A Collaborative Initiative for Patients and Clinical Professionals

AT Forum NEWS NOTES & UPDATES #106

July – August 2006

List of all News/Updates

All URL links noted in documents at this AT Forum website were active at the time of publication.  Since the Internet is constantly changing, some linked sites may have moved or become inactive, which is beyond the control of AT Forum.

Contents

Vincent Dole, “Father of MMT,” Dies at Age 93

NIDA Supports Addiction Treatment in Criminal Justice System

Addiction Counselor Shortage On The Horizon

Unreported Cannabis Use Predicts Cocaine/Heroin Abuse During MMT

MMT Clinic Practices Make Greatest Difference in Patient Retention

Methadone’s Influence on QT Prolongation Studied in Hospital Setting

Low Bone Density Common in MMT Patients; Especially Males

Benefits of Sterile Syringe Access During MMT Examined

Prize Incentives Do Not Increase Gambling Risk

Clinical Comparison of Methadone vs Buprenorphine in Italy

Initial Adoption of Buprenorphine Studied

Screening Tool Helps Identify ADHD In Substance Abusers

Pain Sensitivity, Mood Disturbances: Opioid-Class Effects?

 

Vincent Dole, “Father of MMT,” Dies at Age 93

From Editor (SB Leavitt) –– On August 1, 2006, after a long illness, Vincent Dole, MD, died at age 93. He was acknowledged worldwide as the “founding father” of methadone maintenance treatment (MMT) for having developed the treatment for opioid addiction in the mid-1960s. Yet, he himself always was quick to acknowledge the efforts of his research team, including his wife at the time, Marie Nyswander, MD, Mary Jeanne Kreek, MD, and others.
Their pioneering work, guided by Dole, helped establish opioid addiction as a bona fide brain disease and demonstrated MMT as a medical treatment of unequalled effectiveness. They did so in the face of initially strong opposition, both from government authorities and a skeptical medical community. Their persistence in developing MMT and in training other practitioners has helped millions of persons addicted to opioids become rehabilitated, productive members of society.

Throughout the past decade, Dole was a strong supporter and friend of Addiction Treatment Forum, and he was featured in the Spring 2005 edition (see: http://www.atforum.com/SiteRoot/pages/current_pastissues/spring2005.html#mmtpioneer). Dole’s greatest disappoint was that, to this day, there are still many prejudices against MMT (despite its firm footing in scientific evidence), which stigmatize both methadone itself and recovering patients in MMT. He commented, “I would love to believe that the medical profession has come to accept addiction as a medical problem. That would be my dream. However, there is still so much ignorance and prejudice that it saddens me.”

More insights and lessons shared by Dole will be featured in the Summer edition of AT Forum. Meanwhile we join the entire addiction treatment community in expressing our sincere condolences to his wife Margaret and the entire family.

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NIDA Supports Addiction Treatment in Criminal Justice System

The National Institute on Drug Abuse (NIDA) says that locking up people with addictions is no cure, instead the agency advocates the use of effective treatment in criminal-justice settings. A new report from NIDA urges more use of methadone and other addiction medications in prisons and court-ordered treatment programs; the agency also endorsed using pressure tactics to keep offenders in treatment and drug-testing to track treatment progress and prevent relapse. “The criminal-justice system offers an extraordinary opportunity to help people with drug problems,” said NIDA Director Nora Volkow.

The NIDA report, “Principles of Drug Abuse Treatment for Criminal Justice Populations,” notes the following:

Reported by: Associated Press, July 24, 2006.

[Note: “Principles of Drug Abuse Treatment for Criminal Justice Populations” is available from NIDA at: http://www.drugabuse.gov/drugpages/cj.html. A special report from AT Forum, “Methadone Maintenance Treatment in the Criminal Justice System” is available at: http://atforum.com/SiteRoot/pages/rxmethadone/rxmethadone.shtml#MMTcrimjust. Access to websites checked 8/14/06.]

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Addiction Counselor Shortage On The Horizon

NAADAC, the Association for Addiction Professionals, is predicting that the U.S. could face a shortage of addiction counselors as a cadre of longtime professionals reach retirement age without younger counselors to replace them. According to NAADAC, 80% of addiction counselors are between ages 40-50, with a great many planning to retire during the next decade.

Lack of good pay is preventing young professionals from entering the field: an entry-level addiction counselor can expect to earn $16,000-$25,000 a year. “Within a year or two, they're leaving the field because the money isn't good enough to stay,” said NAADAC deputy director Shirley Mikell. NAADAC is trying to improve counselor recruitment and retention by seeking salary support from the federal government and loan forgiveness for graduate students. But stigma also plays a role in the shortage of counselors; many young people have been told from a young age that people with addictions should be avoided. That may be one reason why addiction programs have the most success recruiting counselors from the ranks of recovering addicts.

Reported by: Associated Press, June 22, 2006.

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Unreported Cannabis Use Predicts Cocaine/Heroin Abuse During MMT

The nonreporting of cannabis (THC) use and its relationship to heroin and cocaine use were investigated in 690 patients enrolled in 25- to 29-week clinical trials of contingency management plus methadone maintenance treatment (MMT). Urine specimens and self-reports of drug use were collected 3 times/week.

Compared to non-THC users (n=317), patients with THC-positive urine screens (n=373) were more likely to be male and have more years of THC use, but were not different on other characteristics. Predictors of THC use nonreporting were a low rate of THC-positive urine screens during treatment, fewer days of THC use in the last 30 day before treatment, and African-American race. Nonreporting of THC use was associated with significantly greater opioid and cocaine use; thus, the researchers concluded that the nonreporting of THC use is a significant predictor of greater cocaine and heroin use.

Source: Ghitza UE, Epstein DH, Preston KL. Nonreporting of cannabis use: Predictors and relationship to treatment outcome in methadone maintained patients. Addict Behav. 2006 [July 31; epub ahead of print].

[Comment: While self-reported THC use could be an important signal of the need for more intensive counseling to stem the expected abuse of heroin/cocaine, it must be recognized that punitive approaches by MMT clinics regarding continued THC use would discourage such reporting by patients. – Editor (SB Leavitt).]

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MMT Clinic Practices Make Greatest Difference in Patient Retention

Retention in Opioid Agonist Therapy (OAT) is associated with reductions in substance use, HIV risk behavior, and criminal activities in opioid dependent patients. To improve the effectiveness of treatment for opioid dependence, it is important to identify predisposing characteristics and clinic-related variables that predict retention in OAT. Participants in this study included 258 veterans enrolled in 8 outpatient methadone maintenance treatment (MMT) programs. Investigators found that clinic/provider-related practices played a vital role in predicting retention in OAT programs, since higher methadone doses and greater treatment satisfaction by patients were among the strongest predictors of retention at 1-year follow-up.

Reference: Villafranca SW, McKellar JD, Trafton JA, Humphreys K. Predictors of retention in methadone programs: a signal detection analysis. Drug Alcohol Depend. 2006;83(3):218-224.

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Methadone’s Influence on QT Prolongation Studied in Hospital Setting

In a study of hospitalized injection drug users, QT-interval prolongation was seen in a considerable number of patients treated with methadone but not among those who were not treated with methadone. The QT interval is a measure of normal heart rhythm, as measured by an electrocardiogram, and its prolongation can signal a potential for cardiac rhythm disturbances. This measurement is usually adjusted to account for heart rate and expressed as QTc (QTc = 0.5 seconds is generally considered the maximum safe limit).

Findings from some laboratory studies have shown that methadone can increase the QTc interval in a dose-dependent fashion. The extent to which this is seen in an inpatient, clinical setting, however, was unclear. To investigate, George B. Ehret, from Geneva University Hospital, Switzerland, and colleagues analyzed data from 247 injection drug users who were treated at a tertiary care hospital over a 5-year period. The subjects included 167 who received methadone maintenance treatment and 80 who did not.

The rate of QTc prolongation to 0.5 seconds or longer was significantly higher among methadone-treated patients than among controls: 16.2% vs. 0%. Moreover, 6 patients (3.6%) receiving methadone had an episode of torsades de pointes, a potentially life threatening arrhythmia. A weak but significant association between QTc length and the daily methadone dose was also noted, the investigators report; however, in addition to methadone dose, other factors tied to QT prolongation included hypokalemia, lower prothrombin level, and the use of drugs that inhibited cytochrome P450-3A4.

“The recognition of cardiovascular adverse effects of methadone is particularly important because young patients rarely undergo cardiac monitoring and are susceptible to the use of drugs that interfere with cardiac electrical activation,” Ehret and colleagues stated in their report. Methadone doses ranged from 4 to 600 mg/d (median 100), and the researchers further observed that prolonged QTc could occur with relatively low doses of methadone.

See: Ehret GB, Voide C, Gex-Fabry M, et al. Drug-induced long QT syndrome in injection drug users receiving methadone: high frequency in hospitalized patients and risk factors. Arch Intern Med. 2006;166(12):1280-7.

[Comment: This study is unique in its hospital setting with controlled conditions; however, a similar potential of methadone to affect cardiac rhythm in certain patients has been previously reported in other settings. For a further discussion of this subject and clinical recommendations, see the AT Forum report, “Cardiac Considerations During MMT.” Available at: http://www.atforum.com/SiteRoot/pages/rxmethadone/rxmethadone.shtml. Access checked 8/15/06.  – Editor (SB Leavitt).]

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Low Bone Density Common in MMT Patients; Especially Males

Researchers at the Boston University School of Medicine examined the frequency and severity of low bone mineral density (BMD) among 92 patients enrolled in a methadone maintenance treatment (MMT) program and determined risk factors for low BMD in this population. Data were derived from a standardized survey, medical record reviews, and X-ray assessments.

Results of X-rays showed below normal bone density in 83% (76/92) of the study sample with 35% showing osteoporosis and 48% showing signs of osteopenia (low bone density). None of the participants reported a known prior diagnosis of osteoporosis.

Risk factors for low BMD included: tobacco use, in 91% of subjects; heavy alcohol use, 52%; and HIV infection, 28%. Significant predictors of low BMD included: male gender, lower weight, and heavy alcohol use. Only 17% of MMT patients were on medications that lower the risk of osteoporosis: estrogen (n=5), testosterone (n=4), or calcium (n=4) and Vitamin D (n=2) supplements.

The researchers concluded that more than three quarters of this sample of patients in a MMT program had low BMD, and treatable conditions associated with low BMD were commonplace. Efforts to increase awareness of low BMD in MMT patients – particularly males, in which this might be unexpected – should be considered so that effective treatment may be employed to lower future bone fracture risks.

Source: Kim TW, Alford DP, Malabanan A, Holick MF, Samet JH. Low bone density in patients receiving methadone maintenance treatment. Drug Alcohol Depend. 2006 [July 19; epub ahead of print].

[Clinical Comment: This subject was previously discussed in AT Forum, and the potential importance of vitamin D supplements during MMT emphasized. It is interesting to note that research in this population consistently shows that male MMT patients have an increased risk of low BMD. See “Vitamin D: A Solution for Bone Aches During MMT?” at: http://www.atforum.com/SiteRoot/pages/current_pastissues/fall2005.html#vitamind. Access checked 8/14/06. – Editor (SB Leavitt).]

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Benefits of Sterile Syringe Access During MMT Examined

Researchers evaluated an intervention designed to improve access to sterile syringes and safe syringe disposal for injection drug users (IDUs) newly enrolled in methadone maintenance treatment (MMT). The study involved two sequential groups of 100 recent entrants into a program in the Bronx, NY.

A substantial number of participants had injected in the previous 6 months, and most continued injecting during the early weeks of MMT. The intervention was associated with significant behavior changes among IDUs, including significantly increased use of pharmacies as a primary source of syringes (11% vs. 37%) and decreases in both purchasing of syringes on the street (51% vs. 27%) and needle sharing (40% vs. 7%). The researcher stated that their findings suggest that drug treatment programs can serve an important role in reducing injection-related risk behavior by facilitating access to sterile syringes; however, the intervention had no impact on the prevalence of illicit drug injection or on syringe disposal practices.

Reference: McNeely J, Arnsten JH, Gourevitch MN. Improving access to sterile syringes and safe syringe disposal for injection drug users in methadone maintenance treatment. J Subst Abuse Treat. 2006;31(1):51-57.

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Prize Incentives Do Not Increase Gambling Risk

Certain contingency management (CM) interventions during methadone maintenance treatment that provide drug-abstinent patients in addiction treatment programs a chance to win prizes of varying magnitudes have been demonstrated as effective in retaining patients in treatment and reducing drug use. However, this intervention has been criticized as possibly increasing gambling because it contains an element of chance.

Gambling behaviors before, during, and 3 months after participation in a multi-site study of CM were compared for stimulant abusers randomly assigned to 12 weeks of standard care with (n = 407) or without (n = 396) prize-based CM. Among study participants enrolled in outpatient non-methadone drug abuse treatment (n = 415), 26% reported gambling during the observation period, and this rate was 37% among participants (n = 388) enrolled in methadone maintenance programs. No differences in gambling over time were noted between those assigned to the prize CM versus standard care conditions, in either methadone or non-methadone programs, indicating that a prize-based CM procedure does not adversely impact gambling behavior among patients in addiction treatment programs.

Source: Petry NM, Kolodner KB, Li R, et al. Prize-based contingency management does not increase gambling. Drug Alcohol Depend. 2006;83(3):269-273.

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Clinical Comparison of Methadone vs Buprenorphine in Italy

A study in Italy compared the effectiveness of buprenorphine (BUP) and methadone maintenance treatment in opioid-addicted patients in a clinical setting. This observational prospective study lasted 24 months.

Of the 257 patients enrolled in the study, 121 received BUP (average 11 mg/day; range = 2-30 mg/d), 136 received methadone (average 54 mg/day; range = 4-140 mg/d). The main efficacy parameters were treatment retention rates and illicit substance abuse, as assessed by urinalysis.

Retention rates were comparable in both treatment groups, but BUP-treated subjects had significantly lower rates of illicit opioid consumption. The investigators concluded that, in a non-experimental clinical practice setting, BUP is as effective as methadone in the treatment of heroin dependence. BUP also offered significantly better opioid abuse control, thus possibly allowing longer and more effective treatment with reduced relapse rates.

Source: Vigezzi P, Guglielmino L, Marzorati P, et al. Multimodal drug addiction treatment: A field comparison of methadone and buprenorphine among heroin- and cocaine-dependent patients. J Subst Abuse Treat. 2006;31(1):3-7.

[Research Perspective: According to other research through the years, the methadone doses in this study were probably too low and subtherapeutic for a great many patients; unless, this clinic population differed in significant ways from others around the world. This could account for some continued opioid abuse in this group. Therefore, the external validity of this comparison of buprenorphine versus methadone maintenance must be questioned. – Editor (SB Leavitt).]

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Initial Adoption of Buprenorphine Studied

A study by researchers at Wayne State University, Detroit, Michigan, examined the adoption of buprenorphine for the treatment of opioid dependence among U.S. substance abuse treatment facilities and their characteristics at the time of the initial availability of the medication. Data came from a 2003 national survey of all substance abuse treatment facilities in the U.S.

Out of a sample of 13,060 facilities, 5.5% reported that they offered buprenorphine. Not unexpectedly, the prevalence was higher in certified opioid treatment programs (11.3%) compared with other facilities (4.6%). Overall results suggested that the adoption of buprenorphine soon after the FDA approved its use for treatment of opioid dependence and the shipping of the medication commenced was associated with facilities already offering pharmacotherapies such as naltrexone and medically-assisted withdrawal. The authors expect that these findings will provide baseline data to track the adoption of buprenorphine by substance abuse treatment programs in future years.

Source: Koch AL, Arfen CL, Schuster CR. Characteristics of U.S. substance abuse treatment facilities adopting buprenorphine in its initial stage of availability. Drug Alcohol Depend. 2006;83(3):274-278.

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Screening Tool Helps Identify ADHD In Substance Abusers

Attention Deficit-Hyperactivity Disorder (ADHD) is a major learning disability among both children and adults; and, it is especially common among drug users and alcoholics, increasing the severity of their addiction problems. ADHD is treatable, but diagnosing it in adult substance users has been difficult and expensive.

Charles Cleland and colleagues at National Development and Research Institutes (NDRI) in New York City found that a screening test originally developed for the general population – the Conners Adult ADHD Rating Scale (CAARS) – also works well to identify ADHD symptoms among substance users. The CAARS is an effective, simple and inexpensive way to screen adult substance users for ADHD, so that they can be referred for confirmatory diagnosis and possible ADHD treatment. Stephen Magura, a principal investigator of the NDRI study, remarks: “Although more research is needed, our study shows that better screening of substance users for ADHD is possible, with the payoff that ADHD will be treated and recovery from addiction will be facilitated.”

Source: Cleland C, Magura S, Foote J, et al. Factor structure of the Conners Adult ADHD Rating Scale (CAARS) for substance users. Addict Behav. 2006;31(7):1277-1282.

[For more information on CAARS, see: http://www.pearsonassessments.com/tests/caars.htm. For a discussion and resource references in AT Forum, see “AD/HD: A Common Problem During MMT?” at: http://www.atforum.com/SiteRoot/pages/current_pastissues/summer2005.html#adhd. Web access checked 8/14/06.]

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Pain Sensitivity, Mood Disturbances: Opioid-Class Effects?

Some research has shown that methadone maintenance treatment (MMT) can be associated with hyperalgesia (increased sensitivity to certain types of pain) and elevated mood disturbance –– effects that are opposite to those induced by acute opioid administration, and which may undermine outcomes during MMT. This study from the National Addiction Centre, Institute of Psychiatry, King's College London, London, UK, examined the impact of switching between methadone and slow-release morphine on pain sensitivity and mood status in 14 MMT patients using an open-label crossover design.

Pain responses were nearly identical for each drug. Patients reporting inadequate withdrawal suppression on methadone showed improved mood stability when transferred to morphine, but overall mood-disturbance levels did not differ between drugs. The authors conclude that hyperalgesia and mood disturbance cannot be resolved by changing from methadone to morphine maintenance.

Reference: Mitchell TB, White JM, Somogyi AA, Bochner F. Switching between methadone and morphine for maintenance treatment of opioid dependence: impact on pain sensitivity and mood status. Am J Addict. 2006;15(4):311-315.

[Clinical Comment: An important implication of this small study is that mood disturbances and increased pain sensitivity sometimes reported with long-term methadone therapy may be opioid-class effects, rather than particular to methadone. That is, switching to long-acting morphine, buprenorphine, or maintenance on other opioids for addiction treatment would not necessarily be a solution. It also is important to recognize that withdrawal suppression and mood stability during methadone maintenance rely highly on providing adequate methadone dosing to begin with. Further research in larger populations would be helpful in clarifying these opioid-class relationships. Issues relating to methadone and mood were discussed in the Winter 2004 edition of AT Forum, see: http://www.atforum.com/SiteRoot/pages/current_pastissues/winter2004.shtml#anchor6. Access checked 8/15/06.  – Editor (SB Leavitt).]

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Notice:

All facts and opinions are those of the sources cited. News reports may have been edited for length and/or modified for clarity without altering essential data as originally published.

Addiction Treatment Forum and its associates do not endorse any medications, products, or treatments described, mentioned, or discussed in any of the sources referenced. Nor are any representations made concerning efficacy, appropriateness, or suitability of any such products or treatments. This News Update is made possible by an educational grant from Mallinckrodt Inc., distributors of methadone and naltrexone.

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.