Archive for the ‘Recovery’ Category

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.

Top Ten Books for Methadone Counselors

I have a fair number of methadone counselors who read my blog. I’m often asked by these counselors what books I recommend, which is like asking me what kind of dessert is good. The list is so long. But here are the ones all methadone counselors should read:

  1.  Medication-assisted Treatment for Opioid Addiction in Opioid Treatment Programs, by the Substance Abuse and Mental Health Services Administration. This is better known as “TIP 43,” because it’s the 43rd book in the series of treatment improvement protocols published by SAMHSA. You can get any book in the series for FREE! Yes, this book and several others are free resources. The website is: http://store.samhsa.gov. While you’re there, order TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, and TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment. Then browse around, and see what else interests you. This is a great website, and all addictions counselors should be very familiar with it. There’s great material for counselors and their clients.
  2.   Pain Pill Addiction: Prescription for Hope, by….me. Hey, it’s my blog, so of course I’m gonna list my book. At least I didn’t put it at number one. But seriously, I do think my book describes what opioid addiction is, why this country is having such problems with opioid addiction now, and the available treatments for this addiction. I focus on medication-assisted treatments, which means treatments with methadone or buprenorphine, better known as Suboxone. After reading my book, any substance abuse counselor should be able to talk intelligently with patients and their families about the pros and cons of medication-assisted treatment. I tried hard to base this book on available research and not my own opinions, though I do state some of my opinions in the book. My book also has summaries of the major studies done using medication-assisted treatments, so that if you need resources to prove why methadone works, you’ll have them. OK. I’m done blathering. Order it on EBay and you’ll save some money.
  3.      Motivational Interviewing by William Miller and Stephen Rollnick. This is a book all addiction counselors should have… and read. I’ve learned so much about how to interact with people as they consider if, how, and when to make changes in their lives by reading this book. The authors demonstrate how the Stages of Change model easily fits with this style of counseling. There are some solid examples of how to incorporate MI techniques.
  4.      Cognitive Therapy of Substance Abuse, by Aaron Beck et. al. This is a venerable text describing cognitive therapy as it applies to substance abuse. The book is relatively concise, but it’s still dense reading. Get out your underliner because you’ll want to find some parts to read again. The dialogues in the book that serve as examples are instructive. This book has been around for some time, as texts go, since it was published in 2001.
  5.     Narcotics Anonymous Basic Text, by Narcotics Anonymous World Service. Now in its sixth edition, this is one of the books that serve as a foundation for 12-step recovery in Narcotics Anonymous. If you are a counselor who’s in recovery, you’ve probably already read it. If you’re not, you need to get it, read it, and be able to talk intelligently about the 12-step recovery program of this 12-step group. The AA “Big Book,” which is AA’s version of a basic text, has much of the original old-time words and phrases, and speaks mostly of alcohol. For these reasons, some addicts won’t like the Big Book as well as the NA Basic Text. However, the Big Book does have a certain poetry that will appeal to others. (….trudge the road of happy destiny…) You can order it at http://na.org or go to that site and download it as a pdf.
  6.  The Treatment of Opioid Dependence, by Eric Strain and Maxine Stitzer. Written in 2005, this is an update to a similar title written in the 1990’s. This book reviews the core studies underpinning our current treatment recommendations for patients in medication-assisted treatment of opioid addiction. I don’t know why more people haven’t read this book, because it’s relatively easy to understand. Don’t make the mistake of assuming it will be too advanced for you. Get it and read it.
  7. Addiction and Change: How Addictions Develop and Addicted People Recover, by Carlo DiClemente. This book describes the paths people follow as they become addicted and as they recover. It’s focused on the transtheoretical model of the stages of change, so named because it can be used with many counseling theories. I think this is a practical book, and easier to understand than some texts.
  8.  Diagnosis Made Easier: Principles and Techniques for Mental Health Technicians, by James Morrison M.D. This is an improvement of his earlier book, DMS IV Made Easy, written in 1992. At any work site, addictions counselors will have to be familiar with the criteria used to diagnose mental illnesses. Since around 30 – 50% of addicts have another co-occurring mental illness, you need to be familiar with the criteria used to diagnose not just addiction, but these other illnesses as well. And this book makes learning relatively painless. It’s practical and easy to read, and based on common sense. It contains many case examples, which keep it interesting.
  9. The American Disease: Origins of Narcotic Control, by David Musto. This book has been updated and is on its third edition, but so much has happened since this last edition in 1999 that the author needs to write an update. This is an interesting book, and it moves fairly quickly. This information puts our present opioid problem into the context of the last century or so. As an alternative, you can read Dark Paradise: A History of Opiate Addiction in America, by David Courtwright in 2001. I included this book, but be warned it’s heavier reading. This author is an historian, so maybe his writing style didn’t resonate with me as much. Still, he has much good information. You can’t go wrong with either book. You could also read The Fix by Michael Massing, which is another book about the history of addiction and its treatment in the U.S… This last book doesn’t focus on just opioid addiction, but still gives all the pertinent history. This book is written by a journalist and will keep your interest. It was written in 2000.
  10.  Hooked: Five Addicts Challenge Our Misguided Drug Rehab System, by Lonnie Shavelson. This book, written by a journalist, follows five addicts through the labyrinth of addiction treatment. You’ll see the idiotic obstructions addicts seeking help are asked to negotiate in our present healthcare system. I was angry as I read the book, seeing obvious simple solutions that couldn’t be enacted for one administrative reason or another. Let this book make you angry enough to demand change from our system. Be an advocate for addicts seeking treatment.

 Have I left out any? Let me know which book have helped you be a better counselor or therapist.

Methadone and Suboxone Can Cause Sweating

All opioids can cause sweating and flushing. But methadone is perhaps worse than the other opioids, since we use doses high enough to block opioid receptors, to get the maximum benefit from methadone in the treatment of opioid addiction. Buprenorphine (active ingredient in the brand Suboxone and Subutex) can also cause sweating, but since it’s a weaker opioid, people don’t seem to be as badly affected by it.

 We don’t know exactly why opioids make people sweat, but it is related to opioids’ effects on the thermoregulatory centers of the brain.

 Excess sweating can also be caused by opioid withdrawal.  If other withdrawal symptoms are present, like runny nose, muscle aches, or nausea, an increase of the methadone dose may help reduce the sweating.

 At least half of all patients on methadone report unpleasant sweating, but some patients have sweats that are more than just inconvenient. These patients report dramatic, soaking sweats, bad enough to interfere with life.

 First, non-medication methods can be attempted. These methods include common sense things like wearing loose clothing, keeping the house cool, and losing weight. Regular exercise helps some people. Talcum powder, sprinkled on the areas that sweat, can help absorb some of the moisture. Antiperspirants can be used in the underarm area, but also in any area that routinely becomes sweaty. The antiperspirant can be applied at bedtime so sweating won’t interrupt sleep. There are prescription antiperspirants, like Drysol or Xerac, but these sometimes can be irritating to the skin. Avoid spicy foods, which can also cause sweating.

 Make sure the sweating isn’t coming from any other source, like an overactive thyroid, and check your body temperature a few times, to make sure you don’t have a fever, indicating the sweating could be from a smoldering infection. A trip to the primary care doctor should include some basic blood tests to rule out medical causes of sweating, other than the dose of methadone.

 Some prescription medications can help, to varying degree, with sweating.

 Clonidine, a blood pressure medication that blocks activation of part of the central nervous system, blocks sweats in some patients.

 Anticholenergic medicines, drugs block the effect of the neurotransmitter acetylcholine in the involuntary nervous system, block sweating. Anticholinergics tend to dry all secretions, causing such common side effects as dry mouth and dry eyes. These medications can cause serious side effects, so they must be prescribed by a doctor familiar with the patient’s medical history.

 Some examples of anticholinergics include oxybutynin (also used for urinary leakage), bipereden (used in some Parkinson patients), scopolamine (also used for sea sickness), and dicyclomine (used for irritable bowel syndrome). All of these have been used for excessive sweating with various degrees of success, in some patients.

 For unusually bad situations, Botox can be injected under the skin of the most affected areas, like armpits, palms and soles. Obviously, this is somewhat of a last-resort measure.

Patients affected with severe sweats, unresponsive to any of the above measures, need to decide if the benefit they get from methadone outweighs the annoyance of the side effects. In other words, if being on methadone has kept them from active drug addiction, which is a potentially fatal illness, it would probably be worth putting up with sweating, even if it’s severe.

Bibliotherapy: More Addiction Memoirs

If I Die Before I Wake, by Barbara Rogers

Anyone struggling with addiction to drugs including alcohol can get something out of this book. The author describes what her addiction was like, what happened to get her into recovery, and what it’s like now. And she went further than that. She described the trials she faced while in recovery, and how she applied the spiritual principles of the twelve steps as she went through these trials. This book is like going to a really good speaker meeting. It will resonate with both newcomers and old-timers in recovery. I will be recommending it to my patients.

Pill Head, by Joshua Lyons

I was envious as I read the book, because he did such a great job of writing an interesting, engaging book, while also educating the reader with (mostly) accurate facts about the disease of opioid addiction. It’s more interesting than my own book, Pain Pill Addiction, though I have more science in mine. Anyway, the author shows the dividedness of many addicts. He wants to be in recovery, and hates the negative consequences that are occurring as a result of his addiction, but he still wants to use pain pills. I don’t think people newly in recovery should read it because it may trigger cravings in the places he describes drug euphoria. His story isn’t one of hope, and I wish he’d waited until he was further into recovery to write the book.

 

Loaded, by Jill Talbot

            Ugh. I didn’t like this book. It was false advertising, for one thing. It was more about her unhappy love life than it was about her alcohol addiction. For the first two-thirds of the book, she laments about how dating married men made her lonely. Duh. Then toward the end she does talk of some sticky situations due to alcohol, and describes her fellow patients at a drug rehab. But then she is vague about her relapse back to drinking, and if she was able to do controlled drinking, or if she went back to her former state.

Wired: the life and Fast Times of Jim Belushi, by Bob Woodward

            It could have been cut in half and been a much better book. The renowned author put in a great many details of the days and nights during the years leading up to the star’s death from drug overdose, and it felt like too much after a few chapters. We get it. He was a wild and crazy guy. He did outrageous things and was tremendously talented and deeply flawed. Maybe knowing the ending made it sad from the start. Another big talent obliterated by addiction.

Broken, by William Cope Myers

            He’s the son of the famous journalist William Myers, and now a spokesman for Hazelden recovery center in Minnesota. This memoir is one of the better ones. He does a good job of describing the guilt that comes after a drug binge, and about his family’s disappointment in him. With a famous father, the press of expectations was an added stress that may have pushed his addiction further.

Go Ask Alice, by Anonymous

I came across a paperback copy in a bargain bin at a thrift store, and bought it to re-read. I read it as a teen, and at that time suspected it was written by an adult to scare kids away from drugs. I wondered if I’d think differently reading it as an adult. I didn’t. I certainly didn’t sound like it was written by a fifteen year old. It’s a fair book, but probably fictional.

Can’t Find My Way Home, by Martin Torgoff

I’ll re-read this one. It’s a comprehensive history of drug addiction in the U.S. from 1945 until 2000. Focused on the various political movements and popular trends of different years, it puts drug use into cultural context. It also gives some specifics behind some famous drug users and drug legalization proponents. It was fascinating. At the end, the author unexpectedly described his own recovery. Anyone wanting to read more about the 1960’s and 70’s drug culture should read this book.

“The End of My Addiction,” by Dr. Oliver Amiesen

            I only got this book because a few patients mentioned it. I pre-judged this book, thinking the author must be a pompous doctor, hater of Alcoholics Anonymous, who wrote a lame book on a half-baked theory about addiction treatment, just for his self-glorification. I was completely wrong. The author writes about his own addiction with self-awareness and humility. He doesn’t claim to have all the answers, but presents a credible treatment that may benefit alcoholics. He started himself on high-dose baclofen, a muscle relaxant that’s been around for years. It quenched his thirst for alcohol. He presents a good enough argument to justify a large randomized controlled trial to test the theory that high-dose baclofen suppresses alcohol cravings. The book is well-written and interesting. Dr. Amiesen describes his own travails with addiction in some detail.

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.

Tennessee, the State of Malignant Denial

 

For the last ten years, local officials in the small towns of Eastern Tennessee have been denying the presence of opioid addiction in their midst. Ironically, as the map shows, Eastern Tennessee has one of the very highest rates of opioid addiction in all of the U.S.

National Survey of Drug Use and Health

   

Over the last ten years, various treatment centers, wanting to treat these addicts with methadone and/or buprenorphine programs, have tried to open in this area. In a show of NIMBY (Not in My Back Yard), town officials vote for zoning changes meant to make it essentially impossible to get approval to open such clinics. Tennessee officials say it will bring drug addicts to the area.

From the Kingsport, Tennessee Times-News, 3/18/09,

“The Church Hill Board of Mayor and Aldermen unanimously approved the first reading Tuesday of an ordinance which, in essence, makes it almost impossible for a methadone clinic to locate within the city limits.

Earlier this month, the Planning Commission recommended the ordinance, which restricts methadone clinics and drug treatment facilities to areas of the city that are zoned M-1 (manufacturing). Without the ordinance, methadone clinics and drug treatment facilities would be permitted in any area of the city zoned to allow medical uses.”

“I think we’re all in the consensus that we don’t want it anywhere,” the alderman said (name deleted).

Similar laws have been passed in Johnson City, Tennessee.

So what happens to untreated pain pill addicts?

There aren’t any studies following pain pill addicts long-term, but we do have studies of heroin addicts.

They die.

Methadone maintenance has been shown to reduce death rates by factors ranging from three fold to sixty-three fold. (1, 2, 3, 4, 5, 6)

In one study, heroin addicts enrolled in methadone treatment were one-quarter as likely to die by heroin overdose or suicide as were heroin addicts not in methadone treatment. This study followed 296 heroin addicts for more than 15 years. In another study, a group of heroin addicts were followed over twenty years. One-third died within that time. Of the survivors, 48% were enrolled in a methadone program for treatment. The authors of the study concluded that heroin addiction is a chronic disease with a high fatality rate, and that methadone maintenance offered a significant benefit.

We suspect, but don’t know for sure, that pain pill addicts will have similar rates of death, since both groups are addicted to opioids. Studies are being done now, following pain pill addicts to see if their outcome will be similar to heroin addicts.

The young addicts of Eastern Tennessee are paying a heavy price for the denial of local officials.

  1. 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.
  2. 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.
  3.  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.
  4. 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.
  5. 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).
  6. 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.

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.

Interview with a Methadone Counselor

I met a skilled drug addiction counselor, previously addicted to heroin, who became abstinent from all drugs, by going to meetings of Narcotics Anonymous. She had been a patient of methadone clinics off and on for many years, prior to getting clean. I met her after she had more than ten years of completely abstinent recovery, yet she happily works at a methadone clinic, helping opioid addicts. I interviewed her because of her personal experience and her striking open-mindedness to different approaches to the treatment of addiction. Here is what she had to say about her experiences with methadone, and her perspective:

JB: Can you please tell me your personal experience of opioid addiction?
RJ: Well, my personal experience began at the age of…probably eighteen….and I was introduced by some people I was hanging out with. I was basically very ignorant about those kinds of things. I wasn’t aware of that kind of stuff going on, ‘cause I was raised in this real small town and just didn’t know this kind of stuff happened.
My first experience was with a Dilaudid. Somebody said we had to go somewhere else to do it, and I really didn’t understand that, because I certainly didn’t know that it would be injected. That was my first experience with a narcotic, with opiates, and….I fell in love!
I loved it. I injected it, and the feeling was…..like none I had ever felt. And even though I did get sick, I thought it was what I was looking for. It was the best feeling in the world.
Obviously, they didn’t tell me about getting sick, [meaning opioid withdrawal] and that after doing it for some days consecutively, when you didn’t have any, you’d get sick. I never will forget the first time I was sick from not having any.
And that lead to a habit that lasted twenty-some years. My experience and my path led me down many roads… with addiction, going back and forth to prison, because I obviously didn’t make enough money to purchase these drugs that I needed to have in my body, to keep from being sick. This lasted for twenty four years. I ended up doing heroin and I liked it, because it tended to be stronger. Morphine I liked a lot, but it wasn’t easily accessible, so I switched over to heroin at some point. Which I liked a lot.
JB: What role did methadone play in your recovery?
RJ: I’ve been in numerous methadone clinics. I typically would get on methadone when I got a charge [meaning legal problems] and I wanted to call myself being in treatment. I never ever got on methadone with any expectations, hopes, or thoughts of changing my life. I got on because it kept me from being sick. And it kept me off the street for a period of time. If I had a charge, I was in treatment and I always thought that would help me in my journeys with the legal systems. That was the part methadone played in my life, it was just to help me get through it.
JB: Did it help you?
RJ: At the time, it did. My problem with methadone was, when I would get on methadone, I would tend to do cocaine, because I could feel the cocaine, and I wasn’t about changing anything. I just wanted temporary fixes in my life. I’d switch to cocaine while I was on methadone. And it [methadone] worked for a time. I never got any take homes, because I continued to test positive for other substances while I was on methadone, but I thought I was doing better, ‘cause I was not doing narcotics. In that aspect it did help.
JB: And you’ve been in recovery from addiction now for how long?
RJ: It will be fifteen years in June.
JB: Wonderful!
KS: Yes, it is wonderful.
JB: And tell me where you work now.
RJ: I work at a methadone treatment facility.
JB: How long have you been working there?
RJ: I’ve been there for almost fourteen years and in this [satellite] clinic for a little over two years, and I’ve been in methadone [as a counselor] for five years.
JB: How do you feel about methadone and what role it should play in the treatment of opioid addiction?
RJ: I believe in methadone. Our [her clinic’s] philosophy certainly is not harm reduction but I believe that’s what it’s about. And I do believe that those people on methadone, and are doing well, have a home, have a life, I think that’s all they aspire to. For them that’s enough, you know, they’re not out ripping and running the roads, they’re not looking for drugs on a daily basis. They come and get their methadone, they go to work, they have a life, they have a family, they have a home, and for them that’s good enough.
JB: Do you think it keeps them from getting completely clean [I purposely chose to use her language to differentiate being in recovery on methadone from being in recovery and completely off all opioids]?
RJ: No. I think they know they have a choice.
JB: OK
RJ: I really believe that a lot of them don’t think that they can ever do anything differently, and I know from personal experience that can be very true. I think that you just get so bogged down in your disease that you don’t see any way out. I think if you can find a place where you can get something legally and you’re not using the street drugs, and you’re not out copping [buying drugs] and you’re working and basically having a life, then that becomes OK, and that becomes good enough.
And addicts by nature are scared of change, and they get in that role and they get comfortable and that’s good enough for them. So I don’t believe they think that they can do any better.
JB: What percentages of your patients have already used street methadone by the time they get to the clinic?
RJ: I’d say seventy-five percent. Very rarely do I do an assessment [on a new patient] that somebody hasn’t already used methadone on the street. Very rarely.
JB: What are your biggest challenges where you work?
RJ: Actually my biggest challenges where I work are internal challenges. Fighting that uphill battle of no consequences for clients. There’s no consequences. We allow them to do basically what they want to do. [She is speaking of her methadone clinic’s style of interaction with patients].
JB: Do you think patients did better when there were a few consequences?
RJ: Oh yeah. Yeah. I mean, when certain clients can continue to have the same behaviors, like use benzos [meaning benzodiazepines like Valium and Xanax] and there are no consequences, certainly they are going to continue doing those behaviors. And those are the things that are challenges now, for us, for me.
I can’t enforce any consequences because we’re not allowed to, because it’s called punishment. The powers that be, they see it as punishment, where I work. Being that I come from living a life of doing the wrong thing always, I’m a big believer in consequences. And I believe that if you don’t have any, you continue to do those things. That’s the kind of stuff, the inadequacies where I work at.
JB: What do you like most about your job?
RJ: (pause) The light…. in somebody’s eyes every now and again. It might not happen much, but now and again the light comes on, and you have that “ah ha” moment. They have it, and you’re like, yes! Or when somebody comes and tells you they have that little spark of hope. Yep. That’s what I like most about my job.
JB: If you could make changes in how opioid addiction is treated, what would you do? If you could tell the people who make the drug laws, what would you recommend? How would you change the system, or would you?
RJ: I don’t know that I would change the system. I think the system works. I think it’s individual facilities that don’t work sometimes. Yeah. I think – methadone’s been around a long time – I mean, obviously it’s worked for a lot of years or it wouldn’t still be in existence. I think methadone maintenance programs work, but each individual facility maybe needs to make changes. You know, that’s just my opinion.
JB: If you were the boss of a methadone treatment center, how would you handle benzodiazepine use by patients?
RJ: They wouldn’t be tolerated. At all.
JB: Why is that?
RJ: Because I think they kill people. I know they kill people.
JB: How about alcohol?
RJ: Alcohol wouldn’t be tolerated either. I mean, obviously you would be given a chance to straighten it and rectify it and clean it up, with help, if you need it. But that would be it. You would get that opportunity and then [if the patient couldn’t stop using alcohol] you would be detoxed from that program. I believe that’s the route to go. We’ve had too many deaths. And there’s nothing to say that it’s not going to continue to happen…so, yeah, if I had a facility it would not be tolerated. There would be zero tolerance, period. There just wouldn’t be any.
JB: What do you say to people that say that’s keeping people out of treatment?
RJ: There are other types of treatment; maybe you need a different level of care. Maybe methadone’s not the answer.
JB: So you don’t think methadone’s the answer for every opioid addict?
RJ: No. No I don’t.
JB: What do you think about people on methadone coming to Narcotics Anonymous?
RJ: I think they have a right to come to Narcotics Anonymous.
JB: Do you think they should share?
RJ: I wish they could share, but I know, there again from personal experience, how methadone is viewed by people in Narcotics Anonymous. And I think that if that person does share [that they are on methadone], they are treated differently.
JB: Do you tell your patients to go to NA?
RJ: I do.
JB: What do you tell them about picking up chips?
RJ: That’s their personal call, because I feel like it is. But then I don’t view methadone as using. See, I look at it as treatment, and somebody taking medication because they’re sick, and trying to get better. So I don’t view that as getting up and doing dope. Therefore if I were on methadone and going to meetings, I’d pick up chips.
JB: Can you think of anything else [you’d like to say]?
RJ: I believe in methadone. I really do. I just believe that it works. I know people who have been on our program for twenty years, and granted, those people will never get off methadone, but they have a life today. And twenty years ago they didn’t have one. They’re not perfect but I’m not either, you know, just ‘cause I don’t use dope any more. But they’re still suffering addicts, just like I am. So I just believe that methadone works, and if you want to make changes in your life, that there are people at every facility who are willing to help you make those changes.

Treatment professionals can also make the mistake of dismissing non-medication treatment of opioid addiction as ineffective, when clearly this is not true. Though treatment with methadone and buprenorphine can provide enormous benefit, so can the other medication-free forms of treatment. And as we have seen, methadone can cause great harm when used inappropriately, and some opioid addicts don’t do well on methadone.
There’s no one best treatment path for every addict. Every evidence-based treatment helps some addicts.

Which is better, Suboxone or methadone?

 

Patients often ask which medication is better to treat opioid addiction: methadone or Suboxone? My answer is…it depends.

 First of all, the active drug in Suboxone is buprenorphine, and I’ll refer to the drug by its generic name, since a generic has entered the market. We’re no longer just talking about one name brand.

 The principle behind both methadone and buprenorphine is the same: both are long-acting opioids, meaning they can be dosed once per day. At the proper dose, both medications will keep an opioid addict out of withdrawal for 24 hours or more. This means instead of having to find pain pills or heroin to swallow, snort, or shoot three or four times per day, the addict only has to take one dose of medication. Addicts can get back to a normal lifestyle relatively quickly on either of these medications. Both methadone and buprenorphine are approved by the FDA for the treatment of opioid addiction, and are the only opioids approved for this purpose.

Buprenorphine is safer then methadone, since it’s only a partial opioid. A partial opioid attaches to the opioid receptors in the brain, but only partially activates them. In contrast, methadone attaches to opioid receptors and fully stimulates them, making it a stronger opioid. Because buprenorphine is a partial opioid, it has a ceiling on its opioid effects. Once the dose is raised to around 24mg, more of the medication won’t have any additional effect, due to this ceiling. But with methadone, the full opioid, the higher the dose, the more opioid effect.

 Because buprenorphine is a safer medication, the government allows it to be prescribed in doctors’ offices, but only if the doctor has taken a special training course in opioid addiction and how to prescribe buprenorphine, or can demonstrate experience with the drug. This office-based treatment of addiction has a huge advantage over treatment at a traditional methadone clinic. Treatment in a doctor’s office doesn’t have to follow the strict governmental regulations that a methadone clinic must follow. Methadone clinics have federal, state, and even local regulations they must follow, and patients have to come to the clinic every day for dosing, until a period of months, when take home doses can be started for weekends.

 The law allowing buprenorphine to be prescribed for opioid addicts from offices instead of clinics was passed in 2000. It was hoped that relatively stable opioid addicts would get treatment at doctors’ offices, and addicts with higher severity of addiction would still be treated at methadone clinics.

 But it hasn’t worked out quite like that. Because buprenorphine is relatively much more expensive than methadone, addicts with insurance or money go to buprenorphine doctors’ offices, and poor addicts without insurance go to methadone clinics. Rather than form of treatment being decided by severity of disease, it’s decided by economic circumstance. This means that some of the opioid addicts being treated through doctors’ offices really aren’t that stable, and have been selling their medication, making it a desirable black market drug. Most of the addicts buying illicit buprenorphine have been trying to avoid withdrawal or trying the drug before paying the expense of starting it.

 Treating opioid addicts for the last nine years, I’m continually surprised at how people’s physical reactions to replacement medications are dissimilar. Some patients don’t feel well on buprenorphine, but feel normal on methadone. For other patients, it’s just the opposite. For many, either medication works well.

 Addicts (and their doctors) tend to assume that all opioid addicts will be the same in their physical reactions to these replacement medications, but they aren’t. For example, last week I saw a lady who insisted she’s never had physical withdrawal symptoms from methadone. But most patients find methadone withdrawal to be the worst of all opioids.

 And sometimes I have a patient I expect will do very well on buprenorphine, but they don’t. they feel lousy.

 So the answer to question of which medication is best – buprenorphine is safer, and not as strong an opioid, so it’s the preferred medication. It’s also more convenient, but much more expensive at present. But a great deal depends on the patient, and how she reacts to medications.

 Neither medication is meant to be the only treatment for opioid addiction. Best results are seen when these medications are used along with counseling, to help the addict make necessary life changes.

Twelve step meetings aren’t group therapy.

The Differences Between Group Therapy and 12-step Meetings

 Before I actually went to some open 12-step meetings, I thought they would be like group therapy meetings. However, 12-step meetings have basic differences from group therapy meetings.

 Twelve-step meetings are free. Most group therapy costs some amount of money.

 Members don’t give advice to each other. Or at least, experienced members of Narcotics Anonymous and Alcoholics Anonymous don’t tend to give advice to each other. Instead, members share their own experiences. They tell about what worked for them, and what didn’t work.  The topic is often about how to get through situations without using drugs or alcohol, but may also be about how to live with difficult life situations, and still retain one’s serenity.

 In group therapy, members are encouraged to give advice, or feedback, to other members. Some treatment centers believe that alcoholics and addicts must be confronted, so that denial can be broken through. Twelve-step meetings don’t take this stance. Instead, members offer their own experience, freely and without expectations. It’s a subtle difference, but important. Other 12-step members don’t assume they know what another person should do about life decisions; they simply offer their own experiences.

 In 12-step meetings, there’s no therapist or counselor in charge of the meeting. Instead, there’s a chairperson, a member of the 12-step program who opens and closes the meeting. This person is in charge only in the sense that she guides, rather than controls, the meeting. Some chairpersons guide more than others. For example, some chairpersons will interrupt a member who’s sharing something that can be harmful to the group. This could mean interrupting a “drunkalog” (long pointless sharing that glamorizes drinking or using drugs). Other chairpersons let the meeting run its course, believing that a Higher Power is always in control. The chairperson is responsible for starting and ending the meeting on time.

 No record of attendance is kept at 12-step meetings. A person is considered to be a member of Narcotics Anonymous when that person says they are a member. The only requirement for membership is a desire to stop using drugs.

 Twelve step meetings are held in slightly different ways in different areas of the country. In some places, meetings range from fifty minutes to an hour and a half.  At “speaker” meetings, one person tells their story of addiction and recovery for the whole hour, traditionally telling “what it was like, what happened, and what it’s like now.” At other types of meetings, all persons present are offered a chance to share or pass to the next person. In some meetings, members who wish to share raise their hands and are called on by the meeting chairperson. In group therapy, all members are usually expected to say something during the session, but at NA or AA, no one is coerced to speak.

 I tell my patients about these differences, because many people who really need the guidance and support that 12-step meetings don’t go, because of their mistaken opinions about meetings.

 They think they will be made to speak at an NA or AA meeting, and don’t want to go for that reason. Other patients say if they hear people talking about drugs it will make them want to use drugs. Other people say they “don’t want to hear everybody else’s problems.”

 Problems are shared at meetings, but the emphasis is on solutions. Most good meetings don’t allow the meeting to become a dumping ground for negative experience.  I explain that in most meetings, sharing about specific drugs is discouraged. NA members are encouraged to share about what they are feeling, and what kind of help they need to remain abstinent from all drugs.

 Overall, the mood of 12-step meetings is one of humbleness, where one recovering addict shares what worked for her with the rest of the group, without expectations and with humility. By contrast, in group therapy, feedback or advice is usually given by other group members. But an addict’s tendency with such an approach is to ask, “Who are you to be telling me what to do?” Narcotics Anonymous meetings recognize that advice and feedback often grates on addicts, and their meetings are constructed differently. Other member’s experiences are offered as learning opportunities.

 Twelve step members aren’t perfect, to say the least. Many members are wrestling with serious mental and emotional problems. Sometimes members do lapse into advice-giving and preaching, but nearly always lose this tendency to try to control others as they progress in their own recovery.

 There’s a reason 12-step recovery has been around for seventy-five years. Many other recovery methods have attained a brief popularity, only to fade away within ten or twenty years. Twelve step recovery has helped millions of people worldwide, continues to grow, and will be with us for a long time to come.