Opiate Addiction

"NOT ENOUGH HELP FOR THOSE BATTLING DRUG ADDICTION"

2009-11-19T11:35:00.003-05:00

That's the heading of a reader letter to the Kennebec Journal Morning Sentinel (Nov 15). The writer mentions, as an illustration of the inadequacy of services, a three-month wait for admission to the methadone clinic in Waterville, Me., and notes that lack of prompt access to care also is a catastrophe for the community that bears the crime and fear that go along with untreated dependence.

But it need not be this way. There is no reason why applicants for methadone treatment, in particular, must be forced to remain on a waiting list for 3 months - as is said to be the case in Waterville.

Earlier this year, just a few hundred miles to the northeast, in St. John, NB, rapid expansion of methadone treatment was accomplished almost overnight and waiting lists eliminated in a matter of a few months. (SEE POSTING). All that's required is commitment.

DRUG TESTING IN SCHOOL AND WORKPLACE

2009-11-12T10:11:00.002-05:00

Recommendations of Expert Committee of Council of Europe. The Expert Committee, reporting in March, 2008, noted that pursuant to the European Convention on Human Rights “… no public authority or private individual has any right to impose on anyone’s private or family life, and even less so to carry out or order drug testing in anyone.” The exceptions are narrowly defined as law enforcement agents acting with explicit legal authority, and “certain health professionals, to the exact extent that obtaining this confidential information is essential … in their patients’ interests…”

With regard to schools, the Committee not only determined that drug testing is ineffective as a deterrent to substance misuse, but concluded that it interferes with monitoring by parents and educators of children’s “emotional, social and intellectual development through dialogue based on trust… [and] undermines the pupil-teacher relationship and the psycho-social climate … which have been proven to have a protective function.” We would note that the same impediments exist in an addiction treatment setting to a “dialogue based on trust” and to the relationship between clinician and patient.

Bottom line: “… [drug] testing procedures in schools or the workplace pose an ethical problem founded on international, universal and absolute rights. It would be appropriate to take steps to prohibit such procedures and to seek to achieve the same ends by means that show greater respect for privacy, family life and the fundamental rights of every individual …”

Full report available at: https://wcd.coe.int/ViewDoc.jsp?id=1279817&Site=DG3

THE EPITOME OF MISUNDERSTANDING:

2009-11-09T11:03:00.002-05:00

The epitome of misunderstanding of methadone treatment in, of all places, the Wall Street Journal of Nov. 9. An article cites a financial guru as comparing the "... recent central-bank stimulus with methadone: unavoidable, perhaps, but putting off a cure until later." Nothing better denotes the (decidedly negative!) popular view of this uniquely effective form of care of opiate dependence. Imagine postulating that chemotherapy puts off a cure for cancer, or L-dopa puts off a cure for Parkinson's, or... Advocates and providers of methadone treatment have a long, long way to go in their efforts to educate the general public.

LOCAL RESIDENTS TURN OUT TO BLOCK MMT FACILITY

2009-10-08T11:10:00.001-04:00

Local residents turned out to vigorously support a zoning rule designed to preclude facilities that would provide methadone maintenance treatment. The current ordinance requires that "the distance from another developer has to be 1000 feet, and the distance from a playground, school, licensed bar, nursing home, is a half mile." An attorney for the corporation that wishes to open a clinic in the Keystone Industrial Park noted, "There is not a single location in Dunmore that would meet those requirements.”

It would seem a tossup which perceived threat is more ridiculous – that to playgrounds, or to schools, or to bars or to nursing homes.

For the full story (dated Oct 6) click here.

“YOUNG AND SUBURBAN, AND FALLING FOR HEROIN”

2009-10-07T16:00:00.001-04:00

On September 27, 2009 The NY Times headlined: “Young and Suburban, and Falling for Heroin.” According to the article, “… officials across the New York region are grappling to understand” the devastating resurgence of heroin use in suburban America (and surely throughout the land), one conclusion seems inescapable: America ’s decades-old policy of absolute prohibition, and the overwhelming focus of Government on supply rather than demand, have been a disastrous failure. The cost of this failure is measured not only in hundreds of billions of dollars, but in the increasing toll of lost lives, including the 25 heroin overdoses in Nassau County alone in the first six months of this year. It is incredible – and irresponsible – that no one seems to be considering alternatives to this deadly, failed strategy.

To read the article, click here.

COST OF WAR ON DRUGS - AN AUSTRALIAN PERSPECTIVE:

2009-10-05T14:00:00.001-04:00

This headline appeared in Sydney Morning Herald 3 Oct. The conclusion that Australia would save almost $Au5 billion ($US4.2 billion) "if illicit drug sales were regulated and taxed the way tobacco is" rests on a number of assumptions that are less than rock solid. What is of note, however, is the statement attributed to an economist with the Australia-based policy institute Centre for Independent Studies, John Humphrey: "It gets interesting when you try to do a cost-benefit analysis on the prohibition [of drugs]. Basically, there aren't any benefits." Food for thought - in Australia and everywhere else! For the Full article

THE BLURRED LINE BETWEEN LAW ENFORCEMENT AND HEALTH CARE:

2009-10-05T12:28:00.003-04:00

From Pain-Topics.Org News, Oct 3, some observations regarding the DEA and opioid prescribing: “Involvement of the U.S. Drug Enforcement Administration (DEA) in the FDA’s plans for an opioid-REMS (Risk Evaluation and Mitigation Strategy) initiative is still unknown. However, if what is happening with the prescribing of buprenorphine is any example, practitioners prescribing opioids for pain may be headed for considerable aggravation in the name of “regulatory responsibility. … While the vast majority of buprenorphine prescribers would probably have nothing to fear from DEA inspections, healthcare providers are understandably loathe to have government agencies scrutinizing their practices for any reason. Many will no doubt opt out of the buprenorphine program. Is this what the future might hold in store for opioid analgesics under REMS initiatives?” For Full story.

PROPOSED RULE AMENDS FEDERAL OPIOID TREATMENT PROGRAM REGULATIONS REGARDING DISPENSING OF BUPRENORPHINE

2009-09-28T14:53:00.002-04:00

The Substance Abuse and Mental Health Services Administration (SAMHSA) requested comments on the proposed rule ammendment regarding the Federal OTPs dispensing requirements for buprenorphine and combination products. My comments are outlined below.

“Opioid Drugs in Maintenance and Detoxification Treatment of Opiate Addiction; Buprenorphine and Buprenorphine Combination; Approved Opioid Treatment Medications Use”

Current regulations demand of all patients receiving buprenorphine in OTPs (Outpatient Treatment Program) daily attendance for several months followed by rigidly defined criteria for less frequent visits thereafter. In marked contrast, patients receiving buprenorphine outside an OTP setting can receive at the first physician visit a prescription to be filled at any pharmacy for a month’s supply of the medication. The proposed rule-making change eliminates this arbitrary and unwarranted disparity by providing that precisely the same flexibility will apply to OTPs as has governed “waivered” physicians for several years; it is to be welcomed!

The proposed regulatory change, however, is exceedingly narrow in scope, focusing exclusively on the administration, dispensing and prescribing of buprenorphine. In stressing that buprenorphine providers and patients in OTPs shall be obliged to “adhere to all other Federal treatment standards established for methadone” the proposed rule-making notice calls attention to these “other standards,” and they demand comment. To say they are extraordinary would be an understatement; they would appear to be unique in American medicine.

For complete comments click here .

NIMBY IN CANADA:

2009-09-28T10:15:00.003-04:00

A tale of 2 cities: two stories on 23 Sept, one from Bracerbriudge, 120 miles north of Toronto, the other from Oakville, 20 miles southwest of Toronto. The former: reportedly very favorable response to news of a new methadone clinic to open in a mall. The manager of a store next door to the site is quoted as saying, “I don’t have any concerns about it. We need places like that. People need help.” And a local outreach and support organization promised to provide its services “in any way we can.”

On the other hand, the site in which a new clinic is expected to open in Oakville generated major opposition. “It’s the right business, but the wrong location.” The President of a local Residents’ Association worried because “When my daughter goes down to catch the bus at 8AM, there may be people lining up before the clinic opens.” According to her, “There’s got to be somewhere better.”

Bracebridge story

Oakville article

UK EXPERTS CALL FOR NATIONAL NETWORK OF 'SHOOTING GALLERIES' AFTER HAILING SUCCESSFUL TRIALS:

2009-09-14T10:03:00.001-04:00

“A group of government-appointed drug experts will call for a nationwide network of ‘shooting galleries’ to provide injectable heroin for hardened drug addicts across the country. A pioneering trial programme prescribing heroin to long-term addicts has shown ‘major benefits; in cutting crime and reducing street sales of drugs.” A positive accompanying editorial was headlined, “An injection of common sense.” Full story in the Independent (London)

ANTIDEPRESSANT MEDICATION DURING PREGNANCY:

2009-09-11T14:22:00.001-04:00

A just published article (Clin OBGYN, 52(3):469-482) concludes: "The decision to expose the fetus to anti-depressant medication during pregnancy must be weighed against the risks of untreated maternal depression to both mother and fetus." Precisely the same orientation should apply to treatment of opioid dependent pregnant women, but in those cases all too many judges and probation officers and child welcome authorities and others (including some physicians!!!!) have only one position: JUST SAY NO TO METHADONE!

PERCEPTIONS OF METHADONE TREATMENT FROM AN IRISH GP:

2009-09-11T14:19:00.001-04:00

In the Irish Medical Times, 9/9/09, a GP, Dr. Cathal O’Sullivan, notes the absurdity of the officially recommended Irish urine toxicology schedule – "at least once weekly" for a total annual cost of approximately $US 10 million.

Some of Dr. O'Sullivan's other observations:
“Relatively new to the drug treatment world, I was struck by the difference in the relationship between the patients and the treatment service and the staff, including doctors, who were treating them. Supervised collection of urine samples seemed to me, at the very least, an undignified process, both for the patient and the person supervising the sample collection. Even the language used around urinalysis was different. Positive opiate tests were called ‘dirty’, negative were ‘clean’. One can still hear doctors working in the addiction service today, referring to a patient, say, ‘he’s dirty this week’. Raised a strict Freudian, I found this very strange (but very interesting).”

Most significant is his summation: “Compared to patients in general practice, where I had worked for the previous twenty years, drug users were seen and treated as a completely different category of customer. They were considered to be inherently untrustworthy, and incapable of telling the truth about their drug use.”

The same must be said of methadone treatment in the US and many other countries.

For Full article

TO THOSE WHO WOULD CRITICIZE SEMANTICS...

2009-08-28T10:31:00.001-04:00

Especially in the US, advocates of methadone (and buprenorphine) maintenance treatment express outrage over the word “substitution”! It would seem more productive if they focused their attention on acts, rather than on words. Thus, one of the oldest and most effective self-help and advocacy groups in Germany calls itself (itself!) JES...“Junkies, ex-junkies, and those being substituted.” And what have they and allies accomplished? First, there are over 70,000 patients receiving “substitution” with methadone in Germany - hardly 20 years earlier there were none; no one group or individual can claim the credit, but JES has been a critical voice. Also, this year on July 21 the 11th national “memorial day in tribute to the victims of the drug war” was marked in dozens of cities, large and small, throughout the country. A journal (cover image shown here) put out jointly by JES, parents’ groups and “German-AIDS Help” gave the highlights of the day for many of these cities. A case in point: Recklinghausen – “the 60th largest city in Germany”, describes its treatment efforts as follows: SUBSTITUTE FOR DRUGS - dependent patients participate in the substitution program and thereby avoid the possibility of death.”

Critics, and especially American critics, of the label German drug users and former users adopt for themselves should reflect on the situation at home: can anyone imagine a large public demonstration in America honoring the memory of victims of the drug war? Let alone dozens of such demonstrations coordinated throughout the US? Would anyone deign to condemn a group as courageous and effective as JES because of the name it uses - proudly and unapologetically - to define itself and its members?

ADDICTION TO NICOTINE - SOME PARALLELS TO NARCOTIC ADDICTION:

2009-08-27T15:19:00.000-04:00

An article in the current issue of Lancet by JD Pollack and colleagues notes that of the estimated 45 million American smokers, over 43% had tried to quit during the past 12 months. Of those who tried to quit on their own, 80% relapsed within one month and only 3% were abstinent at 6 months. The results were better with pharmacotherapy, but "only 15-35% ... were able to remain abstinent for more than a year." Interestingly, there is no mention of anything less than total smoking abstinence - smokers who cut down from, say, two packs a day to five cigarettes apparently were not distinguished from those who never cut down consumption at all.

SCOTLAND DISCOVERS ADDICTION CAN BE FATAL:

2009-08-27T15:17:00.001-04:00

An Aug 12 article in the Guardian headlined: "Scottish drug deaths reach record levels." It would almost appear that Scotland has just now discovered what the world has known for decades: addiction is a chronic, notoriously relapsing, medical condition that often has a tragic, deadly end. What it seems not to have understood is that addiction is eminently treatable but – to date – incurable. Failure to accept this reality with regard to drug dependence is surprising, since “treatable but incurable” has for well over a half-century been the near-universal axiom governing the approach to the related condition of alcoholism.

And yet, critics rail against what they see as "excessive" numbers of patients receiving methadone treatment in Scotland, and damn methadone providers because reportedly only 3% manage to achieve a lasting abstinence. The article quotes the Torie view that “…the SNP are losing the battle against illegal drugs;” to the extent this is the case, it would reflect the fact that there are too few addicts in treatment, and not too many!

HEROIN TRIAL RESULTS - SO MUCH FOR THE IMPACT OF EVIDENCE:

2009-08-26T21:18:00.000-04:00

The Globe and Mail ( Canada ) of August 22: “The Quebec government's decision to cut $600,000 in funding from a study that would give heroin to hard-core drug addicts jeopardizes research into the controversial treatment that would have been a worldwide first. Doctors involved say they're baffled by the decision, which came to light the same week research from a separate study was published that said giving heroin to people with entrenched addictions was far more effective than administering methadone. . . . The Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) would have been the first in the world to compare the effectiveness of medically prescribed heroin against Hydromorphone, a licensed narcotic and whether users will accept the drug in pill form instead of injecting it.” Full story click here.

PROFIT AND MMT

2009-08-24T23:34:00.001-04:00

An article in the Chicago Tribune (August 16, 2009) quoted a Drug Enforcement Administration official expressing concern "... when the motive for treatment is profit," with no evidence to suggest any difference in quality of care. And this at a time when many Americans are expressing their fear and fury over proposals to include a government option for health insurance, to be available alongside those offered by a host of (extremely profitable!) insurance companies!

When it comes to treatment of addiction private facilities are helping to fill the unconscionable void resulting from woefully inadequate services of the Government and voluntary sectors. Their role in lessening demand for illicit drugs is an indispensable component of the nation's efforts to address the problem of drugs in America. No one should know this better than law enforcement officials.

MARIJUANA IN NYC: TWO FACTS

2009-08-12T10:28:00.003-04:00

Fact 1: In NYC marijuana possession has been decriminalized since 1977; one can be given a ticket and fined $100, but no fingerprinting and no jail.

Fact 2: Since 1997 430,000 arrests have been made by the NYPD for possession of small amounts of marijuana; in 2008 alone there were 40,300 such arrests – over 100 a day, every day.

To understand what explains this apparent dichotomy check out an
article by Harry Levine, posted Aug 10 on AlterNet.

MASS EXECUTIONS IN IRAN:

2009-08-07T09:31:00.000-04:00

That's the headline of a joint report of Austrian Presse Agentur and Agence France Presse based on a story in the "reform newspaper", Etemad. It is stated that on 30 July there were 24 hangings for alleged "drug trafficking" in a single day in a prison near the capital. The same prison was the site of 20 hangings earlier in the month, and since the beginning of the year the number of executions in Iran is said to be 219, though Amnesty International puts the total at 246. Human rights activists say that opponents of the regime are being charged with drugs offenses and sentenced to death.
Full APA/AFP report (in German) click here.
(Thanks to our colleague Prof. G. Fischer in Vienna for forwarding this article.)

FROM LONG ISLAND TO IRELAND EXPANSION OF TREATMENT IS NEEDED

2009-08-05T09:37:00.000-04:00

The following Letters to the Editor by Dr. Newman was recently published

Addiction treatment delays are deplorable (Irish Examiner, August 4, 2009)

It is simply irrational to force those wanting to give up their illicit opiate habits to wait two years or more for treatment proven in Ireland and around the world to be enormously effective. Countries as divergent as Germany , Hong Kong, the US and, most recently, Iran and China have been able to achieve massive expansion of services almost from one year to the next.

The only prerequisite has been commitment.

It reflects a perverted sense of priorities when government agencies and committees debate strategies for increasing the "monitoring" of patients who, as you report, may have been in treatment 10 years or more, while continuing to ignore those who are being abandoned by shortsighted policies and practices that tolerate - indeed, ensure - multi-year waiting lists. Not only drug-users but the nation as a whole deserve better.

Robert Newman MD, MPH

Newsday --Letters to the editor, August 2, 2009

Get help for heroin Newsday reported in separate articles on July 24: "Drug deaths up in Nassau " and "Heroin fight: It's just 'everywhere'; 110 nabbed in coordinated raids over 4 months in Suffolk ."

Law enforcement efforts have never made a significant impact on use of heroin or the death rate with which it is associated. For decades it's been documented that heroin addiction is a medical condition that can be treated.

When is the last time anyone heard a public service announcement in Nassau or Suffolk urging those who desperately need help to get it? It is irresponsible - and inexcusable - that treatment services either are unavailable, or are being kept secret.

Robert Newman

DEA "MONITORING" OF BUPRENORPHINE-WAIVERED PHYSICIANS:

2009-07-31T10:59:00.000-04:00

From the Am Soc Addict Med comes this notice:

"It appears the DEA plans to increase its efforts to monitor physician prescribing [of buprenorphine] under DATA 2000." To let docs know what's in store for them, ASAM comments as follows on past DEA "monitoring" - "Investigations usually last one to two hours . . . [and] In 52% of the 425 physicians inspected up to 12/07, no problems were noted. . . " One can imagine the eagerness with which physicians will be seeking to exercise their "waivers" to treat opiate addicts, and the demand by other prqctitioners to join the ranks of those who enjoy the privilege of prescribing buprenorphine!

COULD THERE BE AN AFGHANI POPPY GROWERS’ LOBBYIST IN WASHINGTON?

2009-07-31T10:57:00.000-04:00

According to Join Together (30 July), “… the Obama administration is considering paying local farmers to cease planting poppies, the Associated Press reported July 21”. The possible influence of powerful lobbyists is one of the more generous possible explanations. Regardless how many hundreds of millions of US taxpayer dollars are given to Afghan farmers, can anyone doubt how they will respond when the Taliban make them “an offer they can’t refuse,” offering MORE money with one hand, and holding an AK-47 in the other? Scary! The Join Together story

TRAGEDY OF INACCESSIBLE AND/OR IRRATIONAL TREATMENT OPTIONS FOR ADDICTS:HUGE “REWARDS” WON’T WIN THE DRUG WAR

2009-07-29T10:15:00.000-04:00

Miami Herald on 20 July reported that the US is offering $50 million in rewards for information leading to the arrest of “10 top Mexican drug suspects.” Does anyone believe that even if this phenomenally generous reward (paid for by US taxpayers) leads to the arrest and conviction of these bad guys it would have the slightest impact on availability of drugs in our streets or the number of American drug users? The money would be far better spent supporting treatment for the many drug-dependent Americans who need and desperately want help.
Click to Read the Article

FACTORS ASSOCIATED WITH BUPRENORPHINE VS METHADONE FOR OPIATE DEPENDENCE:

2009-07-28T22:18:00.002-04:00

A UK study has just appeared that assesses factors involved with the choice of opiates for maintenance and detoxification. Although both providers and patients are said to contribute to the decision, a stated preference for buprenorphine was more likely to be honored than a preference for methadone. In any event, patients generally rated the medication they received in this study as the “most helpful” in their previous treatment experiences. The authors’ conclusion: “The results . . . suggest that patient preferences and beliefs about opioid agonist treatments can serve as important influences upon clinical prescribing practices.” And indeed, they should; in the absence of data allowing reliable predictions regarding which patients might expect to do better with one or another opioid medication, one must wonder why patient preference is not always respected.

Article: Ridge G et al. J Subst Ab Treatm 37 (2009) 95-100.

IGNORING EXPERIENCE - REPEATING FAILURE: ILLUSTRATION FROM ITALY:

2009-07-27T09:56:00.001-04:00

In 2006 a bill known as the Fini-Giovanardi Law was passed in Italy, “heralding the mass criminalization of drug users in spite of the success of a 1993 referendum to de-penalize the personal use of drugs.” The result: in less than three years prison overcrowding has reached record levels – some 40% above official “capacity”. There has been a 7.45% increase in arrests, and/but “confiscation of drugs has fallen by 10.5%.” The estimate of addicts behind bars in Italy has risen from 8,363 in December 2006, to 14,743 by Jan 30, 2008. When will they ever learn...
Full story (in Italian)