Media Maintains Methadone is Menacing Mountains

 

NEWS CAT

Last week, a colleague of mine directed my attention to local news coverage of the opioid use disorder epidemic. It’s a four-part series titled “Paths to Recovery.”

Anytime the press covers opioid use disorder and its treatments, I feel hope and dread. I hope the report will be fair and unbiased, and give the public much-needed information. And I dread the more likely stigmatization and perpetuation of tired stereotypes about methadone as a treatment for opioid use disorder.

Overall, the four segments of this news report had some good parts, and some biased parts. It was not a particularly well-done series, and could have benefitted from better editing. It was disjointed and contained non-sequiturs, which I suspect confused viewers.

In the introduction to the first segment, the report says their investigators have spent months digging into treatment options in the area. Their conclusion: there’s a variety of options and treatment is not one-size-fits-all. The report goes on to give statistics about how bad the opioid use disorder situation has become, and they interviewed a treatment worker who says we’re two years in to this, and the community doesn’t grasp the seriousness of the situation. They also interviewed some harm reduction workers, and discussed naloxone rescue for overdoses and needle exchange.

So far, so good, except that of course we are more like two decades into the opioid crisis, not two years.

Part two of this series was “Mountain methadone clinics.” As soon as I saw the dreadful alliteration, I cringed, fearing the content of the segment.

This report didn’t say good things about methadone. In fact, one physician, supposedly the medical director of a new opioid treatment program in the area, says on camera, “Methadone is very dangerous. It has some effects on the heart. The rhythm of the heart, it has some drug interactions.” He went on to say that at the right dose, people could feel normal, and that it replaced the endorphins that were lacking, but I worry people will remember only that a doctor said methadone was a very dangerous drug.

Methadone can be dangerous, if you don’t know how to prescribe it, or if you give a person with opioid use disorder unfettered access to methadone. But in the hands of a skilled and experienced physician, at an opioid treatment program with observed dosing, methadone can be life-saving.

The news report outlined the failings of existing methadone programs in the area, saying staff had inadequate training, and failed to provide enough counseling for patients. It said one program made a dosing error and killed a patient, while another program had excessive lab errors.

All of that sounds very bad.

No positive aspects were presented as a counterpoint to that bleak picture. I felt myself yearning for an interview with a patient on methadone who has gotten his family back, works every day, and is leading a happy and productive life. Of course, those people are hard to find, since they are at work and harder to find by the media, even reporters who have supposedly been “working for months” on this story.

And then…of course they interviewed patients who had misused methadone. One person criticized his opioid treatment program because they allowed him to increase his dose to 160mg per day, and he said “…that’s a lot. I didn’t need that much…” and goes on to admitting to selling his take home medication. Another patient said the methadone made him “sleep all the time.” Another patient said methadone made him “high all the time.”

There will always be such patients…ready to lie to treatment providers to get more medication than needed, break the law by selling that medication, and then blame it all on the people trying to help them. Unable to see their own errors, they blame it all on someone else, or on the evil drug methadone.

Every program has such patients. But these people can also be helped, if they can safely be retained in treatment long enough, and get enough counseling.

Even though these patients are few, they get far more media attention compared to the many patients who want help and are willing to abide by the multitude of rules and regulations laid on opioid treatment programs by state and federal authorities. These latter patients are why I love my job. I see them get their lives back while on methadone. They become the moms and dads that they want to be. They go back to school. They get good jobs and they live normal lives. They don’t “sleep all the time,” as the patients on this report said.

But not one such patient was interviewed for this report.

As I watched this segment, I thought back to an interview the A. T. Forum did with Dr. Vincent Dole, one of the original researchers to study methadone for the treatment of opioid use disorders. This was in 1996, before our present opioid crisis gained momentum.

A.T. FORUM: It seems that, over the years, methadone has been more thoroughly researched and written about than almost any other medication; yet, it’s still not completely accepted. How do you feel about that?

1. VINCENT DOLE:It’s an extraordinary phenomenon and it has come to me as a surprise. From the beginning of our research with methadone we were able to rehabilitate otherwise hopeless addicts that had been through all of the other treatments available. I expected methadone would be taken up very carefully by the addiction treatment community, but with some enthusiasm. Instead of that, we’ve had endless moral and other types of objections which are really irrelevant to the scientific data.

I was surprised, because my background in research had led me to expect that the medical community was a very critical but nonetheless objective group that would respond to solid, reproducible data. Instead I find that we still get the anti-methadone argument of substituting one addictive drug for another.

This is ignoring the scientific data showing that, as a result of methadone treatment, people who have been hopelessly addicted and anti-social and excluded from any normal life or family, are in a wonderful way becoming responsive to social rehabilitation and today constitute a very large number of people who are living normal lives. The fact that people, especially medical practitioners, would dismiss that as unimportant simply staggers me!

[http://atforum.com/interview-dr-vincent-dole-methadone-next-30-years ]

 

What would Dr. Dole think now, twenty more years later, during a terrible wave of death from opioid use disorders, about the continued stigmatization of methadone?

Then next segment was about buprenorphine, and how it can be prescribed in a doctor’s office, making it a better choice for patients. It wasn’t a bad segment, and contained some useful information. Physicians who were interviewed had nothing but good things to say about buprenorphine.

Or rather, they had good things to say about Suboxone.

The brand Suboxone was heavily promoted by this piece. Not once did the reporter use the drug’s generic name, buprenorphine. Every time, the medication was called by its brand name, Suboxone, and every picture of the medication was of Suboxone film. No mention was made of the other brands: Zubsolv, Bunavail, Probuphine, or even that there are generic combination buprenorphine/naloxone equivalents for Suboxone film, for less than half the price.

I know buprenorphine is kind of a mouthful for non-medical reporters, but still, I thought it was odd to use only the name of one brand: Suboxone. It’s as if this was a commercial for that drug company. Indivior, the manufacturer of Suboxone, must be delighted with this coverage. To me, it felt like an advertisement rather than journalism.

Another segment was about sober recovery homes. The investigative reporter talked to owners of sober recovery houses and the tenants at those homes. She said NC has no regulations or standards for recovery homes. She talked on screen to a patient advocate who says patient brokering is going on in Asheville, as well as lab scams at recovery homes where the patients’ best interests aren’t at the heart of the way these homes function.

She talked to Josh Stein, NC Attorney General, about passing laws to better regulate these sober homes, and he agreed that if these laws were needed, they should be passed.

No controversy with that one.

There was a segment about how there’s not enough beds in residential facilities for patients with opioid use disorder who want help. I agree, though I’m not sure this is breaking news for anyone. I don’t think there’s ever been enough beds to meet the treatment need.

Overall, I was left with a bitter taste after this reportage. The news program missed an opportunity to educate viewers about all evidence-based treatments for opioid use disorder, but ended up doing an advertisement for Suboxone and denigrating methadone.

Buprenorphine and methadone both work under the same principle: they are long-acting opioids which, when dosed properly, prevent withdrawal and craving while also blocking illicit opioids. While buprenorphine is a safer drug with fewer drug interactions, it isn’t strong enough for everyone. Methadone has countless studies to support its use to treat opioid use disorder, showing it reduces death, increases employment, decreases crime… but why go on, since facts don’t seem to matter as much as sound bites.

In my opinion, WLOS bungled an opportunity.

New Health Care Laws: How Will They Affect Office-based Treatment with Suboxone?

Last week, one of my office-based buprenorphine patients asked me how I thought the new healthcare laws would affect my business. I’ve considered this question with a mix of anxiety and hope. Until we have more details, I’m not certain I’ll like the new changes. And of course since I’m a healthcare provider, I’ll look at changes differently than if I were an insurance executive.

I told my patient that it will be excellent for my patients in buprenorphine (Suboxone, Subutex) treatment who don’t have insurance now, and are paying out of pocket. My patient then remarked that I’ll be much busier, because more pain pill addicts will be able to afford treatment.

“No,” I said, “I can still only have one hundred Suboxone patients at any one time, so I can’t add any new patients.”

My patient was quiet for a moment and said, “So if an addict calls you because he just got insurance to pay for his treatment, you couldn’t see him anyway?”

“That’s right, unless I lost a patient for some reason, and had an open spot for him.”

“So even if addicts get insurance, they can’t use it? That’s crazy. Why does the government have that law?”

I explained to him about the newness of the DATA 2000 Act, and that some lawmakers were skittish about this program from the beginning. They were worried Suboxone “mills” would open, where hundreds of addicts were treated with little physician oversight or precautions.

Lifting that limit would be the easiest way to get more opioid addicts into treatment.

My private practice, where I treat opioid addicts with buprenorphine (Suboxone, Subutex), is a bare bones operation. Because of the one hundred patient limit, I have enough patients to keep me busy for one day per week. On the other days, I work at opioid treatment programs. I enjoy my own office practice because of the autonomy, and because I have some great patients that I’ve known for years. But at my own office, I make far less than half what I make at the opioid treatment programs.

I have the usual fixed overhead of rent, utilities, answering service, internet, etc., and most of the money I take in goes towards that. I have a part-time health care coordinator, who makes appointments for patients, calls them to remind them of appointments, does most of my office drug screens, screens my after-hours calls, handles the filing, copying and other record-keeping tasks, and deals with those pesky pre-authorization requests that insurance companies make. (She and the counselor have decided I ought not to be allowed to talk with the insurance companies, since I often erupt into profanity).Then I have the best LCAS (Licensed Clinical Addiction Specialist) counselor in the world who works with me on Fridays, doing individual counseling (he’s my fiancé). Since I don’t file insurance, but rather give the patient a receipt so they can file it themselves, I avoid that personnel expense.

And I don’t accept Medicaid or Medicare as payment for treatment. I feel guilty for admitting that, but I don’t think I could stay in practice if I accepted what these government programs pay for treatment. When I first opened my own office in 2010, I saw a handful of these patients for free, since trying to file and going through the necessary red tape isn’t worth the pittance these programs pay for an office visit.

So if my uninsured patients get Medicaid, I’ll have to decide how to deal with that problem.

It’s not legal for me to ask patients with Medicaid and/or Medicare to pay for treatment out of their pocket unless I opt out of those programs completely for a period of years. I can’t do that because some of the other treatment facilities that I work for do bill Medicaid.

So do I start taking Medicaid, with all its headaches, red tape and low re-imbursement? I don’t know. I don’t like the thought of it, but it will perhaps become a necessity. It will depend on reimbursement rates. Plus, I’ll be paid even less since I don’t have electronic medical records. Government programs have decreed that doctors without meaningful use electronic medical records will receive less money for Medicaid/Medicare patients than doctors with these programs.

I’m not against electronic medical records. I use them effectively at both of the opioid treatment programs. One program is completely paperless, and I like that much more than I ever thought. But in my small, one hundred patient office, I can’t afford any software for medical records. It’s not practical or feasible

Since I was trained and still am board-certified as an Internal Medicine doctor, I could fill my other days with primary care patients. I was talking to another doctor who was starting her own Suboxone practice, and she was wondering how to get by financially, only practicing Addiction Medicine. She too is a former Internal Medicine doctor. I suggested she could always do some primary care.

“Just shoot me in the head,” she said, summarizing my feeling exactly. I’ve never liked primary care as much as addiction medicine, to put it mildly.

Addicts are easier to deal with, and are often nicer people than the average soccer mom, demanding an antibiotic to treat her viral upper respiratory infection. But my biggest reason for preferring addiction medicine is that addicts get better. I never saw the big changes in health when I worked in primary care, like I do in people treated for addiction. Primary care feels like a step backwards. I don’t want to go back to treating non-compliant diabetics, and overweight people who won’t exercise. I’d prefer to keep my present patients, in whom I see an intense desire to get well.

I’m addicted to seeing the big changes that I see when I work in addiction medicine. I hope the new changes in healthcare will allow me to stay in the business of helping people change. Like the rest of the U.S., I’ll have to wait and see.

Doctors Are Poorly Trained About Addiction and Recovery

Addiction? What addiction?

Most medical schools and residency programs place little emphasis on educating future physicians about addiction. A survey conducted by the Center on Addiction and Substance Abuse at Columbia University (CASA) revealed that physicians are poorly trained to recognize and treat addictive disorders. (1)

CASA surveyed nine-hundred and seventy-nine U.S. physicians, from all age groups, practice settings, and specialties. Only nineteen percent of these physicians said they had been trained in medical school to identify diversion of prescribed drugs. Diversion means that the drug was not taken by the patient for whom it was prescribed. Almost forty percent had been trained to identify prescription drug abuse or addiction, but of those, most received only a few hours of training during four years of medical school. More shocking, only fifty-five percent of the surveyed doctors said they were taught how to prescribe controlled drugs. Of those, most had less than a few hours of training. This survey indicates that medical schools need to critically evaluate their teaching priorities.  

Distressingly, my own experience mirrors this study’s findings. My medical school, Ohio State University, did a better job than most. We had a classroom section about alcoholism, and were asked to go to an Alcoholics Anonymous meeting, to become familiar with how meetings work. But I don’t remember any instruction about how to prescribe controlled substances or how to identify drug diversion.

Is it possible that I’ve forgotten I had such a course? Well, yes. But if I can still remember the tediously boring Krebs cycle, then surely I would have remembered something juicier and more practical, like how to prescribe potentially addicting drugs. Similarly, less than half of the surveyed doctors recalled any training in medical school in the management of pain, and of those that did, most had less than a few hours of training.

Residency training programs did a little better. Of the surveyed doctors, thirty-nine percent received training on how to identify drug diversion, and sixty-one percent received training on identifying prescription drug addiction. Seventy percent of the doctors surveyed said they received instruction on how to prescribe controlled substances. (1)

This last finding is appalling, because it means that thirty percent of doctors received no training on how to prescribe controlled substances in their residency programs.  Could it be true that nearly a third of the doctors leaving residency – last stop for most doctors before being loosed upon the populace to practice medicine with little to no oversight – had no training on how to prescribe these potentially dangerous drugs? Sixty-two percent leaving residency had training on pain management. This means the remaining thirty-eight percent had no training on the treatment of pain.

Could it be that many of these physicians were in residencies or specialties that had no need to prescribe such drugs? No. The participating doctors were in family practice, internal medicine, OB/GYN, psychiatry, and orthopedic surgery. The study included physicians of all ages (fifty-three percent were under age fifty), all races (though a majority at seventy-five percent were white, three other races were represented), and all types of locations (thirty-seven percent urban, thirty percent suburban, with the remainder small towns or rural areas). This study reveals a hard truth: medical training programs in the U.S. are doing a poor job of teaching future doctors about two diseases that causes much disability and suffering: pain and addiction. (1)

 I remember how poorly we treated patients addicted to prescription medications when I was in my Internal Medicine residency program. By the time we identified a person as addicted to opioids or benzodiazepines, their disease was fairly well established. It didn’t take a genius to detect addiction. They were the patients with thick charts, in the emergency room frequently, loudly proclaiming their pain and demanding to be medicated. Overall, the residents were angry and disgusted with such people, and treated them with thinly veiled contempt. We regarded them more as criminals than patients. We mimicked the attitudes of our attending physicians. Sadly, I did no better than the rest of my group, and often made jokes at the expense of patients who were suffering in a way and to a degree I was unable to perceive. I had a tightly closed mind and made assumptions that these were bad people, wasting my time.

Heroin addicts were not well treated. I recall a discussion with our attending physician concerning an intravenous heroin user, re-admitted to the hospital. Six months earlier, he was hospitalized for treatment of endocarditis (infected heart valve). Ultimately his aortic heart valve was removed and replaced with a mechanical valve. He recovered and left the hospital, but returned several months later, with an infected mechanical valve, because he had continued to inject heroin. We discussed the ethics of refusing to replace the valve a second time, because we felt it was futile.

I didn’t know any better at the time. We could have started him on methadone in the hospital, stabilized his cravings, and then referred him to the methadone clinic when he left the hospital. Instead, I think we had a social worker ask him if he wanted to go away somewhere for treatment, he said no, and that was the end of that. Small wonder he continued to use heroin.

At a minimum, the attending physician should have known that addiction is a disease, not a moral failing, and that it is treatable. The attending physician should have known how to treat heroin addiction, and how to convey this information to the residents he taught. Instead, we were debating whether to treat a man whose care we had mismanaged. Fortunately, he did get a second heart valve and was able to leave the hospital. I have no further knowledge of his outcome.

 Despite having relatively little training in indentifying and treating prescription pill addiction, physicians tend to be overly confident in their abilities to detect such addictions. CASA found that eighty percent of the surveyed physicians felt they were qualified to identify both drug abuse and addiction. However, in a 1998 CASA study, Under the Rug: Substance Abuse and the Mature Woman, physicians were given a case history of a 68 year old woman, with symptoms of prescription drug addiction. Only one percent of the surveyed physicians presented substance abuse as a possible diagnosis.  In a similar study, when presented with a case history suggestive of an addictive disorder, only six percent of primary care physicians listed substance abuse as a possible diagnosis. (2)

Besides being poorly educated about treatments for patients with addiction, most doctors aren’t comfortable having frank discussions about a patient’s drug misuse or addiction. Most physicians fear they will provoke anger or shame in their patients. Physicians may feel disgust with addicted patients and find them unpleasant, demanding, or even frightening. Conversely, doctors can feel too embarrassed to ask seemingly “nice” people about addiction. In a CASA study titled, Missed Opportunity, forty-seven percent of physicians in primary care said it was difficult to discuss prescription drug addiction and abuse with their patients, for whom they had prescribed such drugs. (2).

From this data, it’s clear physicians are poorly educated about the disease of addiction at the level of medical school and residency. Even when they do diagnose addiction, are they aware of the treatment facilities in their area? Patients should be referred to treatment centers who can manage their addictions. If patients are addicted to opioids, medications like methadone and buprenorphine can be a tremendous help.

1. Missed Opportunity: A National Survey of Primary Care Physicians and Patients on Substance Abuse, Center on Addiction and Substance Abuse at Columbia University, April 2000. Also available online at http://www.casacolumbia.org

2. Under the Rug: Substance Abuse and the Mature Woman, Center on Addiction and

Substance Abuse at Columbia University, 1998. Available online at http://www.casacolumbia.org

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?

Description of Methadone Patients

The following is an excerpt from Chapter 2 of my book, titled, “Pain Pill Addiction: Prescription for Hope.” In this chapter I’m describing the patients I saw at methadone clinics where I worked in the years 2001 through 2009.

 I was surprised how casually people shared controlled substances with one another. As a physician, it seems like a big deal to me if somebody takes a schedule II or schedule III controlled substance that wasn’t prescribed for them, but the addicts I interviewed swapped these pills with little apprehension or trepidation. Taking pain pills to get through the day’s work seemed to have become part of the culture in some areas. Sharing these pills with friends and family members who had pain was acceptable to people in these communities.

In the past, most of the public service announcements and other efforts to prevent and reduce drug use focused on street drugs. Many people seemed to think this meant marijuana, cocaine, methamphetamine, and heroin. The patients I saw didn’t consider prescription pills bought on the street as street drugs. They saw this as a completely different thing, and occasionally spoke derisively about addicts using “hard drugs.” Most addicts didn’t understand the power of the drugs they were taking.

 Some opioid addicts came for help as couples. One of them, through the closeness of romance, transmitted the addiction like an infectious disease to their partner. Most were boyfriend/girlfriend, but some were married. The non-addicted partner’s motives to begin using drugs seemed to be mixed. Some started using out of curiosity, but others started using drugs to please their partner. I was disturbed to see that some of the women accepted the inevitability of addiction for themselves as the cost of being in a relationship with an addicted boyfriend. Often, addicted couples socialized with other addicted couples, as if opioid addiction bound them like a common fondness for bowling or dancing. Addiction became a bizarre thread, woven through the fabric of social networks.

 We saw extended family networks in treatment for pain pill addiction at the methadone clinics. One addicted member of a family came for help, and after their life improved, the rest of the addicted family came for treatment too. It was common to have a husband and wife both in treatment, and perhaps two generations of family members, including aunts, uncles, and cousins. Many addicts who entered treatment saw people they knew from the addicted culture of their area, and sometimes old disputes would be reignite, requiring action from clinic staff. Sometimes ex-spouses and ex-lovers would have to be assigned different hours to dose at the clinic, to prevent conflict.

 When the non-profit methadone clinic where I worked began accepting Medicaid as payment for treatment, we immediately saw much sicker people. Over all, Medicaid patients have more mental and physical health issues. Co-existing mental health issues make addiction more difficult to treat, and these patients were at higher risk for adverse effects of methadone. However, data does show that these sicker patients can benefit the most from treatment.

 When I started to work for a for-profit clinic, I saw a slightly different patient population. I saw more middle class patients, with pink and white-collar jobs. Occasionally, we treated business professionals. The daily cost of methadone was actually a little cheaper at the for-profit clinic, at three hundred dollars per month, as compared to the non-profit clinic, at three hundred and thirty dollars per month. However, the for-profit clinic charged a seventy dollar one-time admission fee, to cover the costs of blood tests for hepatitis, liver and kidney function, blood electrolytes, and a screening test for syphilis. The non-profit clinic had no admission fee, but only did blood testing for syphilis. I believe the seventy dollars entry fee was enough to prevent admission of poorer patients, who had a difficult enough time paying eleven dollars for their first and all subsequent days.

The patients at the for-profit clinic seemed a little more stable. Maybe they hadn’t progressed as far into their disease of addiction, or maybe they had better social support for their recovery. This clinic didn’t accept Medicaid, which discouraged sicker patients with this type of health coverage. Both clinics were reaching opioid addicts; they just served slightly different populations of addicts. The non-profit clinic accepted sicker patients, which is noble, but it made for a more chaotic clinic setting. This was compounded by a management style that was, in a few of their eight clinics, more relaxed.

 For the seven years I worked for a non-profit opioid treatment center, I watched it expand from one main city clinic, and one satellite in a nearby small town, to eight separate clinic sites. The treatment center did this because they began to have large numbers of patients who drove long distances for treatment. This indicated a need for a clinic to be located in the areas where these patients lived. Most of this expansion occurred over the years 2002 through 2006.

 Three of these clinics were located in somewhat suburban areas, within a forty-five minute drive from the main clinic, located in a large Southern city. The other four clinics were in small towns drawing patients from mostly rural areas. One clinic was located in a small mountain town that was home to a modest-sized college. Nearly all of the heroin addicts I saw in the rural clinics were students at that college. But by 2008, we began to see more rural heroin addicts, who had switched from prescription pain pills to heroin, due to the rising costs of pills.

Within a few years, clinics near the foothills of the Blue Ridge Mountains of Western North Carolina were swamped with opioid addicts requesting admission to the methadone clinics. These clinics soon had many more patients than the urban clinic.

I saw racial dissimilarities at the clinic sites. In the city, we admitted a fair number of African Americans and other minorities to our program. Most of them weren’t using pain pills, but heroin. I don’t know why this was the case. Perhaps minorities didn’t have doctors as eager to prescribe opioids for their chronic pain conditions, or perhaps they didn’t go to doctors for their pain as frequently as whites. If they were addicted to pain pills, maybe distrust kept them from entering the methadone clinic. In the rural clinics, I could count the number of African-American patients on one hand. They were definitely underrepresented. The minorities we did treat responded to treatment just as well.

A recent study of physicians’ prescribing habits suggested a disturbing possibility for the racial differences I saw in opioid addiction. (1) This article showed statistically significant differences in the rate of opioid prescriptions for whites, compared to non-whites, in the emergency department setting. Despite an overall rise in rates of the prescription of opioid pain medication in the emergency department setting between 1993 and 2005, whites still received opioid prescriptions more frequently than did Black, Asian, or Hispanic races, for pain from the same medical conditions. In thirty-one percent of emergency room visits for painful conditions, whites received opioids, compared to only twenty-three percent of visits by Blacks, twenty-eight percent for Asians, and twenty-four percent for Hispanic patients. These patients were seen for the same painful medical condition. The prescribing differences were even more pronounced as the intensity of the pain increased, and were most pronounced for the conditions of back pain, headache, and abdominal pain. Blacks had the lowest rates of receiving opioid prescriptions of all races.

This study could have been influenced by other factors. For example, perhaps non-whites request opioid medications at a lower rate than whites. Even so, given the known disparities in health care for whites, versus non-whites in other areas of medicine, it would appear patient ethnicity influences physicians’ prescribing habits for opioids. The disparities and relative physician reluctance to prescribe opioids for minorities may reduce their risk of developing opioid addiction, though at the unacceptably high cost of under treatment of pain.

Interestingly, we had pockets of Asian patients in several clinics. We admitted one member of the Asian community into treatment, and after they improved, began to see other addicted members of their extended family arrive at the clinic for treatment. Usually the Asian patients either smoked opium or dissolved it in hot water to make a tea and drank it. When I tried to inquire how much they were using each day, in order to try to quantify their tolerance, the patient would put his or her thumb about a centimeter from the end of the little finger and essentially say, “this much.” Having no idea of the purity of their opium, this gave me no meaningful idea of their tolerance, so we started with cautiously low doses.

One middle aged patient from the Hmong tribe presented to the clinic and when I asked when and why he started opioid use, in broken English and with difficulty, he told me he had lost eight children during the Vietnam War, and was injured himself. After the pain from his injury had resolved, he still felt pain from the loss of his family and he decided to continue the use of opium to treat the pain of his heart, as he worded it. I thought about how similar his history was to the patients of the U.S. and how they often started using opioids and other drugs to dull the pain of significant loss and sorrow. I thought about how people of differing ethnicities are similar, when dealing with addiction, pain, and grief.

1. Pletcher M MD, MPH, Kertesz, MD, MS, et. al., “Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments,” Journal of the American Medical Association, 2008 vol. 299 (1) pp 70-78.

The MOTHER trial – New Information about Buprenorphine and Methadone in Pregnancy

 The long-awaited MOTHER trial is done, and the data just published. (1) MOTHER (Maternal Opioid Treatment: Human Experimental Research) was one of the first studies to follow pregnant opioid-addicts during pregnancy and up to 28 days after they delivered their babies.

 The purpose of the study was to compare the use of buprenorphine during pregnancy with the use of methadone. For the past forty years, methadone has been the treatment of choice for opioid-addicted pregnant women. This is because it prevents withdrawal in the mother and fetus. With short-acting, illicit opioids like heroin or OxyContin without the time release coating, the mother and baby get high peaks of opioid followed by periods of withdrawal.

 Healthy adults get very sick while in withdrawal, but they usually don’t die. However, the developing fetus can die during opioid withdrawal, and miscarriage or preterm labor are more likely to occur. Methadone, since it’s a long-acting opioid, can keep both mother and baby out of withdrawal for twenty-four hours, when properly dosed. Compared with opioid-addicted mothers left untreated, or treated with non-opioid means, methadone-maintained mothers have fewer complications, better prenatal care, and higher birth weight babies.

 Now for the bad part: about half of the infants born to moms maintained on methadone have opioid withdrawal symptoms. No one wants to see a newborn having symptoms of opioid withdrawal. And yet, it’s still better than the alternatives.

 But now, it appears that the use of buprenorphine during pregnancy gives as much benefit as methadone, but less severe withdrawal in the newborns. The percentage of babies with opioid withdrawal was similar in the methadone and buprenorphine groups, but the severity and duration of the babies’ withdrawal were markedly less.

 If a woman addicted to heroin or pain medications discovers she’s pregnant, her best choice is to get into treatment with buprenorphine. But if that’s not available, methadone is still better than other alternatives.

 1. “Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure,” by Hendree Jones, Karol Kaltenbach, et. al., New England Journal of Medicine, December 9, 2010, 363;24: pages 2320-2331.

The New OxyContin Formulation

Over the last three weeks, at least five of the opioid addicts I’ve admitted to treatment said they wanted help because they couldn’t abuse the new form of OxyContin.

 And I say: Hallelujah! It’s about time!!

 This new tablet, approved by the FDA in April of this year, appeared recently on the black markets of this area, replacing the older, more easily abused OxyContin. The new tablet is bioequivalent to the older tablet, meaning the same amount of oxycodone, the active ingredient, is available to the body when swallowed whole, as it’s meant to be. In other words, the same amount of pain reliever is given to the body. However, it’s more difficult to crush for the purpose of snorting or injecting, because it turns into a gummy ball.

Purdue Pharma, the drug company that makes OxyContin, admits this new formulation isn’t abuse-proof, but hopes it will be more resistant to abuse.

The patients I’ve talked to say the new tablet is a big disappointment. One patient, who usually chews her pill to get a faster high, said it was like trying to chew a jelly bean. Other patients said they could crush the tablet, but got a kind of gelatinous mess that was impossible to snort or inject.

 For pain relief, the opioid in OxyContin lasts much longer when it’s taken as directed and swallowed whole. Addicts prefer to crush and snort or inject because of the quick high they feel with this route of administration. But when used in this way, it leaves the body faster, and the addict usually needs to find more opioid within six to eight hours to avoid withdrawal.

Before I applaud Purdue Pharma for this change, my cynical mind asks a few questions: Why didn’t the company make this change earlier?

In 2002, a Purdue Pharma representative testified before congress, saying that the company was working on a re-formulation of OxyContin, to make it harder to use intravenously. This representative said they expected to have the re-formulated pill on the market within a few years. (1)  But it took eight more years.

Sterling, the drug company that makes Talwin, another opioid pain medication, was able to re-formulate their drug within a few years when they discovered it was being abused frequently. This was in the 1980s, when, presumably, medication technology wasn’t as advanced as today. Sterling added naloxone, an opioid blocker that’s inactive when taken by mouth, but puts an addict into withdrawal when it’s crushed and injected. It worked great. Talwin isn’t a commonly abused drug.

 I’m assuming that Purdue Pharma holds the patent for this new formulation that makes their tablet gummy when crushed. Purdue probably teaches its sales staff to market the new OxyContin as a safer option than older versions, perhaps available in cheaper generics. So did they wait to re-formulate until their patent was ready to expire? I don’t know, but time will tell.

At any rate, this drug is now just a little bit safer, for now. People with addictions are often clever and creative. I won’t be surprised if soon there’s a way to defeat this new technology.

Just think what addicted people could do, if they directed their talent and intelligence in ways that would help and not hurt them. There would be no stopping them.

1. United States Senate. Congressional hearing of the Committee on Health, Education, Labor, and Pensions, on Examining the Effects of the Painkiller OxyContin, 107^th Congress, Second Session, February, 2002.

Buprenorphine implants – study results

This week I read an article in the latest issue of the Journal of the American Medical Association describing the results of a randomized controlled trial comparing implantable buprenorphine compared to placebo. Buprenorphine implants are four (five for some patients) small cylinders, inserted just under the skin of the upper inner arm. They are each about an inch long, and release medication up to about six months.

Buprenorphine (brand names Suboxone or Subutex) works well for the treatment of opioid addiction, but only if the patient takes it every day. Like other doctors, I have some patients who occasionally stop taking buprenorphine, so they can use illicit opioids to get high. This problem is eliminated with buprenorphine implants, because the patient receives a steady level of buprenorphine for as long as the implants are in place.

The other problem with Suboxone tablets has been its diversion from patients to the black market. Granted, it’s the safest opioid on the streets, given the ceiling on its opioid effect, but diversion to the black market isn’t desirable to doctors or law enforcement. But the implants, for obvious reasons, can’t be diverted, or at least would be extremely difficult to divert.

In this trial of the buprenorphine implants, patients were randomized to receive either placebo implants or buprenorphine implants. The patients and study evaluators didn’t know who had placebo implants and who had the real thing.

The results surprised no one. The buprenorphine implants were much more effective than the placebo implants. Patients with buprenorphine implants were retained in treatment longer and used less illicit opioids, both at week 16 and week 24. After six months, the implants were removed. The implants were fairly safe, with main problems being related to pain, swelling, or infection at the implant site. In the buprenorphine group, most common side effects compared to placebo were headache and insomnia.

This study is hopeful, but of course the real question is how do buprenorphine implants compare to the sublingual (under the tongue) Suboxone tablets and film? More studies are on the way. But for patients I worry might stop their Suboxone to relapse now and again, and in patients I worry might sell their Suboxone, these implants will be a good option when they become available.

What caused the rise in pain pill addiction?

In the 2006 National Survey of Drug Use in Households (NSDUH) study, 5.2 million people in the U.S. population over age twelve used prescription pain medications, for non-medical reasons, within the month prior to the survey. This means they took prescription opioid pills for reasons other than for the treatment of pain as prescribed by a doctor, inferring they took them to get high. In 2006, the number of new users of prescription pain pills for non-medical reasons, at 2.2 million people, was higher than the number of new users of marijuana, at 2.1 million people. This was the first year – ever – that any drug beat marijuana for number of new drug users, and indicates that the prescription pain pill addiction will be with us for some time to come. (1) 

            The percentage of young adults, age eighteen to twenty-five, currently using prescription pain pills rose from 4.1% to 4.6% in the years between 2002 and 2007. (2) While these numbers are overwhelming, not everyone who misuses prescription pain pills will develop addiction. Presently, best estimates given by governmental studies are that 1.7 million people in the U.S. can be diagnosed with opioid addiction or abuse. (1)

            Beginning in the late 1990’s, several factors contributed to the biggest epidemic of pain pill addiction in more than a hundred years in the U.S. The most obvious reasons included an overzealous pain management movement, which coincided with OxyContin’s release and inappropriate marketing. But less well-recognized factors kindled our present conflagration of opioid addiction.

            Cultural norms and beliefs in the U.S. were fuel for the fire of opioid addiction that started to spread in the late 1990’s. We tend to share our medications. People in this country are sharing powerful and potentially dangerous prescription medications, even controlled substances, like opioids. The 2008 National Survey of Drug Use in Households study surveyed the people over twelve who said they currently used prescription pain pills to get high, and fifty-six percent of these people said they got their prescription opioid drugs from friends or relatives, free of charge. Nine percent bought them from friends or relatives, and about five percent took them from a friend or relative without asking. Eighteen percent of people misusing prescription opioids got them by prescription from one doctor. Only about four percent said they bought drugs from a drug dealer, and only half of a percent said they got their prescription opioids from the internet. (2)

            We don’t just share with adults. Among 12^th graders who were current nonmedical users of prescription opioids, sixty-six percent got them from a friend or relative.  Nineteen percent were prescribed the opioids they misused by one doctor. Only eight percent bought them from a dealer.  Of the kids who got their pills from a friend or relative, thirty-three percent of these youngsters were given their pills. Twenty-one percent bought them and twelve percent stole them. (3)

The image of a villainous drug dealer enticing our nation’s youth to use drugs is a myth. Young people get opioids to abuse from their friends and relatives, not from drug dealers. Young adults trade medication (“I’ll give you my Ritalin if you give me your Vicodin”) and don’t know – or care -that it’s illegal and dangerous. Powerful prescription opioids were viewed as relatively less dangerous than street drugs. Many people mistakenly believed that prescription drugs were safe.

Young people often have mistaken ideas about the risk of prescription drugs. According to one study, forty percent of adolescents in grades seven through twelve believed that prescription drugs are safer than street drugs. (4) Thirty percent believed prescription drugs aren’t addictive. And when a drug is perceived as less dangerous, more people use it.

1. Substance Abuse and Mental Health Services Administration. (2007). Results from the 2006 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-36, HHS Publication No. SMA 09-4434). Rockville, MD.
2. Substance Abuse and Mental Health Services Administration. (2009). Results from the 2008 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-36, HHS Publication No. SMA 09-4434). Rockville, MD.
3. Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (December 11, 2008). “Various stimulant drugs show continuing gradual declines among teens in 2008, most illicit drugs hold steady.” University of Michigan News Service: Ann Arbor, MI. from http://www.monitoringthefuture.org  
4. Partnership for a Drug-Free America – The Partnership Attitude Tracking Study Teens 2008 Report http://www.drugfree.org/Files/full_report_teens_2008