AT Forum NEWS NOTES & UPDATES #137
December 2009 / January 2010
Compiled & Edited by Sue Emerson - Publisher
Prior Edition: November 2009
Contents
MEDICATION-ASSISTED TREATMENT
Methadone Maintenance Therapy Decreases Arrests
Abstinence Rates with Office-based Buprenorphine Treatment Differ by Retention and Insurance Status
GOVERNMENT
Survey Finds Widespread Prescription-Drug Abuse Among U.S. Troops
ONDCP: Seeking Treatment a Positive New Year's Resolution
For ONDCP's McLellan, Addiction Issue is Personal and Professional
New TEDS Report - Characteristics of Adolescent Heroin Admissions
The NIDA Drug Abuse & Addiction Media Guide for Journalists Now Available Online
NIDA Notes Volume 22 #6 Now Available Online
MISCELLANEOUS
Pain Management Failing As Fears Of Prescription Drug Abuse Rise
Words Used to Describe Substance-Use Patients Can Alter Attitudes, Contribute to Stigma
MEDICATION-ASSISTED TREATMENT (MAT)
Meta-analysis Confirms Methadone Maintenance Reduces Illicit Opioid Use and Improves Treatment Retention in Patients with Opioid Dependence
To determine the effectiveness of MMT compared with no treatment or treatments not including agonist treatment in patients with opioid dependence, Cochrane Collaborative researchers conducted a systematic review of clinical controlled trials conducted between 1969 and 2008. Eleven randomized controlled trials including 1,969 patients in 5 different countries were identified. Outcome measures included treatment retention, mortality, opiate-positive drug test results, self-reported heroin use, and criminal activity. Study control groups included patients who received a double-blind placebo, those who received methadone for detoxification only, those who received counseling only, those wait-listed for treatment, or those who received no treatment. The mean dose of methadone among patients in the MMT group was 60 mg or higher in most studies.
- Methadone maintenance significantly increased retention in treatment (relative risk [RR], 4.44), decreased morphine-positive drug tests (RR, 0.66), and decreased self-reported heroin use (no pooled effect estimate due to heterogeneity).
- Pooled estimates of mortality risk and criminal activity were reduced (RR=0.48 and 0.39, respectively), but these changes were not statistically significant.
Comments: There is strong clinical trial evidence that, among opioid-dependent patients, MMT increases treatment retention and reduces heroin use compared with placebo, detoxification, drug-free counseling, and wait-list controls. Other beneficial outcomes from MMT, such as reduced mortality, reduced criminal activity, reduced HIV seroconversion, reduced HIV risk behaviors, and improved birth outcomes, are supported by observational evidence.
Published In: Alcohol, Other Drugs, and Health: Current Evidence a project of the Boston Medical Center issue September/October 2009. Access checked 1/10/10. Alexander Y. Walley, MD, MSc
Original Source: Mattick RP, Breen C, Kimber J, et al. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev. 2009(3): CD002209.
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Methadone Maintenance Therapy Decreases Arrests
Previous observational reports of methadone maintenance therapy (MMT) suggest that MMT reduces criminal activity. Treatment with methadone often includes medication and counseling; interim methadone (IM) provides medication alone in an effort to reduce costs. In this clinical trial, investigators randomized patients awaiting entry into a comprehensive MMT program to receive either IM (n=198) or to a waiting list (n=119). Interim methadone, providing no counseling, was offered for up to 120 days. After controlling for potential confounders, investigators compared retention in treatment among patients in both groups at 6 and 12 months.
- Patients assigned to IM had significantly fewer arrests at 6 months compared with waiting list patients (mean, 0.20 versus 0.34).
- There was no difference in arrest severity between groups at 6 or 12 months; however, there were significantly fewer arrests at 6 and 12 months among patients in continuous treatment compared with patients not in continuous treatment (mean, 0.14 versus 0.29 at 6 months and 0.18 versus 0.40 at 12 months, respectively).
- More patients in the IM group were retained in treatment compared with waiting list patients (65% versus 25%).
Comments: In this randomized clinical trial, patients in the IM arm had fewer arrests and were more likely to be retained in treatment compared with waiting list patients. The policy implication of this study is important in that IM may provide additional benefits (i.e., reduction in criminal activity and retention in treatment) beyond the morbidity and mortality benefits conferred by comprehensive MMT.
Published In: Alcohol, Other Drugs, and Health: Current Evidence a project of the Boston Medical Center issue September/October 2009. Access checked 1/10/10. Hillary Kunins, MD, MPH, MS
Original Source: Schwartz RP, Jaffe JH, O'Grady KE, et al. Interim methadone treatment: impact on arrests. Drug Alcohol Depend. 2009;103(3):148—154
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EUROPAD Journal — Heroin Addiction and Related Clinical Problems. 2009 (December), Vol. 11, No. 4 Now Available Online — Special Issue on QT Interval
Heroin Addiction and Related Clinical Problems, the official journal of EUROPAD (European Opiate Addiction Treatment Association), is a peer-reviewed publication for professionals wanting to stay informed of research and opinion on opioid misuse treatment in Europe and around the world. A particular emphasis is on medication-assisted treatments for opioid addiction.
- QT Interval
- Psychoactive Drugs and Prolongation of the QT Interval
- Opioid Treatment and "Long-QT Syndrome (LQTS)": a Critical Review of the Literature
- Management of Cardiac Risk during Methadone Treatment: Focus on the QT Interval
The PDF of the December issue can be accessed at:
http://atforum.com/documents/HeroinAddict1142009.pdf
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Abstinence Rates with Office-based Buprenorphine Treatment Differ by Retention and Insurance Status
As office-based treatment of opioid dependence with buprenorphine becomes more widespread, an increasing number of reports describe practices and outcomes in real-world settings. This report describes a highly structured office-based program that included a 1—2 day inpatient induction, 5 weeks of 3-hour counseling sessions 4 times per week, then weekly counseling sessions for an additional 12 weeks. Participants attended subsequent monthly follow-up visits and were required to attend thrice weekly 12-step meetings. Full adherence was required to remain in the program. Among the 110 of 176 (63%) consecutively admitted patients available for follow-up at a minimum of 18 months,
- 85 patients (77%) reported continuous buprenorphine treatment.
- Retained patients were more likely to report abstinence (p=0.01) and to be employed (p=0.03) than nonretained patients.
- Retained patients with insurance were more likely to report abstinence than those without insurance (97% versus 86%, respectively) (p=0.04).
Comments: The high retention rate in this structured office-based buprenorphine treatment program may reflect the selection of a highly motivated patient population. One might conservatively estimate that patients not available for follow-up had dropped out of treatment, resulting in a retention rate of 48% (similar to previous reports). The association between insurance status and abstinence is unsurprising given that treatment costs surely prevent full realization of efficacy. It further suggests that coverage for ongoing treatment of substance use disorders might improve long-term outcomes.
Published In: Alcohol, Other Drugs, and Health: Current Evidence a project of the Boston Medical Center issue November/December 2009. Access checked 1/10/10. Hillary Kunins, MD, MPH, MS
Original Source: Parran TV, Adelman CA, Merkin B, et al. Long-term outcomes of office-based buprenorphine/ naloxone maintenance therapy. Drug Alcohol Depend. 2009;106(1):56–60.
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GOVERNMENT
Survey Finds Widespread Prescription-Drug Abuse Among U.S. Troops
Misuse of prescription drugs occurs at a much higher rate among U.S. troops than the general population, with 22 percent of soldiers and 20 percent of Marines reporting prescription-drug abuse within the past year, USA Today reported Dec. 17.
The Department of Defense survey of service members found that prescription painkillers were the most commonly misused drugs.
The survey also found that 11 percent of soldiers exhibited signs of post-traumatic stress disorder in 2008 — notably in the Army and Marine Corps — and that 60 percent of Marines admitted to binge drinking. Two percent of service members acknowledged that they had thought about committing suicide during the past year.
Source: JoinTogether.org — January 1, 2010
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Increasing Substance Abuse Levels Among Older Adults Likely to Create Sharp Rise in Need for Treatment Services in Next Decade
According to a new report, need for substance abuse treatment among Americans over age 50 projected to double by 2020.
A new study done by the Substance Abuse and Mental Health Services Administration (SAMHSA) indicates that the aging of the baby boom generation is resulting in a dramatic increase in levels of illicit drug use among adults 50 and older. These increases may require the doubling of substance abuse treatment services needed for this population by 2020, according to the report.
"This new data has profound implications for the health and well-being of older adults who continue to abuse substances," said SAMHSA Administrator, Pamela S. Hyde, J.D. "These findings highlight the need for prevention programs for all ages as well as to establish improved screening and appropriate referral to treatment as part of routine health care services."
Substance abuse at any age is associated with numerous health and social problems, but age-related physiological and social changes make older adults more vulnerable to the harmful effect of illicit drugs use.
The latest SAMHSA short report, Illicit Drug Use among Older Adults, shows that an estimated 4.3 million adults aged 50 or older (4.7 percent) used an illicit drug in the past year. Although marijuana use was more common than nonmedical use of prescription drugs for adults age 50 to 59, among those aged 65 and older, nonmedical use of prescription drugs was more common than marijuana.
The report, which examines the prevalence of any illicit drug use, marijuana use, and nonmedical use of prescription drugs, is based on data collected during 2006 to 2008 from a nationally representative sample of 19, 921 adults aged 50 or older who participated in SAMHSA’s National Survey on Drug Use and Health.
The full report is available online at:
http://www.oas.samhsa.gov/2k9/168/168OlderAdults.cfm
Source: The Substance Abuse and Mental Health Services Administration — January 8, 2010
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ONDCP: Seeking Treatment a Positive New Year's Resolution
At the beginning of each new year, countless Americans make resolutions to change their behavior-losing weight, starting to exercise, spending more time with their families, or some other changes they hope will make them happier and healthier. Statistics show millions of Americans should consider another resolution: Seeking help for their abuse of substances such as alcohol, prescription medications, and illicit drugs.
"More than 20 million people who need treatment for substance abuse do not receive it," said Gil Kerlikowske, Director of the Office of National Drug Control Policy (ONDCP). "This is a problem we can begin to address by making people aware of treatment options available to them and encouraging families and friends to give their support to people seeking and receiving treatment."
Data compiled by the Substance Abuse and Mental Health Services Administration show that in 2008 some 23.1 million people aged 12 and older needed treatment for a drug or alcohol use problem. However, only 2.3 million received treatment at a specialty facility.
"We are committed to making people aware of the treatment options available to them," said Kerlikowske. "We also need to encourage those who feel they need treatment to summon the courage to step forward and seek help, and we must let them know that seeking treatment is not a sign of weakness, but a sign of strength."
Dr. Thomas McLellan, Deputy Director of ONDCP and a specialist in addiction treatment, said that people who believe they or a loved one needs treatment should consider talking to a primary care physician, seeking help from a mental health professional, contacting an addiction treatment program, or attending a meeting of a mutual help organization. "There have never been as many evidence-based counseling methods and medications to help people overcome substance abuse as there are today," Dr. McLellan said.
Source: Office of National Drug Control Policy — January 5, 2010
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For ONDCP's McLellan, Addiction Issue is Personal and Professional
Tom McLellan, deputy director of the Office of National Drug Control Policy (ONDCP) and a leading addiction researcher, knows the tragedy of alcohol and other drug problems firsthand: a deep family history of addiction includes a son who overdosed last year at age 30, another son who is in recovery, and a wife who is recovering from a cocaine addiction, the New York Times reported Dec. 8.
McLellan, formerly the scientific director of the Treatment Research Institute in Philadelphia and a professor at the University of Pennsylvania School of Medicine, took the job as second-in-command to drug czar Gil Kerlikowske only reluctantly. He said his son's death influenced his decision.
"I thought it was some kind of sign, you know," he said. "I would never have done it. I loved all the people I've worked with, I loved my life. But I thought maybe there's a way where what I know plus what I feel could make a difference."
McLellan's work is predicated on the idea that addiction is a chronic illness, and he and Kerlikowske have been drafting a new Obama administration antidrug strategy that is expected to shift more funding into treatment and prevention rather than law enforcement and interdiction. Kerlikowske has said he wants to triple the number of Americans receiving addiction treatment, for example.
"I think if Obama gave these two guys the spark, they would know how to turn it into a fire," said Joseph Califano, chairman of The National Center on Addiction and Substance Abuse at Columbia University.
"We are going to get the money to do this," said McLellan. "I can't tell you the amount or where it's coming from, but we're going to get it."
Source: JoinTogether.org — December 14, 2009
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New TEDS Report - Characteristics of Adolescent Heroin Admissions
This 6-page report which uses data from the 2007 Treatment Episode Data Set (TEDS), examines the characteristics of substance abuse treatment admissions aged 12 to 17 reporting heroin abuse. Findings include:
- Adolescent admissions reporting heroin abuse were slightly more likely to be male than female (53 vs. 47 percent).
- Most (94 percent) adolescent heroin admissions were between the ages of 15 and 17 at the time of admission.
- Almost half (48 percent) reported injection as the route of administration, and almost a third (32 percent) reported inhalation.
- Most (87 percent) adolescent substance abuse treatment admissions reporting heroin abuse also reported abuse of other substances.
- Almost one third (32 percent) of adolescent heroin admissions reported having a psychiatric problem in addition to their drug use problem (i.e., co-occurring disorders). Male adolescent heroin admissions were less likely than female adolescent heroin admissions to report a co-occurring disorder (27 vs. 37 percent).
- More than half (56 percent) of adolescent heroin admissions had at least one prior treatment episode compared with 30 percent of adolescent admissions for substances other than heroin.
Understanding the characteristics of adolescent admissions reporting heroin abuse may help treatment providers offer age-appropriate services, including behavioral support and pharmacotherapy, to help reduce heroin use and associated negative consequences in this population.
Source: The Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (December 3, 2009). The TEDS Report: Characteristics of Adolescent Heroin Admissions. Rockville, MD. — December 3, 2009.
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The NIDA Drug Abuse & Addiction Media Guide for Journalists Now Available Online
The purpose of this guide published by the National Institute on Drug Abuse (NIDA) is to provide journalists fast and user-friendly access to the latest scientific information on drug abuse and addiction.
- The science of drug abuse and addiction
- Commonly abused drugs
- Resources including: where to find nationwide trends and statistics, NIDA resources, other government sources, a glossary of related terms, and government contacts
This is a valuable resource for opioid treatment programs (OTPs) to share with their local media contacts to help them better understand the science of drug addiction and the benefits if have an OTP in their local community.
The 27-page PDF file can be accessed at:
http://www.nida.nih.gov/mediaguide/mediaguide_web.pdf
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NIDA Notes Volume 22 #6 Now Available Online
The latest edition of NIDA Notes is now available online. The newsletter covers drug abuse research in the areas of treatment and prevention, epidemiology, neuroscience, behavioral science, health services, and AIDS. Articles include:
- Study Gives Green Light to Antiretroviral Medications for HIV-Infected Injection Drug Users
- Anticipation of Methadone Enhances Brain Reactivity to Heroin Cues
- Report Discusses Co-Occurrence of Drug Abuse and Other Mental Disorders
- Teens With Unhealthy Weight Control Behavior Are More Likely to Abuse Drugs
The 20-page PDF file can be accessed at:
http://www.nida.nih.gov/PDF/nidanotes/NNVol22N6.pdf
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MISCELLANEOUS
Pain Management Failing As Fears Of Prescription Drug Abuse Rise
Millions of Americans with significant or chronic pain associated with their medical problems are being under-treated as physicians increasingly fail to provide comprehensive pain treatment — either due to inadequate training, personal biases or fear of prescription drug abuse.
"We have more sophisticated pain management techniques available now than ever before," said Kathryn Hahn, a pharmacist, affiliate faculty member at OSU and chair of the Oregon Pain Management Commission. "But many doctors are not fully informed about all the options available, and also often turn patients away because they're very concerned about the problems with prescription drug abuse. One analysis concluded that admissions to federally supported treatment programs for prescription opioid abuse increased 342 percent from 1996 to 2006.
Concerns about this within the medical profession are sufficiently high, Hahn said, that many doctors prefer not to even work with patients who have ongoing pain issues. They also fear criticism from other doctors if they have high numbers of pain-related cases or prescribe significant amounts of pain medications, she said.
"I see patients every week who have lost their doctors, don't know what to do and these people are scared," Hahn said. Prescription drug abuse is a very real problem, we do have to take necessary steps to address it, but right now the pendulum has swung too far, and legitimate pain problems are not being managed."
Hahn outlined some of these issues in two new publications, one in the Journal of Pain and Palliative Care Pharmacotherapy, and the other in The Rx Consultant.
Long-term solutions, Hahn said, will take education and responsibility by all parties involved, including consumers, physicians, nurses and pharmacists.
See the full press release for Hahn’s suggested steps that may help at:
http://oregonstate.edu/ua/ncs/archives/2010/jan/pain-management-failing-fears-prescription-drug-abuse-rise
Source: Oregon State University — January 4, 2010
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Words Used to Describe Substance-Use Patients Can Alter Attitudes, Contribute to Stigma
Changing the words used to describe someone struggling with alcoholism or drug addiction may significantly alter the attitudes of health care professionals, even those who specialize in addiction treatment. Massachusetts General Hospital (MGH) researchers have found that health professionals' answers to survey questions about a hypothetical patient varied depending on whether he was described as a "substance abuser" or as "having a substance use disorder." Their study will appear in the International Journal of Drug Policy and has been released online.
"We found that referring to someone with the 'abuser' terminology evokes more punitive attitudes than does describing that person's situation in exactly the same words except for using 'disorder' terminology," says John F. Kelly, PhD, associate director of the MGH Center for Addiction Medicine, who led the study. "Reducing the use of such stigmatizing terms could help diminish the shame, guilt and embarrassment that act as barriers, keeping people from seeking help."
Even though the World Health Organization acknowledged "abuser" as a stigmatizing term 30 years ago, it remains in common usage. The current study was designed to determine whether calling someone "a substance abuser" versus "having a substance use disorder" led to different judgments about the individual's ability to regulate behavior, the need for treatment versus punishment and whether that person could be a social threat.
The investigators randomly distributed surveys to more than 700 mental health professionals attending two 2008 conferences focused on mental health and addiction. The surveys began with a paragraph describing the current situation of "Mr. Williams," who is having trouble adhering to a court-ordered treatment program requiring abstinence from alcohol and other drugs. On half of the surveys, he is referred to as a "substance abuser;" on the others, he is described as having "a substance use disorder," with the rest of the narrative being exactly the same. The survey consisted of 32 statements about Mr. Williams' situation, and participants were asked to indicate how much they agreed or disagreed with those statements.
More than 500 completed surveys were returned, and one third of the responding participants indicated they had a professional focus on addiction. While the way "Mr. Williams" was described did not significantly change whether respondents regarded him as a threat or thought he should be referred for treatment, participants who received the paragraph describing him as a "substance abuser" were significantly more likely to agree that he should be punished for not following his required treatment plan. They were also more likely to agree with statements implying that that he was more to blame for his difficulty adhering to the court requirements.
"Our results imply that these punitive attitudes may be evoked by use of the 'abuser' term, whether individuals are conscious of it or not, and suggest that this term perpetuates that kind of thinking," Kelly explains. "From the perspective of the individual sufferers, who often feel intense self-loathing and self-blame, such terminology may add to the feelings that prevent them from seeking help."
Kelly notes that terms like "abuser" are not used in other clinical areas — individuals with eating-related problems are almost universally referred to as having an "eating disorder" and not as "food abusers." While national and international health agencies have advocated eliminating "substance abuser," the term remains in common use, even in literature from federal agencies.
"There's an old proverb that states, if you want something to survive and flourish, call it a flower; if you want to kill it, call it a weed," he adds. "Saying that someone has a substance use disorder conveys the notion that they are suffering from something that may be treatable, which of course is true. Anything we can do to eradicate or minimize stigma-related obstacles to treatment will help reduce the prodigious social impact these disorders have on individuals and society, and changing the way we refer to affected individuals is one simple and achievable step towards that goal."
Kelly is an associate professor in the Harvard Medical School Department of Psychiatry. Cassandra Westerhoff of the MGH Center for Addiction Medicine is co-author of the International Journal of Drug Policy study, which was funded by an MGH institutional grant.
Source: Massachusetts General Hospital — January 13, 2010
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All facts and opinions are those of the sources cited. News reports may have been edited for length and/or modified for clarity without altering essential data as originally published.
Addiction Treatment Forum and its associates do not endorse any medications, products, or treatments described, mentioned, or discussed in any of the sources referenced. Nor are any representations made concerning efficacy, appropriateness, or suitability of any such products or treatments. This News Update is made possible by an educational grant from Covidien Mallinckrodt, St. Louis, MO, a manufacturer of methadone and naltrexone.
In view of the possibility of human error or advances in medical knowledge, Addiction Treatment Forum and its associates do not warrant the information contained in the above news updates is in every respect accurate or complete, and they are not responsible nor liable for any errors or omissions that may be found in such information or for results obtained from use of such information.