Archive for the ‘Opioid Addiction’ Category

Great Book About Opioid Addiction!!!

I orginally started this blog to promote the book I wrote about pain pill addiction. As it’s turned out, the blog has been much more popular than the book (it isn’t exactly flying off the shelves), so I’d like to remind blog readers – again – that if you like the blog, you’ll love my book.

You can order it from Barnes & Noble, or Amazon. But I’m selling it for a much-discounted rate of $13.95 on EBay. That’s with shipping included.

http://shop.ebay.com/i.html_from=R40&_trksid=p5197.m570.l1313&_nkw=pain+pill+addiction&_sacat=See-All-Categories

National Prescription Drug Action Plan

Yesterday, government officials proclaimed the formation of collaborative plan to address this nation’s problem with prescription opioid abuse and addiction. Speakers included Mr. Gil Kerlikowske, the director of the ONDCP (Office of National Drug Control Policy), Dr. Howard Koh, from the department of Health and Human Services (DHHS), Dr. Margaret Hamburg from the Food and Drug Administration ( FDA), and Ms. Michele Leonhart, administrator of the Drug Enforcement Administration (DEA).

 Speakers recited pertinent statistics regarding the state of opioid addiction and abuse in the U.S.  It’s now the faster growing public health problem in our country. Around 28,000 citizens died from unintentional drug overdose in 2007, the latest year for which data is available.  More people in the U.S. now die of unintentional drug overdose than gunshot wounds. In seventeen states and Washington D.C., unintentional overdose deaths outnumber deaths from motor vehicle accidents.

 The plan has four main points. First, both patients and prescribers of controlled substances will be provided with better education about these potentially dangerous medications. The drug manufacturers will be asked to develop educational products for both patients and providers for education, which will be reviewed by the FDA before approved for release. The medications included will likely include sustained-release oxycodone, oxymorphone, hydromorphone, and methadone. Fentanyl patches will also be included. The ONDCP is seeking to introduce legislation that will change the Controlled Substances Act in order to make training mandatory for doctors who prescribe long-acting opioids.

 Second, the national government will push the few remaining states that don’t have function prescription monitoring programs to put them in place, and to be able to share data with adjacent states.

 Third, the government will support more medication “take back” days in communities across the U.S. Citizens will be encouraged to bring old medication to community sites in order for proper disposal. Previous take back days have been very successful, with tons of pills collected and disposed. This will reduce the number of prescription opioid pills available for diversion. Surveys reveal that round 70% of the pills obtained by people misusing prescription medication for the first time are obtained from friends and family members, often without permission, from old prescription bottles.

 Fourth, state and federal agencies plan to crack down further on rogue doctors and clinics that are “pill mills.” This will require participation from state medical boards, law enforcement, and the DEA.

 At the end of this presentation, Karen Perry, founder of NOPE, told the story of her son, a bright young college student who died of an unintentional drug overdose. She described how his death affected her and his siblings. Her face was etched with the grief that can only come from such a profound loss

 The goal of this plan is to achieve a 15% reduction in prescription opioid misuse in this country by at within the next five years.

 I’m so pleased to see this announcement. Back in 2001, when I first started treating prescription opioid addiction, I was amazed at the numbers of people seeking treatment for this disorder. Studies since then have shown the situation has gotten much worse.

 There will be problems with this plan. Many doctors will not be happy they must have mandatory training in order to be able to prescribe some controlled substances (probably schedule II). Some will stand up on their hind legs and protest this new regulation, if it is passed by congress. But after seeing the prescribing habits of some of my brethren and sistren, it’s obvious we need this. We don’t get much education about appropriate prescribing of opioids, recognizing addiction, and referral for treatment. I’ve blogged before about this (see February 10th’s entry)

 I’ve been blathering on to anyone who will listen about the need for prescription monitoring plans (see prior blog entries for March 6, 8, and 31), so I’m delighted more attention is being paid to this. But I still worry about how states will communicate with each other. For example, my practice is close to South Carolina, yet that state has denied me access to their database. The only allow access to doctors licensed in South Carolina. I use the prescription monitoring program in my state both at the two Opioid Treatment Programs where I work and in my own office, where I see Suboxone patients. I’ve been using it since 2007.

I support the pill “take back” programs. While such events probably won’t do much for those with established addiction, they can help reduce the number of new users and experimental users. Remember, opioid overdose deaths don’t just happen to addicts. Youngsters experimenting with opioids can die from overdoses. In fact, new users dabbling with these pills, because they think they’re safer than “street” drugs, may be more likely to die because they don’t have any tolerance to opioids.

 We need good judgment and balance when shutting down pill mills. How can the DEA tell a pill mill from a legitimate pain treatment practice? I believe this is best done by other doctors. In this state, the medical board does investigations, which I feel is more appropriate than having investigations done by law enforcement. Law enforcement personnel just don’t have the training to tell the difference between appropriate care and careless prescribing with disregard for patients. Let other doctors do that. Granted, a few places will be so obvious that little investigation is needed.

 We don’t want the opioid pendulum to swing to the opposite side again, and become completely opioiphobic. These pain medications are addictive, but are also godsends in the right setting and used in the right way. Let’s take care not to throw out the good with the bad. The best people to set policy in this area are well-trained doctors who approach this issue with common sense and balance.

 Coming as late as it does in this epidemic, I could be negative and say the government has had an epiphany of the obvious. But I do know it takes time for all of these agencies to come together in a cooperative manner and form a plan of action. I’m just thankful that action is finally being taken.

Are Opioid Pill Addicts Different From Heroin Addicts?

Most of the opioid addicts I have treated over the last ten years have been addicted to pills, not heroin. But information about prognosis and treatment of opioid addiction was gleaned from studies with heroin addicts. I’ve often wondered if the old data fits the new patients.           

Over the last ten years, the number of people addicted to prescription opioids has ballooned. Prescription opioids are now more likely to cause or contribute to drug overdose deaths than heroin or cocaine. As prescription opioids outpace heroin in many parts of the country, scientists have wondered if there are significant differences between these prescription addicts and heroin addicts. Biologically, addiction to heroin or prescription opioids would appear to be the same disease, because both types of drugs are opioids, and opioids affect the body the same way. But do all opioid addicts respond the same to treatment?

 In the latest issue of Addiction, there was an article describing a study that compared different groups of opioid users. The researchers described four separate groups: opioid users of only heroin, opioid users of only prescription opioids, opioid users of both heroin and prescription opioids, and drug users that used only non-opioid drugs. In this study, drug users weren’t further classified as addicts, abusers, or occasional users. (1)

This study of over nine thousand drug users found that users of both prescription opioids and heroin were more likely to use other, non-opioid drugs than the other three groups. These addicts seemed to have worse mental health issues than the other groups, too, while users of non-opioid drugs tended to have less severe mental health issues than opioid addicts of all types.

The prescription opioid-only addicts were found to use significantly more non-opioid prescription drugs, while the heroin-only addicts were significantly less likely than prescription opioid addicts to abuse sedatives and tranquilizers, like benzodiazepines, than the other two groups of opioid users.

 This last fact definitely squares with what I’ve been seeing. So many of my patients are struggling or have struggled with benzodiazepine addiction. I wonder if opioid pill users are at increased the risk of overdose death when treated with methadone, compared to the heroin-only users of past decades.

This article, at the very least, shows there are significant differences in clinical features for at least three types of opioid users. It’s possible people who are addicted to prescription opioid pills have different prognoses and different responses to treatment than heroin-only addicts. Hopefully we’ll see further studies to guide our treatments.

1. Wu, LT; Woody, GE; Yang, C; Blazer, DG; “How Do Prescription Opioid Users Differ From Users of Heroin or Other Drugs in Psychopathology: Results From the National Epidemiologic Survey on Alcohol and Related Conditions,” Journal of Addiction Medicine, Vol. 5, No. 1, March 2011.

Am I Addicted to Prescription Pain Pills?

I am a guest blogger on addictionblog.org, and recently had a well-received article published on that site about how to know if you are addicted. I thought I’d repeat a version of that column here.

 There’s so much confusion about the differences between the disease of addiction to opioid pain pills and mere physical dependency on pain pills. Even some doctors don’t understand the differences, regretfully. Any person who regularly takes opioid pain pills for a period of weeks to months, for whatever reason, will develop a physical dependency to these drugs. That’s a biologic event. But addiction is much more than just the physical process. With addiction, there’s also a psychological component. People with addiction think about the drug often, spend time using and recovering from the drug, and continue to use the drug even though bad things happen. In physical dependency alone, this doesn’t happen.

 Here are a few specific questions that I ask patients, that help me decide if they have the disease of addiction:

  • Do I take more medication than prescribed? Do I take early doses, or extra doses?
  • Do I take medication in ways it’s not intended? For example, do I snort it, or chew it for faster onset? Do I inject it?
  • Do I get medication from friends, family, or acquaintances because I run out of my prescription pills early?
  • Do I become intoxicated, or high, from my medication? Without telling my doctor?
  • Do I drink alcohol with medication, even though the pharmacist advised against this?
  • Do I look forward to my next dose of medication?
  • Do I get impaired from my medication, to the point I’m unable to function normally?
  • Do I take pain medication to treat bad moods, anxiety, or to get to sleep?
  • Do I use street drugs like cocaine, marijuana, or others?
  • Have I driven when under the influence of pills, when I know I shouldn’t be driving?
  • Do I get prescriptions from more than one doctor, without telling them about each other?
  • Do I spend a great deal of time worrying about running out of medication?
  • Do I spend a great deal of time thinking about my medication, and how it makes me feel? 

One “yes” answer to any of these questions is worrisome, though not necessarily diagnostic of addiction. I think of addiction as a continuum, and it’s easier to diagnose with multiple “yes” answers. For example, people taking prescriptions may have a few worrisome symptoms, like taking an extra pill occasionally. Perhaps they did this because of a temporary increase in pain. Without any other symptoms, I probably wouldn’t diagnose addiction. At the other end of the spectrum, if a patient is crushing pills to inject or snort, I feel confident making the diagnosis of addiction.

 Sometimes addiction only becomes apparent over time. This is why doctors need to see patients frequently who are prescribed potentially addicting medication, like pain pill, stimulant, and benzodiazepines.

 If you had one or more “yes” answers to the above questions, please see a doctor who knows something about addiction, because untreated addiction usually gets worse. In fact, it can even be fatal.

Governor Scott’s Flamingo Express to Misery

Flamingo Express of Florida

All I could think was, “What can he be thinking???”

 I was reading an article about the governor of Florida and his bizarre decision to block the formation of a prescription monitoring program in his state. (1)

 Prescription monitoring programs are databases that contain lists of controlled substances a patient receives, the prescribing doctors, and the dispensing pharmacies. Usually, only approved physicians can get access to these databases. Prescription monitoring programs help prevent “doctor shopping,” which is the term describing the actions of a patient who goes from one doctor to another to get prescription pills, usually opioids, without telling the doctors about each other. Addicts do this to supply their ever-increasing tolerance for the drugs. Drug dealers do this to get pills to sell and make money.

 Forty-two states have approved the formation of prescription monitoring databases, and thirty-four states have operational databases. Florida was one of the last to approve the formation of such a program, in 2009, long after this recent wave of prescription pain pill addiction burned through the country. Now, the new Florida governor wants to cut this program out completely, before it even starts.

 How big of a deal is this?

In the latest survey, 5.3 million people in the U.S. used prescription pain pills nonmedically over the past month. This means they used them in ways not intended, or for reasons not intended by the prescriber… for example, to get high. In the last year, 2.2 million people misused these prescription pain pills for the first time. Our young people are particularly at risk; between 2002 and 2009, the percentage of 12 to 17 years olds misusing prescription opioids rose from 4.1% to 4.8%. Not all of these people will become addicted, thankfully. Some will only experiment, and be able to stop before addiction develops. Many won’t be able to stop taking pills, and will progress into the misery of addiction. Others will die of drug overdoses. (2)

 Why pick on Florida?

Florida is infamous for its pain clinics. As a reporter for Time Magazine pointed out, there are more pain clinics in South Florida than there are McDonald’s franchises. In 2009, 98 of the top 100 prescribers of oxycodone in the nation were all located in Florida. Altogether, these doctors prescribed 19 million dosage units of oxycodone in 2009. Estimates of the numbers of pain clinics located in South Florida vary, but most sources say between 150 and 175. (3, 4) Many of these clinics are “pill mills,” where doctors freely prescribe controlled substances with little regard to usual prescribing standards and guidelines.

 Are all these clinics pill mills?

No. Some of the pain clinics are legitimate, and their doctors follow best practice guidelines, providing quality care to patients with pain. But careful monitoring and screening for adverse events, including the development of addiction, takes time. A conscientious doctor, trying  to do a good job, isn’t going to be able to see fifty pain patients in one day.

 I’ve talked to addicts who were previously patients at these pill mills. They describe how they were shuffled through rapidly, sometimes not even seeing the doctor. Some addicts say they were asked what pills they wanted, and quickly written that prescription, with little or no conversation beyond that. That was the extent of the visit. 

But Florida’s problem doesn’t stay in Florida. Appalachian states like Kentucky, West Virginia, and North Carolina all have addicts who buy these prescription pain pills after they’re transported out of Florida. The DEA sees so many pain pills being transported from Florida to Appalachian states that they call it the “Flamingo Express.” In one of the methadone clinics where I work, I’ve noticed a peculiar upswing in the reported use of Opana, a brand name for the drug oxymorphone. It’s not a drug I’ve seen prescribed much in NC. When I ask patients where the pills come from, many say, “Florida.”

 Governors of several states, including West Virginia and Kentucky, along with congressmen from New York and Rhode Island, have sent a letter to Florida’s Governor Scott, urging him to reconsider his decision to torpedo plans for a prescription monitoring program. Since the leading cause of death in West Virginians for those under the age of 45 is drug overdose, I can see why this governor is protesting Governor Scott’s poor decision. (4)

 It’s estimated that setting up a prescription monitoring program costs about one million dollars. The Florida Prescription Drug Monitoring Program Fund, Inc., a non-profit organization dedicated to raising money for the program, says on their website that they’ve already raised at least half of that from donations. Other states have received the Harold Rogers grant money, available from the federal government to set up these monitoring databases. This leads me to question the excuse of “budget cuts” as the reason for Governor Scott’s poor decision.

 I’ve also seen internet stories that mention the governor’s fear of invasion of privacy. This is a legitimate concern, but there are ways to safeguard the information in such a database, and laws that can regulate who has access. I’m no fan of the government peering into my business, but this database is essential, given the overwhelming numbers of people struggling with pain pill addiction. For a description of the ways in which the North Carolina prescription monitoring database has helped me help my patients, please see the preceding blog entry. It’s been a lifesaver.  

  1. http://articles.sun-sentinel.com/2011-03-05/news/fl-prescription-drug-forum-20110305_1_pill-mills-prescription-drug-monitoring-program-attorney-general-pam-bondi (accessed 3/6/11)
  2. Substance Abuse and Mental Health Services Administration (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4586Findings). Rockville, MD.
  3. Thomas R. Collins, Invasion of the Pill Mills in South Florida, Time, Tuesday, Apr. 13, 2010,  Ft. Lauderdale, FL
  4.  http://manchin.senate.gov/public/index.cfm/press-releases?   ContentRecord_id=f62482b4-f6dd-4adc-8b49-1563d8fa605b&ContentType_id=ec9a1142-0ea4-4086-95b2-b1fc9cc47db5&Group_id=e3f09d56-daa7-43fd-aa8b-bd2aeb8d7777&MonthDisplay=2&YearDisplay=2011 (accessed 3/8/11)

The Facts About Methadone

methadone

The treatment of opioid addiction (heroin or prescription pain pills) with methadone still has an unwarranted stigma attached to it.  I wanted to devote at least one blog entry to a summary of the most well-known studies that support this evidence-based treatment. When people speak against methadone, they usually say they don’t “believe” in it, without being able to give any scientific basis for their stance. 

Well, this is why I do “believe” in it. It’s not opinion. It’s science.

 Amato L, Davoli, et. al., An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research. Journal of Substance Abuse Treatment 2005; 28 (4):321-329. In this overview of meta-analyses and other reviews, they conclude that methadone maintenance is more effective in the treatment of opioid addiction than methadone detoxification, buprenorphine, or no treatment. Higher doses of methadone are more effective than low or medium doses. 

Bale et. al., 1980; 37(2):179-193. “Therapeutic Communities vs Methadone Maintenance” Archives of General Psychiatry Opioid-addicted veterans who presented to the hospital for treatment were assigned to either inpatient detoxification alone, admission to a therapeutic community, or to methadone maintenance. One year later, patients assigned to therapeutic communities or methadone maintenance did significantly better than patients whose only treatment was detoxification. Patients in these two groups were significantly more likely to be employed, less likely to be in jail, and less likely to be using heroin, than the patients who got only detox admission. Patients in the therapeutic communities needed to stay at least seven weeks to obtain benefit equal to patients assigned to methadone maintenance. 

Ball JC, Ross A., The Effectiveness of Methadone Maintenance Treatment. New York, NY: Springer-Verlag Inc., 1991. This landmark study observed six hundred and thirty-three male patients enrolled in six methadone maintenance programs. Patients reduced their use of illicit opioids 71% from pre-admission levels, with the best results (no heroin use) seen in patients on doses higher than 70 milligrams. Longer duration of treatment with methadone showed the greatest reductions in heroin use. Of patients who left methadone maintenance treatment, 82% relapsed back to intravenous heroin use within one year. This study also found a dramatic drop in criminal activity for addicts in methadone treatment. Within one year, the number of days involved in criminal activity dropped an average of 91% for addicts maintained on methadone. This study showed that methadone clinics vary a great deal in their effectiveness. The most effective clinics had adequate dosing, well-trained and experienced staff with little turnover, combined medical, counseling and administrative services, and a close and consistent relationship between patients and staff.

 Caplehorn JRM, Bell J. Methadone dosage and retention of patients in maintenance treatment. The Medical Journal of Australia 1991;154:195-199. Authors of this study concluded that higher doses of methadone (80 milligrams per day and above) were significantly more likely to retain patients in treatment.

 Caplehorn JR, Dalton MS, et. al., Methadone maintenance and addicts’ risk of fatal heroin overdose. Substance Use and Misuse, 1996 Jan, 31(2):177-196. In this study of heroin addicts, the addicts in methadone treatment were one-quarter as likely to die by heroin overdose or suicide. This study followed two hundred and ninety-six methadone heroin addicts for more than fifteen years. 

Cheser G, Lemon J, Gomel M, Murphy G; Are the driving-related skills of clients in a methadone program affected by methadone? National Drug and Alcohol Research Centre, University of New South Wales, 30 Goodhope St., Paddington NSW 2010, Australia. This study compared results of skill performance tests and concluded that methadone clients aren’t impaired in their ability to perform complex tasks.

 Clausen T, Waal H, Thoresen M, Gossop M; Mortality among opiate users: opioid maintenance therapy, age and causes of death. Addiction 2009; 104(8) 1356-62. This study looked at the causes of death for opioid addicts admitted to opioid maintenance therapy in Norway from 1997-2003. The authors found high rates of overdose deaths both prior to admission and after leaving treatment. Older patients retained in treatment died from medical reasons, other than overdose.

 Condelli, Dunteman, 1993: examined data from TOPS, the Treatment Outcome Prospective Study, assessed patients entering treatment programs from 1979 – 1981 and found data on improvement similar to DARP; longer duration of treatment in methadone maintenance shows lower use of illicit opioids. 

Dole VP, Nyswander ME, Kreek, MJ, Narcotic Blockade. Archives of Internal Medicine, 1966; 118:304-309. Consisted of thirty-two patients, with half randomized to methadone and the other half to a no-treatment waiting list. The methadone group had much higher rates of abstention from heroin, much lower rates of incarceration, and higher rates of employment.

 Faggiano F, Vigna-Taglianti F, Versino E, Lemma P, Cochrane Database Review, 2003 (3) Art. No. 002208. This review article was based on a literature review of randomized controlled trials and controlled prospective studies that evaluated the efficacy of methadone at different doses. The authors concluded that methadone doses of 60 – 100mg per day were more effective than lower doses at prevention of illicit heroin and cocaine use during treatment.

 Goldstein A, Herrera J, Heroin addicts and methadone treatment in Albuquerque: a year follow-up. Drug and Alcohol Dependence 1995 Dec; 40 (2): p. 139-150. A group of heroin addicts were followed over twenty years. One-third died within that time, and of the survivors, 48% were on a methadone maintenance program. The author concluded that heroin addiction is a chronic disease with a high fatality rate, and methadone maintenance offered a significant benefit.

 Gordon NB, Appel PW., Functional potential of the methadone-maintained person. Alcohol, Drugs and Driving 1995; 11:1: p. 31-37. This is a literature review of studies examining performance and reaction time of patients maintained on methadone, and confirms that these patients don’t differ from age-matched controls in driving ability and functional capacity.

 Gowing L, Farrell M, Bornemann R, Sullivan LE, Ali R., Substitution treatment of injecting opioid users for prevention of HIV infection. The Cochrane Database of Systematic Reviews, 2008, Issue 2, Ar. No. CD004145. Authors reviewed twenty eight studies, concluded that they show patients on methadone maintenance have significant reductions in behaviors that place them at risk for HIV infection.

 Gronbladh L, Ohlund LS, Gunne LM, Mortality in heroin addiction: Impact of methadone treatment, Acta Psychiatrica Scandinavica Volume 82 (3) p. 223-227. Treatment of heroin addicts with methadone maintenance resulted in a significant drop in mortality, compared to untreated heroin addicts. Untreated addicts had a death rate 63 times expected for their age and gender; heroin addicts maintained on methadone had a death rate of 8 times expected, and most of that mortality was from diseases acquired prior to treatment with methadone. 

Gunne and Gronbladh, 1981: The Swedish Methadone Maintenance Program: A Controlled Study, Drug and Alcohol Dependence, 1981; 7: p. 249 – 256. This study conducted a randomized controlled trial on inpatient opioid addicts to methadone maintenance with intensive vocational rehabilitation counseling, or a control group that were referred to drug-free treatment.  Over 20 years, this study consistently showed significantly higher rates of subjects free from illicit opioids, higher rates of employment, and lower mortality in the group maintained on methadone than the control group.

 Hartel D, Selwyn PA, Schoenbaum EE, Methadone maintenance treatment and reduced risk of AIDS and AIDS-specific mortality in intravenous drug users. Abstract number 8546, Fourth Annual Conference on AIDS, Stockholm, Sweden, June 1988. This was a study of 2400 opioid addicts followed over fifteen years. Opioid addicts maintained on methadone at a dose of greater than 60mg showed longer retention in treatment, less use of heroin and other drugs, and lower rates of HIV infection. 

Hubbard RL, Marsden ME, et.al., Drug Abuse Treatment: A National Study of Effectiveness. Chapel Hill: University of North Carolina Press, 1989. Shows decreased use of illicit drugs (other than opioids) while in methadone treatment, and increased again after discharge.

 Kosten TR, Rounsaville BJ, and Kleber HD. Multidimensionality and prediction of treatment outcome in opioid addicts: a 2.5-year follow-up. Comprehensive Psychiatry 1987;28:3-13. Addicts followed over two and a half years showed that methadone maintenance resulted in significant improvements in medical, legal, social, and employment problems.

 Lenne MG, Dietze P, Rumbold GR, et.al. The effects of the opioid pharmacotherapies methadone, LAAM and buprenorphine, alone and in combination with alcohol on simulated driving. Drug Alcohol Dependence 2003; 72(3):271-278. This study found driving reaction times of patients on methadone and buprenorphine don’t differ significantly from non-medicated drivers; however, adding even a small amount of alcohol (.05%) did cause impairment.

 Marsch LA. The efficacy of methadone maintenance in reducing illicit opiate use, HIV risk behavior and criminality: a meta-analysis Addiction 1998; 93: pp. 515-532. This meta-analysis of studies of methadone concludes that methadone treatment reduces crime, reduces heroin use, and improves treatment retention.

 Mattick RP, Breen C, Kimber J, et. al.,Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. The Cochrane Database of Systematic Reviews,  2003; (2): CD002209. This is a meta-analysis of studies of methadone treatment. The authors concluded that treatment of opioid dependence with methadone maintenance is significantly more effective than non-pharmacologic therapies. Patients on methadone maintenance are more likely to be retained in treatment and less likely to be using heroin. This study did not find a reduction in crime between the two groups. 

Metzger DS, Woody GE, McLellan AT, et. al. Human immunodeficiency virus seroconversion amoung intravenous drug users in- and out- of- treatment: an 18-month prospective follow up. Journal of Acquired Immune Deficiency Syndrome 1993;6:1049-1056. Patients not enrolled in methadone maintenance treatment converted to HIV positivity at a rate of 22%, versus a rate of 3.5% of patients in methadone maintenance treatment.

 Powers KI, Anglin MD. Cumulative versus stabilizing effects of methadone maintenance. Evaluation Review 1993: Heroin addicts admitted to methadone maintenance programs showed a reduction in illicit drug use, arrests, and criminal behavior, including drug dealing. They showed increases in employment. Addicts who relapsed showed fewer improvements in these areas. 

Scherbaum N, Specka M, et.al., Does maintenance treatment reduce the mortality rate of opioid addicts? Fortschr Neurol Psychiatr, 2002, 70(9):455-461. Opioid addicts in continuous treatment with methadone had a much lower mortality rate (1.6% per year) than opioid addicts who left treatment (8.1% per year).

 Sees KL, Delucchi KL, et.al. “Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence” Journal of the American Medical Association, 2000, 283:1303-1310. Compared the outcomes of opioid addicted patients randomized to methadone maintenance or to180-day detoxification using methadone, with extra psychosocial counseling. Results showed better outcomes in patients on maintenance. Patients on methadone maintenance showed greater retention in treatment and less heroin use than the patients on the 180 day taper. There were no differences between the groups in family functioning or employment, but maintenance patients had lower severity legal problems than the patients on taper.

 Sells SB, Simpson DD (eds). The Effectiveness of Drug Abuse Treatment. Cambridge, MA: Ballinger, 1976: This was an analysis of information from DARP, the Drug Abuse Reporting Program, which followed patients entering three types of treatment from 1969 to 1972 and showed that methadone maintenance was effective at reducing illicit drug use and criminal activity. This study also demonstrated that addicts showed more improvement the longer they were in treatment. 

Strain EC, Bigelow GE, Liesbon IA, et. al. Moderate- vs high –dose methadone in the treatment of opioid dependence. A randomized trial. Journal of the American Medical Association 1999; 281: pp. 1000-1005. This study showed that methadone maintenance reduced illicit opioid use, and more of a reduction was seen with the addition of psychosocial counseling. Methadone doses of 80mg to 100mg were more effective than doses of 50mg at reducing illicit opioid use and improving treatment retention. 

Stine, Kosten; Medscape Psychiatric and Mental Health eJournal: article reminds us that though it’s clear that better outcomes for methadone patients are seen with higher doses (more than 80mg), many opioid treatment programs still underdose their patients.

 Zanis D, Woody G; One-year mortality rates following methadone treatment discharge. Drug and Alcohol Dependence, 1998: vol.52 (3) 257-260. Five hundred and seven patients in a methadone maintenance program were followed for one year. In that time, 110 patients were discharged and were not in treatment anywhere. Of these patients, 8.2% were dead, mostly from heroin overdose. Of the patients retained in treatment, only 1% died. The authors conclude that even if patients enrolled in methadone maintenance treatment have a less-than-desired response to treatment, given the high death rate for heroin addicts not in treatment, these addicts should not be kicked out of the methadone clinic.

 Do these studies mean that methadone works for every opioid addict? I don’t think so. Every medication has side effects and dangers. Methadone is no different. For a variety of reasons, methadone may not work for some addicts.  But this treatment has helped many addicts. At the very least, it can keep them alive until a better treatment comes along.

Great New Book to Recommend!

by Rebecca Janes, LMHC, LADC

So there I was, cruising Amazon.com, looking for new books about opioid addiction and treatment, when I saw an intriguing title: Methadone: The Bad Boy of Drug Treatment.

I ordered it, and just finished it.

I fully recommend this book for anyone interested in learning more about methadone treatment. It’s written by Rebecca Janes, LMHC, LADC. The book’s cover says she has around fifteen years’ experience working in methadone treatment centers. She’s obviously knowledgeable about the studies supporting treatment of opioid addiction, and she’s able to summarize this knowledge succinctly. She explains complicated ideas in simple ways that make sense.

 It’s a small book, at 120 pages, and doesn’t have many references, but it covers most essential areas. The price is $12.95, and it’s published by Outskirts Press. As I said, you can buy it on Amazon, where it’s also available as a Kindle edition for only $2.99.

 The first chapter is dedicated to correcting mistaken impressions the general public has about methadone treatment, and Chapter Two corrects myths addicts often tell each other. Chapter Three describes what does not work in treatment, and Chapter Four tells what does work. Chapter Five tackles more controversial aspects, such as appropriate treatment of pain and anxiety for patients maintained on methadone.

 Patients on methadone will find this an ideal book to give to important people in their lives who nag them about getting off methadone. It’s great for parents and other relatives. It would be ideal to give to doctors with negative or judgmental attitudes, since it’s a quick read, and doctors aren’t likely to want to spend much time reading about a treatment they don’t believe in. It would be a great book to recommend to probation officers and social workers who don’t have much knowledge about methadone and its use. 

The only criticisms I have of the book are its few references, and it doesn’t cover buprenorphine at all. But then, if you want more in-depth information about opioid addiction, methadone, and buprenorphine, complete with references, you should buy my book: Pain Pill Addiction: Prescription for Hope. You can get it for $13.95 on EBay, shipping included. Or have I mentioned this before?

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