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AT Forum NEWS NOTES & UPDATES #117

March 2008

Compiled & Edited by Sue Emerson - Publisher

Prior Edition: February 2008

List of all News/Updates

Contents

MEDICATION-ASSISTED TREATMENT (MAT) FOR OPIOID DEPENDENCE

SAMHSA Delayed Reporting of Buprenorphine Problems

Federal Drug Officials Detail Plan to Prevent Abuse of Buprenorphine

Recovery Month – April 2, 2008 Webcast "Medication-Assisted Therapies: Providing a 'Whole-Patient' Approach to Treatment"

Melatonin, Benzodiazepines, and Sleep Quality Among Patients Receiving MMT

GOVERNMENT

SAMHSA Sees Rise in Drug Admissions to Treatment

Federal Drug Budget Defies Policy Priorities, Critic Contends

Addiction, Mental Health Problems Linked to Long-Term Displacement Among Hurricane Survivors

HIV, AIDS

Impact of Substance Use on Adherence to HIV Medications

SMOKING

Smoking Among Patients With Alcohol or Drug Use Disorders

Substance Use and Nicotine Dependence

JOURNALS

New: Mental Health and Substance Use: Dual Diagnosis

New Issue: NIDA’s Addiction Science & Clinical Practice

MISCELLANEOUS

Prescription Drugs Blamed for Rising Overdose Deaths

Prescription Opioid Use and Diversion

Data Shows Substance Abuse Treatment Reduces Crime

 

MEDICATION-ASSISTED TREATMENT (MAT) FOR OPIOID DEPENDENCE

SAMHSA Delayed Reporting of Bupe Problems

The Substance Abuse and Mental Health Services Administration (SAMHSA) knew as early as December 2005 that some patients were crushing and injecting buprenorphine - a drug designed to prevent just such abuse -- but didn't release the findings until January 2008, the Baltimore Sun reported Feb. 12.

On January 28, 2008, SAMHSA posted a report on its website detailing "new" findings about the misuse of buprenorphine, sold commercially as Suboxone, including illicit sales and a "small but persistent" problem of abuse. But Vermont officials had reported those problems to SAMHSA two years earlier, even as SAMHSA was in the middle of a campaign to promote buprenorphine use as an alternative to treating opiate addicts with methadone.

Sen. Bernard Sanders (I-Vt.) chastised SAMHSA for the delay in reporting problems with bupe to Congress and the Food and Drug Administration, calling for the Senate Committee on Health, Education, Labor and Pensions to "look into concerns about buprenorphine and investigate the failure of the FDA and SAMHSA to collaborate and to share and release reports in a timely manner."

Kay Springer, a SAMHSA spokesperson, said that the agency did "take a while" to release the report, which she said was originally supposed to be used internally and not for public release.

SAMHSA commissioned a study of possible bupe abuse a year after receiving the Vermont reports; the study was delivered on Nov. 30, 2006. During the same year, SAMHSA told Congress that use of the drug was progressing with "minimal adverse public health consequences," and lawmakers agreed in December 2006 to expand use of the drug.

The 70 page report can be accessed at: http://buprenorphine.samhsa.gov/Buprenorphine_FinalReport_12.6.06.pdf

Source: Join Together - February 19, 2008

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Federal Drug Officials Detail Plan to Prevent Abuse of Buprenorphine

Federal officials recently detailed a plan to control diversion and abuse of an anti-addiction medication that was specifically designed to resist such problems, the Baltimore Sun reported Feb. 23.

An expert panel recently concluded a two-day, closed-door meeting to discuss problems associated with buprenorphine. The drug was designed by the National Institute on Drug Abuse and pharmaceutical firm Reckitt Benckiser to be resistant to addicts crushing the pills and injecting them.

But experts say that addicts are nonetheless doing exactly that to get high, as well as selling it on the street."The issue of diversion has been out there since 2004," said Dr.  H. Westley Clark, director of the Center for Substance Abuse Treatment. "We've been concerned about that, and we will continue to be concerned about that."

The expert panel called for sterner warning labels on the drug, better training for physicians who prescribe it, and for improved monitoring of prescriptions and drug supplies. Former NIDA head Charles Schuster said, for example, that doctors need to be more cautious about prescribing 30-day supplies of the drug.

"A small minority of doctors are not practicing good medicine," Schuster said.  "That's a problem we need to be concerned with."

Buprenorphine has been praised as highly effective at curbing withdrawal symptoms, and the drug's wider availability has allowed many opiate addicts with limited or no access to methadone programs to get treatment. About 170,000 people have prescriptions to buprenorphine.

Source: JoinTogether.org - February 25, 2008

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Recovery Month – April 2, 2008 Webcast "Medication-Assisted Therapies: Providing a 'Whole-Patient' Approach to Treatment"

Join host Ivette Torres, Associate Director for Consumer Affairs, Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services for this webcast.

The use of medications, in combination with counseling and behavioral therapies, to provide a "whole-patient" approach to treatment has proven successful in helping individuals break their addictions to drugs and alcohol. As part of a comprehensive treatment program, medication-assisted therapies have been shown to increase retention in treatment, decrease criminal activities, decrease homelessness, and increase employment. This program will look at how methadone, buprenorphine, and other medication-assisted therapies continue to help individuals, families, and communities overcome the ravages of alcohol and drug addiction.

This Webcast will be archived for viewing at any time immediately afterwards. The 2008 season will air nine Webcasts, featuring panels of nationwide experts from the field.

Further details can be accessed at http://www.recoverymonth.gov/2008/multimedia/default.aspx

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Melatonin, Benzodiazepines, and Sleep Quality Among Patients Receiving MMT

Both benzodiazepine abuse and sleep disorders are common worldwide among patients receiving methadone maintenance. This double-blind trial evaluated the effectiveness of melatonin in reducing sleep problems among 80 patients who were receiving methadone maintenance and abusing benzodiazepines. These patients were recruited into a benzodiazepine withdrawal program where they each received melatonin (5 mg per day) for 6 weeks, nothing for 1 week (washout week), and placebo for 6 weeks.

• Overall, subjects reported higher subjective sleep quality, regardless of treatment arm, at 6 weeks. 
• About one-third of subjects had stopped using benzodiazepines (as identified by urine toxicology) by 6 weeks. Sleep quality among these subjects was not affected by melatonin but was significantly better than sleep quality among subjects who continued benzodiazepines.
• Of subjects who continued using benzodiazepines at 6 weeks, sleep quality significantly improved with melatonin versus placebo.
• Over approximately 21 months, 63 patients stopped using benzodiazepines, although all but 4 relapsed. Time to benzodiazepine relapse was significantly longer among subjects who received melatonin (125 days) versus placebo (42 days) in the first 6 weeks.

Comments:

This small trial has several findings relevant to the vexing problems of sleep disturbance and benzodiazepine abuse among patients receiving methadone. Most of the improvement in sleep quality was attributable to stopping benzodiazepines, a finding clinicians may choose to highlight when discussing benzodiazepine use with their sleep-disturbed patients who receive methadone. Although melatonin did not improve benzodiazepine discontinuation overall, it improved sleep quality among patients who could not stop benzodiazepines and lengthened the time to relapse among those who did stop. If replicated, these findings will support melatonin's possible use for sleep problems among patients who receive methadone maintenance and use anxiolytics, and as an adjunct to decrease relapse to benzodiazepines. 

Published In: Alcohol, Other Drugs, and Health: Current Evidence a project of the Boston Medical Center issue January/February/March 2008. Article accessed 1/28/08.
Peter D. Friedmann, MD, MPH

Original Source: Peles E, Hetzroni T, Bar-Hamburger R, et al. Melatonin for perceived sleep disturbances associated with benzodiazepine withdrawal among patients in methadone maintenance treatment: a double-blind randomized clinical trial. Addiction. 2007;102

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Government

SAMHSA Sees Rise in Drug Admissions to Treatment

More Americans are being admitted to addiction treatment for methamphetamine, prescription-drug, and marijuana use, while a smaller percentage of treatment admissions are for alcohol problems, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).

SAMHSA's Treatment Episode Data Set (TEDS) 2006 Highlights report found that while alcohol abuse continues to be the most common reason for treatment admissions, admissions for alcohol treatment have fallen from 51 percent of the total in 1996 to 40 percent in 2006. During the same time period, admissions for meth, prescription drugs, and marijuana increased.

Heroin Admissions

• Heroin as a primary substance increased from 14 percent of all TEDS admissions in 1996 to 16 percent in 2001, then declined to 14 percent in 2006.
• About two-thirds (68 percent ) of primary heroin admissions were male.
• More than half (52 percent) of primary heroin admissions were non-Hispanic White, followed by 24 percent who were of Hispanic origin and 22 percent who were non-Hispanic Black.
• For primary heroin admissions, the average age at admission was 36 years.
• Sixty-four percent of primary heroin admissions reported injection as the route of administration, 32 percent reported inhalation, and 2 percent reported smoking.

Other Opiates⁽¹⁾ Admissions

• TEDS admissions for primary abuse of opiates other than heroin increased from 1 percent of all admissions in 1996 to 4 percent in 2006.
• Just over half (54 percent) of primary non-heroin opiate admissions were male.
• Most primary non-heroin opiate admissions (88 percent) were non-Hispanic White.
• For primary non-heroin opiate admissions, the average age at admission was 33 years.
• Almost three-quarters (72 percent) of primary non-heroin opiate admissions reported oral as the route of administration, 14 percent reported inhalation, and 11 percent reported injection.

TEDS includes treatment admissions data from publicly funded addiction-treatment programs.

The report can be accessed at http://oas.samhsa.gov/teds2k6highlights/TOC.cfm

¹ These drugs include codeine, hydrocodone, hydromorphone, meperidine, morphine, opium, oxycodone, pentazocine, propoxyphene, tramadol, and any other drug with morphine-like effects. Non-prescription use of methadone is not included.

Source: JoinTogether.org – February 19, 2008 and SAMHSA

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Federal Drug Budget Defies Policy Priorities, Critic Contends

Carnevale Associates recently released an analysis of the proposed FY2009 drug budget which states that the Bush administration continues to favor supply-reduction programs over demand-reduction programs, with the former receiving at least two-thirds of all federal antidrug funding.

"Since FY02, the budget has emphasized what research has shown to be the least effective ingredients of a federal drug-control policy," the analysis states. "This translates into almost a decade of lost opportunities in achieving performance results."

In fact, Carnevale notes, the supply-reduction side of the budget -- which includes law-enforcement, interdiction, and source-country programs -- has grown 57 percent since FY02, while demand-reduction funding has increased just 3 percent. "If research were our guide, then one would expect the opposite ordering of increases in budgetary resources for drug control," according to the policy brief.

Much of the growth in demand-reduction funding has been in basic research, and funding for prevention has actually declined by 25 percent, according to the analysis. Meanwhile, funding for interdiction has increased 100 percent, while funding for source-country programs has increased 50 percent and law-enforcement funding has risen 31 percent, Carnevale estimated.

The article can be accessed at: http://www.jointogether.org/news/features/2008/federal-drug-budget-defies.html

Source: JoinTogether.org – February 22, 2008

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Addiction, Mental Health Problems Linked to Long-Term Displacement Among Hurricane Survivors

Rates of post-storm addiction and mental-health problems among Hurricanes Katrina and Rita survivors can be directly correlated to how long they were displaced from their homes, according to new research from the Substance Abuse and Mental Health Services Administration (SAMHSA).

The study found that while most survivors displayed great resiliency after the storms, the rate of addiction and mental-health problems was much higher among those who had been forced from their homes for two weeks or more.

SAMHSA researchers who compared drug-use and mental-illness data from before and after the hurricanes found that marijuana use actually decreased in the Gulf States region after the storms, while levels of serious psychological distress remained about the same. Adults in the storm areas had addiction and mental-illness rates roughly the same as the rest of the U.S., according to data from the National Survey on Drug Use and Health.

However, past-month use of illicit drugs among adults displaced for two weeks or longer by the storm was 10.5 percent, compared to 4.9 percent among those who had not been displaced. Likewise, 25.7 percent of the displaced adults suffered serious psychological stress, compared to 9.2 percent of those who weren't dislocated. Displaced individuals also were much more likely to have unmet mental-health treatment needs.

Source: JoinTogether.org – February 7, 2008

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HIV/AIDS

Impact of Substance Use on Adherence to HIV Medications

High levels of adherence to highly active antiretroviral therapy (HAART) are associated with improved outcomes for patients with HIV. Through interviews with 659 patients with HIV, researchers in this study assessed whether illicit substance use and receiving substance use treatment influence adherence to HAART.

• Forty-two percent of the patients had used illicit drugs in the past 6 months (current use); 30% had used illicit drugs, but not in the past 6 months (former use), and 28% had never used illicit drugs.
• Adherence was:
  
  
  • significantly less common among subjects with current use (60%) than among subjects with former (68%) or no (77%) use;
  • similar between subjects with former use who had received recent substance-use treatment and subjects with no use
  • lower in subjects with former use who had not received recent substance- use treatment than in subjects with no use (adjusted odds ratio, 0.6; P=0.05);
  • lower in subjects with current use than in subjects with no use, regardless of receipt of substance-use treatment.

Comments:

This study demonstrates the potential adverse impact of illicit-drug use on adherence to HIV medications. It also indicates the importance of ongoing substance-use treatment for people with past substance use. The study is limited because it did not evaluate biologic outcomes (e.g., CD4 cell count or HIV viral load) or the impact of alcohol separately from the impact of illicit substance use in multivariate analyses. Nonetheless, these findings support the importance of engaging patients with HIV and substance use (current or former) in substance-use treatment.

Published In: Alcohol, Other Drugs, and Health: Current Evidence a project of the Boston Medical Center issue January/February/March 2008. Article accessed 1/28/08.
David A. Fiellin, MD.

Original Source:
Hicks PL, Mulvey KP, Chander G, et al. The impact of illicit drug use and substance abuse treatment on adherence to HAART. AIDS Care. 2007;19(9):1134–1140.

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SMOKING

Smoking Among Patients With Alcohol or Drug-Use Disorders

Smoking is much more common in people with alcohol or drug-use disorders.  But the gender on this relationship is not clear. Therefore, researchers analyzed data from a nationally representative sample of 42,565 U.S. adults who had participated in a survey on alcohol and related conditions.

• Prevalence of daily smoking was 21% among the total sample, 40% among people with a current alcohol-use disorder, and 55% among people with a current drug-use disorder.
• Ex-smokers made up about 20% of the total sample, 13% of people with a current alcohol-use disorder, and 8% of people with a current drug-use disorder.
• The likelihood of daily smoking, versus never smoking, was highest among women with a current drug use disorder (odds ratio [OR], 6.5), followed by men with a current drug use disorder (OR, 4.6), women with a current alcohol use disorder (OR, 3.5), and men with a current alcohol use disorder (OR, 2.9).
• The likelihood of occasional smoking, versus never smoking, was also highest among women (e.g., OR, 5.2 for those with a current alcohol use disorder).

Comments:
While the use of tobacco is more common in men than women in the general population, gender differences in smoking among people diagnosed with substance use disorders has not been widely studied.  These findings suggest that the association between substance use disorders and smoking is moderated by gender, and they reinforce the critical importance of addressing tobacco use within substance use disorder treatment. Specific smoking prevention and treatment strategies targeted to women might prove to be more effective than universal approaches.

Published In: Alcohol, Other Drugs, and Health: Current Evidence a project of the Boston Medical Center issue January/February/March 2008. Article accessed 1/28/08.
Norma Finkelstein, Ph.D, LICSW

Original Source: Husky MH, Paliwal P, Mazure CM, et al. Gender differences in association with substance use diagnoses and smoking. J Addict Med. 2007;1(3):161–164.

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Substance Use and Nicotine Dependence

Persons aged 12 or older who were dependent on nicotine in the past month were more likely than those who were not nicotine dependent to have engaged in alcohol use (61.7 vs. 49.1 percent), binge alcohol use (40.1 vs. 20.1 percent), and heavy alcohol use (14.9 vs. 5.5 percent) in the past month (Figure 1). In addition, persons aged 12 or older who were nicotine dependent in the past month were over 3 times more likely than those who were not nicotine dependent to have used an illicit drug in the past month (20.7 vs. 6.2 percent).

<Click here… > to view the PDF file.

Source: Substance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Studies. (January 24, 2008). The NSDUH Report: Nicotine Dependence: 2006. Rockville, MD.

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JOURNALS

New Journal: Mental Health and Substance Use: Dual Diagnosis

Increased recognition of co-existing mental health and substance use issues over the past 20 years has led to a growing body of discussion and research into the efficacy of interventions, treatment, and service delivery. The journal's primary aim is to explore the complex issues arising from co-existing mental health and substance use. This journal will provide a source of reference for clinicians, managers, service developers, researchers, educators, trainers, and students.

This is a peer-review journal published by Routledge which will be issued 3X/year, and will consist of at least 80% peer reviewed articles. The remaining 20% will focus on book reviews, editorial, and commissioned articles.

Additional information on the journal can be accessed at: http://www.tandf.co.uk/journals/rmhs

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New Issue: NIDA’s Addiction Science & Clinical Practice Journal -
Volume 4, Number 1

A new issue of NIDA’s journal is now available online. In this issue, Dr. Alan J. Budney and colleagues review recent research on marijuana dependence, withdrawal, and treatment. Dr. Sharon Samet and colleagues discuss several formal assessment instruments used to diagnose psychiatric disorders and their utility in diagnosing abuse and addiction. Dr. Diana Sylvestre explains the disease process, screening methods, and treatment of hepatitis C in the context of addiction medicine. Finally, Drs. Michael Dennis and Christy Scott explore the discrepancy between acute-care models of addiction treatment and the compelling evidence that addiction is a chronic condition.

The current issue can be accessed at : http://drugabuse.gov/ascp/index.html

Source: National Institute of Drug Abuse – February 3, 2008

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MISCELLANEOUS

Prescription Drugs Blamed for Rising Overdose Deaths

Unintentional poisoning deaths rose from 12,186 in 1999 to 20,950 in 2004, and the increase is largely being attributed to overdoses on prescription drugs, the Los Angeles Times reported Jan. 26.

Ninety-five percent of unintentional poisoning deaths are drug overdoses; in recent years, prescription-drug overdoses have overtaken cocaine and heroin overdoses as the leading cause of poisoning deaths, the U.S. Centers for Disease Control and Prevention (CDC) said. In fact, a recent spike in prescription-drug overdoses is the cause of the first increase in the nation's injury death rate in 25 years, according to CDC injury-prevention expert Len Paulozzi.

Most overdose deaths are due to opioid painkillers like oxycodone, fentanyl, and methadone. But other prescription drugs also can cause fatal overdoses, such as sleeping pills, antidepressants, and tranquilizers. Overdoses from the latter group of drugs increased 84 percent between 1999 and 2004, the CDC said.

Overall, sales of prescription drugs have increased almost 500 percent since 1990.

The article can be accessed at: http://www.jointogether.org/news/headlines/inthenews/2008/prescription-drugs-blamed-for.html

Source: JoinTogether.org – February 22, 2008

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Prescription Opioid Use and Diversion

Prescription opioid analgesics are the most commonly abused prescription medication. Further, these drugs are more frequently abused than heroin. Researchers in this study interviewed 586 drug users in New York City to determine patterns of prescription opioid use, misuse, and sales (diversion).

• Seventy-two percent of subjects used methadone, and 65% sold it.
• Methadone was used and sold by more individuals than was OxyContin, Vicodin, or Percocet.
• Fifty-eight percent of prescription drug users obtained prescription opioids for pain, withdrawal, or euphoria (which they used and/or sold) from doctors; 42% of subjects who reported using Oxycontin they obtained from physicians, 83% reported having used the drug primarily for pain; 50% used it primarily to prevent opioid withdrawal symptoms, and 38% used it primarily for euphoria.
• Prescription drug users were less likely to use prescription opioids for euphoria than for pain.  When they obtained prescription opioids for euphoria, they usually did so from dealers.

Comments: This study helps to illuminate an emergent, and fairly American, drug abuse pattern—abuse and dependence on prescription opioids. Many individuals used these medications to avoid opioid withdrawal or to treat pain, an informative finding. Also, patients were less likely to use these physician-obtained medications for euphoria than for other indications, which is notable and most likely reflects a high level of opioid tolerance. Finally, many of these patients were interacting with physicians, suggesting that physicians should show caution when prescribing opioids and should consider offering office-based treatment (e.g., buprenorphine) or referral to specialty treatment (e.g., methadone) when indicated.

Published In: Alcohol, Other Drugs, and Health: Current Evidence a project of the Boston Medical Center issue January/February/March 2008. Article accessed 1/28/08.
David A. Fiellin, MD

Original Source: Davis WR, Johnson BD. Prescription opioid use, misuse, and diversion among street drug users in New York City. Drug Alcohol Depend. 2008;92(1–3):267–276

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Data Shows Substance Abuse Treatment Reduces Crime

Community-based substance abuse treatment reduces crime rates and helps states reduce corrections costs, according to a new policy brief released January 22, 2008, by the Justice Policy Institute (JPI).

The policy brief found that:

• Increases in admissions to substance abuse treatment are associated with reductions in crime rates. Admissions to drug treatment increased 37.4 percent and federal spending on drug treatment increased 14.6 percent from 1995 to 2005. During the same period, violent crime fell 31.5 percent.
• Increased admissions to drug treatment are associated with reduced incarceration rates. States with a higher drug treatment admission rate than the national average send, on average, 100 fewer people to prison per 100,000 population than states that have lower than average drug treatment admissions.
• Substance abuse treatment prior to contact with the justice system yields public safety benefits early on. Research has shown that drug treatment programs improve life outcomes for individuals and decrease the likelihood that a drug-involved person will be involved in the criminal justice system.
• Substance abuse treatment helps individuals transition successfully from the criminal justice system to the community. Community-based drug treatment programs reduce the chance that a person will become involved in the criminal justice system after release from prison.
• Substance abuse treatment is more cost-effective than prison or other punitive measures. The Washington State Institute for Public Policy (WSIPP) found that community-based drug treatment is extremely beneficial in terms of cost, especially compared to prison. Every dollar spent on drug treatment in the community is estimated to return $18.52 in benefits to society in terms of reduced incarceration rates and associated crime costs to taxpayers.

The Policy Brief can be accessed at: http://www.justicepolicy.org/content.php?hmID=1811&smID=1581&ssmID=70#a287a287

Source: Justice Policy Institute – January 22, 2008

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Updated April 14, 2008