AT Forum NEWS NOTES & UPDATES #105
May – June 2006
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Contents
MMT Patients With Pain Need Special Care
Factors for MMT Retention Reported
Methadone Treatment in Prison Saves Money
Methadone in Puerto Rican Prison a Success
MMT Improves Cognitive Function & Performance
Breast Feeding is Best for Infants of Addicted Mothers
Depression an Important Consideration in Addiction Treatment
Methadone-Associated Deaths in Belgium Examined
Outreach Gives Former MMT Patients Added Chances for Recovery
Ramifications of Medicaid Cuts on Access to MMT
Nelfinavir Effective, Safe in MMT Patients with HIV/HCV
Cannabis Use Common in MMT Patients
Acupuncture Benefits for Opioid Addiction Questioned
Methadone Compared With Buprenorphine in Australia
Compiled & Edited by Stewart B. Leavitt, PhD
MMT Patients With Pain Need Special Care
Clinicians and researchers have expressed doubt that opioid-dependent patients with significant pain can be effectively treated in methadone maintenance treatment (MMT) programs; however, little specific research exists on this topic. Patients who report significant pain in the month preceding entry to MMT also tend to have a distinct and more severe pattern of polysubstance use, and more medical and psychosocial problems than do those without pain. The present study investigated 1-year treatment outcomes of MMT patients with opioid dependence and pain.
Analyses were based on a national sample of 200 MMT patients. Substance use and related problems were measured at treatment entry and 12 months later. Patients self-reported pain severity during the month preceding treatment entry.
Compared with patients without significant pain, those who reported significant pain at baseline (n = 103) showed similar substance-related improvements, but poorer psychosocial functioning at 1 year. The authors concluded that patients with and without significant pain experience comparable reductions in substance use when provided with standard care in MMT programs. However, additional medical and/or mental health treatment is needed for those with pain.
Reference: Ilgen MA, Trafton JA, Humphreys K. Response to methadone maintenance treatment of opiate dependent patients with and without significant pain. Drug Alcohol Depend. 2006;82(3):187-193.
For a recent update, also see: Leavitt SB. Perils of pain in MMT: Updated evidence. AT Forum. 2006(spring);15(2). Available online at: http://www.atforum.com/SiteRoot/pages/current_
pastissues/spring2006.html. Access checked 6/16/06.
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Factors for MMT Retention Reported
To identify predictors of treatment retention in an Israeli methadone maintenance treatment (MMT) clinic, researchers prospectively studied 492 patients admitted from 1993 and 2003. Analyses included methadone dose and urinalysis results (for methadone, cocaine, opioids, benzodiazepines, THC, amphetamines) of each patient in the first month and after 1 year in treatment (or during the last month if the stay was more than 3 months and less than 1 year) and patients’ characteristics (modified ASI).
The 1-year retention rate was approximately 74%, and two-thirds (66%) stopped opioid abuse after 1 year in treatment. On admission, 14% of patients had used cocaine, and there was a net decrease of 62% in this after 1 year. Factors predicting prolonged retention in MMT treatment were: 1) daily methadone dose of 100 mg or greater, 2) negative urinalyses for opioids after 1 year, and 3) being a parent on admission.
The authors conclude that their high rate of retention, high proportion of opioid abuse cessation, and net reduction in cocaine abuse – similar to normal standards in MMT clinics elsewhere in the world – justify the expansion of the MMT clinic network in Israel. A protocol favoring higher methadone dosage as appropriate is recommended.
Reference: Peles E, Schreiber S, Adelson M. Factors predicting retention in treatment: 10-year experience of a methadone maintenance treatment (MMT) clinic in Israel. Drug Alcohol Depend. 2006;82(3):211-217.
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Methadone Treatment in Prison Saves Money
Prisoners who stay on methadone treatment programs for 8 months or more while incarcerated are 70% less likely than other heroin-addicted inmates to return to jail, at least in the short-term, Australian researchers say.
A four-year study of almost 400 heroin users in NSW jails has prompted the researchers to call for an expansion of methadone programs in Australian prisons. And, they said, broadening the programs to include more prisoners would substantially save taxpayers’ money. The researchers found the risk for released prisoners to end up back in jail decreased the longer they stayed on methadone treatment.
Study author Kate Dolan, of the National Drug and Alcohol Research Center at the University of NSW, noted that the cost of methadone treatment for one inmate is only 5% of the cost for keeping them in jail for a year if they returned to prison. That means methadone treatment only needs to keep a person out of jail for 20 days to be more than cost-effective.
“If they keep on methadone, they stay on the straight and narrow,” Dolan said. “They need to be on it 8 months ... to stabilize themselves.” She further noted that in NSW half of the 8,000 prisoners were heroin injectors, yet less than a quarter of them were on methadone treatment.
Source: Prison methadone saves money. The Age (Australia). April 17, 2006.
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Methadone in Puerto Rican Prison a Success
To describe and evaluate a pilot methadone maintenance program for heroin-dependent inmates of Las Malvinas men’s prison in San Juan, Puerto Rico, researchers examined data from self-reports of inmates’ drug use before and during incarceration, attitudes about drug treatment in general and methadone maintenance in particular, and expectations about behaviors upon release from prison. Data also were gathered from testing inmates’ urine.
The study compared program patients (n = 20) with inmates selected at random from the prison population (n = 40). Qualitative data obtained by interviewing program staff, the correctional officers and superintendent, and commonwealth officials responsible for establishing and operating the program were analyzed to identify attitudes about methadone and program effectiveness.
Heroin use among prisoners not in treatment was common; 58% reported any use while incarcerated and 38% reported use in past 30 days. All patients in the methadone program had used heroin in prison in the 30 days prior to enrolling in treatment. While in treatment, the percentage of prisoner-patients using heroin was reduced, according to self-report (to 1 in 18; a 94% reduction) and urine testing (to 1 in 20; a 95% reduction). Participation in treatment was associated with an increased acceptance of methadone maintenance.
Prison personnel and commonwealth officials were supportive of the program, which appears to be a success. Officials have begun an expansion from the current ceiling of 24 inmates to treat 300 or more inmates.
Reference: Heimer R, Catania H, Newman RG, et al. Methadone maintenance in prison: Evaluation of a pilot program in Puerto Rico. Drug Alcohol Depend. 2006;83(2):122-129.
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MMT Improves Cognitive Function & Performance
A clinical study examined cognitive function in 17 opioid-dependent subjects at baseline and after 2 months of methadone maintenance treatment (MMT). The patients demonstrated significant improvements from baseline on measures of verbal learning and memory, visuospatial memory, and psychomotor speed. At the same time, there was a reduced frequency of illicit drug use relative to baseline.
No effect of illicit drug use was observed when the sample was stratified by urine toxicology results, suggesting that improvements in cognition were not associated with additional illicit drug use. Therefore, results suggest that opioid-dependent subjects exhibit significant improvement in cognitive/mental function during MMT, the researchers note.
Reference: Gruber SA, Tzilos GK, Silveri MM, Pollack M, Renshaw PF, Kaufman MJ, Yurgelun-Todd DA. Methadone maintenance improves cognitive performance after two months of treatment. Exp Clin Psychopharmacol. 2006;14(2):157-164.
[Although most studies, such as this one, support MMT for normalizing mental (cognitive) functioning, it must be noted in fair balance that sporadic reports have depicted less favorable outcomes. See, for example, Prosser et al., Cognitive Impairment During MMT vs Abstinence Studied, in AT Forum News Updates, March-April 2006. Available at: http://www.atforum.com/SiteRoot/pages/news_updates/
news_updates.shtml#_Toc132876187. – SB. Leavitt, PhD.]
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Breast Feeding is Best for Infants of Addicted Mothers
A retrospective chart review, involving 190 drug-dependent mother and infant pairs, assessed the effects of breast milk on the severity and outcome of neonatal abstinence syndrome (NAS). Patients were categorized according to the predominant type of milk consumed by the infant on the fifth day of life (breast milk, n = 85; or formula, n = 105).
NAS was significantly lower in the breast milk group during the first 9 days of life, even after adjusting for infant prematurity and exposure to polydrug and/or methadone. The median time to withdrawal occurred considerably later and significantly fewer infants required withdrawal treatment in the breast milk group. The authors concluded that breast milk intake is associated with reduced NAS severity, delayed onset of NAS, and decreased need for pharmacologic treatment, regardless of the infant’s gestation and the type of drug exposure, including methadone.
Reference: Abdel-Latif ME, Pinner J, Clews S, Cooke F, Lui K, Oei J. Effects of breast milk on the severity and outcome of neonatal abstinence syndrome among infants of drug-dependent mothers. Pediatrics. 2006;117(6):e1163-1169.
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Depression an Important Consideration in Addiction Treatment
A total of 495 heroin users were interviewed for the Australian Treatment Outcome Study (ATOS) and were re-interviewed at 12-months following entry into substance abuse treatment. The rate of current major depression declined significantly from 26% to 11% for the follow-up period. Those with current major depression on follow-up experienced fewer total days in treatment, but engaged in more treatment episodes.
Furthermore, in comparison with those without depression, depressed individuals had less exposure to methadone or buprenorphine maintenance treatment and residential rehabilitation for the follow-up period, but spent more time in detoxification. Those with current major depression on follow-up also reported heavier heroin and other drug use, more risk-taking behaviors, poorer physical health, and greater psychopathology than those without a diagnosis of current major depression.
The authors recommend caution in interpreting these relationships, since individual patient differences must still be taken into account; however, the findings of this study illustrate the need to consider depression as a major concern in the treatment of heroin dependence.
Reference: Havard A, Teesson M, Darke S, Ross J. Depression among heroin users: 12-Month outcomes from the Australian Treatment Outcome Study (ATOS). J Subst Abuse Treat. 2006;30(4):355-362.
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Methadone-Associated Deaths in Belgium Examined
All methadone-associated deaths in Belgium from October 2002 to April 2005 were analyzed. During the 30-month period, 26 deaths related to methadone were listed, of which 3 occurred in accidental circumstances. In the other 23 cases, methadone was found to be always associated with other psychotropic substances, mainly benzodiazepines (18 cases), other opioids (15 cases), and alcohol (5 cases). Based on the nature of the agents combined with methadone, records were divided into two groups: 1) 17 observations – drugs at less than therapeutic levels were detected, 2) 6 observations – drugs at high and toxic levels were detected.
Blood serum methadone concentrations were similar between the 2 groups of individuals; the median values (ranges) were 308 (110-1,300) ng/mL methadone for group 1, and 776 (93-2,080) ng/mL for group 2. Thus, there is an important overlap between the therapeutic blood methadone concentrations (150-400 ng/mL) and blood concentrations observed in fatalities. The authors stress that it is necessary for all information and post-mortem results to be examined in a critical way to identify and justify exact causes of drug-related deaths involving methadone.
Reference: Denooz R, Charlier C. Methadone fatal intoxication [in French, English abstract]. Acta Clin Belg Suppl. 2006;(1):32-36.
[This investigation supports the many others that have found (A) methadone-associated mortality more often than not also involves other substances of abuse, and (B) there is a broad overlap of lethal and therapeutic serum levels of methadone. That is, what might be fatal in one person can be therapeutic in another, and taken out of context it is inappropriate to suggest that any single amount of methadone in an individual’s blood serum is automatically lethal. Unfortunately, this is a lesson that is usually overlooked by the mass media, and some pathologists, when reporting on methadone-related deaths. – SB. Leavitt, PhD]
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Outreach Gives Former MMT Patients Added Chances for Recovery
Opioid dependence is a chronic relapsing disease often requiring multiple treatment experiences. Despite this knowledge, few methadone maintenance treatment (MMT) programs follow-up with discharged patients who frequently continue to engage in risky behaviors. The aim of this project was to evaluate the effectiveness of outreach case management for post-discharged methadone patients.
At 90 days post-discharge from MMT, 128 active out-of-treatment illicit-opioid users were randomly assigned to receive either a passive referral (PR) for drug treatment (n=52) or were provided with 6 weeks of outreach case management (OCM), an intervention designed to help motivate and coach patients to re-enter MMT (n=76).
At 6 months post-baseline, 29% of the OCM participants had successfully re-enrolled in drug treatment compared with only 8% of the PR participants. A further analysis of this significant difference showed that OCM participants were nearly 6 times more likely than PR participants to re-engage in MMT. Moreover, OCM subjects had fewer opioid and cocaine positive urine tests at the 6-month follow-up as compared with PR subjects.
These findings highlight the importance of engaging former patients in treatment and actively assisting in treatment re-entry. OCM is a simple approach to reduce the number of out-of-treatment drug users; however, the authors concede, the availability of funding for outreach and treatment often limits enrollment opportunities.
Reference: Coviello DM, Zanis DA, Wesnoski SA, Alterman AI. The effectiveness of outreach case management in re-enrolling discharged methadone patients. Drug Alcohol Depend. 2006 [May 1; epub ahead of print].
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Ramifications of Medicaid Cuts on Access to MMT
An observational study examined changes in access to methadone maintenance treatment (MMT) following Oregon’s decision to remove expanded access to substance abuse treatment from the state’s Medicaid benefit. Access was compared before and after the benefit change for two groups of adults addicted to opioids presenting for publicly funded treatment.
Illicit-opioid users presenting for publicly funded treatment after the change were less than half as likely to be placed in an MMT program, as compared with the prior year. Further analysis revealed that those with no recent treatment history were less likely to even attempt access to treatment after the benefit change. These results have implications for states considering Medicaid cuts; especially, if the anticipated increases in illegal activity, emergency room utilization, unemployment, and mortality due to less treatment access can be demonstrated.
Reference: Deck DD, Wiitala WL, Laws KE. Medicaid coverage and access to publicly funded opiate treatment. J Behav Health Serv Res. 2006;33(3):324-334.
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Nelfinavir Effective, Safe in MMT Patients with HIV/HCV
The safety, efficacy, and tolerability of nelfinavir(NFV)-containing antiretroviral therapy were evaluated in 51 methadone maintenance treatment (MMT) patients co-infected with HIV and hepatitis C (HCV). Nelfinavir was discontinued in 2 patients for liver function abnormalities but resumed in 1 patient. In 12 patients, pre-NFV therapy liver function abnormalities resolved completely during NFV therapy. Changes in CD4-cell counts and viral loads were favorable. Three patients had diarrhea and 4 patients had constipation. Nelfinavir was not discontinued or the dose adjusted in any of these patients. Patients who had received NFV for 36 months or longer had a smaller increase in mean methadone dose compared with patients who had received NFV less than 36 months. The authors conclude that NFV is safe, efficacious, and well tolerated in MMT patients.
Reference: Brown Jr LS, Kritz S, Chu M, Madray C. Safety, efficacy, and tolerability of nelfinavir-containing antiretroviral therapy for patients coinfected with HIV and hepatitis C undergoing methadone maintenance. J Subst Abuse Treat. 2006;30(4):331-335.
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Cannabis Use Common in MMT Patients
More than 8-in-10 drug users who are on methadone maintenance treatment (MMT) continue to use cannabis, and some also use cocaine regularly, according to research among MMT patients of the Health Service Executive (HSE) in North Dublin, Ireland.
The large survey of 851 methadone-treated patients, titled “High Incidence of Polydrug Usage among Methadone Patients,” also concluded that cocaine abuse is emerging as a major problem among MMT patients, with a great majority of them also using cannabis on a daily basis. According to investigators, more than 70% of the participants were receiving medium to high daily doses of methadone [amounts unstated – Editor].
Zeibun Ramatoola, lecturer in pharmaceutics at the Royal College of Surgeons of Ireland (RCSI), who headed up the survey, said further study was needed to measure the impact of continuing drug use by those on the methadone program. However, the survey warned that despite its perception as a “safe drug,” cannabis is known to have “both acute and chronic health effects and does produce dependence.”
Source: Shanahan C. Eight-in-10 methadone patients use cannabis. Irish Examiner.com 04/19/06. Survey findings were to be presented at RCSI Research Day, 2006.
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Acupuncture Benefits for Opioid Addiction Questioned
A review of the efficacy of acupuncture as a treatment for opioid addiction, covering 33 years of reported literature in western scientific journals, was systematically undertaken. Some abstracts from Chinese language journals were also briefly reviewed.
According to the author of this review, supportive evidence often came from less rigorous studies (e.g., no control groups, unblinded). When well-designed clinical trials (randomized, controlled, single-blind methodologies) were used, there was no significant evidence for acupuncture being a more effective treatment than controls. Some of the current supportive evidence for efficacy came from Chinese journals that have not been translated into English as yet.
Reference: Jordan JB. Acupuncture treatment for opiate addiction: A systematic review. J Subst Abuse Treat. 2006;30(4):309-314.
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Methadone Compared With Buprenorphine in Australia
While there are some problems with the analyses and conclusions, a previously reported Australian comparative trial of methadone and buprenorphine maintenance has generated very useful data, according to Caplehorn and Deeks in this present paper. Contrary to the researchers’ conclusions in the Australian comparative trial, the data do provide good evidence that methadone is better than buprenorphine at retaining addicts in programs where clinicians can adjust their patients’ daily doses. The trial also provides the first evidence that methadone is significantly cheaper than buprenorphine maintenance. The savings from less frequent clinic attendance were more than offset by the extra time spent dispensing buprenorphine and the greater cost of the buprenorphine itself. In cost-effectiveness terms, the trial’s results show methadone “dominates” buprenorphine as an opioid maintenance drug because it is not only more effective but also cheaper, say Caplehorn and Deeks.
Reference: Caplehorn J, Deeks JJ. A critical appraisal of the Australian comparative trial of methadone and buprenorphine maintenance. Drug Alcohol Rev. 2006;25(2):157-160. cultural and ethic backgrounds or those with co-occurring mental disorders and medical conditions.
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TIP 45 Released, Addresses Drug Detox & Treatment
The Substance Abuse and Mental Health Services Administration (SAMHSA) has released a new Treatment Improvement Protocol (TIP 45) titled, “Detoxification and Substance Abuse Treatment.” It provides clinicians with the latest information on detoxification; emphasizing that, by itself, detoxification does not constitute complete substance abuse treatment, and it stresses the necessity for linking patients in detoxification with substance abuse treatment services.
Developed by a consensus panel of experts with diverse experience in detoxification services, TIP 45 is a revision of TIP 19, “Detoxification from Alcohol and other Drugs.” It provides up-to-date information about the physiology of withdrawal, pharmacologic advances in the management of withdrawal, patient placement procedures, and managing detoxification services within comprehensive systems of care. Additionally, the TIP provides medical information on detoxification protocols for specific substances, as well as considerations for individuals from diverse cultural and ethic backgrounds or those with co-occurring mental disorders and medical conditions.
TIP 45 (Item #BKD541) is available for download on the web at: http://www.ncadi.samhsa.gov/. Or, copies may be obtained free of charge from SAMHSA’s National Clearinghouse for Alcohol and Drug Information by calling (800)729-6686.
Source: SAMHSA Press Release, June 13, 2006.
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SAMHSA Director Resigns Post
Charles Curie, administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA) for nearly the entire span of the Bush administration, has resigned. He plans to leave the agency on August 5, 2006.
In his resignation letter dated May 22nd, Curie offered no hint of the reasons behind his departure, rather taking the opportunity to lavish praise on the administration’s New Freedom Initiative and Access to Recovery programs. His departure will leave SAMHSA with multiple gaps in its senior leadership. The agency’s deputy administrator job has been filled on an acting basis by dentist Eric Broderick; likewise, Dennis O. Romero has temporarily been leading SAMHSA’s Center for Substance Abuse Prevention (CSAP) since Beverly Watts Davis moved to the SAMHSA administrator’s office as a prevention advisor to Curie in late 2005. The deputy director’s seat at CSAP also is being filled on an interim basis, by Rose Kittrell, a staffer previously involved in the agency’s high-risk-youth and women’s programs.
Source: Curley B. Join Together online. May 26, 2006.
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Updated Directory of Addiction Treatment Programs Available
The Substance Abuse and Mental Health Services Administration’s (SAMHSA) updated guide to finding local addiction treatment programs is now available. The guide, “National Directory of Drug and Alcohol Abuse Treatment Programs 2006,” provides information on thousands of alcohol and drug treatment programs located in all 50 states, the District of Columbia, Puerto Rico, and four U.S. territories.
The directory, a nationwide inventory of nearly 11,000 drug abuse and alcoholism treatment programs and facilities, is organized and presented in state-by-state format for quick reference by health care providers, social workers, managed care organizations, and the public. It lists public and private facilities, all of which are licensed, certified, or otherwise approved by substance abuse agencies in each state.
This directory is a paper-based complement to SAMHSA’s Internet-based Substance Abuse Treatment Facility Locator Service. The Internet service, which is continuously updated, provides driving directions to the nearest treatment facilities, as well as descriptions of services available, and contact information, including addresses and telephone numbers. The direct website link is: http://findtreatment.samhsa.gov/.
To obtain a free hard copy of the “National Directory of Drug and Alcohol Abuse Treatment Programs 2006,” contact SAMHSA’s Clearinghouse or call (800)729-6686.
Source: SAMHSA Press Release, May 30, 2006.
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