountable
when they are provided little in the way of specific guidance from
federal and state authorities or accreditation organizations. And,
the few explicit regulations that do exist are of minimal help
for improving substance-abuse monitoring practices.
Thus, clinics are left on their own to educate themselves and
satisfy the requirements of agencies to which they are accountable.
At the same time, questions about where funding will come from
for better approaches remain largely unanswered.
Substance-abuse monitoring is important and we will be exploring
this subject further from various perspectives. Please help by
responding to the survey in this edition of AT Forum.
Stewart B. Leavitt, PhD, Editor
ATFeditor@comcast.net
Addiction Treatment Forum
P.O. Box 685; Mundelein, IL 60060
Phone/Fax: 847-392-3937
Internet: http://www.atforum.com
E-mail: Feedback@atforum.com
NEW SURVEY: Drug Monitoring in MMT?
Please respond to the following survey questions:
1. At your clinic, how many drug screens or tests at a minimum must each patient
have during a 12-month period? _____
2. What substances are always assessed?
(check all that apply): __ alcohol; __ amphetamines;
__ barbiturates;
__ benzodiazepines; __ cocaine; __ marijuana; __ methadone;
__ opioids; __ PCP;
__ other: _______________.
3. Are on-site
drug screens (not requiring shipping to a laboratory) used?
__ Often; __ Sometimes;
__
Never.
4. If on-site screening devices
are used, what specimens are collected? __ Urine; __ Oral
fluid;
__ Both.
5. Are you responding as a __ patient, or __ clinic
staff member?
There are several ways to respond to AT
Forum surveys:
A. provide your answers on the postage-free feedback
card in this issue; B. write, fax, or e-mail
[info above]; or, C. visit our web site to
respond online. As always, your written comments are important. |
Wide
Reach of AT Forum
Did you know… AT Forum reaches more readers than
most other publications in the addiction treatment field.
According to data recently compiled by the International Society
of Addiction Journal Editors, there are 75 journal and newsletter
publications worldwide specifically addressing addiction treatment
topics. The average print circulation of each is a mere 1,250 copies
(median 1,000; range 155 to 4,000). In contrast, AT Forum is
mailed free of charge to 12,000 subscribers in the U.S. every quarter.
Plus, all of our publications are freely accessible
at our website (www.ATForum.com). Each month there are more than
20,000 visitors to the site from around the world.
So, as you think about submitting articles or responding to AT
Forum surveys, keep in mind that you will be reaching the
widest audience of any publication in the field.
ATForum.com Updated
Visit our website for the most complete offering of FAQs in
the field. Sixteen new frequently asked questions, along with evidence-based
answers, have been added and the remainder have been updated – a
total of 36 FAQs.
Other improvements to the site are ongoing. Navigation tabs have
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been checked and updated.
News & Updates , primarily focusing on methadone
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As always, the Addiction Resources section contains
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to the latest reader survey on a topic of interest to the field,
or provide your comments and feedback – click on the new Contact
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Back to Contents
Clinical Concepts
Substance-Abuse Monitoring in MMT
Drug screening and testing – substance-abuse monitoring – is
an aspect of methadone maintenance treatment (MMT) that has great
potential for doing either good or harm. Yet, this is an area in
which treatment clinics are provided very little specific, evidence-based
guidance and few best-practices recommendations.
Consequently, most clinics have traditionally established policies
and procedures in this area based on convenience or habit, while
adhering to the few regulations that do exist. Monetary constraints
also are taken into account, but there often is a simple acceptance
of whatever screening and testing services are most readily available,
rather than choosing the best approach from a therapeutic perspective.
This article discusses a few areas of confusion that have surfaced
during research for a more comprehensive and evidence-based White
Paper report currently in development by AT Forum.
A Therapeutic Tool
In general medicine, “monitoring” is a therapeutic
tool allowing oversight of a patient’s progress and
response to treatment. It is not intended as a form of meddling
surveillance merely to detect noncompliance or misbehavior by
the patient.
For example, blood glucose levels are used to gauge response
to insulin in controlling diabetes. Blood pressure readings assess
the effectiveness of antihypertensive medication.
Similarly, monitoring for substances of abuse in MMT settings
is one important way to assess patient progress in treatment,
as well as effectiveness of the program itself. There also are
vital safety concerns in identifying patients who are experiencing
a drug relapse or using substances that may lead to drug overdose
or interact with methadone in a harmful manner.
In addiction treatment settings, monitoring also has a surveillance
role. For example, there have been long-standing regulatory interests
in monitoring, especially screening for methadone, to curtail methadone
diversion. Yet, its effectiveness for this purpose is debatable.
Misbehaving patients with diabetes or hypertension who binge
on sweets or salty snacks, respectively, receive reprimands and
education from their physicians. However, MMT patients who abuse
drugs may face worse fates. Punishments for drug-positive urinalyses
have included methadone dose decreases, loss of take-home methadone
privileges, or withdrawal from methadone entirely; although, the
advantages of such “negative reinforcers” have never
been convincingly demonstrated.
Substance-abuse monitoring in MMT is typically a 2-stage process,
involving drug screening and drug testing. Distinctions
between the two types of analyses, or assays, are important from
perspectives of patient benefit, clinic operations, regulatory
compliance, and cost. Still, this is a source of some confusion.
Presumptive Screening
Screening uses relatively straightforward
techniques for detecting the presence or absence of an illicit
drug or drug class (e.g., opioids) in a specimen provided by the
patient. Urinalysis is the “gold standard” in this
regard.
This has been described as a preliminary or “presumptive” approach,
meaning that it may serve to quickly eliminate or rule-out the
most common substances of abuse; except for methadone, which should
be present in the screen. Positive screening results for illicit
drugs should be accepted with less certainty.
Easy-to-use drug-screening devices have been developed – using
urine or, less commonly, oral fluid specimens – that can
provide results in the clinic, at the point-of-collection (POC).
These POC on-site screens offer important benefits by
allowing immediate feedback to MMT patients and an appropriate
therapeutic response, if necessary. Laboratories also can perform
screening procedures as a first step in the specimen analysis but,
considering the availability of on-site screening devices, this
may not always be the best approach. See Table.
Confirmatory Testing
Testing , on the other hand, uses more
technically sophisticated and precise methods to “definitively
confirm” if a substance detected in a drug screen specimen
is truly present. It requires delicate equipment and trained operators,
beyond the capabilities of almost all MMT clinics, so it entails
shipping the specimen to a qualified laboratory and waiting for
results.
When is Lab Testing Necessary?
Since it is more rigorous and less affected by specimen adulteration,
and medications or other substances patients may be taking – called “cross-reactivity” – laboratory
testing is required for legal proceedings. It also is used when
drug monitoring results might decide issues of employment, professional
licensing, sports eligibility, and the like.
In most MMT clinics, only a minor proportion of patient specimens
typically would be positive for substances of abuse during screening,
and not all of those would require confirmatory lab testing.
When informed of the results, many patients will attest to their
drug use – along with the quantity and quality of drug, mode
of administration, and frequency of use. Considerable research
evidence suggests that patient self-reports can provide valuable
information, beyond that gained from screening or testing alone, if the
therapeutic environment is supportive and nonthreatening.
Therefore, except for specific cases, such as court-mandated
monitoring, the necessity of the added time and expense for routine
laboratory testing of all MMT-patients’ specimens
is highly questionable. Yet, it appears that many MMT programs – as
well as regulatory and accreditation agencies – often do
not make necessary distinctions between screening and testing,
or between the relative appropriateness of on-site versus laboratory
approaches.
This is despite recommendations from CSAT’s own National
Advisory Council (NAC) that, “Drug testing is a medical
service and therefore decisions about how it should be done, or
when/whether it can be changed, are completely within the purview
of the program’s Medical Director.” In other words,
there should be no official barriers to MMT programs modifying
and improving their substance-abuse monitoring practices.
Federal Mandates
According to Greg Carlson – Director, Addiction Medicine,
Hennepin County Medical Center, Minneapolis – when he started
work in the MMT field more than 35 years ago substance-abuse monitoring
was not required at all.
FDA regulations in 1972 were the first to mandate drug testing
in MMT, requiring a minimum of 8 random screens during the first
year of treatment. However, this was interpreted by most MMT programs,
not as a “minimum” but as the clinical “standard.”
“So we went from no monitoring requirement at all to a
relatively rigorous schedule,” he says. “However, it
took a week or two to get test results back from the lab, costs
were high, and the results were often unreliable.”
Through the years, laboratory urinalysis techniques and turnaround
times greatly improved. “Still, this represents a significant
financial investment during each year,” Carlson observes.
He believes that properly-applied monitoring can provide therapeutic
benefits in helping to bring about and measure positive changes
in patients’ lives; however, he adds, “If you’re
not going to do anything constructive with the results, why invest
the time and money in the first place?”
Unless substance-abuse monitoring is done
frequently enough it offers little of value.
Monitoring Frequency
Unless monitoring is done frequently enough it has little value,
Carlson believes. Federal Regulations revised in 2001 require only
a minimum of 8 random substance-abuse
assessments each year during MMT (without actually distinguishing
between screening or testing, or the type of specimen to be assessed).
Why 8 was chosen is unknown. Carlson and colleagues used a computer-generated
model to simulate how long a patient’s drug use might go
undetected with different scenarios (reported in AT Forum,
Fall 2004). Theoretically, with 8 yearly screens, a patient relapsing
to weekly cocaine abuse could go nearly 11 months before it is
detected.
This makes sense, since on a trulyrandom basis
all 8 urinalyses could come in the first month. Even if only one
urinalysis is done each month, on a random day, patients will soon
figure out that the remainder of each month and 4 months every
year will be unmonitored “holidays” to freely abuse
drugs if they are so inclined. Increasing the monitoring frequency
to every month – 12 times yearly – offers little improvement.
In Carlson’s opinion, “drug screening less frequently
than twice-monthly is clinically ineffective and a waste of money.
At the current minimum urinalyses per year only daily or near-daily
drug users would be easily detected and you may not even need drug
screening for that if proper counseling is ongoing.”
Therefore, clinics need to be flexible in their approach. Some
clinicians have suggested that specimen collection should become
a very frequent and routine part of the therapeutic regimen. To
control expenses only a random portion of all specimens collected
need to be assessed. There have been studies demonstrating that
the mere act of collecting samples as part of ongoing monitoring,
whether or not all samples are assayed, has beneficial
effects on treatment outcomes, Carlson notes.
A critical therapeutic question is: How long should a drug
relapse continue before it is detected? Serious relapse
is always a possibility during any stage of recovery, and the
sooner problems are detected the greater the chances of helping
the patient before he/she drops out of treatment entirely. Money
saved by infrequent monitoring is offset by high costs of clinical
ineffectiveness.
On-Site
Screen Advantages
On-site drug-screening devices are relative newcomers to substance-abuse
monitoring, although they have been available for more than a decade.
They come in different formats: dip sticks, cups, cassettes, and
card devices – all of which visually display results in only
minutes while patients are present.
During recent years, costs for these have decreased while their
quality has increased dramatically. It is important to understand
that looking only at past research studies conducted using older
on-site devices, rather than more current versions, can be misleading.
The effectiveness of these modern on-site devices for preliminary
screening purposes in MMT programs has been underestimated. Their
ability to produce results that are accurately either drug-positive
or drug-negative approaches that of more sophisticated laboratory
assays, in most cases.
And, as Carlson notes, “the quicker you have access to
information the more helpful it can be. On-the-spot drug screening
results provide a more powerful clinical tool.”
Official Recognition
New government guidelines from SAMHSA for Federal Workplace Testing
programs have accepted on-site screening procedures and recognized
their potential utility. And, CSAT’s NAC has stated, “Properly
conducted POC urine testing [that is, point-of-collection on-site
screening] … is adequate and probably offers clinical benefits,
in terms of rapidity of clinical feedback, over and above those
of laboratory testing of either OF [oral fluid] or urine.”
Furthermore, they recommend that additional monitoring should
be performed whenever there is an appearance of patient intoxication,
and “POC testing [i.e., screening] of urine may be especially
helpful for this purpose.”
Therefore, there is nothing in any guidelines or regulations
prohibiting on-site drug screening and, in fact, this modality
appears to have been recommended by official sources.
Patient safety and therapeutic merit should
be
driving forces behind monitoring in MMT.
Safety & Therapeutic Challenges
The driving force behind substance-abuse monitoring in MMT, as
with other practices, should be patient safety and the therapeutic
merit in fostering addiction recovery. As Carlson stresses, “this
is but one clinical tool that must be integrated with other information
about the individual patient.”
He notes that, if clinic staff are using urinalyses to “catch” patients
in a game of “cops ‘n robbers,” or if results
from infrequent assessments are being misinterpreted, it could
do more harm than good. “For example, we’ve had transfers
from programs where patients were administered only the minimum
8 screens per year and were supposedly doing very well,” he
says. “When we do weekly drug screens during the first month
after transfer they ‘suddenly’ become patients with
serious substance abuse problems.”
As noted at the outset, this is an aspect of MMT for which clinics
have no officially sanctioned manual or protocol to follow. Therefore,
the challenge ahead will be for clinic staff to become more educated
and develop better substance-abuse monitoring practices based on
available evidence. AT Forum plans to assist in that endeavor.
NOTE: Due to space limitations, references for
information contained in this article have not been listed. Watch
for a comprehensive evidence-based report from AT Forum titled, “SAM*
in MMT (*Substance-Abuse Monitoring).”
Back to Contents
Research Update
Pregnancy & MMT
Substance abuse in pregnant women is of great concern due to
the risks to unborn children. Methadone maintenance treatment (MMT)
is the standard of care, yet there have been controversies through
the years regarding effective and safe methadone dosing in these
women, and the advisability of breastfeeding after delivery. There
also has been increasing interest in using buprenorphine.
These issues have been extensively studied and some current findings
are briefly summarized here.
Methadone vs Buprenorphine?
There have been reports that buprenorphine may be equally effective
and safe as methadone during pregnancy. However, whereas methadone
is classified by the FDA as a Pregnancy Category B medication,
relatively limited data are available on buprenorphine during pregnancy
and it carries a C classification, recommending greater caution
in its use. A recent Treatment Improvement Protocol from CSAT specifically
notes that buprenorphine has not as yet been fully approved for
use in pregnant patients.[1]
A neonatal abstinence syndrome (NAS) requiring medical intervention
is sometimes experienced by methadone-exposed newborns, and some
preliminary evidence suggests that buprenorphine may help reduce
the incidence and/or severity of NAS.[2] However, most investigations
have found that the two opioid medications are generally comparable
in terms of health outcomes for mothers and their newborns, including
NAS.[3,4]
Usually, small groups of pregnant patients were studied,[4] and
doses may have been inadequate for some; ranging from 30 to 100
mg/day of methadone, and 8 to 24 mg/day of buprenorphine.[2,4]
Patient selection criteria defining which pregnant women might
do better on methadone versus buprenorphine when entering treatment
are still unresolved.
Adequate Methadone Dosing?
MMT continues to be plagued by misunderstandings of its use during
pregnancy. In a recent newspaper advice column, an obstetrician
described methadone as having harmful effects, especially at higher
doses. It was alleged that all fetuses develop dependence and,
after birth, go through a painful withdrawal that is worsened by
the amount of methadone the mother is taking.[5]
It was once thought that methadone during pregnancy should not
exceed 20 mg/day. Current guidelines acknowledge that pregnant
women require at least 50 to 150 mg/d for therapeutic efficacy,
often more.[1] Additionally, significant dose increases are
often required during later stages of pregnancy.[6]
Researchers have determined that NAS is unaffected by maternal
methadone dose,[7] even in women receiving up to 200 mg/d.[8] In
fact, NAS tended to be more severe in newborns of women receiving
low doses. Consequently, pregnant women should receive whatever dose
is most therapeutically adequate on an individual basis.[6-8]
Furthermore, it seems the best way to deliver adequate methadone
during pregnancy is to split the daily dose into two or more amounts,
particularly during the 3rd trimester.[9] This has been found beneficial
for the developing fetus [10] as well as in helping to reduce ongoing
substance abuse by the mother.[9]
Continued Substance Abuse?
Pregnancy and concerns about the health of their unborn children
appear to motivate many women to enter MMT and achieve illicit-drug
abstinence. However, ongoing stresses often seem to overcome this
motivation and pregnant patients do not appear to become more abstinent
in treatment than any other women.[11]
In comparing pregnant and non-pregnant groups of women, investigators
have found equivalent rates of retention in treatment and ongoing
substance abuse.[11] A newly-reported Swiss study found that 64%
of pregnant women continued abuse of heroin and cocaine, and this
reversed the normally positive effects of methadone on birthweight
in their newborns.[12]
Some researchers have reported even higher rates of substance
abuse.[11] And, such problems also are found in pregnant women
treated with buprenorphine.[4]
Research in this area often neglects to consider how low, subtherapeutic
maternal methadone doses may affect continued illicit-drug use.
Women in the Swiss trial with high rates of substance abuse, noted
above,[12] were receiving only 50 mg/d of methadone on average,
with most administered less than 70 mg/d. In contrast, a recent
study found that three-quarters of women receiving methadone doses
averaging 94 mg/d (and ranging up to 240 mg/d) achieved illicit-drug
abstinence during their pregnancies.[13]
Breastfeeding Concerns?
Participation in MMT does not prohibit breastfeeding, although
methadone is excreted in human milk. Long ago, researchers observed
that the typical 0.012 to 0.057 mg/day of methadone in breast milk
would not have any adverse clinical effect on a newborn;[14] also,
due to variable metabolism, this amount does not correlate with
any particular daily methadone dose in the mother.
The American Academy of Pediatrics [15] and the American Osteopathic
Association [16] have both come out in favor of mothers in MMT
breastfeeding their infants. They emphasize the health benefits
of breastfeeding for those infants whose mothers are in successful
recovery from addiction.
To minimize possible infant exposure, it might be recommended
that breastfeeding not be done during the time of expected peak
serum methadone level (SML) in the mother , which is typically
from 1 up to 6 hours after dosing. For example, the mother might
take her daily methadone dose just after breastfeeding and prior
to the infant’s longest sleep time, or use a milk supplement
for feeding during peak SML periods.[14]
Some flexibility in the scheduling of dosing would be required.
And, the benefits versus risks should be considered; taking into
account any potential contraindications to breastfeeding, such
as HIV infection, and the mother’s continued substance abuse,
if any.
1. CSAT. Substance Abuse Treatment for Persons With Co-Occurring
Disorders. TIP 42. Rockville, MD: Substance Abuse and Mental Health
Services Administration; 2005. DHHS Publication (SMA) 05-3992.
2. Jones H. Role of buprenorphine in the treatment of opioid
dependent pregnant women. In: Program and abstracts of the 6th
European Europad Conference; November 1-3, 2004; Paris, France.
3. Gourarier L, et al. A prospective study of 259 pregnant women
treated with either buprenorphine or methadone through delivery,
and neonatal parameters of their 260 children. Paper presented
at: CPDD (College on Problems of Drug Dependence) 65th Annual Meeting;
June 2004; San Juan, Puerto Rico.
4. Primorac A, et al. Double-dummy, double-blind comparison of
buprenorphine and methadone in pregnant opioid-dependent women.
Paper presented at: CPDD (College on Problems of Drug Dependence)
65th Annual Meeting; June 2004; San Juan, Puerto Rico.
5. Cressman B. Methadone. Daily Mountain Eagle (Jasper, AL).
August 26, 2004.
6. Jarvis MA, Wu-Pong S, Knisley JS, Schnoll SH. Alterations
in methadone metabolism during late pregnancy. J Addict Dis. 1999;18[4]:51-61.
7. Kuschel CA, Austerberry L, Cornwell M, Couch R, Rowley RS.
Can methadone concentrations predict the severity of withdrawal
in infants at risk of neonatal abstinence syndrome? Arch Dis Child
Fetal Neonatal Ed. 2004;89(5):F390-F393.
8. Berghella V, Lim PJ, Hill MK, Cherpes J, Chennat J, Kaltenbach
K. Maternal methadone dose and neonatal withdrawal. Am J Obstet
Gynecol. 2003;189:312-317.
9. DePetrillo PB, Rice JM. Methadone dosing and pregnancy. Int
J Addict. 1995;30[2]:207-217.
10. Wittmann BK, Segal S. A comparison of the effects of single-
and split-dosing methadone administration on the fetus: ultrasound
evaluations. Int J Addict. 1991;26[2]:213-218.
11. Crandall C, Crosby RD, Carlson GA. Does pregnancy affect
outcome of methadone maintenance treatment? J Subst Abuse Treat.
2004; 26(4):295-303.
12. Kashiwagi M, Arlettaz R, Lauper U, Zimmermann R, Hebisch
G. Methadone maintenance program in a Swiss perinatal center. Management
and outcome of 89 pregnancies. Acta Obstet Gynecol Scand. 2005;84(2):140-144.
13. Welle-Strand GK. Medication assisted rehabilitation and pregnancy:
the Norwegian experience. In: Program and abstracts of the 6th
European Europad Conference; November 1-3, 2004; Paris, France.
14. Kreek MJ, Schecter A, Gutjahr CL, et al. Analyses of methadone
and other drugs in maternal and neonatal body fluids: use in evaluation
of symptoms in a neonate of mother maintained on methadone Am J
Drug Alcohol Abuse. 1974;1(3):409-419.
15. American Academy of Pediatrics Committee on Drugs. The transfer
of drugs and other chemicals into human milk. Pediatrics. 2001;108(3):776-789.
16. AOA stands strong on breastfeeding [press release]. US Newswire,
July 21, 2003.
Back to Contents
MMT Pioneers: Marie Nyswander, MD – Listening
to Patients
Despite
a life marked by many changes, Marie Nyswander, MD, seems destined
to have become a leader in the addiction treatment field.
Her straightforward manner, her unsentimental compassion, and
her easy rapport with patients were legendary. Most important,
at a time when her fellow psychiatrists viewed drug-addicted persons
with disdain as being mentally-deficient moral outcasts, she promoted
the idea of addiction as a disease.
It is commonly recognized that no other American psychiatrist
of her generation benefitted the lives of so many opioid-addicted
patients.
Addiction as a Medical Problem
Marie was born Mary Elizabeth Nyswander (which she later changed
to Marie) in Reno, Nevada, in 1919. Her father, James, was a mathematics
professor and her mother, Dorothy, earned a doctorate in psychology
after the couple’s divorce when Marie was still a toddler.
Marie was raised by her mother and the two eventually moved to
New York City in 1936. Marie attended Sarah Lawrence College and
later went to Cornell University Medical College, graduating in
1944.
After completing a surgical internship, she joined the Navy as
a surgeon. However, the Navy had no place for female surgeons in
those days and Nyswander was posted to the Lexington Narcotic Hospital
in Kentucky run by the U.S. Public Health Service.
The Lexington experience was a turning point. Nyswander saw drug
addicts from all walks of life branded as psychopaths, mistreated,
and subjected to racial insults. She became convinced that these
patients could and should be treated more humanely, as individuals.
When she left the service, Nyswander decided that surgery was
not for her and pursued a career in psychiatry. She trained at
New York Medical College in the late 1940s and established a private
psychiatric practice in the early 1950s.
She volunteered much of her time treating impoverished drug-addicts
and, in 1955, Nyswander helped establish the Narcotic Addiction
Research Project — a first of its kind outpatient program
providing actively addicted patients with intensive individual
psychotherapy. She also set up a clinic to treat jazz musicians
addicted to heroin and by the early 1960s was treating addicts
in an East Harlem storefront clinic.
Nyswander described her clinical experiences in a book, The
Drug Addict as a Patient (1956). Her patients’ repeated
cycles of brief recovery inevitably followed by drug relapse
were frustrating, yet she believed they could be helped by clinicians
willing to learn more about addiction. She presented a radical
viewpoint, at the time, that addiction should be approached from
the perspective of patients with a medical problem.
Nyswander’s empathy with patients may have been influenced
by her self-acknowledged addiction to nicotine; she was a 3-pack-a-day
smoker. In Nat Hentoff’s excellent book on her work, A
Doctor Among the Addicts (1968), she tells of once attempting
to quit: “The craving for cigarettes exists as an entity,
separate from pleasure. Nor did the craving diminish with time. …if
it’s this hard to stop smoking, think what it must be like
to stop taking a drug such as heroin.”
Birth of MMT
Another turning point came for Nyswander in the early 1960s when
she was invited to join Vincent Dole, MD, at Rockefeller University
in New York City. He was embarking on a project exploring new pharmacotherapies
for opioid addiction and had read Nyswander’s book. He believed
she had the necessary skills and experience in working with drug-addicted
patients. In 1964, a third member joined the team – Mary
Jeanne Kreek, MD – who was a young clinical investigator
and first year resident in internal medicine.
After testing a number of agents, the team soon discovered that
methadone stemmed withdrawal and relieved narcotic hunger, yet
at stabilized doses it did not produce the euphoria of other opioids.
By spring 1965, the team had data on 22 patients successfully treated
with methadone and published their remarkable findings. Expansion
of their program and further publications soon followed, giving
birth to the methadone maintenance treatment field.
Essential Lessons; Seeing the Inner Person
According to Mary Jeanne Kreek – who is now Professor and
Head of the Laboratory of the Biology of Addicted Diseases at Rockefeller
University – Nyswander was intense and rather firm at times.
However, she was always open-minded when it came to discussing
individual patients and their treatment.
“Many therapists and clinicians would dismiss what patients
were saying as the ramblings of disturbed, addicted minds,” Kreek
notes. “Yet, Marie reminded us again and again, ‘listen
to the patient.’”
“Marie felt that much could be learned by careful listening,” Kreek
says. “Then, if the whole story was not forthcoming, patients
could be questioned.”
A major new concept of the team was viewing addiction as a brain
disease. Patients should not be defined by their past behaviors
and merely viewed as criminals or weak-willed. “Marie knew
that behavior management alone was insufficient to deal with
addiction,” Kreek continues. “However, the notion
of using pharmacotherapy, such as with methadone, to treat the
drug-addicted brain was a new idea and slow to catch on.”
In 1965, Nyswander married Vincent Dole, and she passed away
in 1986 at the age of 67. Each year since 1983 the Nyswander-Dole
Award created in their honor – and now simply known as “The
Marie Award” – has been bestowed on individuals who
have made outstanding contributions to the methadone treatment
field.
Looking back, Dole once remarked that her secret was an ability
to see the inner person. No doubt, such vision was aided by better
listening to patients.
Back to Contents
Does Age Matter in MMT?
At
a recent national forum on drug addiction in the elderly sponsored
by the National Institute on Drug Abuse (NIDA), federal officials
said the number of seniors with alcohol and other drug problems
is expected to leap 150% by 2020 to 4.4 million. Most, two-thirds,
of substance abuse in these older adults – in their 50s and
60s – is long-standing, rather than late-onset.
NIDA noted that elderly addicts have many of the same problems
as young persons with addictions, plus other issues unique to their
age group. Furthermore, at least half have problems with drugs
other than alcohol, with opioids becoming a prominent problem requiring
attention. Unfortunately, methadone maintenance treatment (MMT)
was not a part of NIDA’s agenda.
More Than Just Getting Old
AT Forum has previously focused on this topic – broadly
called the “Graying of Methadone” (see, Fall 1995;
Winter 2003; and Fall 2003). Generally, the MMT population
is aging, with a quarter to a third of patients in some clinics
age 50 or older.
It was suggested that aging is more than simply “getting
old,” but is a process involving biological, social, emotional,
and often financial changes affecting a patient’s health
and well-being. MMT federal regulations, state guidelines, and
many clinics have largely ignored the special needs of elderly
patients.
Elders Do Well in MMT
A recently reported study[1] examined a large cross section of
older patients in MMT. Among 10 programs surveyed, estimates of
patients age 55 or older ranged from 2% to 60%. The researchers
found that significantly more older patients were married and were “highly
successful” in treatment, although fewer were employed.
Overall, older patients had more chronic medical problems than
younger ones, but the differences were not statistically significant.
Of particular concern were hypertension, diabetes, liver disease,
and stroke – which are illnesses expected in an aging population.
Older and younger patients were identical in terms of psychiatric
problems.
The authors note that they did not expect that the older patients
would do so well in MMT. They speculate that this group might be
more compliant with treatment and have more stability in their
lives.
Another possibility is that, as patients age, they tend to engage
in fewer drug-related activities and, consequently, less drug abuse
while in treatment. However, other recently-reported research found
that if older patients are exposed to illicit-drug use in their
neighborhoods and social relationships they are significantly more
likely to abuse drugs.[2]
Time for Action
The evidence suggests that older patients can do just as well
in MMT as younger ones and, in many cases, much better. Yet, there
is still very little research on the special needs of those older
patients.
Prior articles in AT Forum have called for broader surveys
regarding the aging population in MMT, as well as special programs,
seminars, or other efforts focusing on “graying of methadone” issues.
Yet, to date, there have not even been presentations or panel discussions
on this topic at association conferences in the field.
1. Firoz S, Carlson G. Characteristics and treatment outcome
of older methadone-maintenance patients. Am J Geriatr Psychiatry.
2004;12(5):539-541.
2. Rosen D. Factors associated with illegal drug
use among older methadone clients. Gerontologist. 2004;44(4):543-547.
Back to Contents
Survey Results: Sleep Disorders
Sleep Disturbances Are Common During MMT
Approximately 130 readers (60% of them clinic staff) responded
to the survey on “Sleep Disorders in MMT” relating
to a feature article on the subject in the Summer 2004 edition
of AT Forum (Vol. 13, #3).
On average, respondents noted that half (50%) of the patients
at their respective clinics had complained of persistent sleep
disorders. However, nearly a third of those responding said that
80% or more of patients had serious problems with sleep, which
is consistent with other surveys of MMT populations.
Few Patients Get Rx Meds
Most readers (89%, see graph) agreed
to some extent that sleep disturbances can trigger drug or alcohol
abuse during MMT. Yet, responses indicated that only 1 in 4 clinics
(25%) prescribe medications to help patients sleep.
The most frequently prescribed sleep medications included (in
order of frequency): zolpidem, trazodone, diphenhydramine, doxepin,
quetiapine, and some benzodiazepines (e.g., diazepam, alprazolam).
However, a few physicians noted concerns about addictive potential
with quetiapine.
Readers Share Experiences
“I’ve always had sleep problems, which have gotten
worse since starting MMT. I have a very hectic lifestyle and can’t
seem to make myself lay down at night. I get on average about 2
to 3 hours of sleep each night. The clinic doctor has given me
sleep aids but all they do is make me groggy in the evening and
don’t allow me to stay asleep. I’ve tried melatonin
and valerian root, and [diphenhydramine] but nothing helps.”
“Many patients at our clinic suffer from PTSD (post-traumatic
stress disorder) and that adds to their sleep problems. If these
patients do not get relief from trazodone or short-term zolpidem,
we try to refer them for sleep evaluations.”
“I’ve been on methadone for 32 years and have always
had sleeping problems – I wake up every 2 hours.”
“At our clinic we’ve had success with acupuncture
in helping patients achieve greater quality of sleep. It also helps
with pain management, anxiety, and depression.”
“I’ve been an MMT patient for 10 years and the only
thing that helps me sleep is splitting my take-home dose; otherwise,
I frequently wake up due to withdrawal during the night. Yet, the
clinic doesn’t approve of this.”
New Sleep Meds Soon Available
Most of the current sleep-aid medications are recommended for
short-term use only; whereas, sleep problems are often chronic
afflictions. A newer generation of drugs is coming along that may
provide involuntary night owls with the sweet dreams they are longing
for. At the same time, these agents are not expected to promote
abuse or dependency.
Last December (2004), the FDA approved eszopiclone,
the first prescription non-benzodiazepine sleep medication considered
safe and effective for long-term use. It is indicated for patients
who have difficulty falling asleep as well as for those unable
to sleep soundly through the night. Studies are continuing on its
effectiveness for patients also suffering from depression or pain.
Another drug, indiplon, is a unique
non-benzodiazepine agent that works on specific brain receptors
responsible for promoting sleep. Studies demonstrated its safety
and effectiveness for long-term use. An application for approval
of indiplon to treat multiple forms of insomnia has been submitted
to the FDA.
Finally, ramelteon is a unique medication
that may promote sleep by helping to regulate the body’s
24-hour sleep-wake cycle. It is a non-benzodiazepine agent affecting
special brain centers comprising a “master clock” that
helps the body shift easily between phases of day and night to
encourage sleep onset. A new drug application for ramelteon has
been submitted.
Back to Contents
Events to Note
For
additional postings & information, see: www.atforum.com
April 2005
American Counseling Association Annual Convention
April 6-10, 2005
Atlanta, Georgia
Contact: 800-347-6647; www.counseling.org
Western Psychological Association 85th Annual Convention
April 14-17, 2005
Portland, Oregon
Contact: 253-851-7546; www.westernpsych.org/
ASAM (American Society of Addiction Medicine) - 36th
Annual Conference
April 15-17, 2005
Dallas, Texas
Contact: 301-656-3920; www.asam.org
May 2005
American Psychiatric Association Annual Meeting
May 21-26, 2005
Atlanta, Georgia
Contact: 703-907-7300; www.psych.org
June 2005
NMHA (Natl. Mental Health Assn.) Annual Conference
June 9-11, 2005
Washington, DC
Contact: 703-684-7722; www.nmha.org
CPDD (College on Problems of Drug Dependence) – 67th
Annual Meeting
June 18-23, 2005
Orlando, Florida
Contact: 215-707-3242; www.cpdd.org
UPCOMING 2005…
American Psychological Association 113th Annual Convention
August 18-21, 2005
Washington, DC
Contact: 202-336-5500; www.apa.org
American Psychiatric Association 57th Institute
October 5-9, 2005
San Diego, California
Contact: 703-907-7300; www.psych.org
American Public Health Assn. 133rd Annual Meeting
November 5-9, 2005
New Orleans, Louisiana
Contact: 202-777-APHA; www.apha.org/meetings/
[To post your event announcement in A.T. Forum and/or
our Web site, fax the information to: 847-392-3937 or
submit it via e-mail from www.atforum.com]
