A.T.F. Volume X #4 Fall 2001
Disease in MMT : Part 1 - Critical Concerns
- Cardiovascular Health in MMT Patients
From the Editor
- New Visions for the 21st Century
Where to get
- MMT Attitudes
Disease in MMT: Part 1 - Critical Concerns
The epidemic of
liver disease in methadone maintenance treatment (MMT) programs, lurking
like a massive iceberg with only its tip exposed to public view, has
been noted before in AT Forum.[1,2]
Former intravenous (IV) drug addicted persons may harbor several types
of hepatitis: A, B, C, and D. Hepatitis C (HCV) is perhaps the greatest
threat, since most persons who contract it go on to develop chronic
illness. Liver failure due to HCV results in up to 10,000 deaths annually
in the United States and is the leading cause of liver transplantation
An emerging life or death issue is refusal on the parts of many medical
specialists to treat liver disorders in MMT patients and/or to allow
those patients on transplant waiting lists. A critical focal point of
this controversy is methadone itself.[4,5]
Medical, ethical, legal, and economic concerns have arisen. This article
is the first in a series focusing on those issues and on some possible
Hepatitis C (HCV) is a blood-borne virus affecting approximately 4 million
Americans, the majority being past or present illicit IV-drug users.
This group represents the greatest proportion of new infections each
year and the largest pool of persons eventually needing liver transplantation.
HCV causes inflammation of the liver that can lead to scarring and failing
liver function. At later stages, HCV can cause cirrhosis, in which the
liver is scarred throughout and there is the risk of complete liver
failure (end-stage liver disease).
Based on a synthesis of statistics reported in the literature,[6-9]
roughly 90 of every 100 injection-drug users entering MMT programs are
likely to be infected with HCV. Only 14 of those patients will recover
from HCV on their own; the remaining 76 will probably develop chronic
disease unless they receive successful treatment. There is no way of
predicting who will recover without treatment.
Even with treatment, about 17 of those initial 100 MMT patients will
go on to develop cirrhosis and 8 will require a liver transplant for
survival. Although treatments for HCV have been improving, there could
be as many as 14,000 current MMT patients in America eventually needing
From Bad to Worse
Unfortunately, last year there were only about 5,000 liver transplants
performed in 122 transplant centers across the U.S. As of September
2001, there were nearly 18,500 persons on waiting lists for liver transplants.
So, in the best of circumstances, less than a third of those on wait-lists
receive new livers.
Since 1988, only an estimated 180 MMT patients have had liver transplants;
less than 0.5% of the 40,468 procedures performed. Today, there are
merely an estimated 102 MMT patients on waiting lists, or 0.6% of the
Making matters worse, the MMT population is aging. Many patients who
contracted HCV years ago are at stages in their illness where treatment
or transplant is a do or die situation.
A majority of illicit IV-drug users with HCV may be coinfected with
HIV, which greatly accelerates the devastation of HCV. As an emerging
problem, coinfected persons are facing insurmountable obstacles to treatment
or transplant for their liver disease. Furthermore, many MMT patients
also use excessive alcohol, which compounds cirrhosis and related complications
in those with HCV.
Tragically, there has been an irrational withholding or delaying of
available treatments for hepatitis in MMT patients and/or their rejection
by liver transplant programs.
On the basis of recommended guidelines from consensus conferences held
in the United States, Canada, and Europe, most specialists refuse to
administer antiviral HCV treatment until all illicit-drug use has ceased
for a period of time usually 6 months. Some practitioners also
require abstinence from methadone.
In actuality, these guidelines provided little explanation or justification
for those practices, have been largely misinterpreted, and say nothing
A more recent guideline on HCV management from the National Institute
of Diabetes and Digestive and Kidney Diseases (NIDDK) specifically states,
Patients can be successfully treated while on methadone.
This message has been largely overlooked by liver treatment specialists.
According to Diana Sylvestre, MD Executive Director of O.A.S.I.S.-Abuse
(Organization to Achieve Solutions in Substance Abuse) in Oakland, California
the most serious impediment may be stigma, prejudice, and misinformation
surrounding addiction and MMT. Her nonprofit clinic specializes in serving
patients with HCV, particularly referrals from MMT clinics, in the San
Francisco Bay Area.
A physician can state a lot of reasons for not treating HCV in
MMT patients, she says, but it often comes down to prejudice.
Superficially, the reason usually seems justifiable, since there are
so many potential barriers to treating HCV in MMT patients that a rationale
can usually be derived for denial of treatment.
In general, some authors have noted that up to 36% of all HCV-infected
patients never receive antiviral treatment, and this proportion is
greater in addiction treatment populations. Sylvestre observes that,
of approximately 850 HCV-diagnosed patients seen at her clinic, only
100 have received treatment to date.
Treatment is legitimately delayed in some patients because they have
active psychiatric disease, an unstable family or job situation, or
a medical condition needing more immediate attention. However, Sylvestre
works closely with these patients to remove the barriers to successful
It also has been suggested that patients at very early stages of HCV
may not benefit from treating the disease. However, a new study from
Germany reported that the HCV virus became undetectable in 98% of patients
treated within 3-months of becoming infected.
Sylvestre points out that it is very difficult to identify acute HCV
infections in opioid-addicted persons, since at the time of infection
they are rarely attending to their medical needs. Furthermore, her experience
has been that if the person is still injecting illicit drugs there will
be extremely poor response, if any, to antiviral treatment for HCV.
With transplantable livers in such short supply, transplant programs
jealously guard each place on their waiting lists. Only those candidates
considered most likely to achieve long-term survival with a new liver
Many liver transplant centers, while claiming to evaluate patients on
an individual basis, will consider only those MMT patients who withdraw
Relatively recent survey results, encompassing 90% of liver transplant
programs, depict severe discrimination against patients taking methadone.
The authors found that 44% of the programs denied acceptance of MMT
patients on their waiting lists and nearly a third of those that did
accept MMT patients required withdrawal from methadone. Essentially,
62% of liver transplant programs prohibited methadone in one way or
Sylvestre referred a male MMT patient with advanced cirrhosis to a major
west coast transplant center for evaluation. They insisted he first
withdraw from methadone, although the patient was otherwise qualified
for a transplant.
Due to the stress of withdrawal the man experienced upper gastrointestinal
complications, including bleeding esophageal varices. The man continued
methadone withdrawal to receive a liver transplant and eventually died
from a variceal bleeding crisis.
Ellen Weber, JD, Senior Vice President of the Legal Action Center (LAC)
in Washington DC, tells of a female MMT patient who was listed for a
liver transplant at a center in Maryland. However, when she moved to
Florida, the local transplant center refused to even evaluate the woman
as long as she was on methadone. The woman chose to remain in MMT and
her liver disease has progressed to the point that she is currently
in a nursing home.
To date, there has been very little research on liver transplant outcomes
in opioid-dependent persons or those maintained on methadone. In
particular, there is no scientific evidence to support discontinuing
methadone as a requirement for liver transplantation. In catch-22
fashion, such a requirement may induce relapse in formerly stable patients
and, because of this, would disqualify them from transplant.
Another absurdity, described by Sylvestre, is that the California Medicaid
program Medi-Cal will pay for medications and office visits
if the person has a recognized disability. Unfortunately, the criteria
for being classified as disabled on the basis of HCV requires evidence
of decompensated (very severe) liver disease that, under most circumstances,
precludes treatment with medication; a transplant would be needed. This
results in a very large population with treatable HCV in her clinic
that does not qualify for financial assistance.
In one case, Sylvestre was successful in getting a patient wait-listed
for a liver at an enlightened transplant center. However, Medi-Cal authorities
insisted that the patient withdraw from methadone before transplant.
She says those authorities have not been able to provide any medical
rationale for this requirement.
Is there a remedy in law?
The LACs Weber comments that Section 504 of the Rehabilitation
Act of 1973 prohibits discrimination on the basis of disability by institutions
receiving federal financial assistance. To the extent that transplant
centers are denying patients the opportunity to be considered for transplant
on the basis of past addiction problems requiring methadone therapy,
a legal challenge can be filed in court or with the Department of Health
and Human Services (DHHS) Office of Civil Rights.
To refute discrimination claims, healthcare institutions must demonstrate
a scientific or medical rationale for the denial of services. This same
principle applies to individual medical practices under the Americans
with Disabilities Act treatment cannot be denied solely on the
basis of methadone use, unless scientific or medical data exists to
support that standard of care.
Weber believes a Guidance from DHHS on Section 504 nondiscrimination
requirements in the delivery of health services would clarify issues
relating to HCV treatment and transplant in MMT patients. Development
of this could take time.
Meanwhile, Weber has made a start and is gathering information on individual
cases. Regrettably, the LACs efforts have been hampered by a lack
of funding to more actively pursue these issues.
The LAC, with offices in Washington and New York, has focused for the
past 28 years on protecting individual rights and expanding access to
treatment for persons with drug problems and AIDS, among others, at
no charge to clients.
A Role for MMT Clinics
Sylvestre believes MMT programs can be more proactive. Programs need
to become educated on HCV-treatment criteria and the barriers to treatment
so they can make appropriate referrals.
If MMT programs make inappropriate referrals to liver specialists in
the community, that referral base will disappear. It doesnt
do any good to send a homeless MMT patient who is actively psychotic
and has little potential for successful outcomes to a hepatologist,
Programs also should become advocates for their patients needing treatment.
She finds that those programs that are knowledgeable and have earned
patients trust are most successful in getting them into HCV treatment.
MMT staff then need to be proactive in helping HCV-treatment providers
manage these patients throughout the course of treatment.
1. Leavitt S. Hepatitis C - health crisis of the century.
Addiction Treatment Forum. 1999;8(2):6. Available online at:
www.atforum.com. Access checked October 1, 2001.
2. Leavitt S. Hepatitis haunts MMTPs. Addiction Treatment Forum.
1995;4(1):1-3. Available online at: www.atforum.com. Access checked
October 1, 2001.
3. Edlin BR, Seal KH, Lorvick J, et al. Is it justifiable to withhold
treatment for hepatitis C from illicit- drug users? N Engl J Med.
4. Peck P. Liver transplant: no methadone users need apply, please.
WebMD Health [online seri al]. February 27, 2001. Available at: http://
my.webmd.com/content/article/1728.73678. Accessed October 16, 2001.
5. Stephenson J. Former addicts face barriers to treatment for HCV.
6. Novick DM. The impact of hepatitis C virus infection on methadone
maintenance treatment. Mt Sinai J Med. 2000;67(5-6):437-443.
7. Simon S, Sholiton C, Chassis B. Hepatitis C awareness: an informative
reference guide [brochure]. Scotch Plains, NJ: Hepatitis C Association;
8. Nadler JP. HIV and hepatitis C another perspective. Infect
9. Davis GL, Rodrigue JR. Treatment of chronic hepatitis C in active
drug users. N Engl J Med. 2001;345(3):215-217.
10. U.S. facts about transplantation. UNOS Critical Data. [UNOS Web
site]. Available at: http:// www.unos.org/Newsroom/critdata_main.htm.
Accessed October 16, 2001.
11. Koch M; Banys P. Liver transplantation and opioid dependence. JAMA.
12. Chronic hepatitis C: current disease management. Bethesda, MD: National
Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). NIH
Publication No. 99-4230, May 1999. Available online at: www.niddk.nih.gov/health/diget/pubs/
chrnhepc/chrnhepc.html. Access checked October 2001.
13. Jaeckel E, Cornberg M, Wedemeyer H. Treatment of acute hepatitis
with interferon alfa-2b. NEJM. (In press: to appear in the November
15, 2001 issue).
CSATs Office of Pharmacologic & Alternative Therapies (OPAT)
is developing an evidence-based research monograph supporting treatment/transplant
in MMT patients with liver disease. This will be distributed to liver
specialists and transplant centers.
Meanwhile, readers should respond to the survey in this edition of AT
Forum on liver disease in MMT. Use the feedback card or visit www.atforum.com
Ellen Weber at the Legal Action Center is gathering specific case information
regarding MMT patients who have been denied liver transplants. Contact
her at 202-544-5478 or via email@example.com.
Clinical Concepts- Cardiovascular Health in MMT Patients
By Mori J. Krantz,
to current estimates nearly 61 million Americans have one or more types
of cardiovascular disease, including coronary artery disease (CAD),
congestive heart failure, and hypertension. Methadone maintenance
treatment (MMT) patients are clearly part of this larger demographic,
and there are unique clinical characteristics in this group warranting
High Risk, Less Access
Patients entering MMT are a very high-risk population from a general
health maintenance standpoint. As a rule, patients who use illicit drugs
expose themselves to a number of health risks, and are less likely to
regularly interface with the healthcare system. An increased reliance
on emergency services and a lack of integration into healthcare delivery
systems create a backdrop for poor outcomes.
The literature confirms that barriers to high quality care for cardiovascular
disease are greater in vulnerable patient populations, such as minorities
and the poor. A great many MMT patients fall into both of those categories.
For example, African Americans and low-income patients are less likely
to receive care by a cardiologist. In contrast, white race, higher income,
and college education independently predict care by a cardiologist.
Available data suggest that the gap in cardiovascular disease mortality
between the poor and uneducated versus the wealthy and well educated
has not lessened and may be widening. The National Conference on Cardiovascular
Disease Prevention concluded that to attain the goals set forth by the
U.S. Surgeon Generals Healthy People 2010 initiative, we should
focus on reducing disparities in health status on the basis of race,
ethnicity, and socioeconomic status.
To make matters worse, mainstream physicians often stigmatize MMT patients.
This further distances these patients from regular, preventive health
Some Specific Cardiac Risks
Intravenous drug users (IVDUs) are at high risk for developing infections
of their heart valves (infective endocarditis). These infections are
a direct result of bacteria entering the bloodstream at the skin site
Acute infection accounts for the majority of hospital admissions among
IVDUs and endocarditis is found in 10% of these episodes. Most of
these patients have no pre-existing cardiovascular disease.
The symptoms of this disorder may include persistent fever, chills,
sweats, muscle and joint aches, malaise, and back pain. These symptoms
are invariably preceded by an episode of intravenous drug use.
Endocarditis has very high morbidity and mortality. It can necessitate
extended intravenous antibiotic therapy and in many patients will require
complex heart valve surgery or even valve replacement. Other consequences
of endocarditis include brain abscess, kidney failure, and death.
MMT offers substantial protection from this deadly disease by eliminating
or dramatically reducing the amount of illicit drug use. In our local
hospital experience during 2000-2001, practically none of the heroin-abusing
patients admitted with endocarditis were in methadone treatment programs.
Furthermore, in my oversight of hundreds of MMT patients during nearly
a decade, I have encountered only 3 cases of endocarditis in that population.
This evidence is anecdotal and retrospective, but supports the common
sense notion that methadone treatment dramatically reduces the risk
of endocarditis in IVDUs.
Coronary Artery Disease (CAD)
CAD is the number one cause of death in the Western world  and MMT
patients are no exception. These patients may be at particularly high
risk given that as many as 90% of them smoke tobacco, which is a known
risk factor for CAD.
Additionally, cocaine abuse is seen with some frequency in this population.
Cocaine use has been linked to the development of arrhythmias, CAD,
heart attack, and death.
Despite the uses of tobacco and cocaine in MMT patients there have been
no published reports documenting a higher overall incidence of cardiovascular
disease in these patients. In my MMT practice, there are very few patients
with established CAD. This is remarkable, given the fact that a significant
proportion are beyond 50 years of age and many continue to smoke cigarettes.
Is there a possible explanation for this relatively low incidence of
CAD in MMT patients?
The evidence is not clear. However, there is some pharmacologic data
suggesting that methadone may exert a calcium channel blocking effect.
Calcium channel-blocking medications lead to slower heart rates and
reduced cardiac work, and these agents are effectively used to treat
CAD patients who develop symptoms of angina (chest pain).
Also, opiates, including methadone, are known to reduce blood pressure
and slow the heart rate. Morphine, for instance, is a commonly used
medication to treat hospitalized patients who experience a heart attack.
Thus, due to these properties, methadone is theoretically protective
in preventing or reducing cardiac ischemia (lack of blood supply to
There is no compelling evidence in the literature to suggest that methadone
treatment is a direct cause of sudden cardiac death or fatal heart rhythm
In clinical practice, the risk of cardiac arrhythmias attributable to
these treatments currently appears to be quite small. Future research
and accurate incidence data will help clarify any contribution of opioid-agonist
therapies to arrhythmia risk.
MMT Minimizes Cardiac Risks
Ongoing participation in MMT affords patients many heart health benefits.
For one thing, these patients have significantly greater access to preventive
cardiac-health services than opioid-dependent persons not in treatment.
MMT patients are provided periodic monitoring of their blood pressure
and pulse. Vital signs are obtained upon admission, during yearly physical
exams, and during dose changes.
In my experience, this has offered a tremendous opportunity to screen
patients for hypertension and then provide adequate treatment. Hypertension
afflicts 50 million Americans; it is a leading contributor to CAD and
the number one cause of stroke.
In my practice, a full lipid panel is obtained annually in all patients
to check cholesterol levels. Those with elevated levels can be offered
effective treatment with cholesterol-lowering medications, which have
clearly been shown to reduce the risk of heart attack and death in patients
who are at high risk.[10-12]
patients in MMT have access to frequent professional counseling, which
presents ideal opportunities for discussing the importance of smoking
cessation for long term cardiac health. The most common cause of death
in smokers is coronary artery disease (CAD).
Stopping smoking dramatically reduces the risk of future heart attack
or death. We regularly counsel patients on tobacco risks and many are
able to quit or significantly reduce tobacco consumption as part of
comprehensive treatment plans.
In conclusion, from a cardiovascular perspective, methadone is a safe
medication and MMT program staff can perform vital roles in providing
effective cardiac risk-reduction services.
1. American Heart Association. Heart and Stroke Statistical
2. Auerbach AD, Hamel MB, Califf RM, et al. Patient characteristics
associated with care by a cardiologist among adults hospitalized with
congestive heart failure. J Am Coll Cardiol. 2000;36:2119-2125.
3. Cooper R, Cutler J, Desvigne-Nickens P, et al. Trends and disparities
in coronary heart disease, stroke and other cardiovascular diseases
in the United States. Findings of the National Conference on Cardiovascular
Disease Prevention. Circulation. 2000;102:3137-3147.
4. Murphy JG. Mayo Clinic Cardiology Review. 2nd ed. Philadelphia: Lippincott
Williams & Wilkins; 2000:412.
5. Mandell GL. Principles and Practice of Infectious Diseases. 4th ed.
Churchill Livingstone; 1995:748.
6. Practitioner panel: methadone and heart health. Addiction Treatment
7. Lange RA, Hillis LD. Cardiovascular complications of cocaine use.
N Engl J Med. 2001;345:351-358.
8. Lee CH, Berkowitz BA. Calcium antagonist activity of methadone, l-acetylmethadol
and l-pentazocine in the rat aortic strip. J Pharmacol Exper Ther.
9. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic
stable angina. J Am Col Cardiol. 1999;33:2092-2190
10. Long term treatment with pravastatin in ischaemic disease (LIPID)
study group. Prevention of cardiovascular events and death with pravastatin
in patients with coronary heart disease and a broad range of initial
cholesterol levels. N Engl J Med. 1998;339:1349-1357.
11. Scandinavian Simvastatin Survival Study Group. Randomized trial
of cholesterol lowering in 4444 patients with coronary heart disease:
The 4S trial. Lancet. 1994;344:1383-1389.
12. Sacks FM, Pfeffer MA, Moye LA, et al. Cholesterol and Recurrent
Events Trial Investigators. The effect of pravastatin on coronary events
after myocardial infarction in patients with average cholesterol levels.
N Engl J Med. 1996;335:1001-1009.
*Mori Krantz, MD is Director of the Cardiovascular Risk Reduction Program,
Denver Health Medical Center, and Assistant Professor of Medicine and
Cardiology, University of Colorado.
the Editor - New Visions for the 21st Century
Despite tragic events
of last September and concerns about travel, more than 1,200 persons representing
15 countries gathered in St. Louis, Missouri on October 7-10, 2001 for
the American Methadone Treatment Association (AMTA) Conference.
There were an unprecedented 10 pre-Conference sessions, followed by 39
workshops and hot-topic sessions, along with 35 exhibits and 27 poster
presentations. A plenary session on each day of the conference featured
distinguished speakers addressing the theme Opioid Treatment in
the 21st Century: Implementing the Vision. Here are some highlights.
AMTA Now AATOD
Association President, Mark Parrino, MPA, stressed, We are probably
in the midst of the most profound and dynamic changes since the implementation
of MMT. The field is now supported by pure science, undeniably defining
how methadone works and its value.
He asserted that it is time to become more involved in mainstream medicine
and in the criminal justice system. There also is a need to embrace pharmacologic
alternatives for opioid addiction treatment, such as buprenorphine, which
can augment, but not replace, methadone therapy.
In view of those broad objectives, AMTA is changing its name to the American
Association for the Treatment of Opioid Dependence (AATOD).
5-Year Plan Released
Parrino discussed the Associations 10-point, 5-year plan for methadone
maintenance treatment (MMT) in the United States. The starting point is
supporting improvements in the quality of MMT services through accreditation.
Furthermore, it is necessary to increase treatment referrals through drug
courts, probation departments, and prisons.
Training and education are also prominent in the plan. The Association
will continue physician, clinic management, and program staff training
via conferences, symposia, and on-site offerings or distance-learning
initiatives. Furthermore, educating the American public about the value
of MMT is an ongoing priority and essential for future success, Parrino
There is plenty of room for AATOD growth in coming years, as only 19 of
42 states with MMT programs are Association members; although, this represents
more than 80% of methadone programs in the U.S. An aggressive initiative
has been launched to recruit individual MMT providers in non-member states,
which also may lead to formation of new statewide associations.
Continuing the discussion of critical changes, H. Westley Clark, MD, JD,
MPH, Director, Center for Substance Abuse Treatment (CSAT), commented
that the new rule regarding MMT program accreditation went into effect
last May. During the Conference, CSAT sponsored several special seminars
addressing accreditation issues, and Clark offered that persons with questions
should call 1-866-463-6687 or visit www.opat.samhsa.gov.
In the course of the initial testing phase, 94% of programs evaluated
by CARF received 1- to 3-year accreditation and 86% of JCAHO-evaluated
programs received 3-year accreditation. Others were granted more provisional
accreditation and only three programs failed entirely.
Clark said a study on the impact of the accreditation process is to be
completed by the summer of 2002. He projected that there will be a 3%
growth rate in MMT programs during coming years.
Buprenorphine/LAAM in Limbo
As for alternative opioid agonist medications, Clark mentioned that buprenorphine
and the buprenorphine/naloxone combination are still under review by the
FDA. He speculated that these agents might be approved by early 2002,
but it would take another several months before they are in distribution.
The eventual cost of the drugs is still unknown.
Meanwhile, Clark observed, there has been ongoing training of physicians
in how to use buprenorphine. He expects there will be 2,000 physicians
qualified as prescribers by the end of this year.
Will buprenorphine replace methadone?
No, according to Laura McNicholas, MD, Director of CESATE,
University of Pennsylvania, who presented a special pre-Conference session
on buprenorphine clinical guidelines. Despite certain distinct advantages
of buprenorphine in some patient populations, there also are some limitations.
For one thing, the maximum effective dose of buprenorphine is equivalent
to only about 60 mg/day of methadone. Patients requiring higher opioid
agonist doses, such as those with longer-term or more recalcitrant opioid
dependencies, might not fare as well on buprenorphine.
Furthermore, the buprenorphine/ naloxone combination is not appropriate
for use during pregnancy, since effects on the fetus are unknown. And,
there could be difficulties in patients needing chronic pain management,
since there is a ceiling effect of buprenorphine and it also blocks other
Regarding LAAM, Clark commented that, according to new FDA labeling, the
agent is now recommended for use only in patients who have failed other
treatment modalities. There has been a reported low frequency potential
for fatal outcomes due to cardiac complications with LAAM, he said,
and there are still questions regarding its safe use.
During the Conference it was announced that Roxane Laboratories was seeking
a buyer for the marketing rights to its LAAM product, Orlaam®. According
to some sources, further clinical evaluations of LAAMs safety were
requested by the FDA, and discussions were underway with the National
Institute on Drug Abuse (NIDA) regarding assistance in funding those trials.
In his always entertaining though informative style, Alan Leshner, PhD,
Director of the National Institute on Drug Abuse (NIDA), stressed that
a new discourse is needed in the addiction treatment field one
that stops polarizing the issues.
What matters most in addiction is compulsion, he said. Particular
distinctions between physical and psychological, or biological and behavioral,
factors are less important.
Prolonged drug use changes the brain in ways that engender compulsion
and interfere with behavior. The fact is that drug dependent persons just
cant say no and quit. Substances of abuse usurp normal
intrinsic motivational systems in the brain and provide greater rewards
than anything else in life. For example, research has demonstrated that
cocaine can provoke a greater response in the brain of an addicted person
However, according to new research, Leshner observed, the brain of a drug-abstinent
person can recover over time. Unfortunately, it can take a long time.
Medications can help stabilize brain chemistry during recovery. Leshner
suggested that methadone might be more aptly called stabilization
therapy to overcome the stigmatizing myth that it is merely substituting
one opioid with another.
He further declared that the time has come to do away with simplistic
metaphors. For example, the War on Drugs is meaningless as
a slogan: it has been taken the wrong way and has lost its true focus.
The ultimate strategies for dealing with drugs in America have to be as
complex as the problems themselves, and science enables us to address
those complexities in understandable ways.
Also, he continued, addiction treatment does not have to be voluntary
to be effective treatment while in the criminal justice system
works very well. Although, he conceded, treatments usually offered in
the criminal justice system are too restrictive and often erect barriers
to the use of medications such as methadone.
[After the Conference, it was announced that Dr. Leshner would be leaving
his post at NIDA, effective December 2001.]
Views From The Bench
Addressing the integration of MMT services into the criminal justice system,
Peggy Fulton Hora, Judge of the Superior Court of Alameda County (Haywood)
California observed that the brain disease model of addiction
described by Leshner greatly appeals to judges, since it is science based.
She believes judges are very receptive to scientific evidence if it is
Judge Hora acknowledged that there has been antagonism toward methadone
by judges and prosecuting attorneys in the past. She proposed, however,
that the time is right for change and this will come via greater interaction
between the judicial and treatment communities. Changing just one judges
mind can benefit thousands of people, she suggested.
A national agenda is needed to provide methadone in jails and prisons,
Hora continued. In that regard, correctional facilities need methadone
treatment protocols. This has been accomplished in California, she observed,
where methadone is allowed in jails if it is verified that the inmate
was previously in an MMT program.
Jeri B. Cohen, Circuit Court Judge, Dade County (Miami) Florida, concurred
that methadones efficacy has been established, yet drug court judges
often disapprove of the modality. To overcome this, MMT providers need
to reach out to the judicial system and, if necessary, go into court with
patients to explain why those persons need to be on methadone.
In her own case, as a family court judge, Cohen expressed frustration
at the lack of cooperation from and among local addiction treatment providers.
She is often faced with separating children from their heroin-addicted
parents because local drug-treatment programs prohibit methadone therapy.
These fathers or mothers were unable to withdraw from opioids and dropped
out of treatment or died, leaving their children behind, she said. Meanwhile,
MMT providers in her jurisdiction have remained silent, Cohen lamented,
as she exhorted the audience to become more involved in the justice system.
Doing Our Parts
During the closing session, Edward H. Jurith, Acting Director, Office
of National Drug Control Policy (ONDCP), Washington, DC, observed that
the Bush administration is committed to drug treatment and supports MMT.
This is evidenced by the nomination of Andrea Barthwell, MD, a member
of the AMTA Board of Directors, to be Deputy Director of ONDCP for Demand
Five-million persons are in need of drug treatment, yet only a fraction
receive it, Jurith noted. President Bush has asked for $1.65 billion over
the next five years to close that gap.
Were thinking of how we can better integrate resources of
the drug treatment system into the criminal justice system, he continued.
We now have more than 1,050 drug courts in this country, compared with
only 10 in 1991, and there are plans to increase this system.
We have taken the treatment debate out of the political realm and
put it in the public health arena where it belongs. We know more about
drug abuse and how it works in the brain, and how to treat it, and how
to prevent it than at any other time in our history, Jurith concluded.
We need to be more aggressive in putting that knowledge into practice.
We all have our parts to do.
Nations Capitol Next
Reserve April 13-16, 2003 on your long-range calendar for the next AATOD
(formerly AMTA) Conference, which will be in Washington, DC. Plan to bring
the whole family.
Survey Liver Disease in MMT Patients
As a follow-up to our article in this edition on Liver Disease in MMT
Patients, we want to survey our readers experiences. Please respond
to the following questions:
1. Do you know of patients who were denied treatment for hepatitis C because
they were on methadone?
____no; ___ yes. If yes, how many? ____
2. Do you know of patients who were denied a liver transplant because
they were on methadone?
____no; ___ yes. If yes, how many? ____
3. Do you know of MMT patients who died because they could not get treatment
or a transplant for their liver disease? ____no; ___ yes. If yes, how
There are several ways to respond:
A. Provide your answers on the postage-free feedback card in this issue;
B. Write or fax us [see info below], or;
C. Visit our Web site to respond online.
As always, your written comments are important for helping us discuss
the results in an upcoming issue.
Stewart B. Leavitt, PhD, Editor
Addiction Treatment Forum
P.O. Box 685
Mundelein, IL 60060
additional postings & information, see: www.atforum.com
3rd Annual Juvenile & Family Drug Court Training Conference
January 24-26, 2002
Ascuagas Nugget Hotel; Reno, Nevada
International Conference on Addictions
(Council on Substance Abuse - NCADD)
February 10-11, 2002
Civic Center, Montgomery, Alabama
Summit for Clinical Excellence (Ben Franklin Institute)
February 21-24, 2002
Behavioral Health International Conference (Sponsored
March 16-19, 2002
Marriott Univ. Park Hotel; Tucson, Arizona
National Conference on Co-Occurring Disorders
March 27-29, 2002
Westin La Cantera; San Antonio, Texas
Contact: 888-869-9230 or 615-742-1000
ASAM 33rd Annual Meeting & Scientific Conference
April 25-28, 2002
Hilton Atlanta, Atlanta, Georgia
NADCP 8th Annual Training Conference
June 13-15, 2002
Marriott Wardman Park; Washington, DC
Contact: 703-706-0576; Fax: 703-706-0577
NAADAC 26th Annual Conference on Addiction Treatment
July 3-6, 2002
Marriott Copley Place; Boston, Mass.
Contact: 800-548-0497 or 703-741-7686
post your event announcement in A.T. Forum and/or our Web site, fax
the information to: 847-392-3937 or
submit it via e-mail from http://www.atforum.com]
to Get Info
Video Depicts Addiction/MMT
METHADONE TREATMENT: The Hope for a New Life is a 30-minute videotape
providing critical information on opioid addiction and methadone maintenance
treatment (MMT). Produced by COMPA (Committee of Methadone Program Administrators,
Inc.) of New York State, it depicts the true story of opioid addiction,
including the disease process and its devastating effects on the addicted
person, the family, and the community.
On camera testimony of experts in the field and patients clearly underscore
the overwhelming efficacy of MMT. Viewers will find the video compelling
and enlightening, providing new insights into addiction and methadone
treatment that are certain to dispel myths and help overcome stigma.
The video normally costs $90. However, it is being made available to
AT Forum readers for only $45 plus $5 shipping and handling (be sure
to mention AT Forum when ordering). Contact COMPA at: 250 Fifth Ave,
Suite 210; New York, NY 10001. Phone: 518-281-8965; fax: 518-426-1046.
Methadone Primer for Patients
About Methadone is a 50-page booklet from the Lindesmith Center-Drug
Policy Foundation that covers most of the questions patients and their
loved ones might have about methadone maintenance treatment. Written
in nontechnical language, it gives facts, dispels myths, and also provides
helpful tips on such topics as traveling with methadone, storing the
drug, concerns about overdose, and much more.
To obtain copies, contact the Lindesmith Center at 212-548-0695; methadone@drugpolicy,
or visit www.drugpolicy.org.
Advocacy Newsletter Resurrected
NAMA Advocate is the latest incarnation of the National Alliance of
Methadone Advocates newsletter. This publication reports on diverse
issues pertaining to methadone and other subjects of interest to patients
in MMT programs. Clinic staff will find this publication worthwhile
reading to keep informed of events on the advocacy front.
Available online at www. NAMAnews.com. To join NAMA and receive the
print edition contact: 212-595-NAMA; or visit www.methadone.org.
Reader Survey - MMT Attitudes
The Spring 2001
edition of AT Forum (Vol. 10, No. 2) surveyed reader attitudes regarding
methadone maintenance treatment (MMT). Responses expressed agreement
or disagreement with the following three statements:
1. An MMT patient who continues to use heroin should be given higher
doses of methadone.
2. Complete abstinence from illicit drugs is essential for recovery
3. Many patients need to be maintained on methadone indefinitely.
There were 430
respondents (280 staff; 150 patients).
Disagreement with the first and third statements, and agreement with
the second, might characterize what has been called an abstinence
orientation. This was first discussed in AT Forum about 5 years
ago (Fall 1996, Vol. 5, No. 3), referring to research by John Caplehorn,
MD and colleagues.
Their research found that abstinence- oriented clinic policies were
closely tied to suboptimal methadone doses, zero tolerance for illicit
drug use, and negative views of long-term methadone. It was suggested
that such policies, grounded in underlying attitudes that are somewhat
anti-methadone, adversely affect treatment outcomes.
This present AT Forum survey suggests that an abstinence orientation
persists among many staff members and, surprisingly, in a sizable
proportion of patients. Among staff, 22% and 25% disagreed with statements
1 and 3, respectively; 63% agreed with statement 2. See graph.
Increase Methadone Dose?
Staff and patients appeared to have similar views (80% on average)
regarding the benefit of increasing methadone dose if a person continues
to abuse heroin. However, it would be interesting to know how the
20% disagreeing with statement number 1 might handle seemingly recalcitrant
One patient wrote that he has been in MMT for more than 24 years,
and believes he is a model patient who owes his life to
methadone. Yet, he admitted that every 2 or 3 years he has used illicit
drugs: There is simply no compulsion or desire to do so more
Another patient noted that she was prescribed 30 to 40 mg/day of methadone
for years and continued using heroin. It wasnt until I
was given a substantial increase due to positive urine screens and
a pregnancy that a miracle happened, she wrote. I stopped
On average, 64% of patients and staff agreed that abstinence was essential
One staff member who disagreed, thus reflecting less of an abstinence
orientation, commented that complete abstinence from illicit drugs
is a goal that may take some time as the patient deals with obstacles
A patient noted that just because a person slips up once
in a while does not mean that they have failed. It should not affect
their recovery overall.
Reflecting abstinence-oriented disagreement with the third statement,
one clinic medical director stated that, while many patients may want
to stay on methadone indefinitely, he believed that very few needed
it for a lifetime.
Many patients who disagreed with indefinite MMT expressed frustration
with their clinics and the stigma surrounding methadone. However,
other approaches, such as medical maintenance away from less flexible
clinic settings, could make lifelong methadone therapy much more appealing
to stabilized patients.
Finally, a staff member, whose responses indicated a strong abstinence
orientation, suggested that methadone is only one tool among many
to increase the potential for recovery, and it may not be the best
tool. As is sometimes the case, there is a question as to why this
person would want to work in an MMT clinic.