Addiction Treatment Forum

Addiction Treatment Forum reports on substance use news of interest to opioid treatment programs and patients in medication-assisted treatment.

A.T.F. Volume VIIi #1. Winter 1999

by

 

  • Clinical Concepts
  • Naltrexone Nexus – Part 3
  • From the Editor
  • Events to Note
  • Where to Get Info
  • MMT Dose Survey­ – Continued
  • Readers Survey

 

Cinical Concepts

How MMT Saves Money

“There is a unique disconnect between scientific facts and public perceptions of substance abuse and its treatment,” according to Joel Egertson, senior advisor to the director, Medications Development Division, NIDA. Most people are simply not fully aware of the negative consequences substance abuse has on health in the United States.

 

Ominous Prevalence

For example, the proportion of AIDS cases attributed to injecting drug users (IDUs) soared from 17% in 1985 to 37% in 1998, and during that same period the number of total cases skyrocketed from 10,000 to over 600,000. Half of new cases each year are substance abuse-related.

Added to that, 70-90% of hepatitis B and 50-83% of hepatitis C cases are among IDUs, and the toll in terms of human suffering and health care costs is staggering, Egertson notes. Yet, of the one million heroin abusers in the U.S., only 1 in 5 or 200,000 are in drug treatment of any sort.

Despite this, funding for treatment programs, including methadone maintenance treatment (MMT), is an ongoing challenge.

 

Significant Savings

Steven L. Batki, MD points out, “Recognizing substance use disorders as a major public health threat has significant policy implications for providing funding for treatment programs, and in defining their role and the expectations made of them.” MMT is still limited, traditionally under-funded, and viewed with ambivalence by many.

Batki ­ who is director of the Division of Substance Abuse and Addiction Medicine at San Francisco General Hospital, and clinical professor of psychiatry at the University of California, San Francisco ­ observes that for every dollar spent on MMT, there are four dollars or more ultimately saved in health care costs. When it comes to HIV as an example, MMT not only reduces risky injection drug use dramatically, it also decreases HIV seroconversion.

Egertson adds that, according to research by Michael French, PhD and colleagues, if only one case of HIV/AIDS is avoided for every 15 IDUs who remain in treatment, the annual cost of MMT (15 X $4,000 = $60,000) is well below the average cost of morbidity associated with HIV/AIDS ($157,800 per patient). This results in nearly a $100,000 savings, and one need not be an accountant to add up the tremendous financial benefits to society.

The value of avoiding the morbidity associated with a moderate case of hepatitis B in a single addict would be more than $2,100, says Egertson. Other health problems are also frequently seen in substance-dependent populations, for example: soft tissue infections, tuberculosis, seizures, pancreatitis, sexually transmitted diseases, hypertension, and trauma of all sorts. For all of these, MMT clinics can help realize savings in health care costs.

 

MMT Clinic Role

What can MMT clinics do? Batki suggests that providing health care services within the clinic environment and/or case management are good starting points. Such on-site care can be more effective, because patients often do not keep appointments when they are referred to outside services.

  • Clinics might offer such services as:
  • Health screening and vaccinations;
  • HIV, hepatitis, and tuberculosis treatment;
  • Patient education and family planning;
  • Linking patients to primary care providers.

However, Batki acknowledges, some patients’ health care needs may grow beyond the clinic’s capabilities and outside referrals would be appropriate. And, compared to patients’ pre-MMT behaviors, outpatient visits to other health care providers may increase, merely because recovering drug abusers can make and keep appointments.

Other benefits come from the fact that patients take better care of themselves while in an MMT program. This reduces both emergency department visits and hospitalizations.

 

Research Confirms Benefits

Batki and several colleagues conducted two research studies assessing the impact of MMT on hospital use among IDUs. The first group consisted of 96 patients admitted to the San Francisco General Hospital MMT clinic. Most (83.3%) were HIV-positive.

During MMT treatment, the average number of hospitalizations for this group decreased significantly by 42% and the average number of days in the hospital declined by 50%. As might be expected, the reductions in health care services utilization were greatest for the HIV-negative patients. Overall, however, there were remarkably 90% fewer hospital admissions due to soft tissue infections, such as injection-related abscesses and cellulitis.

The second research group included 55 opioid-dependent, HIV-negative, but tuberculin skin-test-positive patients. They were randomly assigned to either a six-month trial of MMT or routine care (i.e., referral to a TB clinic and 21-day methadone detoxification, but no MMT). For the MMT-treated group, average annualized medical costs decreased by 65%, while charges in the non-MMT treatment group remained the same as before.

Batki stresses that MMT was associated with significant reductions in medical care utilization in these studies, largely due to fewer hospital admissions for soft tissue infections associated with drug injection. He suggests that more studies are needed in various MMT clinic environments. Certainly, the measured health care cost savings can be substantial, and the benefits to patients and the community could help support increased funding for addiction treatment.

For more information regarding Batki’s research, he may be contacted at: 415/206-3968; batki@itsa.ucsf.edu.

 

Naltrexone Nexus – Part 3

Back From The Brink

A third role of naltrexone, as part of the nexus described in this series of articles, is in the treatment of alcoholism. Part one portrayed naltrexone ­ a non-addictive, mu opioid-receptor antagonist ­ as useful in relapse prevention following opioid detoxification. Our second article described naltrexone’s application for opioid detoxification itself.

The focus now turns to naltrexone for helping those who have lost powers of choice and self-control over alcohol. As 19th Century American poet Edward Rowland Sill wrote:

At the punch-bowl’s brink,

Let the thirsty think,

What they say in Japan:

First the man takes a drink,

Then the drink takes a drink,

Then the drink takes the man!

Naltrexone was approved for alcoholism treatment by the federal Food & Drug Administration (FDA) in December 1994. This new indication was authorized in part because of naltrexone’s safe use for more than 20 years in the treatment of opioid dependency and the results from two placebo-controlled studies demonstrating its usefulness in alcoholism.

It is widely accepted that both alcohol-dependent persons and alcohol abusers need treatment, although the goals may differ. According to the FDA, “In most cases of alcohol abuse, the goal is to limit drinking, while for alcoholism, it is to stop drinking altogether.” This has some important implications when establishing expectations for treatments, such as with naltrexone, and in assessing therapeutic success.

 

Naltrexone Actions

Most scientists agree that a combination of genetic, environmental, and neurological factors influence a person’s vulnerability to alcohol problems. Alcohol is a complex substance, possibly affecting a number of neurotransmitter and receptor systems in the brain, including: opioid/endorphin, dopaminergic, serotonergic, and glutamatergic.

It is suspected that when alcoholics imbibe, their brains release elevated levels of endorphins, activating the opioid system, which triggers rewarding sensations enticing the person to drink more. This hypothesis is supported by observations that alcohol abusers experience increased opioid system activity in response to alcohol.

Naltrexone, as an opioid-receptor antagonist, is believed to block the endorphin-mediated rewarding effects of drinking alcohol. It suppresses ethanol’s physiologically reinforcing effects and impedes the subjective “high” perceived when drinking alcohol.

 

Pivotal Research

The two initial and often-cited clinical trials leading to the 1994 FDA alcoholism treatment indication for naltrexone were single-centered, double-blind, randomized, placebo-controlled trials conducted by separate investigative groups led by Joseph Volpicelli, MD and Stephanie O’Malley, PhD. First reported in 1992, both studies had experimental subjects taking 50 mg of naltrexone daily for up to 12 weeks as part of recovery programs, including psychotherapeutic interventions.

In a combined analysis of the two studies, naltrexone was associated with nearly a 25% reduction in the risk of patients drinking any alcohol during treatment. Among naltrexone-treated patients who did drink, their risk of clinically significant relapse was reduced by about one third, compared to those receiving a placebo.

This, and subsequent research, has demonstrated that naltrexone used as part of a recovery program can reduce:

  • the percentage of days drinking any alcohol;
  • the amount of alcohol consumed during a drinking episode;
  • the risk of relapse to compulsive, excessive drinking.

Naltrexone helps provide a critical period of abstinence or at least a reprieve from destructive drinking, during which patients can learn to live without alcohol.

 

Necessity of Psychotherapy

Most researchers investigating naltrexone as an aid to alcohol dependency, plus the FDA, have advocated that it be an adjunct to a formalized, comprehensive treatment approach. However, in one investigation, subjects received daily naltrexone in a primary care clinic. During 10 weeks, they were seen for an initial “new patient” visit and seven “brief” follow-up visits with primary care providers.

These patients improved significantly from baseline: a 52.2% increase in days abstinent; 51.4% decrease in heavy drinking days. The authors concluded that naltrexone plus brief counseling by primary care providers appeared feasible and effective.

However, another study compared naltrexone plus coping skills cognitive therapy versus “treatment as usual”, wherein the drug was merely dispensed without any special psychotherapeutic attention. Cognitive therapy along with naltrexone increased retention in treatment and was significantly better in reducing aberrant drinking behaviors. The authors expressed concern about naltrexone being dispensed by untrained general practitioners or indiscriminately by alcoholism clinics.

Investigations to date have not specifically explored the efficacy of naltrexone used in conjunction with attending 12-step program meetings, although one researcher did observe that the one year compliance rates for taking naltrexone increased from 20% to 45% when attendance at Alcoholics Anonymous was emphasized.

 

Side Effects & Dose

Naltrexone has been mainly associated with nausea and vomiting. Less common side effects include headache, anxiety or depression, low energy, skin rashes, and decreased alertness.

However, reported investigational dosages have ranged from 25 mg every third day to 200 mg daily. Karen Miotto, MD, a researcher/clinician at the University of California, Los Angeles, Neuropsychiatric Institute, suggests that many patients are started on too high a dose of naltrexone. She generally prescribes a quarter of a tablet (i.e., 12.5 mg) for the first day or two, increasing gradually up to 50 mg/d as lower doses are tolerated. However, some researchers have noted that blood levels of naltrexone are quite variable, and it is possible that some individuals are not getting a 100% blockade of opiate receptors with 50 mg/d.

 

Hepatic Toxicity

Since naltrexone undergoes extensive first-pass metabolism in the liver, there has been concern about the potential for liver damage at high doses. This might be of special importance in chronic alcohol abusers, who typically have compromised liver functions, and the drug is contraindicated in patients with acute hepatitis or liver failure.

Reported hepatotoxicity came from small studies of naltrexone used for purposes other than substance dependence. Further investigations with dosages up to 200 mg/d have found no greater measurable evidence of hepatic injury in those who received naltrexone for alcoholism than those who did not. In fact, liver function indices actually improved for patients treated with naltrexone, possibly due to reductions in alcohol intake.

 

Behavioral Perspective

David Sinclair, PhD, senior researcher in the Department of Alcohol Research, National Public Health Institute, Helsinki, Finland, has proposed a behavioral extinction model to help explain the efficacy of naltrexone. His approach is based on the notion that, regardless of initial etiologies, alcohol drinking is learned and alcoholism is a conditioned behavior disorder.

Furthermore, Sinclair ­ who was an early investigator of naltrexone in animal models and has since been intensely involved in clinical research ­ proposes that aberrant drinking behaviors can be extinguished by drinking alcohol while on naltrexone, which blocks reinforcement for the behavior. Others seem to have indirectly supported Sinclair’s premise.

Psychiatrist Richard Resnick [interviewed in Part 1 of this series] has noted: “For extinction to occur, there must be some exposure to the conditioned stimulus without any reinforcement.” And, unless such extinction occurs, addicts are vulnerable to relapse; by itself, the amount of time the patient has been abstinent is not sufficient to prevent relapse.

In their pivotal study, Volpicelli et al. similarly observed, “naltrexone had its most important effects in decreasing subsequent drinking once drinking occurred…. Thus, naltrexone treatment is particularly helpful in patients who are likely to sample alcohol.”

 

Extinction Protocol

Recognizing the ethical dilemma of instructing abstaining alcoholics to start drinking again, Sinclair has advocated an “extinction protocol.” Administration of naltrexone is begun without prior alcohol detoxification or required abstinence.

Generally, patients currently drinking alcohol on a regular basis are provided naltrexone without admonishments to immediately abstain, although abstinence may be the eventual goal. After a period of daily naltrexone, a more “targeted” approach may be used: patients are told to take naltrexone only prior to encountering situations where they are likely to drink. This practice may continue indefinitely, and any future bouts of drinking while on naltrexone would expectedly serve to reinforce the extinction process and prevent relearning of drinking behaviors leading to relapse.

All this is not to say that there are no benefits gained from detoxification and abstinence as components of therapy prior to initiation of naltrexone. Sinclair does concede that some trials have found evidence of positive effects of naltrexone prior to drinking; however, he believes these are weaker benefits compared to the extinction protocol. Also, giving naltrexone prior to detoxification allows alcohol withdrawal to be distributed over several weeks or even months, thus improving retention in treatment programs and possibly diminishing potential side effects of naltrexone.

 

Stronger at Broken Places

Research statistics relating to the effectiveness of any substance-dependency treatment can be misleading. Even small improvements can be meaningful, for each percentage point may represent thousands of lives benefited.

Pharmacotherapy may not be a solution for every abusive drinker or full-fledged alcoholic, and recovery goals may differ. The patient may want to achieve abstinence or only curtail drinking. Naltrexone can apparently aid in either of those goals, but it must be properly matched with other treatment considerations.

As Ernest Hemingway wrote in A Farewell to Arms, “The world breaks everyone and afterward many are strong at the broken places.” But, before strength can build, patients must be lured away from the brink of alcoholic devastation. Medications like naltrexone may help.

 

The article above was excerpted from a much longer version, including references. For a free copy of that version, plus the other two articles in this Naltrexone Nexus series, mark the appropriate box on the postage-free response card in this issue and mail it.

From the Editor

Envisioning Tomorrow’s Opportunities, Today

“Ignorance and political cynicism are our greatest adversaries. For too long we have been hiding in the shadows. We need to advocate for what we do,” said Mark W. Parrino, MPA, president of the American Methadone Treatment Association, speaking at the association’s 1998 conference in New York City last September.

Emphasizing the conference theme ­ “Access: Change, Challenge, Opportunity” ­ he continued, “We cannot cling to what we started with 30 years ago, we must lead innovation in the field of methadone maintenance treatment.” The question is: “Do we provide the best therapeutic climate for individualized patient care?” To that end, there is a need to free up treatment slots in existing programs and move stable patients into the care of community-based methadone providers.

The 1,600+ conference attendees from 26 countries spent an exhausting several days at three plenary sessions featuring 14 speakers, and choosing from thirty workshop sessions, demonstrations, and hot-topic round table discussions. “Without question, this was the most successful conference we’ve had,” Parrino later told us. “Curiously, New York Mayor Giuliani’s extraordinary attack against the methadone treatment system [claiming it is just a substitute addiction] framed our event with a powerful and positive energy.”

 

Plenary Session Highlights

Jean Somers Miller, Esq…

…commissioner, New York State Office of Alcohol & Substance Abuse Services (OASAS) ­ “The social and public effects of addiction are highly visible,” she said, “so policy-makers want to know what they are getting for their money invested in addiction treatment.” They need to understand that recovery is a matter of incremental progress rather than overnight successes.

Policy-makers don’t understand why methadone patients may still test positive for cocaine, alcohol, and other substances. “We need to address the problems of polydrug addiction.”

She reminded the audience that addiction treatment is still a relatively young field, covering many professional specialties. The problem is that there is no single discipline to advocate for it.

A partnership between the government and the private sector is essential. Although government agencies may need to establish minimum standards, there needs to be room for professional judgment. “We have to be open to new research and new expectations.”

 

Alan Leshner, PhD…

…director, National Institute on Drug Abuse (NIDA) ­ Noting that there are 72 risk factors for substance abuse and addiction, Leshner, in his always captivating style, boiled them down to two reasons why people take drugs: to feel good (sensation seeking); to feel better (self-medicating).

He noted that NIDA funds 85% of the world’s addiction treatment research, and the neuroscience of drug abuse and addiction has become a “hot area,” ever since it was discovered that prolonged drug use changes the brain in fundamental and long-lasting ways. “The brains of addicts are different,” he stressed.

The person moves quickly from a voluntary decision to use drugs to a state of compulsive behavior, often motivated by craving. “It’s as if a switch has been flipped on and there is now a brain disease.”

But, more than addiction being a brain disease, there are embedded behavioral and social context aspects. Hereditary and environmental influences also interact.

A major task of treatment is to compensate for the brain alterations or change the brain back to normal. The best treatments will combine behavioral and pharmacological modalities, he suggested.

Methadone reduces drug use and returns the patient to a functional and more normal state. “It is not a substitute for heroin,” Leshner emphasized, “the two are very different drugs.” Methadone is more a substitute for the brain’s natural endorphins and maintains a neuropharmacologic comfort zone.

To foster a greater understanding of addiction science, Leshner announced that NIDA is establishing a “National Drug Treatment Clinical Trial Network.” The goal is to build an infrastructure for ongoing research and a way to disseminate new discoveries into everyday clinical practice.

 

H. Westley Clark, MD, JD, MPH…

…incoming director [as of the day he spoke at the conference], Center for Substance Abuse Treatment (CSAT) ­ Clark very eloquently asserted that society expects more from the addiction treatment field than from any other providers of care for chronic diseases.

“We have to be flexible and adaptable,” he emphasized, “applying new science as it becomes available.” Each and every patient should benefit from the latest and best clinical practices.

Researchers need to listen to clinicians, so their research relates to practical experiences. Research designs must be sensitive to realities of the addiction community.

“We need to go to politicians with messages of what works and the evidence to support that,” Clark said. The moral position is to increase the welfare of the community at large, and to do that by turning addict-patients from consumers of tax dollars into tax payers.

However, he cautioned, addicts cannot be transformed overnight. Years of addictive behaviors cannot be undone in 90 days.

 

Beny J. Primm, MD…

…executive director, Addiction Research and Treatment Corporation ­ He emphasized that addiction treatment focuses on the mind, body, and spirit. Yet, the spirit is an often neglected part of the treatment plan.

Addiction cannot be treated in isolation. “We need to match the patient with his or her specific and personal rehabilitative needs. All treatment modalities are effective, and they can be mixed to become more effective.”

Primm advised against developing a “modality eliteness,” with one viewed as better than another. He suggested that what’s most needed is a “Supermarket of Services” providing one-stop shopping for patients to meet their needs, including: job training, legal assistance, family counseling, and other services.

 

Thomas A. Kirk, PhD…

…deputy commissioner, Connecticut Department of Mental Health and Addiction Services ­ As a result of state legislation and partial funding from CSAT, Connecticut is launching a 6-month pilot study to evaluate the efficacy of providing methadone treatment in physicians’ offices.

Sixty patients with at least 12 months of stability in treatment will be split into two groups: 30 will be treated in 5 doctors’ offices; 30 will remain in MMT clinics. Physicians will attend two training sessions and local clinic pharmacies will prepare the methadone and deliver it to participating doctors’ offices.

This pilot study can have significant impact, since other states and the federal government [see McCaffrey below] are interested in learning from the results.

 

General Barry R. McCaffrey…

…director, White House Office of National Drug Control Policy (ONDCP) ­ A closing highlight of the conference was McCaffrey’s much publicized appearance. Claiming that methadone treatment in the U.S. has not gone far enough, he pointed the finger of blame at ignorance. For example, he noted that methadone drug dosages are too often determined by policy rather than individual patient needs. And, eight states still allow no MMT programs.

He said we need a more rational drug policy that treats addiction similar to other areas of medicine, like heart disease. To that end, “treatment must be provided in all settings in which drug abuse occurs ­ at inner-city clinics and in suburban doctors’ offices alike.”

McCaffrey wasn’t specific about how and when this would occur, but did say increased funding has been proposed for expanding treatment capacity. Also, as physicians become trained in administering methadone in private offices, new regulations expanding access to such treatment would be issued.

He also mentioned ­ and this had already been a topic of much discussion during the conference ­ that the current regulatory approach to MMT will be replaced with a new system reflecting an outcome-oriented accreditation model. Regulatory oversight for methadone will be integrated into CSAT/SAMHSA; law enforcement (anti-diversion) responsibilities will remain with the DEA.

The goal is to have accreditation standards by June 2000. “If you meet them you get to operate [your] mental health clinic, if you don’t, you get closed down,” McCaffrey told the crowd. He conceded, however, “We don’t want to wreck the existing 900 treatment programs in the process of doing this.”

 

Unanswered Questions

In talking with Mark Parrino following the conference, he suggested there were unanswered questions: “Accreditation will enhance the quality of services in the field, but what will be the financial costs of that to MMT programs? Will the improved outcome of patients, which is expected, be justified by those costs? And, will programs receive technical assistance from CSAT to meet the new requirements?”

Also, although expansion of methadone treatment is certainly desirable, the American Methadone Treatment Association has viewed that issue from a “medical maintenance” perspective ­ allowing stable patients to be treated by specially trained and qualified private practitioners who are aligned with clinics.

However, McCaffrey’s suggested broadening of the field raises new questions, Parrino notes: “Should all doctors in the U.S. be able to prescribe methadone to any opioid-dependent patient because that’s the right thing to do? Will those physicians know how to prescribe the right dose, and how to give patients individualized care and counseling, and deal with HIV, hepatitis, tuberculosis, etc.? Why would doctors want to do that? Which doctors? And, who is going to pay for that?” [These were also questions discussed in A.T. Forum a year ago, Vol. VII, #1, Winter 1998.]

Essentially, McCaffrey’s statements might be taken more as a vision for tomorrow. The specifics of how to get there have not been outlined, and Parrino says, “The next two years will be a time of establishing the groundwork for expanded access to treatment. Federal agencies will need to work together with the states and with individual treatment providers.”

 

Next Conference

Attendance at the New York Conference was over a third greater than Chicago in 1997. Will the next gathering be even bigger and better? To find out for yourself, save this date: April 9-12, 2000 at the Hyatt Regency San Francisco in Embarcadero Center, San Francisco.

 

Reader Survey – Docs Prescribing Methadone?

The notion of recovering opioid addicts receiving methadone from community-based physicians may stir mixed emotions among many in the addiction treatment field. McCaffrey, during questioning from the audience, allowed that, after all is said and done, any “trained” physician would be able to prescribe methadone, any time, any place.

 

What do you think? Here are four questions:

1. Is methadone treatment in private doctors’ offices a good idea?

Yes No Don’t Know

2. Will private physicians have an interest in treating opioid addiction?

Yes No Don’t Know

3. How much specialized training should those physicians have?

1 to 2 day course

MMT clinic experience

Addiction specialists only

Other: ___________________

4. How long should patients attend clinic programs before referrals to doctors’ offices?

No clinic necessary

6 months

1 year

2 years

3+ years

There are several ways for you to reply: 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 will help us better discuss the results in our next issue.

 

Stewart B. Leavitt, PhD, Editor
stew202@aol.com
Addiction Treatment Forum
1750 East Golf Rd., Suite 320
Schaumburg, IL 60173
FAX: 847-413-0526
Internet: http://www.atforum.com

Events to Note

For additional postings & information, see: www.atforum.com
JANUARY 1999
Prevention Think Tank Symposium
January 21-24, 1999
Singers Island, Florida
Sponsor: Prevention Think Tank
Contact: Barbara Jacobi 301-518-2354; bajacobi@erols.com
Treatment of Addictive Disorders
January 25-29, 1999
Colorado Springs, CO
Sponsor: Psychotherapy Associates
Contact: Gary Forrest 719-594-9304
FEBRUARY 1999
Annual FSAM/ASAM Conference on Addictions
Feb. 5-7, 1999
Orlando, FL
Contact: Robert Donofrio 850-484-3560; healthsystems@pen.net
10th Annual Youth-At-Risk Conference
February 28 – March 2,1999
Hyatt Regency Hotel on the Historic Riverfront, Savannah, Georgia
Sponsor: College of Education – Georgia Southern University
Contact: Sybil Fickle 912-681-5555; sfickle@gsaix2.cc.gasou.edu
MARCH 1999
12th National Youth Crime Prevention Conference
March 3-6, 1999
Adams Mark Hotel, Denver, CO
Sponsor: Youth Crime Watch of America and National Crime Prevention Council
Contact: M. Catoggio 305-670-2409
APRIL 1999
American Orthopsychiatric Association 76th Annual Meeting
April 9-11, 1999
Washington, DC
Contact: 212-564-5930
ASAM ­ 30th Annual Medical-Scientific Conference
April. 29 – May 2, 1999
Marriott Marquis; New York, NY
Contact: 301-656-3920; asamoffice@aol.com or www.asam.org
[To post your event announcement in A.T. Forum and/or our Web site, fax the information to: 847/413-0526 or submit it via e-mail from http://www.atforum.com]

Where to Get Info

New Books of Interest

Counselor Text on Dual Diagnoses
David F. O’Connell, PhD, psychotherapist and clinical director of a leading addiction treatment facility, has written a must-have book for all addiction counselors and associated staff. Dual Disorders: Essentials for Assessment and Treatment, released this year, will help health care professionals become better diagnosticians, develop improved treatment plans, and communicate more meaningfully with other mental health professionals. Soft cover (250pp), ISBN: 0-7890-0401-1, $19.96 (US$). Haworth Press: 1-800-429-6784; outside US/Canada 607-722-5857; www.haworthpressinc.com.
PDR Publisher Offers Herbal Guide
PDR for Herbal Medicines is a new guide aimed at giving health care workers unbiased data to guide patients who may be taking such alternative therapies. The book is from the publishers of the Physician’s Desk Reference (PDR). ISBN 1-5636-3292-6, $59.95 (800pp); Medical Economics Company, Montvale, New Jersey; 1-800-PDR-9206.
ASAM Updates Addiction Tome
The American Society of Addiction Medicine has released the Second Edition of its comprehensive textbook on alcohol, nicotine and other drug dependencies. Principles of Addiction Medicine (2nd ed) encompasses original and previously published work in 100 chapters, written by 157 authors. From ASAM Publications: 1-800-844-8948, Fax 301-206-9789; $155.00 for non-members, $130.00 for members
Book Ties Neuroscience, Behavior
Drug Addiction and Its Treatment: Nexus of Neuroscience and Behavior, edited by Bankole Johnson and John Roache, proposes that the behavioral and neuroscience disciplines would benefit from a mutual understanding of each other’s technology. It suggests ways of integrating behavioral and pharmacological treatments of drug addiction. From Lippincott-Raven, Philadelphia, 1997 (448pp, illustrated); ISBN 0-3975-1764-5; $131.00.
Most books are also available from www.amazon.com and other on-line booksellers.

MMT Dose Survey ­ Continued

Regional & Clinic Operation Trends

In the last issue of A.T. Forum (Vol. VII, #3; Fall 1998), we reported on readers’ responses to our survey of methadone dosage practices at MMT clinics. To summarize: between 1988 and 1998 in the United States, there was an encouraging 54% ten-year increase in mean “average dose,” rising to 69.4 mg/day; mean “highest dose” rose 56% over that period to 123 mg/d.

As in our 1993 survey, we also examined possible differences by United States regions and clinic operations; i.e., whether the clinic operated on a for-profit or non-profit/public basis. For the first time, we also tallied responses from readers outside the U.S.

 

Regional Shift

Figure 1 shows that each of the four regions we examined had statistically significant increases for both highest and average methadone doses between 1993 and 1998. Focusing on 1993, the only significant regional difference was for highest dose in the Eastern region. In our 1998 survey, the only region reporting a significant difference from the others was for the highest dose in the Midwest.

Thus, in 1998 there was an unanticipated shift from the East to the Midwest as having the greatest mean “highest dose.” Otherwise, dosing patterns appeared consistent across U.S. regions in 1998.

 

Clinic Operations Equalized

Figure 2 indicates that all of the dose increases observed from 1993 to 1998 ­ for both types of clinic operation ­ were statistically significant. However, whereas in 1993 the for-profit/public clinics had a significantly higher average dose, by 1998 our survey found no significant clinic operation differences for either highest or average dose.

Hence, the non-profit clinics appear to have caught up with the for-profits, and this would seem to dispel any misperceptions about for-profit clinics giving patients higher methadone doses. Our 1998 survey might also more accurately represent for-profit clinics, since there were over twice as many respondents from these types of clinics compared to 1993.

 

O.U.S. Similar to U.S.

Figure 3 demonstrates that the highest dose reported by readers from outside the U.S. (O.U.S.) in 1998 was similar to the East, West and South regions; average dose was similar to all U.S. regions. This may lead one to hypothesize that dosage policies are consistent across international borders. However, our sample was relatively small and potential differences between various O.U.S. countries could not be analyzed. This seems an appropriate area for further research.

 

Summary

In terms of highest and average methadone dose, and on a regional and clinic operation basis, there were significant increases between 1993 and 1998. For unknown reasons, the Midwest U.S. region now has the greatest average “highest dose”; otherwise, the regions are very similar. In 1998, there were no differences between for-profit and non-profit clinics in terms of dose levels. Methadone dosing levels reported from outside the U.S. were very much like those in the United States.

Our article last fall described a number of methodological limitations inherent in A.T. Forum surveys. However, assuming the trends are accurate, the field has come a long way in providing more liberal, and optimal, methadone doses. Research consistently shows that, on average, higher doses lead to greater patient retention in treatment and fewer episodes of illicit opioid use. Of course, an uncertainty of average figures is that individual patient needs must still be taken into account.

We would encourage other organizations to undertake further surveys of this nature, ideally international in scope.

Readers Survey

Better Detox Ranked High

The Fall 1998 edition of A.T. Forum (Vol. VII, #3) featured several articles emphasizing a need for more and better research on addiction. Recognizing that there are many addiction treatment challenges worthy of further investigation, in the face of limited funding, we asked readers for their opinions as to where more research funds should be spent.

There were 202 responses, either on mail-in cards or at our Web site, www.atforum.com. Here is a recap of those opinions (by percent):

– Evaluating better detoxification methods ­ 30%
– Improving counseling techniques ­ 25%
– Expanding uses of maintenance drugs (besides methadone and LAAM) ­ 20%
– Defining hereditary influences in addiction ­ 10%

Although the top three were fairly close, developing better detoxification methods had highest priority. However, there are no indications of what might be lacking in present detox approaches.

Improving counseling techniques also received a large share of votes, and this is exactly the sort of research being pursued by D. Dwayne Simpson, PhD and his group at TCU in Texas, as described in our last edition. In fact, as we noted, interested readers can access a great wealth of information on the subject at the Institute for Behavioral Research Web site: www.ibr.tcu.edu.

Next, there was interest in expanding uses of maintenance drugs. And, as the 1995 IOM report “Development of Medications for the Treatment of Opiate and Cocaine Addictions” concluded, “Pharmacology for the treatment of drug addiction has received far too little attention… over the last 30 years only two additional medications [besides methadone] have been approved for the treatment of opiate addiction ­ naltrexone and levo-alpha-acetylmethadol (LAAM) ­ and it is important to note that both those medications were developed in the 1960s and 1970s.” Many reasons for this were suggested, and perhaps the situation has improved in the past few years, but readers obviously want to see more activity in this arena.

As might be expected, research into hereditary influences was ranked relatively lower than the others. Being able to predict hereditary factors in addiction has apparent value for prevention, but would not help those already addicted. However, being able to modify (i.e., correct) the gene structures of addicts after-the-fact may seem like science fiction today, but could become a future reality if research proceeds in that direction.

 

Readers Comments

The remaining 15% of responses indicated “other,” and some readers included research suggestions:

  • Outcome studies on MMT effectiveness to demonstrate needs for increased funding.
  • Evaluate the efficacy of methadone along with other psychotropic medicines.
  • Research on the value of take-home methadone and the true extent of diversion.
  • Interaction between methadone and AIDS therapies.
  • Studies using herbs and other alternatives to lessen withdrawal symptoms.
  • Investigations of the endorphin system and the role of opiate receptors in addiction and recovery.
  • Individualizing methadone dose based on clinical and metabolic responses (evaluating serum levels, liver enzyme function, hereditary influences, etc).
  • Research on quality control in MMT.
  • Explore relationships of methadone dose and socioeconomic factors (employment, housing, family life, etc.)

 

Expand Treatment

Finally, one reader suggested using funds to make treatment more affordable and finance the expansion of treatment centers. Although this does not seem to be a research objective, it suggests a reapportionment of funds from other areas for expanding community-based treatment programs.

Several readers wanted more research on the value of medical maintenance and/or community physicians prescribing methadone. Those are ongoing concerns, also explored elsewhere in this issue of A.T. Forum.