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AT Forum NEWS NOTES & UPDATES #101

September - October 2005

Compiled & Edited by Stewart B. Leavitt, PhD

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.

Study: Higher Methadone Doses More Effective at Suppressing Heroin Use

Baltimore, MD; October 2005 – Clinical research suggests that methadone doses larger than those used in most clinics are more effective at suppressing illicit heroin use. This increased efficacy may result from greater cross-tolerance to the reinforcing effects of heroin.

Researchers at Johns Hopkins School of Medicine, Baltimore, conducted a study to examine the relationship between methadone maintenance dose and the reinforcing effects of heroin. Participants were stabilized on 50, 100, and 150 mg/day of methadone during separate outpatient periods before being admitted to an inpatient research unit for testing at each maintenance dose.

During each 4-week inpatient testing period, participants sampled 3 doses of heroin (0, 10, or 20 mg; random order; one dose per week) and were subsequently allowed 7 opportunities to choose between another injection of that week’s heroin dose and varying amounts of money ($2-$38).

Five opioid-dependent volunteers completed the study. The number of heroin injections chosen decreased as methadone dose was increased, and larger alternative monetary reinforcers were required to suppress heroin self-administration during maintenance on 50 as compared with 100 or 150 mg/d methadone. Larger methadone doses also completely blocked the subjective effects of heroin and produced greater withdrawal suppression during the outpatient periods.

The authors concluded that their results support other clinical and laboratory-based research indicating that persistent heroin use may be reduced by providing larger methadone maintenance doses that produce more effective cross-tolerance to heroin.

Source: Donny EC, Brasser SM, Bigelow GE, Stitzer ML, Walsh SL. Methadone doses of 100 mg or greater are more effective than lower doses at suppressing heroin self-administration in opioid-dependent volunteers. Addiction. 2005(Oct);100(10):1496-1509.

CSAT Releases New TIP 43 on Medication-Assisted Treatment

Rockville MD; October 2005 – After several years in development, it is expected that CSAT will release in late October 2005 its newest guidance for opioid treatment programs (OTPs) on the use of methadone, LAAM, buprenorphine, and naltrexone.

This new Technical Improvement Protocol (TIP 43) is titled, “Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs.” It combines and updates 4 earlier TIPs, and contains 14 chapters and 6 appendices in its 332 pages.

Reference: Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 05-4048. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2005.

To order a free copy, visit: http://ncadi.samhsa.gov/research/library.aspx and search on “TIP 43.”

[A more complete review of this new TIP will appear in the Fall edition of AT Forum. – Ed.]

Anesthesia-Assisted Heroin Detox Not Recommended: Study

Journal of the American Medical Association; August 24, 2005 – According to the authors, rapid opioid detoxification with opioid antagonist induction using general anesthesia has emerged as an expensive, potentially dangerous, unproven approach to treat opioid dependence. This study examined how anesthesia-assisted detoxification with rapid antagonist (naltrexone) induction for heroin dependence compared with 2 alternative detoxification and antagonist induction methods.

A total of 106 treatment-seeking heroin-dependent patients, ages 21 through 50 years, were randomly assigned to 1 of 3 inpatient withdrawal treatments lasting 72 hours, followed by 12 weeks of outpatient naltrexone maintenance with relapse prevention psychotherapy. The 3 withdrawal treatments were: 1) Anesthesia-assisted rapid opioid detoxification with naltrexone induction, 2) buprenorphine-assisted rapid opioid detoxification with naltrexone induction, and 3) clonidine-assisted opioid detoxification with delayed naltrexone induction.

Average withdrawal severities were similar across the 3 treatments. Compared with clonidine-assisted detoxification, the anesthesia- and buprenorphine-assisted detoxification interventions had significantly greater rates of naltrexone induction (94% anesthesia, 97% buprenorphine, and 21% clonidine), but the groups did not differ in rates of completion of inpatient detoxification. Treatment retention through 12 weeks was not significantly different across groups; however, retention was generally low, ranging from 9% (clonidine group) to 24% (anesthesia group). Induction with 50 mg of naltrexone significantly reduced the risk of dropping out and there were no significant group differences in proportions of opioid-positive urine specimens. The anesthesia procedure was associated with 3 potentially life-threatening adverse events.

The authors concluded that their data do not support the use of general anesthesia for heroin detoxification and rapid induction on naltrexone.

Reference: Collins ED, Kleber HD, Whittington RA, Heitler NE. Anesthesia-Assisted vs Buprenorphine- or Clonidine-Assisted Heroin Detoxification and Naltrexone Induction. A Randomized Trial. JAMA. 2005;294(8):903-913.

[Heroin, and other opioid, detoxification using general anesthesia can cost upward of $15,000 at private clinics. This study demonstrated that this approach provided no added benefits in terms of helping patients and it entails risks for serious complications. All three groups stayed with the post-detox naltrexone therapy about the same amount of time – 2.5 weeks on average. However, nearly 9 of 10 patients soon relapsed: only 11% provided researchers with opioid-free urine samples 12 weeks after treatment. – Ed.]

MMT Patients Can Be Effectively Treated for HCV

Journal of Substance Abuse Treatment; September 23, 2005 – Although most cases of hepatitis C virus (HCV) infection are associated with injection drug use, there are few data regarding the impact of possible barriers such as psychiatric disease and current drug use on HCV treatment outcomes.

To define the impact of characteristics often cited as reasons for withholding HCV treatment, researchers studied HCV treatment in a real world sample of 76 recovering heroin users maintained on methadone. Overall, 21 (28%) had a sustained virological response and 18 (24%) discontinued treatment early. Although there was a modest decrease in response rates in patients reporting a preexisting psychiatric history, neither current drug use nor a short duration of pretreatment drug abstinence led to significant reductions in virological outcomes.

The authors concluded that injection drug users can be safely and effectively treated for HCV despite multiple barriers to treatment when they are treated in a setting such as an methadone maintenance treatment (MMT) program that can address their special needs.

Reference: Sylvestre DL, Litwin AH, Clements BJ, Gourevitch MN. The impact of barriers to hepatitis C virus treatment in recovering heroin users maintained on methadone. J Subst Abuse Treat. 2005;29(3):159-165.

HCV Prevalence in MMT Patients Greater Than Self-Reported

Richmond, VA; October 2005 – This study assessed hepatitis C virus (HCV) serostatus, risk factors, and desire for education about HCV among methadone maintenance treatment (MMT) patients.

Investigators surveyed 200 MMT patients and reviewed charts for 276 patients. The self-reported HCV seroprevalence was an adjusted 52%; whereas, the chart review HCV seroprevalence was 70%. Along with that, most participants had risk factors for contracting or spreading HCV.

The authors concluded that there is discrepancy in HCV seroprevalence by self-report versus serum test results among MMT patients. Some HCV+ MMT patients engage in high-risk behaviors for HCV transmission and may not disclose HCV+ status, although patients did express an interest in HCV education.

Source: Weaver MF, Cropsey KL, Fox SA. HCV prevalence in methadone maintenance: self-report versus serum test. Am J Health Behav. 2005;29(5):387-94.

Sexual Abuse History Not Predictive of MMT Success

Journal of Substance Abuse Treatment; October 2005 – Women entering drug abuse treatment programs who report a history of sexual abuse are also likely to report poorer psychosocial functioning, more drug-related problems, and more family-of-origin problems. This study investigated outcome differences at follow-up between women with and those without sexual abuse histories who were treated at an outpatient methadone maintenance treatment (MMT) program.

Follow-up interviews were conducted with 98 women, 40% of whom reported prior sexual abuse. Those with a history of sexual abuse who reported problems at intake with psychosocial functioning and family support continued to report such problems at follow-up, as compared with the women without a history of sexual abuse. However, no difference was found at follow-up between women with and those without sexual abuse histories in terms of drug use, employment, criminality, or HIV-risky behaviors. The findings suggest that sexual abuse history alone cannot predict outcomes for women in methadone treatment.

Source: Bartholomew NG, Courtney K, Rowan-Szal GA, Simpson DD. Sexual abuse history and treatment outcomes among women undergoing methadone treatment. J Subst Abuse Treat. 2005;29(3):231-235.

High-Dose Methadone During Pregnancy Does Not Increase NAS

American Journal of Obstetrics and Gynecology; September 2005 – This study assessed the effect of higher doses of methadone during pregnancy on maternal and fetal outcomes.

Researchers retrospectively reviewed clinical data for 81 mothers who received methadone maintenance and their 81 offspring. Subjects were divided into high-dose (≥100 mg/d) and low-dose (<100 mg/d) methadone groups. There were no differences in the rate of medication treatment for neonatal abstinence symptoms (NAS) or days of infant hospitalization between the high-dose (mean, 132 mg/d) and low-dose (mean, 62 mg/d) groups. Despite longer histories of opioid abuse, the high-dose group had less illicit drug use at delivery. Overall, subjects received an average of 101 mg/d and had an 81% rate of negative toxicology screens at delivery.

The authors concluded that high doses of methadone were not associated with increased risks of neonatal abstinence symptoms and were beneficial in reducing maternal drug abuse. Arbitrarily limiting methadone dose as a way of minimizing the risks of neonatal abstinence symptoms may be unwarranted, they noted.

Source: McCarthy JJ, Leamon MH, Parr MS, Anania B. High-dose methadone maintenance in pregnancy: Maternal and neonatal outcomes. Am J Obstet Gyn. 2005;193(3):606-610.

Methadone During Pregnancy May Affect Fetus

American Journal of Obstetrics and Gynecology; September 2005 – The purpose of this study was to investigate the effect of methadone on fetal neurobehavioral functions and maternal physiologic indicators in 40 women attending an MMT program and with otherwise uncomplicated pregnancies.

Evaluations were conducted at peak and trough serum methadone levels. Fetal measures included: heart function; motor activity; and fetal movement-heart rate coupling. Maternal measures included maternal heart function, electrodermal skin conductance, and respiration.

At peak serum methadone levels, fetuses exhibited signs of impaired heart regulation: e.g., slower heart rates and fewer heart rate accelerations. The duration of fetal movements and the total amount of fetal activity were reduced by half at peak maternal methadone levels. In contrast, mothers responses were generally the same at high and low methadone levels.

The authors concluded that maternal methadone administration has significant effects on fetal neurobehavioral functions that are independent of effects on the mother.

Source: Jansson LM, DiPietro J, Elko A. Fetal response to maternal methadone administration. Am J Obstet Gyn. 2005;193(3):611-617.

[This article by Jansson et al. seems somewhat contradictory to the study above by McCarthy, et al. Both appeared in the same edition of the American Journal of Obstetrics and Gynecology. From the McCarthy et al. research it appears that methadone, at adequate dose, does not influence neonatal abstinence syndrome. Yet, looking at some specific physiological measures during fetal development, Jansson and colleagues found there might be some cause for concern.

MMT during pregnancy helps the mothers avoid illicit drugs and reduces fetal mortality, but does it otherwise harm the unborn baby? In an article on her research by Reuters News Service, Jansson said, “The answer to this question lies in the benefit that can be obtained from the ancillary services that can be provided along with methadone maintenance,” referring to services such as prenatal care and parenting training, in addition to substance abuse treatment. “Methadone maintenance should only be provided during pregnancy in combination with these services, and never in their absence to this group,” she concluded. – Ed]

MMT Clinics Favor, But Neglect, Smoking-Cessation Treatment

American Journal on Addictions; July-September 2005 – Although smoking increases poor health and death rates among patients in addiction treatment, few methadone maintenance treatment (MMT) clinics provide routine smoking-cessation treatment. To understand staff attitudes in this regard, these authors surveyed leaders of outpatient MMT programs nationwide.

The survey response rate was 59% (408/697). Most clinic leaders thought they should provide smoking treatment (76%) or refer patients for such care (91%); however, fewer than half of these had provided smoking-cessation treatment in the month prior to the survey. Leaders said smoking treatment would benefit their clinics, patients, and communities; however, they said barriers—primarily insufficient staff training—prevented routine care.

Source: McCool RM, Richter KP, Choi W. Benefits of and Barriers to Providing Smoking Treatment in Methadone Clinics: Findings from a National Study. Am J Addict;14(4):358-366.

“Methadonia” Details Troubled Lives of MMT Patients

Join Together Online (www.jointogether.org); October 7, 2005 – A new documentary shown at the New York Film Festival paints a bleak picture of the life of long-term methadone patients, the New York Times reported October 6, 2005.

The movie, “Methadonia,” – which also was shown on HBO October 6th – profiles opioid addicts who have been going to a clinic for methadone maintenance treatment (MMT) for 30 years or more. Director Michel Negroponte followed those patients for more than a year at the New York Center for Addiction Treatment Services.

Some in the methadone treatment community have complained that the film focuses too much on problems and not enough on recovery. Among other things, the film delves into the problem of patients developing secondary addictions to anti-anxiety medications like Xanax, Klonopin, and Valium, which produce euphoria when combined with methadone.

“The former addicts profiled in the film are not representative of the vast majority of methadone users in the city, who hold jobs and support families and are not overdosing or getting HIV or hepatitis C from sharing needles,” said Andrew Kolodny, medical director for the mental hygiene division of the New York City Department of Health.

Mark W. Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), agreed that cross-addiction to prescription drugs is a growing problem, but only affects about 15% of MMT patients. He said the film “hurts more than helps” the cause of methadone treatment and reducing stigma.

[It is unfortunate that a biased and narrow-focused docudrama such as this was presented on nationwide television as representative of all MMT programs. Obviously, the director believed that MMT success stories would not be as entertaining as the failures he chose to feature. Much could be said about the poor research and lack of objectivity that went into this production, including how the patients blatantly enjoyed “hamming it up” in front of the camera. Hopefully, the viewing audience was not easily fooled; although, that may be asking too much of an American public that still is largely uneducated about MMT and may be unconvinced of its benefits. – Ed.]

Patients With Pain During MMT Need Added Services

Menlo Park, CA; October 7, 2005 – Both 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 research exists on this topic. Patients who report significant pain in the month preceding entry to MMT often also have a distinctly more severe pattern of polysubstance use, medical, and psychosocial problems than do those without pain.

The present study investigated the 1-year treatment outcomes of MMT patients with opioid dependence and pain. Analyses were based on a national sample of 200 patients who reported pain severity during the month preceding treatment entry. Substance use and related problems were measured at treatment entry and 12 months later. Compared with patients not experiencing significant pain, those who did report significant pain at baseline (n=103) showed similar substance-related functioning 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, those with pain require additional medical and/or mental health treatment for their pain and other problems.

Reference: Ilgen MA, Trafton JA, Humphreys K. Response to methadone maintenance treatment of opiate dependent patients with and without significant pain. Drug Alcohol Depend. 2005, October 7 [Epub ahead of print].

Factors Favoring Retention in MMT Explored

Tel-Aviv, Israel; October 7, 2005 – The aims of this study were to identify predictors of treatment retention in an Israeli methadone maintenance treatment (MMT) clinic, and to compare the findings with other international settings.

Investigators prospectively studied during a 10-year period 492 MMT patients, assessing methadone dose and urinalysis results (for methadone, cocaine, opioids, benzodiazepines, THC, amphetamines) for each patient in the first month and after 1 year in treatment (or during the last month if the stay was >3 months and <1 year) and patients’ characteristics (modified Addiction Severity Index).

Roughly three-quarters (74.4%) of patients were retained in MMT for 1 year and two-thirds stopped opioid abuse after 1 year in treatment. On admission, 14% of patients had used cocaine and there was a net decrease in such substance abuse of 62% after 1 year. Factors predicting prolonged retention in MMT treatment were: A) daily methadone dose of 100 mg or greater, B) urinalyses negative for opioids after 1 year, and C) being a parent on admission.

The researchers concluded that their favorable outcomes – high rate of retention rate, high proportion of opioid abuse cessation, and net reduction in cocaine abuse – are similar to normal standards in MMT clinics elsewhere in the world. They suggested that this justifies the expansion of the MMT clinic network in Israel in order to make treatment available to all those who need it. Furthermore, a protocol favoring higher methadone dosage as appropriate is recommended.

Source: 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. 2005, October 7 [Epub ahead of print].

Sleep Apnea a Problem in MMT Patients

Victoria, Australia; September 2005 – This study examined the prevalence and possible causes of central sleep apnea in a group of methadone maintenance treatment (MMT) patients.

Central sleep apnea (CSA) is a neurological condition causing breathing cessation during sleep. The person is then aroused from sleep by an automatic breathing reflex and, since this may occur frequently during the night, may end up getting very little restful sleep through the night.

Previous studies by the authors demonstrated that 6 of 10 (MMT) patients may experience the disorder. This present investigation involved 25 male and 25 female MMT patients who were matched against 20 “normal” subjects in terms of age-, sex-, and body mass index (BMI). They all were assessed via sleep quality testing, blood toxicology, and other physiological measures.

The results indicated that 30% of stable MMT patients had CSA, only a minority of which could be explained by blood methadone concentration. Matched-control group subjects did not exhibit CSA. Other physiologic variables may also play a role in causing CSA in MMT patients and further research is indicated to explore these.

Source: Wang D, Teichtahl H, Drummer O, et al. Central sleep apnea in stable methadone maintenance treatment patients. Chest. 2005;128(3):1348-1356.

[This relatively high prevalence of sleep disturbance in MMT patients may be a factor influencing complaints of fatigue and drowsiness after dosing, or throughout the day. The possibility of sleep apnea in these patients rather than excessive methadone doses might be worthwhile considering. – Ed.]

SAMHSA Releases TIP on Substance Abuse Treatment in the Criminal Justice System

Rockville, MD; September 2005 – The Substance Abuse and Mental Health Services Administration (SAMHSA) has released a new Treatment Improvement Protocol (TIP 44) that presents clinical guidelines to help substance abuse treatment counselors who treat persons in the criminal justice system. Titled Substance Abuse Treatment for Adults in the Criminal Justice System, it was released by SAMHSA Administrator Charles Curie at the Treatment Accountability for Safer Communities (TASC) conference in Cleveland.

TIP 44 provides information on state-of-the-art screening, assessments, treatment services, and follow-up services for individuals in a variety of criminal justice settings. The TIP is designed for treatment counselors and clinicians working with clients who are involved in the criminal justice system under full or partial supervision; on probation; on parole; or on pretrial release. It is also useful for criminal justice system personnel dealing with offenders who abuse alcohol or drugs.

For a free copy: TIP 44 is available on the web at http://www.SAMHSA.gov, located under Substance Abuse Treatment Capacity. Or, go to: http://www.samhsa.gov/news/newsreleases/TIP%2044-CJA.pdf. Access checked 10/15/05.

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.