AT Forum NEWS NOTES & UPDATES #140
April 2010
Compiled & Edited by Sue Emerson - Publisher
Prior Edition: March 2010
Contents
METHADONE & MEDICATION-ASSISTED TREATMENT (MAT)
New Resources on Methadone Interactions With Other Drugs
PCSS-Methadone Issues Guidance on Methadone Drug Interactions
Is Sleep-Disordered Breathing a Major Cause of Sleep Disturbances in Methadone-Maintained Patients?
GOVERNMENT NEWS & REPORTS
McLellan Resigning as ONDCP Deputy Director
NDIC Issues National Drug Threat Assessment Report 2010
FDA Approves New Formulation for OxyContin
FDA Staff Concerned About Additive Designed to Combat Pain Drug's
Healthcare Reform Law Gives Big Boost to Addiction Treatment and Prevention
RESEARCH IN THE NEWS
Poisoning by Prescription Drugs on the Rise
METHADONE & MEDICATION-ASSISTED TREATMENT (MAT)
New Resources on Methadone Interactions With Other Drugs
American Journal on Addictions — Special Issue on Methadone Interactions With Other Medications and Abused Substances
The March/April 2010 issue of the American Journal on Addictions, published on behalf of the American Society of Addiction Psychiatry, has devoted the issue to key articles on methadone and buprenorphine interactions with other drugs. Articles in this issue include:
- Drug Interactions of Clinical Importance with Methadone and Buprenorphine
- Drug Interactions of Clinical Importance Among the Opioids, Methadone and Buprenorphine, and Other Frequently Prescribed Medications: A Review
- Effect of Cocaine Use on Methadone Pharmacokinetics in Humans
- Benzodiazepines, Methadone and Buprenorphine: Interactions and Clinical Management
- Indicators of Buprenorphine and Methadone Use and Abuse: What Do We Know?
- Methadone and Buprenorphine Toxicity in Children
- Drug Interactions Between Antiretroviral Medications and Medications Used in the Treatment of Drug Addiction: Research Needs
PDF files of the individual articles are available for free download at:
http://www3.interscience.wiley.com/journal/123215724/issue.
Access checked May 10, 2010.
PCSS-Methadone Issues Guidance on Methadone Drug Interactions
On February 6, the Physicians Clinical Support System for methadone (PCSS-M) issued guidelines on methadone interactions with other drugs. PCSS-M is a support system to connect prescribers of methadone with experienced clinicians for one-to-one mentoring regarding the use of this medication. PCSS-M is coordinated by the American Society of Addiction Medicine (ASAM) in conjunction with other leading medical societies, and is made possible by support from the Center for Substance Abuse Treatment (CSAT), and the Substance Abuse and Mental Health Services Administration (SAMHSA).
The guidelines can be accessed at:
http://www.pcssmethadone.org/pcss/documents2/PCSSM_OpioidTherapiesDrugInteractions.pdf
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EUROPAD Journal — Heroin Addiction and Related Clinical Problems — March 2010 Issue Now Available Online
Heroin Addiction and Related Clinical Problems, the official journal of EUROPAD (European Opiate Addiction Treatment Association), is a peer-reviewed publication for professionals wanting to stay informed of research and opinion on opioid misuse treatment in Europe and around the world. A particular emphasis is on medication-assisted treatments for opioid addiction. Articles in the new March issue include:
- Evaluation of Opioid-Dependent Prisoners in Oral Opioid Maintenance Therapy
- Dose Determination in Dual Diagnosed Heroin Addicts During Methadone Treatment
- Urine Labeling Marker System for Drug Testing Improves Patient Compliance
- Quality of Life as a Means of Assessing Outcome in Opioid Dependence Treatment
- Why There Has Been an Excess of Overdoses in Norway Since 1990?
The PDF file of the March issue can be accessed at:
http://atforum.com/documents/HeroinAddict1212010.pdf
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Is Sleep-Disordered Breathing a Major Cause of Sleep Disturbances in Methadone- Maintained Patients?
More than 75% of opioid-dependent patients receiving methadone report sleep problems. In this cross-sectional investigation, researchers sought to determine the prevalence of sleep-disordered breathing (SDB), including central and obstructive sleep apnea (CSA and OSA, respectively), in methadone-maintained patients who report sleep disturbances and also examined the association between SDB, sleep-complaint severity, methadone dose, and illicit substance use. Eligible participants (N=71) had subjective sleep complaints as defined by a validated measure. Patients with psychotic or bipolar disorders, recent trazodone use, unstable housing, chronic medical illness, or <3 months of stable methadone dose were excluded. Sleep and respirations were measured via portable polysomnography.
- Thirty participants (42%) had SDB; of these, 20 met criteria for OSA, 5 for CSA, and 5 for both OSA and CSA.
- Sleep disturbances included decreased sleep efficiency, decreased REM sleep, and increased stage-2 sleep. These did not differ among participants with and without SDB.
- Neither OSA nor CSA was associated with severity of sleep complaints.
- CSA was not associated with methadone dose or benzodiazepine use.
- Patients with SDB had received methadone for a significantly longer period of time than those without.
Comments: Although SDB was common in this sample of methadone-maintained patients with sleep disturbances, the majority did not have SDB. Other factors must be sought to explain and guide treatment for sleep disturbances in such patients. Since medical illness was an exclusion from this sample, SDB rates observed herein may under-represent actual rates of SDB among a broader sample of methadone-maintained patients.
Published In: Alcohol, Other Drugs, and Health: Current Evidence a project of the Boston Medical Center issue January/February 2010. Access checked 4/12/10. Hillary Kunins, MD, MPH, MS
Original Source: Sharkey KM, Kurth ME, Anderson BJ, et al. Obstructive sleep apnea is more common than central sleep apnea in methadone maintenance patients with subjective sleep complaints. Drug Alcohol Depend. 2010;108(1-2):77-83.
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GOVERNMENT NEWS & REPORTS
McLellan Resigning as ONDCP Deputy Director
Respected addiction researcher Tom McLellan has announced that he will resign as deputy director of the Office of National Drug Control Policy (ONDCP) this summer.
McLellan told Alcoholism and Drug Abuse Weekly in an interview that he was not unhappy with ONDCP's mission, its personnel, or the forthcoming National Drug Control Strategy. "There's no deep dark secret here — I'm just ill-suited to government work," he said.
ONDCP issued a statement on April 16 confirming McLellan's plans to resign. "Tom has been a leader in helping the Obama administration fashion a comprehensive and balanced approach to drug policy that puts new emphasis on prevention, treatment, and recovery while acknowledging the important role of law enforcement," said ONDCP Director Gil Kerlikowske. "I will miss having Tom at my right hand, but we will continue to benefit from his wise counsel and knowledge."
McLellan said he would remain at ONDCP over the next several months to help implement the new drug strategy. "With the passage of health care reform and the crafting of the new drug control strategy that will be released soon, I believe we have laid the foundation to make real progress in reducing drug use and its consequences," he said.
"Tom has brought science, passion and common sense to the Office of National Drug Control Policy," said David Rosenbloom, Director of Join Together. "The groundwork he laid to move policy toward effective treatment will have lasting impact and help people with addiction find recovery for many years to come. All Americans should be grateful for his service."
Source: JoinTogether.org — April 16, 2010
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NDIC Issues National Drug Threat Assessment Report 2010
The National Drug Intelligence Center (NDIC), a component of the U.S. Department of Justice, recently released their 2010 National Drug Threat Assessment Report. The report provides a strategic overview and predictive outlook of drug trafficking and abuse trends within the U.S.
In releasing the assessment, NDIC Director, Michael T. Walther stated, "The trafficking and abuse of drugs affects everyone. The economic cost alone is estimated at nearly $215 billion annually."
The report cited the following trends related to opioids.- Increased heroin availability evidenced by higher purity, lower prices, and elevated numbers of heroin-related overdoses and overdose deaths is partly attributable to increased production in Mexico.
- The threat posed by the diversion and abuse of controlled prescription drugs (CPDs), primarily pain relievers, is increasing, evidenced by the sharp rise in the percentage (4.6% in 2007 to 9.8% in 2009) of state and local law enforcement agencies reporting CPDs as their greatest drug threat. Increased abuse of CPDs has led to elevated numbers of deaths related to prescription opioids, which increased 98 percent from 2002 to 2006.
- Prescription opioid users will increasingly switch to heroin because, according to reporting from law enforcement and treatment providers, in many instances heroin is less expensive than diverted prescription opioids.
Director of National Drug Control Policy, Gil Kerlikowske said, "The 2010 National Drug Threat Assessment highlights diversion and abuse of prescription drugs as a serious and increasing problem. As part of the Obama Administration's comprehensive approach to reduce drug use and its consequences, ONDCP and Federal partner agencies have developed a plan to curb prescription drug abuse, which includes expanding prescription drug monitoring programs and educating healthcare providers and patients about the danger of abusing prescription drugs."
The 84-page PDF file of the report can be accessed at:
http://www.justice.gov/ndic/pubs38/38661/
Source: U.S. Department of Justice National Drug Intelligence Center — March 25, 2010
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Oxycontin in the News
FDA Approves New Formulation for OxyContin
The U.S. Food and Drug Administration (FDA) today approved a new formulation of the controlled-release drug OxyContin that has been designed to help discourage misuse and abuse of the medication. The reformulated OxyContin is intended to prevent the opioid medication from being cut, broken, chewed, crushed or dissolved to release more medication. The new formulation may be an improvement that may result in less risk of overdose due to tampering, and will likely result in less abuse by snorting or injection; but it still can be abused or misused by simply ingesting larger doses than are recommended.
"Although this new formulation of OxyContin may provide only an incremental advantage over the current version of the drug, it is still a step in the right direction," said Bob Rappaport, M.D., director of the Division of Anesthesia and Analgesia Products in the FDA's Center for Drug Evaluation and Research. According to the U.S. Substance Abuse and Mental Health Services Administration's National Survey on Drug Use and Health, approximately half a million people used OxyContin non-medically for the first time in 2008.
Source: Food and Drug Administration - April 5, 2010
FDA Staff Concerned About Additive Designed to Combat Pain Drug's Abuse
Food and Drug Administration (FDA) staffers have questioned whether a proposed new drug that would add the B vitamin niacin to oxycodone in order to combat abuse would be effective and safe, Reuters reported April 20.
In a summary written for an FDA advisory panel that will issue a recommendation on the medication Acurox, staff with the federal agency stated that a study from one of the drug's manufacturers found little deterrent effect on abuse from adding niacin to oxycodone. Manufacturers King Pharmaceuticals and Acura Pharmaceuticals have stated that adding niacin would discourage use of high doses of oxycodone because large amounts of niacin can cause uncomfortable flushing.
The FDA staff summary states that "while the oxycodone component in Acurox is efficacious, the agency has concerns about the use of niacin." Staffers said the addition of niacin also appears to worsen the medication's side effect profile, particularly with regard to flushing in pain patients.
Acura Pharmaceuticals has countered in its own summary for the FDA advisory panel that Acurox would limit misuse of oxycodone in numerous ways, including through ingredients that can cause burning in the nose if the medication is crushed and snorted. "It is not a perfect solution to the opioid abuse crisis, but it is a solution that warrants approval of the product," states the Acura summary.
Source: JoinTogether.org - April 22, 2010
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Healthcare Reform Law Gives Big Boost to Addiction Treatment and Prevention
Don't count addiction recovery advocates among those who see healthcare reform as 'Armageddon': the bill signed into law by President Obama on March 23 includes addiction and mental health services in its basic benefits package and is being broadly praised by treatment, prevention and recovery leaders.
According to an analysis from the Legal Action Center (LAC), the Patient Protection and Affordable Care Act (HR 3590) requires a basic benefit package for all health plans in the individual market and small-group markets. "All such plans will be required to cover mental health and substance use disorder services," according to the LAC, which said the measure represents a "ground-breaking expansion of addiction and mental health coverage of prevention, treatment and recovery."
"When the law is fully implemented, 32 million Americans who are uninsured today will have access to health insurance coverage, including for addiction," according to Faces and Voices for Recovery. "The new law builds on the principle of equity for addiction with other health conditions in the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and marks significant progress in making it possible for many more Americans to get the help they need to recover from addiction."
"Including addiction treatment in the basic benefit for all medical insurance is a major public-health achievement," added David Rosenbloom, Ph.D., director of Join Together. "Now we must turn our attention and advocacy to ensure that the promise is actually delivered in every community."
The new law:- Requires all group and individual plans to comply with the Wellstone/Domenici Parity Act, which requires that addiction and mental-health benefits be provided in the same way as all other covered medical and surgical benefits.
- Expands Medicaid eligibility to all Americans up to 133 percent of federal poverty, and requires that all newly eligible parents and childless adults receive basic benefits, including parity addiction and mental-health services.
- Creates a national prevention council with the director of the Office of National Drug Control Policy as a member and alcohol and other drug addictions listed as a national priority for that council's report to Congress.
- Names behavioral-healthcare workers as a high priority in the bill's National Workforce Strategy section.
- Lists addiction and mental-health providers as eligible for community health-team grants.
"National health reform fully embraces treatment for addiction and mental illness within medical care. Our challenge will be to face this opportunity," said Eric Goplerud, Ph.D., head of the Center for Integrated Behavioral Health Policy at George Washington University. "Combined with parity, the workforce and health information technology resources from [the federal Recovery Act], the national health reform legislation sets the stage for prevention and treatment of addiction to become truly effective and truly part of the fabric of health and health care."
Source: JoinTogether.org — News Feature by Bob Curley — April 9, 2010
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RESEARCH IN THE NEWS
Poisoning by Prescription Drugs on the Rise
New Study Indicates U.S. Hospitalizations for Poisoning by Opioids, Sedatives and Tranquilizers Increased 65% from 1999-2006
Poisoning is now the second leading cause of unintentional injury death in the U.S. While several recent high-profile Hollywood celebrity cases have brought the problem to public attention, the rates of unintentional poisoning deaths have been on the rise for more than 15 years, and in fact, unintentional poisoning has surpassed motor vehicle crashes as the leading cause of unintentional injury death among people 35—54 years of age.
In a study published in the May issue of the American Journal of Preventive Medicine, researchers found that hospitalizations for poisoning by prescription opioids, sedatives and tranquilizers in the U.S. have increased by 65% from 1999 to 2006.
"Deaths and hospitalizations associated with prescription drug misuse have reached epidemic proportions," said the study's lead author, Jeffrey H. Coben, MD, of the West Virginia University School of Medicine. "It is essential that health care providers, pharmacists, insurance providers, state and federal agencies, and the general public all work together to address this crisis. Prescription medications are just as powerful and dangerous as other notorious street drugs, and we need to ensure people are aware of these dangers and that treatment services are available for those with substance abuse problems."
Dr. Coben believes that while the data reveals a fast-growing problem, there's an urgent need for more in-depth research on this wave of injuries and deaths. Writing in the article, he said, "Interviews with survivors could provide important additional details regarding the pathways to abuse of these drugs, the methods used to obtain the medications, the sequencing and combination of drugs that result in overdose, and the immediate precursors to these serious events. The association between hospitalization for prescription opioids, sedatives, and tranquilizers and subsequent morbidity and mortality is another area in need of further research."
While the majority of hospitalized poisonings are classified as unintentional, substantial increases were also demonstrated for intentional overdoses associated with these drugs, likely reflecting their widespread availability in community settings.
From 1999—2006, total estimated hospitalizations in the U.S. for poisoning by prescription opioids, sedatives, and tranquilizers increased by 65%; while unintentional poisonings by these drugs increased by 37%. In comparison, during this same period, hospitalizations for poisoning by other drugs, medicinal and biological substances increased by 33%, while all other hospitalizations increased by just over 11%.
The largest percentage increase in hospitalizations for poisoning for a specific drug was observed for methadone (400%). Poisonings by benzodiazepines increased 39%. Hospitalizations for poisoning by barbiturates actually decreased 41%, as did hospitalizations for poisoning by antidepressants (a decrease of 13%).
Original Article: "Hospitalizations for Poisoning by Prescription Opioids, Sedatives, and Tranquilizers" by Jeffrey H. Coben, MD, Stephen M. Davis, MPA, MSW, Paul M. Furbee, MA, Rosanna D. Sikora, MD, Roger D. Tillotson, MD, and Robert M. Bossarte, PhD. The article, doi: 10.1016/j.amepre.2010.01.022, appears in the American Journal of Preventive Medicine, Volume 38, Issue 5 (May 2010)
Source: American Journal of Preventive Medicine - News release issued April 6, 2010
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Abstinence Is More Common among Patients Who Use Heroin or Crack Cocaine Alone Compared with Those Who Use Both
Crack cocaine use can be difficult to treat and is a common comorbid condition among heroin-dependent individuals. Since 2007, the National Health Service in England has tracked past-month drug use among patients with heroin and/or crack-cocaine dependence admitted to treatment. Patients report heroin and/or crack cocaine use at admission, every 6 months, and at discharge. Researchers reviewed self-reported drug use among 14,656 such patients to determine whether heroin and crack-cocaine use decreased during treatment and to assess whether use of both drugs at admission was associated with lower abstinence. The mean time from admission to review was 19 weeks.
- People who used only heroin reduced their average use from 23 of 28 days at admission to 7 of 28 days at review. Forty-two percent achieved abstinence.
- People who used only crack cocaine reduced their average use from 13 of 28 days at admission to 5 of 28 days at review. Fifty-seven percent achieved abstinence.
- People who used both heroin and crack cocaine reduced their heroin use from 23 of 28 days at admission to 9 of 28 days at review, and their cocaine use from 13 of 28 days at admission to 5 of 28 days at review. Thirty-three percent achieved abstinence from heroin, and 51% achieved abstinence from cocaine.
Comments: This large cohort study demonstrated substantial in-treatment reductions in both heroin and crack-cocaine use within 6 months of entering treatment. Abstinence rates were higher among people using either heroin or crack cocaine alone. Although people with both heroin and crack-cocaine use also benefit from treatment, these results indicate they are less likely to achieve abstinence and may require additional treatment.
Published In: Alcohol, Other Drugs, and Health: Current Evidence a project of the Boston Medical Center issue January/February 2010. Access checked 4/12/10. Alexander Y. Walley, MD, MSc
Original Source: Marsden J, Eastwood B, Bradbury C, et al. Effectiveness of community treatments for heroin and crack cocaine addiction in England: a prospective, in-treatment cohort study. Lancet. 2009;374(9697):1262—1270.
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New National Study Shows Less Than Half of All Substance Abuse Treatment Facilities Perform On-site Infectious Disease Screening
Fewer than half of all substance abuse treatment facilities surveyed nationwide reported that they conduct on-site infectious disease screening, according to a new study sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA).
Rates of HIV, tuberculosis, sexually transmitted diseases, hepatitis, and hepatitis C are high among drug users. Injection drug users, in particular, are at increased risk for contracting HIV, hepatitis B, and hepatitis C. These diseases, if not identified and treated, can pose a significant health threat to both the individual with the disease and to the community.
"Arranging for screenings for infectious diseases should be a routine part of substance abuse treatment services," said SAMHSA Administrator Pamela S. Hyde, J.D. "People enter treatment for different needs and screening provides an opportunity to identify additional healthcare needs as part of the recovery process."
This study was based on data from the 2007 National Survey of Substance Abuse Treatment Services (N-SSATS), an annual census of all known substance abuse treatment facilities in the U.S. The survey solicits information regarding the provision of on-site screening for: hepatitis B, hepatitis C, HIV, sexually transmitted diseases and tuberculosis.
More than half of the approximately 1,100 opioid treatment programs provided on-site screening for hepatitis B (62.1 percent), hepatitis C (64.1 percent), HIV (69.8 percent), sexually transmitted diseases (67.8 percent), or tuberculosis (93.3 percent).
The report can be accessed at:
http://oas.samhsa.gov/2k10/227/227DiseaseScreen2k10.htm
Source: The Substance Abuse and Mental Health Services Administration — March 23, 2010
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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 Covidien Mallinckrodt, St. Louis, MO, a manufacturer 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.