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AT Forum NEWS NOTES & UPDATES #102

November – December 2005

Compiled & Edited by Stewart B. Leavitt, PhD

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Contents

New Study Depicts Benefits from Lifelong MMT
Factors Influencing MMT Participation Reported
DINO-VAMP: Acronym Helps Determine Optimal Methadone Dose
Latest Study on Methadone Dose During Pregnancy Reported
Structured Counseling Improves Outcomes During MMT
Incentives Improve Counseling Attendance During MMT
Patterns of Substance Abuse Vary in MMT Patients
MMT a Significant Success in Puerto Rico Prison
Differences in Methadone vs Buprenorphine Plasma Concentrations
Abuse Potential of Buprenorphine & Methadone Compared
HIV+ Female MMT Patients May Need Extra Care
MMT Retention and Re-Entry Patterns Evaluated
Congress Asked to Include Addiction Services in Disaster Response

New Study Depicts Benefits from Lifelong MMT

Research Triangle Park, NC; November 16, 2005 – A new study conducted by researchers at RTI International estimates that methadone maintenance treatment (MMT) for heroin users generates 7 times more economic benefits than previously thought.

The study is the first to present lifetime estimates of the costs and benefits associated with drug use and its treatment and was funded by a grant from the National Institute on Drug Abuse. While previous studies have examined the benefits and costs of drug treatment, they have typically focused on a single treatment episode, implicitly treating drug abuse as an acute problem that can be cured in one episode.

The researchers designed an innovative simulation model to represent the progression of individuals from 18 to 60 years of age with respect to their heroin use, methadone treatment for heroin use (including the possibility of multiple MMT episodes), criminal behavior, employment, and health care use.

Results of the study showed that MMT for heroin users yields $38 in economic benefits for each $1 spent on treatment, which is 7 times greater than in previous studies.

Reference: Zarkina GA, Dunlapa LJ, Hicks KA, Mamob D. Benefits and costs of methadone treatment: results from a lifetime simulation model. Health Econ. 2005;14:1133–1150.

Factors Influencing MMT Participation Reported

Vancouver, Canada; December 2005 – This study identified methadone maintenance therapy (MMT) participation during follow-up interviews and examined associations between MMT use and sociodemographic and drug-related variables. Of the 1,587 participants recruited, 170 (11%) were enrolled in MMT at baseline and an additional 498 (31%) initiated MMT during follow-up. Of those ever enrolled in MMT, 406 (61%) ceased treatment and re-initiated MMT on more than one occasion. The median treatment duration was slightly more than 14 months.

Factors that were negatively and significantly associated with – i.e., decreased – MMT participation included: recent incarceration; sex trade involvement; syringe lending; heroin injection. Conversely, factors that had a significantly positive influence MMT participation included: female gender, HIV positivity, and crack cocaine smoking. Unstable housing, syringe borrowing, prior non-fatal overdose, and cocaine injection had no influence on participation in MMT. In sum, this study demonstrates high rates of initiation of and retention in MMT among local injection drug users. While the use of MMT was associated with reductions in heroin use and HIV risk behavior, the positive association with increased crack cocaine use deserves further study, according to the researchers.

Source: Kerr T, Marsh D, Li K, Montaner J, Wood E. Factors associated with methadone maintenance therapy use among a cohort of polysubstance using injection drug users in Vancouver. Drug Alcohol Depend. 2005(Dec);80(3):329-335.

DINO-VAMP: Acronym Helps Determine Optimal Methadone Dose

Journal of Maintenance in the Addictions; October 2005 – Methadone clinics commonly provide inadequate methadone doses for patients in treatment, resulting in continuing heroin use and high-risk activities. In order to optimize methadone dosing to achieve opiate “blockade,” it is practical to apply the acronym, DINO-VAMP, when interviewing heroin-using patients. By asking about the areas represented by each letter, providers can identify and manage issues relating to methadone dosing in a systematic, user-friendly manner. D for drug use and dose, I for drug Interactions, N for neuroleptic (psychiatric) issues, O for opiate withdrawal symptoms, V for vitamin C and hepatitis C, A for home atmosphere (stress), M for menopause and medical issues, and P for pregnancy and plasma methadone levels. This allows providers to cover all major significant areas related to methadone dosing. The clinic that applies this acronym demonstrates repeatedly a 30% lower heroin positivity in their patients compared with others not using the same system.

Source: Tenore PL. DINO-VAMP: A helpful acronym in determining optimal methadone dosing and brief review of dosing literature. J Maint Addict. 2005;2(4):29-44.

[This very useful approach proposed by Dr. Tenore was previously discussed in AT Forum; Spring 2003, Vol 12, No. 2 –– Clinical Concepts - Guidance On Optimal Methadone Dosing. It is available online at: http://www.atforum.com/SiteRoot/pages/current_pastissues/spring2003.shtml#anchor1484333.]

Latest Study on Methadone Dose During Pregnancy Reported

London, UK; November 2005 – Measurements of plasma methadone concentration (SML, or serum methadone level) were used to investigate the rate of clearance of methadone prescribed for heroin dependence in the first, second, and third trimesters of pregnancy. A secondary objective was to evaluate the outcome of pregnancy.

Subjects included 9 pregnant opioid-dependent patients in methadone maintenance treatment (MMT) at the Leeds Addiction Unit, an outpatient community based treatment center. SML versus time data for methadone was collected during each trimester and post-partum for the subjects. Trough mean SMLs decreased as the pregnancies progressed from the first to the third trimester and weight-adjusted methadone-clearance rates gradually increased during that same time period; although, patterns differed substantially among the 9 women. Eight of the subjects delivered within 2 weeks of their due dates and the ninth was premature (21 days). The mean length of gestation was nearly 40 weeks and none of the neonates met criteria for low birth weight. Five neonates spent time (0.5-28 days) in a special care baby unit and 4 of these displayed signs of methadone withdrawal.

The authors conclude that general practitioners and hospital doctors should recognize the significant benefits of prescribing methadone for heroin-dependent women during pregnancy. They recommend that if a pregnant MMT patient complains of methadone withdrawal symptoms (i.e., that the methadone dose does not “hold” them) the prescribing clinician should take this observation seriously and consider a more detailed assessment.

Source: Wolff K, Boys A, Rostami-Hodjegan A, Hay A, Raistrick D. Changes to methadone clearance during pregnancy. Eur J Clin Pharmacol. 2005(Nov);61(10):763-768.

Structured Counseling Improves Outcomes During MMT

Journal of Maintenance in the Addictions; October 2005 – This study examined the affect of total exposure to counseling sessions on outcomes during MMT in a sample of 298 patients. The total number of minutes actually spent in counseling sessions during a 6-month period was used to create a measure of patient exposure to treatment. Patients were divided into three groups, depending on how much time they ended up spending in counseling sessions: low (< 270 minutes), medium (270-399 minutes), and high (400+ minutes). Results supported the hypothesis that patients in the low-exposure group did not develop as much rapport or “bond” as well with their counselors as patients in the higher treatment exposure groups. Several factors predicted which patients spent more time in counseling sessions, namely: being female, heavy alcohol use, a history of childhood problems, higher methadone dosage, and structured counseling sessions. Among these, the most significant predictor of patients being in the high treatment exposure group was participation in structured counseling sessions. This finding supports the use of structured treatment interventions as a method of improving patient/counselor relationships and better during-treatment outcomes through increased treatment exposure time.

Reference: Rowan-Szal GA, et al. Structure as a determinant of treatment dose. J Maint Addict. 2005;2(4):55-70.

Incentives Improve Counseling Attendance During MMT

Journal of Substance Abuse Treatment; December 2005 – Despite the importance of counseling in methadone maintenance treatment (MMT), many patients do not take advantage of these services. Researchers at Johns Hopkins University School of Medicine offered incentives to methadone-maintained patients for attending group counseling during an orientation phase of treatment or during required attendance at a relapse group later in treatment. Upon attending each counseling session, patients could draw for prizes under an escalating prize-value system with a 50% probability that draws would result in a prize. Incentives included small ($1), moderate ($5), and large ($20) prizes, with chances of winning inversely related to prize costs, and a maximum possible total of $160 per patient. It was anticipated that this policy would provide a relatively low-cost approach to improving counseling attendance at the MMT clinic. The incentive policy did significantly increase the percent of counseling sessions attended (52% vs. 76%) and promoted periods of continuous attendance. These data further support the effectiveness of low-cost incentive programs in enhancing counseling attendance among methadone patients.

Source: Sigmon SC, Stitzer ML. Use of a low-cost incentive intervention to improve counseling attendance among methadone-maintained patients. J Subst Abuse Treat. 2005(Dec);29(4):253-258.

[Contingency management / incentive reward programs as part of MMT were discussed in the AT Forum Spring 2005 edition (Vol. 14, No. 2) and can be accessed online at: http://www.atforum.com/SiteRoot/pages/current_pastissues/spring2005.html. – Editor.]

Patterns of Substance Abuse Vary in MMT Patients

Journal of Substance Abuse Treatment; December 2005 – Patients’ use of heroin, cocaine, and alcohol during long-term methadone maintenance treatment (MMT) was studied by a group in Zurich, Switzerland. They prospectively collected and evaluated data from 103 heroin-addicted individuals who were consecutively admitted for MMT and remained 2 years in treatment. The patients were assessed every 6 months with a standardized interview. Three longitudinal patterns of drug abuse emerged and were identified. A proportion of patients abstained fully from their particular drug use (26% from heroin, 39% from cocaine, and 20% from alcohol); a proportion (40%, 33%, and 47%, respectively) switched between periods of abuse and nonuse of these drugs; and chronic drug users (34%, 28%, and 33%, respectively) continued use, including periods of daily abuse throughout MMT. This study recognizes that patients in MMT express different patterns of substance abuse over time and specialized therapeutic interventions may be needed that take this into account.

Reference: Dobler-Mikola A, Hättenschwiler J, Meili D, et al. Patterns of heroin, cocaine, and alcohol abuse during long-term methadone maintenance treatment. J Subst Abuse Treat. 2005(Dec);29(4):259-265.

MMT a Significant Success in Puerto Rico Prison

Yale University School of Medicine; December 2005 – Researchers described and evaluated a pilot methadone maintenance treatment (MMT) program for heroin-dependent inmates at Las Malvinas men’s prison in San Juan, Puerto Rico. Data from self-reports of inmates’ drug use before and during incarceration, attitudes about drug treatment in general and MMT in particular, and expectations about behaviors upon release from prison and from testing inmates’ urine were analyzed. Comparisons were made between MMT-program patients (n=20) and 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 abuse among prisoners not in treatment was common; 58% reported any use while incarcerated and 38% reported use in the past 30 days. All patients in the MMT program had used heroin in prison in the 30 days prior to enrolling in treatment. While in MMT, the percentage of patients using heroin was dramatically decreased, according to self-report (1 in 18, or a 94% reduction) and urine testing (1 in 20, or 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 and the program appears to be a success. Prison officials have begun an expansion from the current ceiling of 24 inmates to treat 300 or more inmates.

Source: Heimer R, Catania H, Newman RG, Zambrano J, Brunet A, Ortiz AM. Methadone maintenance in prison: evaluation of a pilot program in Puerto Rico. Drug Alcohol Depend. 2005;Dec 2 [Epub ahead of print].

Differences in Methadone vs Buprenorphine Plasma Concentrations

Addiction Biology; December 2005 – Researchers in Vienna, Austria conducted the first trial to compare the relationship of opioid-medication plasma concentrations in methadone maintenance treatment (MMT) versus buprenorphine-maintained subjects. Sixty opioid-dependent subjects (19 females, 41 males) were recruited and treated at the Drug Addiction Outpatient Clinic at the University of Vienna. Of these, 44 (11 female, 33 male) were included in the analyses of plasma concentrations. Subjects received either daily sublingual buprenorphine (2 mg or 8 mg tablets for a maximum daily dose of 8 mg) or oral methadone [dose not specified in abstract – Ed.] and were maintained on a stable dose after an induction period of 2 weeks. Average correlation of dose-to-plasma concentration was 0.51 for buprenorphine, whereas the correlation for methadone was 0.69. Dose-to-plasma concentration ratios were much more variable in buprenorphine-treated patients and acceptance of treatment also was significantly lower in this group of patients. Furthermore, there did not appear to be differences between treatment completers and dropouts among buprenorphine-maintained patients on the basis of withdrawal scores, dose or plasma concentration, dose-to-plasma concentration ratios, or intraindividual variation.

Reference: Jagsch R, Gombas W, Schindler SD, Eder H, Moody DE, Fischer G. Opioid plasma concentrations in methadone-and buprenorphine-maintained patients. Addict Biol. 2005(Dec);10(4):365-371.

Abuse Potential of Buprenorphine vs Methadone Compared

New York, NY; December 2005 – Although buprenorphine is used worldwide as a safe and effective maintenance medication for opioid dependence, some countries have reported a growing incidence of abuse of this medication, according to the authors of this study. Buprenorphine is considered to have lower abuse potential because of its partial-agonist action, but no studies have directly compared the reinforcing effects of buprenorphine with those of a full mu-opioid agonist like methadone in humans.

This double-blind, placebo-controlled inpatient study compared the reinforcing and subjective effects of intravenously administered buprenorphine (0.5, 2, and 8 mg) and methadone (5, 10, and 20 mg). Participants (n=6) were detoxified from heroin during the first 1 to 2 weeks after admission. During subsequent weeks, participants received a sample drug dose and $20 on Monday, and they could either self-administer the sampled dose or receive $20 on Thursday and Friday. All active doses were self-administered more frequently than placebo; although, there were no significant differences in administration frequencies between buprenorphine and methadone or among the different doses of drug. Importantly, several subjective ratings – including “good drug effect,” “high,” and “liking” – increased as doses also were increased (dose-dependent) after administration of both buprenorphine and methadone, and the peak ratings for these effects did not significantly differ for the two drugs. These results demonstrate that under these experimental conditions buprenorphine and methadone were equally effective in producing reinforcing and desired subjective effects.

Reference: Comer SD, Sullivan MA, Walker EA. Comparison of intravenous buprenorphine and methadone self-administration by recently detoxified heroin-dependent individuals. J Pharmacol Exp Ther. 2005(Dec);315(3):1320-1330.

[This small study may be of importance because it has been thought that buprenorphine would be largely undesirable and ineffective as a substance of abuse; however, this is apparently not the case. – Editor.]

HIV+ Female MMT Patients May Need Extra Care

San Francisco General Hospital, CA; November 2005 – This study examined baseline gender differences among HIV-positive methadone maintenance treatment (MMT) outpatients currently prescribed antiretroviral medications. Participants were enrolled in a larger clinical trial, which included a 4-week observation period using electronic monitors to track medication adherence. Contrary to previous literature, no significant differences were detected between men (n=42) and women (n=36) in terms of medication adherence or depression. Both groups showed remarkably poor medication adherence during baseline (average 56% of doses taken on time), as well as high overall prevalence of depression (47%) and illicit cocaine use (47%). Compared with men, women reported significantly more medication side effects, a higher severity of psychiatric problems, and a lower health-related quality of life in physical and emotional functioning. Women also tested positive for opioids at higher rates than men (53% vs. 29%, respectively), whereas men were more likely to be positive for benzodiazepines than women (26% vs. 6%, respectively). Findings suggest that gender differences between male and female MMT patients have relevance for treatment providers and extensive assessments, plus specialized medical and mental health services, may be warranted in the treatment of HIV-positive female drug abusers.

Reference: Haug NA, Sorensen JL, Lollo ND, Gruber VA, Delucchi KL, Hall SM. Gender differences among HIV-positive methadone maintenance patients enrolled in a medication adherence trial. AIDS Care. 2005(Nov);17(8):1022-1029.

MMT Retention and Re-Entry Patterns Evaluated

Drug & Alcohol Dependence; January 2006 – Researchers in Sydney, Australia note that there are few descriptions of patterns of long-term participation in methadone maintenance treatment (MMT). There has been progressive expansion of MMT in Australia in the past 15 years, and by international standards Australia has a high participation rate in MMT. Therefore, they sought to analyze predictors of retention in treatment (a proxy measure of treatment effectiveness) in 3 groups of people entering public and private methadone treatment during 1990, 1995, and 2000 in the state of New South Wales (NSW), and to compare retention rates with those reported from recent clinical trials. Secondarily, they describe the pattern of participation in subsequent treatment and predictors of re-entry.

The sample analyzed comprised 342 subjects commencing treatment in private and 135 in public MMT settings. Retention did not differ between settings. At 6 months, 51% in the current study were retained, compared with 48% in other clinical trials from Australia. There was a significant year-group effect: at 3 months, retention was significantly better in the 1990 cohort; however, by 12 months, differences between the year-cohorts were not statistically significant. Most people who left treatment dropped out on their own; however, two-thirds subsequently re-entered MMT, often having multiple treatment episodes. Participation in non-continuous treatment was around 45% for the 5 years after first entering treatment. The most significant predictors of re-entry to treatment were age, and duration of first treatment episode; specifically, older people and those with >12 months continuous treatment were significantly less likely to re-enter.

The authors conclude that retention in MMT in everyday practice, across a range of settings, appears comparable to treatment delivered in clinical trials. Participants cycle in and out of treatment, and this recycling appears to have increased as MMT programs have expanded and access to treatment has increased.

Reference: Bell J, Burrell T, Indig D, Gilmour S. Cycling in and out of treatment; participation in methadone treatment in NSW, 1990-2002. Drug Alcohol Depend. 2006(Jan);81(1):55-61.

Congress Asked to Include Addiction Services in Disaster Response

Join Together; October 24, 2005 – Addiction counseling should be included as a distinct component of emergency services delivered to disaster victims by the federal government, the Addiction Leadership Group wrote in a letter sent to key members of the U.S. House Committee on Energy and Commerce.

The letter, endorsed by more than a dozen groups –– including Community Anti-Drug Coalitions of America, the National Association of State Alcohol and Drug Abuse Directors (NASADAD), Faces and Voices of Recovery, and the National Council on Alcohol Abuse and Alcoholism –– urged committee chair Rep. Joe Barton (R-Texas) and ranking minority member Rep. John Dingell (R-Mich.) to amend Section 416 of the federal Stafford Act, which establishes the Federal Emergency Management Agency’s (FEMA) Crisis Counseling Training and Assistance Program (CCP).

CCP provides mental-health assistance to people coping with the aftermath of disasters, like hurricane Katrina, and is administered by the Substance Abuse and Mental Health Services Administration (SAMHSA). Section 416 of the Stafford Act currently reads: “The President is authorized to provide professional counseling services, including financial assistance to State or local agencies or private mental health organizations to provide such services or training of disaster workers, and to victims of major disasters in order to relieve mental health problems caused or aggravated by such major disaster or its aftermath” [emphasis added]. The Addiction Leadership Group is requesting that lawmakers add “substance abuse” to both places where the law currently references only “mental health.”

NASADAD recently issued a policy brief on trauma and addiction. Some in the addiction field have criticized the federal response to addiction problems in the wake of Katrina as inadequate. Meanwhile, a pair of recent Katrina-related bills introduced in Congress also address addiction issues, the Legal Action Center reported. “The Emergency Health Care Relief Act of 2005,” introduced by Sen. Charles Grassley (R-Iowa), calls for treatment of addictive disorders determined to result from the hurricane and its aftermath. “The Louisiana Katrina Reconstruction Act,” introduced in the House and Senate, would provide $400 million to the Louisiana Department of Health and Hospitals’ mental-health division, including $100 million earmarked for addiction assessment, early intervention, prevention, and treatment.

The full article can be accessed online at: http://www.jointogether.org/y/0,2521,578490,00.html

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.