AT Forum NEWS NOTES & UPDATES #109
January-February 2007
Compiled & Edited by Stewart B. Leavitt, PhD
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Contents
Alcohol-Consuming MMT Patients Do Less Well
Few Remain Opioid-Abstinent Following Detoxification
Delayed Symptom Onset After Methadone Overdose
Prison Methadone Programs Established in Pennsylvania
Guideline Recommends Contingency Management in MMT
Guidance for Methadone and Buprenorphine Therapy from NICE
Early Entry Into MMT Benefits Mothers, Newborns
NAS Management Compared in Neonates of Opioid-Maintained Mothers
EUROPAD Journal Available Free From AT Forum
HBO Launches “ADDICTION” Project; Documentary to Air in March
Congress Raises Buprenorphine Treatment Cap to 100
Dr. Terry Cline New Head of SAMHSA
Alcohol-Consuming MMT Patients Do Less Well
This study evaluated the impact of excessive alcohol consumption on the health-related quality of life of 192 patients receiving methadone maintenance treatment (MMT) for opioid dependence in England. Quality of life (QoL) was assessed using the Medical Outcomes Study: General Health Survey, Short Form (SF-12). Alcohol consumption was assessed using the Alcohol Use Disorders Identification Test (AUDIT).
Approximately one-third of the sample (57/192) were AUDIT-positive (score >/= 8) and 20 of the 135 AUDIT-negative patients reported a past history of alcohol problems. AUDIT-positive patients were less satisfied with their methadone dose than AUDIT-negative patients (P = 0.002), despite having a higher methadone dose. AUDIT-positive patients also reported significantly more physical and psychological health problems, and poorer QoL. The researchers concluded that excessive alcohol consumption may be associated with a distinctive pattern of QoL impairment in MMT patients. In addition to advising patients regarding their alcohol consumption, comprehensive care plans should seek to restore normal personal, family, and social role functioning through the provision of appropriate health and social care.
Source: Senbanjo R, Wolff K, Marshall J. Excessive alcohol consumption is associated with reduced quality of life among methadone patients. Addiction. 2007;102(2):257-263.
[Comment: Patients in MMT often believe that, since opioids were their primary problem, continuing to consume alcohol should be allowed. As this study suggests, such patients often hinder their addiction recovery and find less satisfaction with MMT, including the adequacy of their methadone dose. – Ed (Stewart B. Leavitt, MA, PhD)]
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On-Site Services Best in MMT
This study examined whether the mechanism through which a methadone maintenance treatment (MMT) program offers 7 treatment-related and support services is related to whether a patient receives such services. Mechanisms included a) the provision of services on-site, b) at another program site, or c) through formal or informal linkage arrangements. Analysis was conducted on a nationally representative sample of MMT sites.
Providing services on-site was found to be positively related to patient access to a majority of services; whereas, in general, offering services at another program site or through formal or informal linkages to other service providers was not found to be effective. Not-for-profit or public ownership of treatment sites was also found to be positively related to patient access to services.
Reference: Berkman ND, Wechsberg WM. Access to treatment-related and support services in methadone treatment programs. J Subst Abuse Treat. 2007;32(1):97-104.
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Few Remain Opioid-Abstinent Following Detoxification
Many patients with chronic opioid dependence are referred to drug-free outpatient treatment following inpatient detoxification, even though successful outpatient treatment engagement and abstinence from opioids occur only in a minority of cases. This retrospective analysis of medical records documents the post-discharge outcome in a treatment setting that maximizes support during the transition to abstinence-oriented outpatient care; including comprehensive social, medical and mental health services, and the availability of naltrexone. Participants were male veterans (N = 112) admitted at an urban VA medical center in the United States.
Most patients (78%) successfully completed acute detoxification, 49% initiated naltrexone, and 76% accepted a VA aftercare plan. At 90-day follow-up, only 22% remained in aftercare, and fewer than 3% had toxicology-verified abstinence from opioids. At one-year follow-up, 1 out of 5 had been readmitted for detoxification and 4.5% had died. Most patients successfully detoxified from opioids, but very few remained engaged and stabilized in abstinence-oriented outpatient treatment.
Source: Davison JW, Sweeney ML, Bush KR, et al. Outpatient treatment engagement and abstinence rates following inpatient opioid detoxification. J Addict Dis. 2006;25(4):27-35.
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Delayed Symptom Onset After Methadone Overdose
Methadone overdose may cause coma and require naloxone infusion; however, few studies exist regarding the time to development of symptoms following methadone overdose in adults. After a brief training period, reviewers who were blinded to the purpose of the study completed a standardized data collection sheet, and then 2 consecutive years of poison center patient encounters were reviewed. Age, outcomes, co-ingested drugs, vital signs, clinical manifestations, hospital admissions, and mortality were abstracted.
In total, 44 cases of isolated methadone overdose in patients older than 18 years were identified. A mean age of 32.5 (18-58) years and an average presumed ingestion of 106 mg of methadone was calculated. Of the 44 patients, 32 received naloxone for symptoms consistent with opiate toxicity. All symptoms occurred within 9 hours of methadone ingestion, with a mean symptom onset of 3.2 hours. All patients had resolution of symptoms within 24 hours. No deaths were recorded.
Reference: LoVecchio F, Pizon A, Riley B, Sami A, D’Incognito C. Onset of symptoms after methadone overdose. Am J Emerg Med. 2007 Jan;25(1):57-59.
[Comment: This study was limited by its retrospective nature, relying on patient histories. However, it is important to note that symptoms of methadone overdose took, on average, several hours to develop, but could take up to 9 hours. Practitioners should be aware and patients warned of this delayed effect. – Ed (Stewart B. Leavitt, MA, PhD)]
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Prison Methadone Programs Established in Pennsylvania
Prisons in 3 Pennsylvania counties are setting up methadone programs for inmates who had been on methadone maintenance before being incarcerated. Nationally, few inmates receive methadone because of concerns about prescribing an “addictive” drug behind bars. But Pennsylvania prison officials say methadone can help heroin addicts and prevent recidivism.
New York’s Rikers Island was, for years, the only prison in the U.S. where inmates could take part in a methadone-maintenance program. But that’s changing, experts say, as studies have shown the effectiveness of methadone and good results have been reported from prisons in Connecticut, Chicago, California, and New York that have established methadone maintenance treatment programs.
“People don’t understand that heroin is a lasting addiction, a chronic condition like diabetes,” said R. Scott Chavez, administrative vice president for the National Commission on Correctional Health Care. “You wouldn’t think of not giving diabetics insulin. Studies have pretty much shown that the heroin addict must consider some replacement therapy or he will go back into heroin-seeking behavior.”
Source: JoinTogether.org (from Allentown Morning Call), January 23, 2007.
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Guideline Recommends Contingency Management in MMT
A draft guideline on the psychosocial management of drug misuse by the National Health Service (NHS) in England and Wales recommends that services for drug misusers should introduce contingency management programs that use incentives to reduce illicit drug use and that improve engagement with those services among people undergoing methadone maintenance treatment (MMT). Incentives, which would usually be privileges such as access to a rapid dosing line, or vouchers, would be given each time a patient tests negative for the presence of drugs. The guidance suggests that vouchers should increase in value with each additional and continuing period of abstinence.
Screening – probably by urinalysis – should be carried out 3 times each week for the first 3 weeks, twice a week for the next 3 weeks, and then once weekly until the patient has achieved stability. The draft guideline also recommends the use of modest material incentives, such as shopping vouchers, to encourage specific harm reduction objectives, such as attending for hepatitis and HIV testing.
The guideline development committee found evidence that contingency management is effective in reinforcing a range of behaviors, including abstinence from drugs, reducing drug use, and promoting engagement with psychosocial interventions. At a broader level, the draft guideline recommends that healthcare professionals should involve people who misuse drugs in decisions on their treatment, including options to promote and maintain abstinence and reduce harm.
Source: Mayor S. NICE (National Institute for Health and Clinical Excellence, UK) proposes incentives to keep addicts free of drugs. BMJ. 2007;334:229.
The guidance document – Drug Misuse - Psychosocial: NICE Guideline – is available at: www.nice.org.uk/page.aspx?o=397260.
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Guidance for Methadone and Buprenorphine Therapy from NICE
January 2007 – The National Institute for Health and Clinical Excellence (NICE), UK, has issued guidance for managing opioid dependence with methadone and buprenorphine. They note that methadone and buprenorphine (given as a tablet or a liquid) are recommended treatment options and a decision about which is the better treatment should be made on an individual basis, in consultation with the patient, taking into account the possible benefits and risks of each treatment for that particular person. If both drugs are likely to have the same benefits and risks, methadone should be given as the first choice. Treatment with methadone or buprenorphine should be given as part of a comprehensive support program to help the person manage their opioid dependence.
For document, go to >> http://www.nice.org.uk/guidance/TA114#documents.
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Early Entry Into MMT Benefits Mothers, Newborns
This study examined the association between retention in methadone treatment during pregnancy and key neonatal outcomes. Obstetric and perinatal characteristics of Australian women who were retained continuously on methadone maintenance treatment (MMT) throughout their pregnancies were compared with those who entered late in their pregnancies (less than 6 months prior to giving birth) and those whose last treatment episode ended at least 1 year prior to birth of their infants.
There were 2,993 births to women recorded as being on methadone at delivery of their infants. Compared to mothers who were maintained continuously on MMT throughout their pregnancy, those who entered treatment late also presented later to prenatal care services, were more likely to arrive at the hospital for delivery on an emergency basis, were more often unmarried, and smoked more heavily. A higher proportion of neonates born to late entrants into MMT were born at less than 37 weeks gestation and were admitted to special care nurseries more often.
The researchers conclude that continuous MMT during pregnancy is associated with earlier prenatal care and improved neonatal outcomes. Innovative techniques for early engagement in MMT by pregnant heroin-using women or those planning to become pregnant should be identified and implemented.
Reference: Burns L, Mattick RP, Lim K, Wallace C. Methadone in pregnancy: treatment retention and neonatal outcomes. Addiction. 2007 Feb;102(2):264-70.
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NAS Management Compared in Neonates of Opioid-Maintained Mothers
Neonates born to opioid-maintained mothers are at risk of developing neonatal abstinence syndrome (NAS), which often requires pharmacological treatment. This study examined the effect of opioid maintenance treatment on the incidence and timing of NAS, and compared two different NAS treatments (phenobarbital versus morphine hydrochloride).
Included in this study were 53 neonates born to mothers receiving either methadone (n = 22), slow-release oral morphine (n = 17), or buprenorphine (n = 14) throughout pregnancy. Irrespective of maintenance treatment, all neonates showed APGAR scores comparable to infants of non-opioid dependent mothers [see comment below].
No difference was found between the 3 maintenance groups regarding neonatal weight, length, or head circumference. Sixty percent (n = 32) of neonates required treatment for NAS [68% in the methadone-maintained group (n = 15), 82% in the morphine-maintained group (n = 14), and 21% in the buprenorphine-maintained group (n = 3)].
The mean duration from birth to requirement of NAS treatment was 33 hours for the morphine-maintained group, 34 hours for the buprenorphine-maintained group and 58 hours for the methadone-maintained group. In neonates requiring NAS treatment, those receiving morphine required a significantly shorter mean duration of treatment (9.9 days) versus those treated with phenobarbital (17.7 days). Results suggest that morphine hydrochloride is preferable for neonates suffering NAS due to opioid withdrawal.
Reference: Ebnera N, Rohrmeisterb K, Winklbaura B, et al. Management of neonatal abstinence syndrome in neonates born to opioid maintained women. Drug Alcohol Depend. 2007;87(2-3):131-138.
[Comment: It is noteworthy that APGAR scores in neonates across treatment groups were comparable to opioid-free mothers. The APGAR score is a simple way to assess the health of newborns across 5 dimensions: Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration. The delayed time to NAS requirement related to methadone would be expected, since it is the longest-acting of the agents received by the mothers; however, there is no indication of maintenance doses received by the mothers, which might have variably affected NAS requirement in their infants. – Ed (Stewart B. Leavitt, MA, PhD)]
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EUROPAD Journal Available Free From AT Forum
Heroin Addiction and Related Clinical Problems, the official journal of EUROPAD (European Opiate Addiction Treatment Association), is a peer-reviewed publication for professionals wanting to stay informed of research and opinion on opioid misuse treatment in Europe and around the world. A particular emphasis is on medication-assisted treatments for opioid addiction. Courtesy of EUROPAD, full copies of all journal editions are available for free download as PDF documents at the AT Forum website.
The current edition – 2006(Dec), Vol. 8, No. 4 – includes the following contents:
- Combating the Stigma: Discarding the Label “Substitution Treatment” in Favour of “Behaviour-Normalization Treatment”
- In the Service of Patients: The Legacy of Dr. Dole
- Injecting Buprenorphine Tablets: A Manageable Risk
- QTc Prolongation in Methadone Maintenance: Fact and Fiction
- Methadone: Is It Enough?
Go to: http://www.atforum.com/Europad.php
[Comment: AT Forum has strongly recommended this journal ever since its founding in 1999. In each issue, editor Icro Maremmani, MD does an outstanding job of gathering together some of the most practical research and commentary on the treatment of opioid addiction available in any publication. Making all of the issues available free of charge via AT Forum is a testament to the dedication of Maremmani and EUROPAD in advancing best medical practices in the field of addiction treatment. – Ed (Stewart B. Leavitt, MA, PhD)]
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HBO Launches “ADDICTION” Project; Documentary to Air in March
In partnership with the Robert Wood Johnson Foundation, the National Institute on Drug Abuse (NIDA), and the National Institute of Alcohol Abuse and Alcoholism (NIAAA), HBO will soon launch its “ADDICTION” project, an unprecedented multi-media campaign aimed at helping Americans understand addiction as a treatable brain disease. The centerpiece of the campaign is a documentary called “ADDICTION” – which is eye-opening, hopeful, and provides guidance in navigating the often confusing world of addiction treatment and recovery, according to a promotional announcement.
The 14-part documentary debuts Thursday, March 15, 2007 (9:00-10:30 pm ET/PT). The series will initially be offered during a free HBO preview weekend from Thursday, March 15 to Sunday, March 18 in participating cable TV systems.
For the first time, HBO will use all of its digital platforms, including the HBO main service, multiplex channels, HBO On Demand, podcasts, web streams, and DVD sales to support a campaign that includes a 14-part documentary series, a book published by Rodale Press, and a national community grassroots outreach campaign funded by the Robert Wood Johnson Foundation.
Source: CADCA Forumblog and JoinTogether.org, January 22, 2007.
[Comment: HBO is the organization that hosted the documentary “Methadonia” by Michael Negroponte, which was arguably one of the most misinformed and biased presentations of methadone maintenance treatment to date. Hopefully, this new initiative by HBO will be more accurate and fair in its treatment of addiction. Those interested should check local program time listings or visit http://www.hbo.com for more information. – Ed (Stewart B. Leavitt, MA, PhD)]
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Congress Raises Buprenorphine Treatment Cap to 100
December 2006 – President Bush signed into law an amendment to the Drug Abuse Treatment Act of 2000 that increases from 30 to 100 the number of buprenorphine patients that individual doctors may treat in their medical offices.
The 30-patient cap per physician was included in the original DATA-2000 legislation, which also limited group medical practices with multiple physicians to treating a maximum of 30 patients. The latter restriction had been lifted by Congress in July 2006, so that each physician in a group could treat up to 30 patients. The new law allows any doctor who has been certified to prescribe buprenorphine for at least one year to treat up to 100 patients.
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Dr. Terry Cline New Head of SAMHSA
December 2006 – The U.S. Senate confirmed the nomination of Oklahoma Health Secretary Terry Cline to lead the Substance Abuse and Mental Health Services Administration (SAMHSA).
In addition to serving as Oklahoma secretary of health, Cline was the commissioner of the state Department of Mental Health and Substance Abuse Services. He had previously worked at SAMHSA before returning to Oklahoma in 2001, serving as a health care policy fellow and focused on the organization and financing of mental health services. Cline also has been a clinical instructor in psychiatry at Harvard Medical School in Boston and served as chairman of the governing board for a Harvard teaching hospital in Cambridge. Cline holds a bachelor’s degree from the University of Oklahoma, and masters and doctorate degrees from Oklahoma State University.
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In view of the possibility of human error or advances in medical knowledge, Addiction Treatment Forum and its associates do not warrant the information contained in the above news updates is in every respect accurate or complete, and they are not responsible nor liable for any errors or omissions that may be found in such information or for results obtained from use of such information.
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