- Coke Confounds MMT
- Patients’ Perspective
- From the Editor
- Events to Note
- Current Comments
- Reader Survey Responses
- Where to Get Info
- Case Challenge
Coke Counfounds MMT
“How does one deal with a patient, stabilized on 70 mg/day of methadone, who continues to use cocaine on a regular basis? Should we medically detox the person for failure to abstain from coke per clinic policy, or increase the methadone? Can an increase in methadone dose automatically curtail cocaine use?” A counselor at a New York methadone clinic.
Coexisting dependence on opioids and other substances of abuse (polysubstance abuse) is a frequent problem for methadone maintenance treatment (MMT) programs, as the counselor’s questions above suggest. Unfortunately, according to the State Methadone Maintenance Treatment Guidelines from the Center for Substance Abuse Treatment, research in this area is inadequate and initial hopes that MMT would in itself reduce cocaine use have been abandoned.
Of course, methadone treatment was designed to only control the use of heroin and other opioids. So, developing effective interventions within MMT programs for opioid addicts who are also cocaine-dependent and, who might also have multiple psychological disabilities and social problems has been difficult.
Heroin is a narcotic, while cocaine is a stimulant. Hence, the cravings and effects are quite distinct for each drug.
A heroin addict takes his drug, gets calm, waits a few hours, then takes it again. With cocaine it’s different, as comedian George Carlin once said: “What does cocaine make you feel like? It makes you feel like more cocaine!”
There’s some science behind Carlin’s jest. Researchers have found that cocaine’s half-life is merely about 20 minutes and such rapid clearance encourages its prompt readministration. The pleasurable response experienced after taking cocaine is linked to the release of dopamine in the brain it “primes” the brain’s reward system and the continuous activation of neural pathways leads to intensified cravings for more of the drug.
In short, heroin is like a tall, cold drink which satisfies thirst for a time; whereas cocaine is like salty snacks – take one and you’ll soon be grabbing for more… and more.
Heroin and cocaine counteract each others’ side effects. Heroin “mellows out” cocaine-induced agitation, while cocaine allows the addict to experience opioid euphoria without the “nod.”
Cocaine withdrawal may also produce severe depression. By using heroin to self-medicate such effects, cocaine addicts also develop physiologic dependence on heroin and can greatly benefit from MMT.
Evaluations of MMT programs in the U.S. have discovered a range of 16 percent to 75 percent of patients using cocaine while in methadone treatment. Cocaine use is also a common problem among opioid-dependent patients treated with LAAM (a long-acting opioid agonist), naltrexone (a strong opioid antagonist), or buprenorphine (an opioid agonist).
For many MMT patients, cocaine use represents a continuation of drug abuse that began prior to admission to the program. Unfortunately, in the case of those injecting cocaine, the demonstrated benefit of MMT programs for slowing the spread of AIDS are greatly diminished. Furthermore, remediations of criminal activities otherwise engendered by MMT are lost among those who continue to use cocaine.
The link between heroin and crack cocaine (a smokable form) leading to IV drug injection and possible exposure to AIDS is of great concern. A survey of over 1,200 addicts revealed that crack smokers may turn to heroin injection to ease crack withdrawal.
Cocaine use has increased the number of MMT patients who have failed to comply with clinic rules and, therefore, have been discharged. This circumstance, of course, makes it impossible for methadone programs to treat, let alone rehabilitate, their clients.
Some believe that MMT programs may actually unwittingly promote cocaine use among treated addicts by not providing comprehensive treatments specifically for cocaine use. And since methadone blocks euphoric effects of heroin, but does not prevent patients from getting a cocaine “high,” cocaine becomes all the more appealing for its effects.
Further, it has been suggested that some addicts may use cocaine as a stimulant to self-medicate any sedating effects of methadone, perhaps due to inappropriate methadone dosing. And, patients no longer needing to support an expensive heroin habit, may simply have more money to spend on cocaine.
Insufficient resources, inadequate staff training, and high staff turnover have plagued clinics in their efforts to deal with the cocaine problem among patients. However, while many believe the effectiveness of MMT is proportional to drug abuse counseling and rehabilitative services in addition to the methadone itself, others claim the levels and types of those services appear unlikely to have much of an impact.
It has been recommended that cocaine-using MMT patients be referred to specialized programs for this and other forms of stimulant abuse. However, cost and accessibility concerns have limited such an approach.
Few MMT programs have treatment protocols targeted specifically at patients who abuse both cocaine and opioids, although different behavioral interventions have been reported in this regard:
- contingencies for testing urine more frequently, and confronting patients and staff about cocaine-positive tests;
- methadone detox after continued cocaine abuse;
- rewarding patients with methadone take-homes for not using cocaine;
- stopping methadone take-home privileges;
- lowering methadone doses;
- increasing individual and/or group counseling.
Yet, there is still the question of how effective such measures, some quite draconian in nature, might be for these polyaddicted patients. Studies of the first three interventions listed above have reported some reductions in cocaine use, but those investigations have not been replicated under more rigorous experimental conditions. Furthermore, the sample sizes were small and it is unclear whether the limited successful outcomes were due more to the interventions or to continuously relapsing patients selectively dropping out of the respective programs (and not being included in the statistical analysis).
Other suggested interventions have included:
- cognitive-behavioral therapies focusing on reducing depressive symptoms associated with chronic cocaine use;
- cue extinction approaches targeting the deconditioning of physiological and psychological cravings for cocaine;
- skills training that enhances patientsí abilities to manage stress and anxiety and resolve problems of everyday life to better manage triggers for cocaine relapse.
However, it must be conceded that these behavioral interventions may not work for patients in whom the perceived psychological and physiological rewards of cocaine, especially the powerful attraction of crack cocaine, overshadow the rewards or punishments of the interventions.
Current belief is that contingency contracts and other forms of setting limits on substance abuse behavior should not involve methadone dose levels in a negative sense (e.g., reduction or withdrawal of dose). And, it has been strongly recommended that, in this era of HIV-spectrum disease and multidrug-resistant TB, there are few, if any, compelling reasons to abruptly discharge patients from addiction treatment.
Fairly recent studies within MMT programs at the Narcotic Rehabilitation Center of Mount Sinai Medical Center, Beth Israel Hospital in New York, and the Montefiore Substance Abuse Treatment Program, Bronx, NY assessed various solutions to the cocaine conundrum.The first two centers focused on intensive individual and group therapy approaches, while the third experimented with acupuncture treatments. While all three produced decreases in cocaine positive urine during the studies, it is interesting to note that each approach also experienced a one-third drop out rate of subjects for unexplained reasons. Among patients completing the programs, decreases in the frequency of cocaine use ranged from 33 to 41 percent, and 21 percent of the Mount Sinai group achieved abstinence.
The studies mentioned above looked at treatment modalities for cocaine within the context of MMT programs, but did not elucidate any potential of methadone itself as a factor in reducing cocaine use. Nor did they comment on the efficacy of various methadone doses or program practices on continued drug abuse.
Research in California included 74 cocaine-using MMT patients who were initially maintained on methadone dosages between 30 and 80 mg/day. Slightly over 28 percent ceased cocaine use when their methadone dosages were progressively raised to a maximum of 160 mg/d. The authors noted also that cocaine appeared to accelerate elimination of methadone, since “inadequate methadone serum concentrations” of below 100 ng/ml were found in over 70 percent of subjects. (Concentrations below 200 ng/ml might be expected to produce objective signs of abstinence syndrome.)
It is interesting to observe that the authors concluded from their study that alternative treatments for cocaine abuse in MMT patients must be identified; rather than suggesting raising methadone doses to overcome the serum concentration lowering effect of cocaine.
Other researchers, such as Shinderman and Maxwell of the Center for Addictive Problems in Chicago have observed that clinically determined “high doses” of methadone (ranging up to 580 mg/day depending on individual patient needs) not only greatly increased retention in treatment and opiate cessation, but decreased cocaine use as well.
Protocols for treating polydrug addiction using higher methadone dose levels than previously examined would seem worthy of further clinical research.
No Easy Answers
As one examines the literature to date concerning polydrug abuse among MMT patients it appears the field is still very much in its infancy. Even the results of positive studies are sometimes unimpressive and the dosages of methadone involved are often below what many practitioners today would consider optimal.
In response to this article’s opening query from the MMT counselor: Given the current state of research, medically withdrawing the patient from methadone as punishment for not abstaining from cocaine would seem to serve no purpose other than returning an active addict to the streets and the potential ravages of HIV-TB-Hepatitis, criminality, and socioeconomic impoverishment. Increasing methadone dose could be advantageous if the amount was indeed sufficient to be optimal for that individual patient. And, while such dose adjustment may resolve the opioid problem, long-term cessation of cocaine use might also depend on adjunctive psycho social services and/or other interventions within the context of an enlightened MMT program.
It would certainly be much easier and economical if, as was once widely promulgated, addicts could be simply admonished: “Just say no to drugs!”
The above article was excerpted from a much longer and complete research report “The Cocaine Conundrum & MMT” which includes 27 references. Readers may obtain a free copy by completing the feedback card in this issue and mailing it in.
MMT Advocates Voice Concerns
Without doubt, a focal point of methadone patient advocacy seems to be the National Alliance of Methadone Advocates (NAMA). The organization was formed in 1988 by current and former methadone patients, and professionals who recognized the need for a mechanism whereby patients could voice their concerns and champion their own needs. Membership has grown to over 14,000 members in over 60 affiliate groups representing the 50 United States, including Puerto Rico, and fourteen other countries worldwide.
Joycelyn Woods, NAMA’s New York-based Executive Vice President, observes that professionals and program staff who at first view advocate groups suspiciously often find that such groups can be important assets for the their clinics and make their jobs easier. “Many times, the patient volunteers serving advocate groups put their own treatment on the line for other patients, and their only reward is hard work and the knowledge that they’re making methadone treatment better for us all,” she says.
Woods boils down the challenge facing all advocacy groups to two words: prejudice and stigma. “People do not understand addiction, they think it’s a behavioral problem. Therefore, they also misunderstand methadone treatment,” she says.
Beth Francisco, Executive V.P. of Detroit Organizational Needs in Treatment (DONT), adds: “We need to get people to recognize that addiction is a medical problem and should be treated no differently than any other medical condition. Addicts are immediately judged guilty and have to prove themselves innocent whenever there is a problem, whether it be a dirty urine test or needing an increase in medication. It is assumed the addict wants to get high if they ask for an increase in medication, instead of actually physically needing an increase.”
Katharine Bolton of the Philadelphia Chapter of NAMA believes, “Another challenge is educating patients, the public, and professionals about methadone treatment, which is why our newsletter Methadone Awareness was started over 4 years ago. Our goal is to dispel the myths and rumors that surround MMT, and to give patients a voice and a place to express their thoughts and opinions.”
Another group, ABATE (Advocates for the Betterment of Addiction Treatment and Education) is concerned with all treatment modalities and choices, but methadone is a high priority because it is so misunderstood and unfairly criticized in spite of its obvious benefits and positive results. According to co-founder Anthony Scro, a critical ABATE objective is bridging the gaps among the major treatment modalities by uniting those persons who have benefited from the different therapeutic approaches.
The ABATE message is very clear, Scro says, “anything (attitudes, practices, philosophies, etc.) that divides or polarizes treatment professionals hurts patients and their families. However, our greatest challenge is helping organize recovering people and their supporters into a national political force which will get the attention of and demand changes from local, state, and federal political leaders.”
Jessica Durnin, President of B.A.M. (Baltimore. Advocates for Methadone) faces the challenge of programs in her area not being allowed to open due to community opposition. Her group has written letters to local newspapers, which have subsequently run articles on the issues.
In another part of the country, Robin Robinette, Acting Director of Tennessee Methadone Advocates Coalition, is dealing with a one year moratorium on new clinic licensing while methadone regulations are rewritten by the State Legislature.
Similar challenges are experienced outside the U.S. According to Joergen Kjaer, Vice President, Danish Drugsusers Union (Brugerforeningen), “Our volunteers are working to eliminate discrimination against methadone patients and make methadone maintenance accepted by all people. Also we are working to help preserve patients’ dignity and rights.”
Each group advocates for patients in its own way. Some are very local in scope, focusing on a particular clinic, while others have a broader reach. Many have also organized special services for members.
NAMA emphasizes education, with its newsletter, the Ombudsman, and well-researched special reports on various topics. “However, the first group that needs to be educated are methadone patients themselves,” Woods stresses. “Many patients don’t understand why they’re taking methadone. They think it’s just another addictive drug, and so they feel bad about themselves and about their medication. How can you expect patients to recover when they still think of themselves as ‘just an addict’?”
Francisco says, “Through our newsletter, Methadone Today, and communication with clinic staff, we try to change the closed-minds and misinformation held by many employees, from counselors to doctors. Many counselors seem to think they must get patients to withdraw from methadone or lower their dose even though the patients insist they are not ready some patients may never be ready. We supply patients with knowledge so that the clinic staff can no longer respond to their requests and concerns with the worn-out answer, ‘that’s federal regulations.'”
“Through our web page and local members we are gathering and analyzing feedback from those concerned about the very dangerous trends taking place in this country against addicts and their families,” notes ABATE’s Scro. “High on our agenda is organizing a National Advocacy Leadership Conference bringing together all the responsible resources in the field to make a powerful statement that we are all together in this battle against the number one public health problem in this country, drug addiction. We want governmental policies/strategies on drugs to reflect the input of those whose lives may be most affected by proposed changes.”
ABATE has supported the integration of methadone treatment and the fellowship movement by promoting the expansion of MA (Methadone Anonymous or Awareness) groups in local clinics. Additionally, Scro says his group has advocated for methadone patients who have been unfairly treated or denied due process by healthcare providers or human services agencies.
In the Pacific Northwest, Ed Barios, Secretary of SOMA (Southern Oregon Methadone Advocacy), says, “We continue to have advocacy meetings that include clinic staff members, when appropriate, to work out grievances patients may have. SOMA members also participate in ‘harm reduction’ events, some participating as presenters where law enforcement and policy makers are present.”
Members of the SOMA advocacy committee accompany patients, who may not be articulate or get nervous, to clinic staffing meetings. “In this way, we’ve been able to help individual patients and the overall patient population.” Barios observes. “The director of our clinic even reviewed the patient handbook with us, and accepted our input for helping explain the philosophies behind certain decisions and policies. This led to much better working relationships all around.”
In Denmark, Kjaer’s group has a cafe and organizes sports and cultural activities. “All work is performed free by drug users, and we are working on opening more local chapters around Denmark beyond the five we now have,” he says. “We’re also lecturing to young people on drug problems and appearing at harm reduction events.”
According to Woods, other NAMA affiliates have established methadone information libraries available to patients and professionals, organized holiday parties for children of patients, lobbied state agencies to save their clinics, and one group even opened its own clinic when the original provider was shut down by authorities.
Message To Washington
A.T. Forum asked the advocate group leaders what message they’d most like to send to key policy makers and legislators. Here are a few of their responses:
Francisco “Regulations are too stringent, especially for long-term patients who have clean urines, stable lives, and are productive citizens. For these patients, forced counseling is not productive and merely a waste of time. There should be a 2-week take-home schedule for some people, and medical maintenance for others. It is counterproductive and expensive to tie older, long-term patients to the clinic.”
Bolton ”Methadone treatment needs to be made more available and the regulations relaxed. There needs to be more clinics opened; amazingly, there are still some states that do not have any MMT clinics!”
Scro “I’d advise policy makers to follow their own recommendations. For example, the 1994 federal Institute of Medicine (IOM) Report was very clear about the value of methadone as an effective treatment protocol and as a valuable HIV/AIDS prevention tool. How many of those very reasonable recommendations [in the Report] have been implemented?”
Robinette “To NIDA, CSAT, and the other federal agencies: Please use your influence to educate state policy makers! We can’t do it alone. How about instituting federal clinics so that capricious state regulations can be by-passed and effective treatment be made available. Thanks for such great research… now lets put more of it into action.”
Durnin “We [methadone patients] are people. We are people who have a medical problem for which we take medication. That medication is methadone and it has helped countless addicts to get their lives back. We have rights and we are tired of being treated like children and/or criminals.”
From the Editor
The 18th Century Venetian adventurer, philanderer, and alchemist Giovanni Jacopo Casanova de Seingalt reputedly said, “In the hands of the wise, poison is medicine. In the hands of a fool, medicine is poison.”
And, although cocaine was not part of Casanovaís infamous repertoire, the drug has enjoyed a mixed reputation as both the medicine and poison of which he spoke.
Cocaine is also somewhat of a plague tormenting methadone maintenance treatment (MMT) programs.
Cocaine has an interesting background in the pharmacopeia of professional and more questionable practitioners.
During the 1880s, patent medicine companies promoted nostrums made of menthol, sugar, milk, and cocaine guaranteed to cure coughs, pains, warts, and many other ills. As late as 1900, cocaine was still an ingredient of Coca Cola.
In 1884, New York surgeon William Stewart Halsted injected a patient with cocaine, pioneering the practice of local anesthesia. However, during his experiments, Halsted also became addicted to the drug and later substituted morphine to overcome this dependency.
Medicinal cocaine has survived as a useful anesthesia for numbing membranes of the eyes, nose, and throat. The drug also serves a humane function as a component of TAC solutions (Tetracaine, Adrenaline, Cocaine) used as a topical anesthesia, especially in children, without the need for painful injection.
Passions for Poison
The mood altering, some would say mind-poisoning, effects of cocaine have long been recognized and pursued. In reaction, the Harrison Act of 1914 placed cocaine under legal restriction, erroneously classifying the stimulant as a narcotic. However, this did little to eradicate the passion addicts have shown for the drug over the years.
The latest infatuation is with “crack,” a solidified form of free base cocaine. Although the formulation can be traced to the 1970s, it wasn’t until the late ’80s that crack became an important part of the American drug scene.
As of 1990, there were reportedly up to three million frequent cocaine users, including 600,000 youngsters between age 12 and 17 hooked on crack. Its popularity has continued to the present day and cocaine, in one form or another, is often an accompaniment of opioid addiction among patients entering MMT programs.
The dilemma of dealing with cocaine-dependent opioid addicts within MMT programs is the subject of a featured article in this issue of A.T. Forum. It was excerpted from a more comprehensive research report “The Cocaine Conundrum & MMT” which includes extensive references. Readers may obtain a free copy by completing the feedback card in this issue and sending it in.
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Stewart B. Leavitt, PhD, Editor
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