AT Forum NEWS NOTES & UPDATES #112

July - August 2007

Compiled & Edited by Sue Emerson - Publisher

Prior Edition: May-June 2007

List of all News/Updates

Contents

Research Roundup

Younger IDUs Less Likely to Enter MMT Programs

Therapeutic Workplace Combined with MMT More Economic

Fewer Post-Release Prisoners Use Heroin When Transferred to Methadone Maintenance

Women and Opioid Dependence Treatment: Office-Based versus Opioid Treatment Program-Based Care?

MMT Patients Require More Opiate Analgesics After Cesarean Delivery

High Dose Diazepam Combined with Methadone or Buprenorphine Evaluated

Alcohol Drinking Patterns Unlikely to Change Upon Entering MMT

Demographic and Geographic Variations in Injection Drug Use – National Survey  on Drug Use and Health (NSDUH)

MMT Clinic News

Pennsylvania Methadone Clinic Wins Federal Lawsuit

Pennsylvania Court Rules Methadone Clinics can be Held Liable for Corporate Negligence

Government News

Senate Committee Passes Legislation to Change Names of NIDA, NIAAA

SAMHSA Anticipated FY 2008 Funding Opportunities “At A Glance”

NIDA's Scientific Journal to Become Journal of Addiction Science & Clinical Practice

New Books and Resources of Interest

New Resource Guide for MMT - Methadone Maintenance Treatment in the U.S.    A Practical Question and Answer Guide

Updated Directory of SAMSHA Drug and Alcohol Abuse Treatment Programs

Promoting Awareness of Motivational Incentives (PAMI)

Related Website of Interest

Understanding Addiction – Animated Presentation

 
Research Roundup

Younger IDUs Less Likely to Enter MMT Programs

This Boston University School of Social Work study evaluated Injection Drug Users (IDUs) by age groups (18-25), (26-39), and (40+), entering all state licensed drug treatment programs over an 8 year period (1996-2002). Outcomes determined that younger abusers (ages 18-25) were mostly male, unemployed and typically heroin dependent. This younger age group was more likely to utilize detoxification treatment only, and not enter any additional treatment. The younger abusers, were also less likely to enter Methadone Maintenance Treatment (MMT), and considerably more likely to enter residential treatment compared to the older IDUs.

The authors concluded that strategies should be developed to facilitate transition from detoxification to more comprehensive treatment, and especially methadone maintenance treatment (MMT) in the younger IDUs.

Source: Shin SH, Lundgren L, Chassler D.Examining Drug Treatment Entry Patterns Among Young Injection Drug Users. Am J Drug Alcohol Abuse. 2007(Mar);33(2):217-225.

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Therapeutic Workplace Combined with MMT More Economic

This Johns Hopkins study reviewed patients in Methadone Maintenance Treatment (MMT) programs where patients had access to training or employment for which they received payment. The Drug Abuse Treatment Cost Analysis Program was used to estimate the economic costs associated with this therapeutic workplace intervention. A total of 122 MMT patients participated in the study.

The review found that the weekly cost of MMT and the therapeutic workplace was estimated at US$362, which is less than that of other treatments that may be used to help promote abstinence in MMT patients. The authors concluded that “given prior evidence of effectiveness, these cost data may be useful to policy makers, social service agencies, and researchers interested in using or further developing the therapeutic workplace intervention.”

Source: Knealing TW, Roebuck MC, Wong CJ, Silverman K.Economic Cost of the Therapeutic Workplace Intervention Added to Methadone Maintenance.J Subst Abuse Treat. 2007Jul 3 [Epub ahead of print]

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Fewer Post-Release Prisoners Use Heroin When Transferred to Methadone Maintenance

The objective of this study was to examine the effectiveness of MMT provided to prisoners with pre-incarceration heroin addiction. This randomized controlled clinical trial was conducted between September 2003 and June 2005. A total of 211 Baltimore inmates who were heroin dependent during the year prior to incarceration participated in the study. The inmates were randomly assigned to one of three equally divided groups. 1) counseling only with passive referral to treatment upon release, 2) counseling in prison with transfer tomethadone treatment upon release, and 3) counseling and MMT in prison with continued treatment in community MMT programs post release.

Follow-up interviews were conducted with 200 participants The percentages of participants that entered MMT treatment upon release were 7.8% for counseling only, 50.0% for counseling and transfer to MMT, and 68.8% for counseling and methadone in prison. The one month post release results showed that prisoners who received both counseling and MMT in prison had the lowest rate (27.6%) for testing positive for opioids,  Both of the other groups had higher positive test results for opioids; counseling with referral to MMT (41%) and counseling only (62.9%).

Source: Kinlock TW, Gordon MS, Schwartz R, O’Grady K, Fitzgerald TT, Wilson M.A Randomized Clinical Trial of Methadone Maintenance for Prisoners: Results at 1-Month Post-Release.Drug Alcohol Depend2007Jul [Epub ahead of print]

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Women and Opioid Dependence Treatment: Office-Based versus Opioid Treatment Program-Based Care?

Women tend to be under-represented in opioid dependency treatment, yet statistics reveal that, as the non-medical use of prescription pain relievers increases, more women will require this treatment. Women in opioid-dependency treatment programs tend to exhibit higher rates of psychiatric illness, more concerns regarding substance abuse and treatment in pregnancy, higher rates of trauma, relationships that put women at risk for sexually transmitted diseases, and social factors such as lower economic status and responsibilities as care givers.

Traditional approaches to opioid-dependency treatment, such as methadone maintenance programs (MMPs), have not consistently addressed these needs, and do not provide flexible care and anonymity. Recent data suggest that, in comparison to MMPs, a greater percentage of women are entering office-based treatment. The authors concluded, that while it is uncertain whether physicians' offices will be equipped to adequately handle women's treatment needs, OBT may provide a solution for women concerned about anonymity, stigma, and the requirement of daily visits to a MMP.

Note: MMT programs need to better address the special needs of opioid-dependent women to overcome the barriers addressed in this study.

Jones. ES, Fiellin, DA. Women and Opioid Dependence Treatment: Office-Based versus Opioid Treatment Program-Based Care.Substance Abuse. 2007,28(2):3-8

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MMT Patients Require More Opiate Analgesics After Cesarean Delivery

This study was conducted to determine whether methadone maintenance alters intrapartum or postpartum pain or medication requirements. Sixty-eight patients who were treated with methadone for opiate dependence during pregnancy (vaginal n=35; cesarean n=33) were matched retrospectively to a control group. Analgesic medication and pain scores were extracted from medical records.

Results of the study indicated that there were no differences in intrapartum pain or analgesia. After vaginal birth, methadone-maintained women experienced increased pain but no increase in opiate use; after cesarean delivery both pain and opiate use increased. The authors concluded that methadone-maintained women have similar analgesic needs and response during labor, but require 70% more opiate analgesic after cesarean delivery.

Source: Meyer M, Wagner K, Benvenuto A, Plante D, Howard D. Intrapartum and postpartum analgesia for women maintained on methadone during pregnancy.Obstet Gynecol. 2007Aug;110(2):261-6.

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High Dose Diazepam Combined with Methadone or Buprenorphine Evaluated

The objective of this study was to investigate the effects of co-administering diazepam with methadone or buprenorphine under high dose conditions. The study examined the effects of diazepam dose (0mg versus 40mg) and opioid dose (100% versus 150% normal dose) which were observed during four sessions in 4 methadone and 7 buprenorphine-prescribed patients.

Psychological and performance measures in patients were studied prior to and 6 hours after dosing. Results of the study showed that high dose diazepam was associated with time-dependent increases in the intensity of subjective drug effects such as strength of drug effect and sedation, and decreases in psychological performance such as reaction time for both groups of patients. These effects were generally independent of the opioid dose administered. The authors concluded that “high dose diazepam significantly alters subjective drug responses and psychological performance in patients maintained on methadone and buprenorphine.”  

Comment:  It could be inappropriate to draw significant conclusions from such a small study.

Source: Lintzeris N, Mitchell TB, Bond AJ, Nestor L, Strang J. Pharmacodynamics of diazepam co-administered with methadone or buprenorphine under high dose conditions in opioid dependent patients. Drug Alcohol Depend. 2007Jul 10 [Epub ahead of print]

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Alcohol Drinking Patterns Unlikely to Change Upon Entering MMT

The objective of this systematic review, was to determine whether alcohol consumption is affected during the course of MMT (from prior to treatment initiation to once on maintenance). Of the 15 clinical studies that met the inclusion criteria, three studies supported an increase in alcohol use, three supported a decrease in alcohol use, and nine supported no change in alcohol use. The studies varied in their methodology and in their definition of problematic alcohol use. This review found that alcohol use, although often problematic in methadone-using patients, likely does not change upon entering MMT. The authors recommend routine screening and treatment for problematic alcohol use in patients on MMT.

Srivastava A, Kahan M, Ross S. The effect of methadone maintenance treatment on alcohol consumption: A systematic review.J Subst Abuse Treat. 2007 Jun 25 [Epub ahead of print]

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SAMHSA Demographic and Geographic Variations in Injection Drug Use – National Survey on Drug Use and Health (NSDUH)

This report released July 19th examines variations in the rates of past year injection drug use among persons aged 12 or older by gender, age, race/ethnicity, county type, and region. Because past year injection drug use rates remained relatively stable from 2002 through 2005, the report focuses on combined annual averages of 2002 to 2005 NSDUH data.

Respondents aged 12 or older were told to report whether they ever used a needle to inject heroin, cocaine, methamphetamine, other stimulants, or other drugs that were not prescribed for them or that they took only for the feeling or experience they caused.  Highlights of the survey include:

• 0.18% of all respondents (an estimated 424,000 persons annually) injected heroin, cocaine, methamphetamine or other stimulants in the past year.
• Males were twice as likely as females to have injected these drugs in the past year (0.24% vs. 0.11%).
• Rates of injections were 3 times higher among adults aged 18 to 34 compared with youths and adults aged 35+ (0.34% vs. 0.10% and 0.12%).
• Past year injection of these drugs varied significantly among racial/ethnic groups, with the lowest rate among Asians at 0.01%. Whites were more likely than blacks to have injected these drugs in the past year.
• Persons living in the Northeast were more likely to inject heroin than persons living in the Midwest or South; however, persons living in the Northeast were less likely to have injected methamphetamine.
• More than two fifths of past year heroin users injected heroin in that period compared with less than a tenth of past year users of cocaine, methamphetamine, and other stimulants who injected these drugs.

To view the 4-page report < click here… >

Source: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (July 19, 2007). The NSDUH Report: Demographic and Geographic Variations in Injection Drug Use. Rockville, MD.

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MMT Clinic News

Pennsylvania Methadone Clinic Wins Federal Lawsuit

On June 15th, a Philadelphia US Court of Appeals ruled in favor of New Directions which originally filed and lost a Federal lawsuit in 2001 against Reading, Pennsylvania.  When New Directions sought to open a methadone clinic in Reading, city officials said “no,” citing a 1999 Pennsylvania statute that barred such clinics from operating near a residential area.

The federal appeals court struck down the state statute, saying it violated federal law. "The court says you cannot impose restrictive zoning requirements solely on methadone treatment facilities," said Richard Churchill, a Philadelphia attorney who represented New Directions. The decision by the 3rd U.S. Circuit Court of Appeals in Philadelphia described the case in a 52-page opinion as a "familiar conflict between the legal principle of nondiscrimination and the political principle of not-in-my-backyard."

Source: NAMA (National Alliance of Methadone Advocates)

Followup Note: According to an article published June 26, 2007, in the Du Bois, PA Courier-Express, the proposed Reading site was a drug treatment center before, which made it difficult to uphold the Pennsylvania state statute.

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Pennsylvania Court Rules Methadone Clinics can be Held Liable for Corporate Negligence

ALTOONA, Pa., Aug. 6 /PRNewswire-USNewswire/ -- In what is believed to be the first ruling of its kind in Pennsylvania, a Blair County Common Pleas Court judge has ruled that, just like hospitals, methadone clinics can be liable for corporate negligence.

The ruling stems from a lawsuit brought against the private, for-profit clinic, a hospital and a psychiatrist by the estate of Crystal M. Ickes, a single mother of three who died as a result of an August 2004 head-on car crash that occurred shortly after she left Alliance Medical Services, Inc.'s methadone clinic in Johnstown, Pa., for the 46-mile drive back to her home in Altoona. Less than an hour after receiving a methadone dose, the car Ickes was driving eastbound crossed a median strip on U.S. Route 22 and struck a westbound car operated by Matthew Stever, who suffered severe head injuries that resulted in permanent neurological damage.

The Ickes Complaint asserts that the combination of methadone and various anti-depressants and sleeping pills Ickes had been prescribed impaired her ability to drive safely, and that as a result she either suffered a seizure or fell asleep at the wheel. This conclusion was supported by the fact that her car left no skid marks.

"For purposes of corporate liability, Alliance clearly meets the criteria of a healthcare provider," Judge Hiram A. Carpenter ruled in an opinion and order in response to defendants' objections.

Attorneys for Alliance, citing a 1998 Superior Court decision in Shannon v. McNulty, a lawsuit against an HMO, argued that corporate liability is inapplicable to facilities that deal with limited aspects of a patient's care - in contrast to the total healthcare of a patient such as that provided by a hospital.

But finding that the defendants' reliance on Shannon was "misplaced," Judge Carpenter ruled that the factual allegations of the Ickes case, if believed, meet the two-prong corporate liability test established in Thomson v. Nason - the 1991 Pennsylvania Supreme Court decision which first extended the doctrine of corporate liability to hospitals.

"First, Plaintiff alleges that Alliance knew that its policies were ineffective in protecting the safety of its patients, yet failed to correct them," the judge wrote. "Plaintiff additionally alleges that failure resulted in Ms. Ickes being allowed to leave the facility to operate a vehicle in an overly-sedated state, causing her injuries."

Donna Lee Jones, an attorney with SMBB, said, "The clinic and the other defendants clearly bear responsibility for this tragic collision. At one previous visit the clinic recorded in Ickes' chart that she was falling asleep in line waiting for her methadone dose, and during another visit she couldn't even sign her name she was so sleepy. She also had suffered seizures as a result of medications her psychiatrist had prescribed, for which she was taken to the Emergency Department at Altoona Hospital."

In addition to Alliance Medical Services, defendants include Joseph L. Antonowicz, MD, the psychiatrist who was treating her for depression at Altoona Hospital, the hospital and the Altoona Regional Health System.

Michael F. Barrett, Managing Shareholder of SMBB and plaintiff's co- counsel with Jones, added, "Crystal Ickes should never have been allowed to drive away from the clinic that morning." He added, "State law requires all medical providers to report impaired patients like Ms. Ickes to the Division of Motor Vehicles to determine if their driver's licenses should be revoked, but neither the clinic, her psychiatrist nor the hospital did so."

Barrett also noted that just last month in Mahaffey, Clearfield County, a grandmother and her three-year-old daughter were killed in a crash believed to be caused by an out-of-control driver returning from a methadone clinic in the county. Given the known impairments associated with mixing methadone and anti- depressant drugs, a methadone clinic's responsibility to its patients is not merely limited to providing them with methadone and sending them on their way.

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 Government News

Senate Committee Passes Legislation to Change Names of NIDA, NIAAA

On June 28th, the Senate, Health, Education, Labor, and Pensions (HELP) Committee passed the Recognizing Addiction as a Disease Act of 2007. The bill would change the name of the National Institute on Drug Abuse (NIDA) to 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). A similar bill has been introduced into the House of Representatives.

Source: Join Together

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SAMHSA Anticipated FY 2008 Funding Opportunities “At A Glance”

On July 13th, The Substance Abuse and Mental Health Services Administration (SAMHSA) issued a preliminary forecast of anticipated funding for discretionary grant programs in FY 2008, based on the President’s FY 2008 budget request. These plans may change and final figures will not be available until after SAMHSA receives its FY 2008 appropriation.

For each program, the chart provides estimated funding, number and size of awards, a program description, eligibility restrictions, contact information for the project officer, and a target publication date.
Click here to view the preliminary FY 2008 funding opportunities.

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NIDA's Scientific Journal to Become Journal of Addiction Science & Clinical Practice

On August 1st, The National Institute on Drug Abuse (NIDA) announced that it is changing the name of its scientific journal Perspectives to the Journal of Addiction Science & Clinical Practice, beginning with the November issue.  According to NIDA, “The new title is designed to better reflect the journal's commitment to covering the exchange of ideas between researchers, clinicians, and others in the field of addiction science. NIDA will also increase the number of issues per year from once to twice a year."

The journal can be accessed at http://www.drugabuse.gov/perspectives/

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Books and Resources of Interest

New Resource Guide for MMT
Methadone Maintenance Treatment in the U.S. A Practical Question and Answer Guide

This user-friendly reference book on Methadone Maintenance Treatment (MMT) programs, was written for a diverse audience, including clinicians, program administrators, substance abuse treatment researchers, and other health service professionals who want to learn more about all aspects of MMT.

Authors Wendee M. Wechsberg, PhD; Jennifer J. Kasten, PhD; Nancy D. Berkman; and Amy E. Roussel offer insights into the history and effectiveness of methadone, methadone dosing practices, the characteristics of successful methadone treatment programs (budgets, treatment services, staff, etc.), as well as regulation and accreditation issues.

The information presented in this guide is based on a study of more than 100 MMT programs in 15 states.

Where to get this book…Methadone Maintenance Treatment in the U.S. A Practical Question and Answer Guide is available from Springer Publishing at: http://www.springerpub.com/prod.aspx?prod_id=01305 (ISBN: 0-826-10130-5, publication date May 2007; soft cover; 216 pages; list price $35.00). It is also available at discount prices from http://www.amazon.com and at other online booksellers.

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Updated Directory of SAMSHA Drug and Alcohol Abuse Treatment Programs

The Substance Abuse and Mental Health Services Administration (SAMHSA) has updated their guide to assist in finding local substance abuse treatment programs. The National Directory of Drug and Alcohol Abuse Treatment Programs 2007, provides information on alcohol and drug treatment programs located in all 50 states, the District of Columbia, Puerto Rico and four U.S. territories. Released June 11, 2007.

Copies may be obtained free of charge from SAMHSA’s Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727) or http://ncadistore.samhsa.gov/catalog/productDetails.aspx?ProductID=17684
Request inventory number SMA07-4290.
The online version of the directory is available at: http://dasis3.samhsa.gov/.

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NIDA/SAMHSA Offer New Tools For Successful Treatment Outcomes
Promoting Awareness of Motivational Incentives (PAMI)

The Promoting Awareness of Motivational Incentives (PAMI) Blending Team developed the tools contained in this package to build awareness of Motivational Incentives (MI) or contingency management, as a science-based therapeutic strategy within the addiction treatment field. The products in this package illustrate positive outcomes and lessons learned from the NIDA Clinical Trials Network (CTN) study, Motivational Incentives for Enhanced Drug Abuse Recovery (MIEDAR).

Training materials include: a video, PowerPoint presentation, and additional support materials for program administrators and clinicians. This training package can be downloaded at: http://pami.nattc.org/aboutUs/blendingInitiative/products2.htm.  

Related Website of Interest

Understanding Addiction – Animated Presentation

The University of Utah Genetic Learning Center has developed a clever animated presentation using mice to help depict how seven drugs including heroin interact with dopamine neurotransmitters in the brain’s reward pathway. The “Mouse Party is designed to provide a small glimpse into the chemical interactions at the synaptic level that cause the drug user to feel ‘high.”
<Click here to view the presentation… >

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