A Collaborative Initiative for Patients and Clinical Professionals

AT Forum NEWS NOTES & UPDATES #110

March-April 2007

Compiled & Edited by Stewart B. Leavitt, PhD

Prior Edition: January/February 2007
For other past editions see Addiction Resources.

To view past news updates that are archived in volumes under Addiction Resources click here.

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Contents

MMT Prolongs Life of Those Staying in Treatment

Treatment Contracts Offer Hope to Addicts

Treatment Admissions for Heroin Decrease, Other Opioids Increasing

Rx Opioid Abuse Common in New MMT Patients

Adequate Methadone Helps Reduce Alcohol, Cocaine Abuse in MMT

Few Addicted Prisoners Get Treatment, Study Says

MMT Clinics Not Source of Methadone ODs, Yet Controversy Continues

Outstanding Success of MMT Startup in China Reported

Reducing HIV Risks During MMT Without Enforced Drug-Abstinence

Illicit Drug Abuse Affects Adherence to Methadone Therapy

Brochure Addresses “Methadone Treatment for Pregnant Women”

Case Report: Neonatal Arrhythmia Influenced by MMT in Mother?

Cardiac Effects of Methadone vs Buprenorphine Compared

Beliefs About Medication-Assisted Addiction Therapy Explored

Offers of HCV Treatment Increasing, But Many Patients Refusing

Buprenorphine of Benefit for Opioid Withdrawal

SAMHSA Updates Guidance on Outpatient Substance Abuse Treatment

NIDA Launches First Study of Treatment for Addiction to Rx Opioids

Name Changes Proposed for NIDA, NIAAA

 

MMT Prolongs Life of Those Staying in Treatment

A study examined total deaths related to methadone in Sweden during 1988 to 2000. The population comprised all individuals (n = 848) who had been in contact with the methadone maintenance treatment (MMT) program in Stockholm during the study period, including those patients who had been discharged from treatment and those opiate abusers who had applied for but not received methadone treatment. All deaths that had been the subject of medico-legal examination at the Department of Forensic Medicine in Stockholm where methadone was found in blood or urine were also analyzed during the same period.

Deaths were lower among those persons who remained in MMT and 91% of the deceased individuals in MMT had died due to natural causes; in most cases related to HIV or hepatitis C, acquired before admission to the program. Those who had been discharged from MMT had a 20 times higher risk of dying from unnatural causes compared with patients who remained in treatment. The majority died due to heroin injections (‘overdoses’). Eighty-nine cases of fatal methadone intoxication were found, but in only 2 of these cases was there evidence of methadone diversion from a treatment program.

The authors conclude that MMT is safe as long as the patients remain in treatment, and there are very few deaths due to diversion from the program. However, there is a high death rate among patients discharged from MMT and only a minority of the heroin users in Stockholm had applied for treatment.

Source: Fugelstad A, Stenbacka M, Leifman A, et al. Methadone maintenance treatment: the balance between life-saving treatment and fatal poisonings. Addiction. 2007(Mar);102(3):406-412.

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Treatment Contracts Offer Hope to Addicts

In an Edinburgh Evening News (UK) article, March 12, 2007, author Tom Wood states, “On the face of it, imposing contracts on seriously chaotic drug and alcohol users seems a bit silly. How can a person whose life is without structure adhere to any contract or agreement? And, by definition, contracts need sanctions. What are you going to do if one of the parties fails? Remove medical or social help?”

He notes that in Edinburgh, Service Level Agreements are being introduced, which will be “contracts” between patients and the agencies that receive public funding. The agreements will state the quality and quantity of services expected in exchange for funding. Such contracts are not, Wood states, “some Draconian repressive measure aimed at punishing those who fail to beat their addiction. Nor are they pieces of paper full of targets, which merely serve to demoralize a group of people who usually suffer from low self-esteem.”

He continues, “In developing such an agreement, we need to sit down with a client and establish, ‘What does success look like to you realistically?’ For some, this is becoming drug-free or achieving stability through a heroin substitute. Others might see success as gaining qualifications, moving into employment or securing a house tenancy.”

The most important factor of a contract, he notes, is that it is the patients themselves who have the opportunity to design the future that they want. Based on this, a “pathway of care” can be established, outlining key milestones for all concerned, and effectively binding on both patient and service provider. It will then be very clear what progress is being made, and if any stumbling blocks exist.

[Comment: Treatment contracts for MMT patients was the subject of an editorial in the Summer 2006 (Vol.15, #3) edition of AT Forum. Results of a reader survey on the topic appeared in the Winter 2007 (Vol.16, #1) edition. To view these editions, go to: http://www.atforum.com/SiteRoot/pages/current_pastissues/current_pastissues.shtml. – Ed (Stewart B. Leavitt, MA, PhD)]

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Treatment Admissions for Heroin Decrease, Other Opioids Increasing

The Center on Substance Abuse Research (CESAR) at the University of Maryland reported in mid-March, 2007, that the percentage of admissions to state-funded substance abuse treatment facilities citing heroin as a primary substance of abuse decreased from a recent peak of 15.5% in 2000 to 13.8% in 2005, according to data from the national Treatment Episode Data Set (TEDS).

In contrast, admissions for the primary abuse of opioids other than heroin, such as oxycodone and nonprescription methadone, have more than tripled during the past decade, reaching a high of 3.7% in 2005.

For details, including data charts, source information and caveats, download the PDF file at http://www.cesar.umd.edu/cesar/cesarfax/vol16/16-09.pdf.

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Rx Opioid Abuse Common in New MMT Patients

A multi-state survey in the U.S. of 5,663 opioid dependent persons enrolling in 72 methadone maintenance treatment (MMT) programs was conducted to determine the prevalence of prescription opioid (RxO) abuse, factors associated with RxO abuse, and sources for RxOs. A person’s “primary opioid” was defined as the drug used the most before coming to the MMT program.

Among those who were primarily heroin abusers, 69% reported also abusing RxOs. The most frequent types of opioids abused among primary RxO abusers included: oxycodone (79%), hydrocodone (67%), methadone (40%), morphine (29%), hydromorphone (16%), fentanyl (9%), and buprenorphine (1%). Factors that significantly correlated with RxO abuse included: rural location (in comparatively low population density counties), white ethnicity, no history of injecting primary drug, no previous methadone treatment, younger age, chronic pain, and pain as a reason for enrollment.

The most frequent sources of RxOs were dealer, friend or relative, and doctor’s prescription; least frequent sources were the Internet and forged prescriptions. One-third of RxO abusers reported a history of injecting their primary drug. RxO abuse was highly prevalent among MMT program patients.

Reference: Rosenblum A, Parrino M, Schnoll SH, et al. Prescription opioid abuse among enrollees into methadone maintenance treatment. Drug Alcohol Depend. 2007(Mar) [Epub ahead of print].

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Adequate Methadone Helps Reduce Alcohol, Cocaine Abuse in MMT

Continuing alcohol and cocaine abuse results in unsatisfactory outcomes for opioid-addicted persons engaged in Methadone Maintenance Treatment (MMT) Programs. Researchers in Italy monitored changes in cocaine and alcohol use in 53 heroin addicts who had been stabilized on methadone. A control group was composed of 76 patients who had been terminated from MMT due to noncompliance with treatment recommendations, poor attendance, or failure to have their opioid abuse stabilized within a year. The association of psychiatric severity with alcohol and cocaine abuse was assessed in continuing MMT patients.

The investigators found that cessation of illicit opioid abuse and retention in MMT favorably influenced decreases in alcohol and cocaine abuse, and this also was associated with the absence of psychosocial complications in successful patients. The average methadone dose was 84 mg/day (range 5-240 mg/d), with a quarter of patients requiring more than 100 mg/day for stabilization. Cocaine-abusing patients required significantly higher methadone doses for stabilization.

Reference: Maremmani I, Pani PP, Mellini A, et al. Alcohol and cocaine use and abuse among opioid addicts engaged in a methadone maintenance treatment program. J Addictive Dis. 2007;26(1).

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Few Addicted Prisoners Get Treatment, Study Says

Less than 10% of inmates who need addiction treatment get such services, according to a new study from the National Institute on Drug Abuse. The National Criminal Justice Treatment Practices Survey (NCJPS) found that “far too few programs and services exist, and the ones that do exist are only offered to a handful of offenders,” said NIDA Director Nora D. Volkow, MD. “Since offenders are 4 times as likely as the general population to have a substance abuse disorder, treating the offender population could measurably lower the demand for drugs in our society, and reduce the crime rate.”

NIDA’s report represented the first findings from the NCJPS study, which is gathering data on treatment available across the broad spectrum of correctional settings, from jails and prisons to community corrections agencies.

Reference: Taxman FS, Young DW, Wiersema B, Rhodes A, Mitchell S. (2007) The National Criminal Justice Treatment Practices survey: Multilevel survey methods and procedures. J Subst Abuse Treat. 2007;32(3): 225-238.

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MMT Clinics Not Source of Methadone ODs, Yet Controversy Continues

As reported by Join Together Online, April 10, 2007, methadone has been involved in a growing number of drug overdoses, but diversion from MMT (methadone maintenance treatment) clinics is not the source of the problem, according to officials at the federal Substance Abuse and Mental Health Services Administration (SAMHSA).

Rather, most of the methadone associated with overdoses originated with physicians prescribing the drug as a painkiller. “While deaths involving methadone increased, experiences in several states show that addiction treatment programs are not the culprits,” said H. Westley Clark, MD, JD, MPH, Director of SAMHSA’s Center for Substance Abuse Treatment. His comments reflected the findings of an expert policy panel convened in 2003 and published in “Methadone-Associated Mortality, Report of a National Assessment.”

The Associated Press reported on April 9, 2007, that the state of West Virginia, concerned over rising methadone overdoses, has put a moratorium on opening new MMT clinics. But a SAMHSA official said that a report from the Centers for Disease Control and Prevention on methadone overdoses in nearby North Carolina found that 85% involved drugs from pharmacies, not methadone clinics.

Phil Herschman, President of the outpatient division of CRC Health Group, which runs 7 methadone clinics in West Virginia, said his programs are being wrongly blamed for problems associated with the drug. Still, some state lawmakers said the moratorium is not just about overdoses, but whether methadone clinics are doing enough to wean patients off the drug. Residents in Huntington, West Virginia, also complained that a methadone program there has become a magnet for panhandling and prostitution, which clinic officials dispute.

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Outstanding Success of MMT Startup in China Reported

To evaluate the effectiveness of the first 8 pilot methadone maintenance treatment (MMT) clinics in China a questionnaire surveyed patients at entry to treatment, and at 6 and 12 month follow-up. There were 585, 609, and 468 patients surveyed at baseline, and at 6 month and 12 month follow-up, and the proportion of patients injecting drugs declined from 69.1% to 8.9% and 8.8%, respectively, at those time points. The frequency of drug injection in the prior month was reduced from 90 times per month to 2 times per month during the year.

Also after 12 months, employment rate increased from 23% to 41%, and self-reported criminal behaviors declined from 21% to 4%. Roughly two-thirds of patients reported a healthy family relationship at the end of one year, an increase from 47% at entry. Nearly all, 96%, of patient reported that they were satisfied with the MMT service.

The authors concluded that the pilot MMT program reduced drug use, drug injecting behaviors, and drug related criminal behaviors, while improving relationships with family members. Therefore, MMT clinics should be considered as a platform for providing comprehensive services to drug users throughout China.

Source: Pang L, Mi GD, Wang CH, Luo W, Rou KM, Li JH, Wu ZY. Evaluation of first 8 pilot methadone maintenance treatment clinics in China [article in Chinese, English abstract]. Zhonghua Shi Yan He Lin Chuang Bing Du Xue Za Zhi. 2007(Mar);21(1):2-4.

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Reducing HIV Risks During MMT Without Enforced Drug-Abstinence

A study assessed injection-related HIV risk behavioral changes among opioid users in low-threshold (harm reduction based) methadone maintenance treatment (MMT) programs within needle exchange services in Kingston and Toronto, Ontario, Canada. Changes were assessed for all participants (whole cohort), participants who continued to use illicit drugs by any route (drug-using subgroup); and those who continued to inject drugs (injecting subgroup). An interviewer-administered questionnaire examining injection-related HIV risk behaviors was administered to 183 study participants at entry to MMT and 6 months later.

The researchers found that the proportion of participants injecting drugs, sharing needles, sharing other drug equipment, and using shooting galleries declined during the followup period for the whole cohort. Within the drug-using group, there was a decrease in the proportion of individuals who injected drugs, while within the injecting group the sharing of injection equipment and the use of shooting galleries declined. These findings suggest that low-threshold MMT programs can reduce the risk of HIV without the rigid enforcement of abstinence-based policies.

Source: Millson P, Challacombe L, Villeneuve PJ, Strike CJ, Fischer B, Myers T, Shore R, Hopkins S. Reduction in injection-related HIV risk after 6 months in a low-threshold methadone treatment program. AIDS Educ Prev. 2007(Apr);19(2):124-136.

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Illicit Drug Abuse Affects Adherence to Methadone Therapy

Studies evaluating the effectiveness of opioid agonist therapy programs typically report on drug abstinence and treatment retention as their primary outcomes. However, in many circumstances (eg, directly observed therapy [DOT] programs within methadone maintenance treatment [MMT] programs), methadone adherence is an extremely relevant clinical outcome. Canadian investigators sought to evaluate the impact of ongoing illicit drug use on methadone adherence within a DOT program for the treatment of HIV-infection.

Patients were enrolled in a DOT program, whereby methadone and HIV medication were coadministered by a community pharmacist. Illicit drug use (amphetamines, benzodiazepines, cocaine, and opiates) was assessed by repeated urinalysis results. Methadone adherence was calculated as the fraction of days that methadone was administered.

Ongoing drug abuse, and polysubstance abuse was common, with only 4 of 60 patients abstaining from all illicit drug use. Overall methadone adherence was 85%; however, amphetamine use (without benzodiazepine and cocaine use), benzodiazepine use (without amphetamines), and higher methadone doses were associated with higher methadone adherence. As might be expected, illicit opiate abuse was associated with decreased methadone adherence. The interaction of other substance abuse with methadone adherence was complex; although, the abuse of amphetamine or benzodiazepine as sole agents had less negative impact on methadone adherence than polydrug abuse.

Reference: Raffa JD, Grebely J, Tossonian H, et al. The impact of ongoing illicit drug use on methadone adherence in illicit drug users receiving treatment for HIV in a directly observed therapy program. Drug Alcohol Depend. 2007(Mar) [Epub ahead of print].

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newBrochure Addresses “Methadone Treatment for Pregnant Women”

A one-page brochure from the Center for Substance Abuse Treatment (CSAT, part of the Substance Abuse and Mental Health Services Administration, or SAMHSA) provides helpful information for pregnant women in methadone maintenance treatment (MMT) programs. The brochure very briefly addresses how MMT works, infant withdrawal from methadone and breastfeeding after delivery, and the role of child protection services. It also discusses birth control for women. References to helpful resources at SAMHSA are provided.

The brochure is available for free download at: http://www.csat.samhsa.gov/publications/PDFs/PregnantWomen.pdf.

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newCase Report: Neonatal Arrhythmia Influenced by MMT in Mother?

There has been some concern regarding methadone being associated with QT-interval lengthening in adults. In a case report, the authors present, for the first time, clinically significant QT interval lengthening in a neonate born to a woman receiving methadone maintenance treatment (MMT). They recommend that neonatal pediatricians should be aware of this important and potentially serious clinical phenomenon. Bradycardia, tachycardia, or an irregular heart rate in an infant born to a mother on methadone should not be ignored and a 12-lead electrocardiogram should be performed. Furthermore, there is a need for a prospective study of QTc intervals in infants born to mothers receiving methadone.

Source: Hussain T, Ewer AK. Maternal methadone may cause arrhythmias in neonates. Acta Paediatr. 2007(Mar) [Epub ahead of print].

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Cardiac Effects of Methadone vs Buprenorphine Compared

Prolongation of the QT-interval in the ECG and cases of torsade de pointes (TdP) have been reported in patients receiving methadone maintenance treatment (MMT). Since heroin addicts sometimes faint during use of illicit drugs, the authors of this report suggested that doctors might attribute too many episodes of syncope (fainting) to illicit drug use during MMT and thereby underestimate the incidence of TdP in this special population. Furthermore, mortality in this population may in part be caused by proarrhythmic effects of methadone.

In this cross-sectional study, interviews, ECGs, and blood samples were collected in a population of 450 adult heroin addicts in Copenhagen being treated with either methadone or buprenorphine for addiction on a daily basis. The QT interval was estimated from 12 lead ECGs, and all participants were interviewed about any episodes of syncope, which might have been a sign of transient TdP arrhythmia.

Increasing methadone dose was significantly associated with QT-interval prolongation; whereas, no such association between buprenorphine and QTc was found. In methadone treated subjects, 28% of the men and 32% of the women had prolonged QTc-intervals, but none of buprenorphine treated subjects had a QTc-interval greater than 440 msec. A 50 mg/day higher methadone dose was significantly associated with a 1.2 times higher odds for experiencing syncope.

Reference: Fanoe S, Hvidt C, Ege P, Jensen GB. Syncope and QT prolongation among patients treated with methadone for heroin dependence in the city of Copenhagen. Heart. 2007(Mar) [Epub ahead of print].

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Beliefs About Medication-Assisted Addiction Therapy Explored

Attitudes, perceived social norms, and treatment intentions were assessed for 376 counselors and 1,083 patients from outpatient, methadone maintenance treatment (MMT), and residential drug treatment programs in Oregon regarding 4 medications used to treat opiate dependence: methadone, buprenorphine, clonidine, and ibogaine.

Attitudes, social norms, and intentions to use varied by treatment modality. MMT patients and counselors had more positive attitudes toward the use of methadone, whereas their counterparts in residential and outpatient settings had neutral or negative assessments. Across modalities, attitudes, perceived social norms, and intentions toward the use of buprenorphine were relatively neutral. Assessments of both clonidine and ibogaine were negative for patients and counselors in all settings. Social normative influences were dominant across settings and medications in determining counselor and patient intentions to use medications, suggesting that perceptions about the beliefs of peers may play a critical role in use of medications to treat opiate dependence.

Source: Rieckmann T, Daley M, Fuller BE, Thomas CP, McCarty D. Client and counselor attitudes toward the use of medications for treatment of opioid dependence. J Subst Abuse Treat. 2007(Mar);32(2):207-215.

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Offers of HCV Treatment Increasing, But Many Patients Refusing

Since 2002, clinicians have been encouraged to offer treatment for chronic hepatitis C virus (HCV) to patients with injection drug use histories. Researchers conducted 69 baseline and 31 follow-up interviews between September 2002 and November 2004 in HCV patients who were treatment-naïve and receiving regular medical care at an HIV or methadone clinic in New York City at baseline. Of the 31 patients re-interviewed, 20 (65%) were offered treatment but only 2 (7%) were treated. Reasons for 38 of the original group not being re-interviewed included loss to follow-up at the original site of care (30), death (6), and refusal to be re-interviewed (2). Whereas offers of HCV treatment may be increasing, in order to increase actual treatment rates there is a need to improve continuity of care, patient-provider communication, and patient education regarding available HCV treatment options.

Reference: Schackman BR, Teixeira PA, Beeder AB. Offers of Hepatitis C Care Do Not Lead to Treatment. J Urban Health. 2007(Mar) [Epub ahead of print].

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Buprenorphine of Benefit for Opioid Withdrawal

Researchers conducted a preliminary study to compare the effectiveness of buprenorphine versus methadone as opiate detoxification treatments. The sample comprised 123 drug misusers who had been dependent on opiates only or who were codependent on opiates and benzodiazepines. Patients receiving methadone doses of up to 70 mg/day were eligible for the study. Medically supervised opioid withdrawal took place within a specialist inpatient drug-dependence unit. Withdrawal symptom severity was assessed on a daily basis and outcome measures included reductions in severity of withdrawal symptoms, treatment retention, and treatment completion.

Opioid withdrawal using buprenorphine was associated with less severe withdrawal symptoms than with methadone. Opiate/benzodiazepine codependent patients reported less severe withdrawal symptoms during treatment with buprenorphine than with methadone and were also more likely to complete detoxification when treated with buprenorphine.

Reference: Reed LJ, Glasper A, de Wet CJ, Bearn J, Gossop M. Comparison of buprenorphine and methadone in the treatment of opiate withdrawal: possible advantages of buprenorphine for the treatment of opiate-benzodiazepine codependent patients? J Clin Psychopharmacol. 2007(Apr);27(2):188-192.

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SAMHSA Updates Guidance on Outpatient Substance Abuse Treatment

Updated guidance to help clinicians and administrators improve outpatient treatment for substance abuse was released by the Substance Abuse and Mental Health Services Administration in 2 new Treatment Improvement Protocols (TIPs).

TIP 46, Substance Abuse: Administrative Issues in Outpatient Treatment focuses on core staffing and retention issues, while exploring managing staff stress and supporting career development. Also addressed are program growth and promotion, expanding cultural diversity, and building financial stability.

A companion text, TIP 47, Substance Abuse: Clinical Issues in Intensive Outpatient Treatment, is aimed at clinicians and presents 14 guiding principles of intensive outpatient treatment (IOT) and supporting research. It explores how IOT fits in the continuum of care and what services a program should provide. The TIP also confronts clinical issues, describes approaches in detail, and addresses the needs of diverse populations.

For copies, go to…

TIP 46: http://download.ncadi.samhsa.gov/prevline/pdfs/tip46small.pdf
TIP 47: http://download.ncadi.samhsa.gov/prevline/pdfs/TIP_47.pdf.

Copies also may be obtained free of charge by calling SAMHSA’s Health Information Network at 1-877-726-4727 and requesting item BKD545 for TIP 46 and BKD551 for TIP 47.

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NIDA Launches First Study of Treatment for Addiction to Rx Opioids

The National Institute on Drug Abuse (NIDA) is launching the first large-scale national study in the U.S. evaluating treatments for addiction to prescription opioid analgesics. Known as POATS (Prescription Opioid Addiction Treatment Study), this will be a randomized 2-phase, open-label, multi-center study in outpatient treatment settings. The main objective is to identify effective treatment regimens using the sublingual buprenorphine-naloxone combination (BUP/NX) in patients dependent on prescription opioid medications

The first phase will assess the currently prevailing 1-month detoxification practice. The second phase will compare the effectiveness of standard medical management with BUP/NX and medical management (BUP/NX) enhanced by intensive individual drug counseling in those patients who were not successful in the previous detoxification phase. The study will involve about 672 participants, recruited from approximately 12 sites.

For more information on the study, go to: http://www.drugabuse.gov/CTN/protocol/0030.html.

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Name Changes Proposed for NIDA, NIAAA

Under legislation introduced into the U.S. Congress by Senator Joe Biden (D-Delaware) the National Institute on Drug Abuse (NIDA) would become the National Institute on Diseases of Addiction, and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) would be renamed the National Institute on Alcohol Disorders and Health (NIADH).

Community Anti-Drug Coalitions of America reported on April 10, 2007 that Biden’s bill, S-1011, is intended to reduce the stigma associated with addiction by removing the term “abuse” from the names of the two agencies. “Addiction is a neurobiological disease – not a lifestyle choice – and it’s about time we start treating it as such,” said Biden. “We must lead by example and change the names of our federal research institutes to accurately reflect this reality. By changing the way we talk about addiction, we change the way people think about addiction, both of which are critical steps in getting past the social stigma too often associated with the disease.”

The name change also would more clearly link the concepts of addiction and disease, according to Biden. The reference to alcohol “disorders” in the NIAAA name would reflect the consensus among researchers that there is a continuum of disorders involving alcohol misuse, including excessive use and alcohol dependence.

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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.