A.T.F. Volume VIII #3 Summer 1999 – Addiction Treatment Forum

The Value of Addiction Treatment
Clinical Concepts- Why Measure Methadone Blood Levels?
From the Editor
Events to Note
Where to Get Info
Readers Survey – MMT Clinic Challenges?
Brainstorm: Exploring the Body, Mind & Soul of Addiction Part 1

The Value of Addiction Treatment

There is often a disconnect between facts and perceptions regarding addiction. And when placing a value on the benefits of addiction treatment, public and political skepticism sometimes emerges.

Everyone, it seems, knows someone for whom an expected treatment “cure” has failed. Consequently, there are periodic campaigns to cut addiction treatment budgets or curtail new clinic openings.

While the current state of addiction treatment may not be perfect, a multitude of reliable sources claim that it certainly does work. But, who says so? And how can a value be placed on it?

Costs & Consequences

In 1997, there were an estimated 27.8 million Americans needing addiction treatment, with only 3 million persons entering treatment in any year. According to the Center for Substance Abuse Treatment (CSAT), every American man, woman, and child pays over $1,000 each year to cover the $275 billion tab for untreated substance abuse. Such costs are from lost productivity, law enforcement and justice, health care, welfare and other indemnity.[1]

It would cost each American about $45 per year to provide a full continuum of services for treating all addictive disorders [1] – less than 5% of the current per person toll for lack of treatment.

A 2-year California Drug and Alcohol Treatment Assessment (CALDATA) study, following 150,000 persons through treatment, found that for every $1.00 spent on treatment more than $7.00 in future costs were saved by reductions in substance abuse-related criminal activity and hospitalizations. From pre- to post-treatment, criminal activity declined by 2/3 and hospitalizations by 1/3.[2]

Medical Costs Cut

Although addicted persons are among the highest consumers of medical care, only 5-10% of the costs are due to addiction treatment itself. The rest is attributed to injuries and disorders – such as, certain forms of cancer, pancreatitis, endocarditis, HIV/AIDS – that often result from the addiction.[3] Over 72 medical conditions have risk factors attributable to substance abuse.[1]

Studies in 15 states conducted by the National Association of State Alcohol and Drug Abuse Directors (NASADAD) found decreases in hospitalizations resulting from addiction treatment ranged from 36% in California to 66% in Ohio.[2] In one California program, mental health hospitalizations alone decreased 44%. Other reports claimed health care costs for patients were 87% less by the third year after addiction treatment.[1]

Criminality Curtailed

About a third of all justice system costs derive from untreated substance abuse, not including $250 billion in losses borne by victims of drug-related crime. Over 1.2 million prison inmates are substance abusers and addicts. Yet, in 1996, only 18% of state and federal inmates needing addiction treatment received it.[1]

Iowa realized savings of $87 million from reductions in crime by providing addiction treatment during incarceration. Oregon found that a 1-year investment in treatment resulted in 58,000 fewer crimes in the following 3 years.[1]

A National Institute of Justice study conducted in Delaware found that inmates receiving addiction treatment in prison and during work release programs were 75% drug-free and 70% arrest-free after 18 months. Of those prisoners not treated, 80% went back to drugs and 2/3 were arrested again.[4] The NASADAD study found that arrests after treatment dropped dramatically: e.g. a 50% decrease in Iowa, 90% decrease in Ohio.[2]

A recent program in Arizona, sentencing nonviolent drug offenders to treatment rather than prison, saved taxpayers more than $2.56 million and 78% of the participants later tested drug-free.[5]

Families Resurrected

A RAND Corporation study determined that providing treatment to all addicts in the U.S. could save more than $150 billion in social costs over the next 15 years, while requiring only $21 billion in treatment expenditures.[4]

About half of domestic violence is related to addiction problems. Injuries to women by their partners total over $44 million in annual medical costs, and 80% of all child abuse cases involve parental substance abuse.[1]

Approximately 78% of children entering foster care are from families ravaged by substance abuse, and drug exposure is a factor in 87% of abandoned infants. However, CSAT demonstrated that up to 87% of children and mothers were reunited one year after the mothers completed addiction treatment.[1]

Methadone Cost-Effective

According to the Office of National Drug Control Policy (ONDCP), there are over 800,000 untreated heroin addicts in the U.S. On any given day about 179,000 patients in the U.S. receive methadone treatment for heroin; merely 18% of the total who might benefit.[6]

Comprehensive cost/benefit analyses of methadone maintenance treatment (MMT) have shown that every $1.00 spent on MMT accrues $4.00 in economic benefits.[7] Among other factors, research has demonstrated that MMT significantly reduces the rate of HIV infection among patients, and 70% of addicts enrolled in MMT reduce or eliminate criminal activity during the first year of continuous treatment.[6]

Of the various treatment modalities examined by the CALDATA study, continuing methadone treatment was the lowest in cost: 90% lower than residential treatment and 20% lower than outpatient drug-free treatment.[2]

Research by Steven Batki, MD and associates at San Francisco General Hospital demonstrated a 42% reduction in hospitalizations and a 50% decline in hospital days among HIV-positive heroin addicts during MMT treatment. Overall, there also were 90% fewer hospital admissions for illicit drug injection-related soft tissue infections. For addicts with tuberculosis, ongoing MMT treatment decreased annualized medical costs by 65%.[8]

Chronic Medical Disorder

It is easy to believe that addiction is unlike other diseases and addicts are different from other patients. Yet, as a chronic medical condition, often with a genetic contribution, drug dependence is comparable to diabetes, hypertension, or asthma. And, addiction treatment has success outcomes equivalent to or better than treatments for those other chronic conditions. In fact, a Harvard University study found that substance abuse interventions ranked among the top 10% of over 500 cost-saving and life-saving medical treatments.[3]

As with other health problems, certain behaviors – diet, exercise, attending clinic visits, properly taking medications – affect the natural progression and treatment outcomes of drug addiction. According to the Physician Leadership on National Drug Policy, behavioral and medication compliance among recovering addicts is comparable to patients being treated for diabetes, hypertension, or asthma. Surprisingly, the relapse rate (likelihood of needing re-treatment within a 12-month period) is actually lower for drug addiction treatment (see chart).[3,9]

Stigma Stymies Success

Obviously, there are many sources providing scientific data on the costs and consequences of drug addiction and the benefits of its treatment. It is important to note that the data and calls for action are largely coming from credible government agencies and respected research institutions, rather than treatment providers or advocacy groups that might have more biased or self-serving interests.

Unfortunately, pervasive stigma is often a barrier to those who would otherwise seek addiction treatment, to health care practitioners who would otherwise do more to treat addiction, and to legislators and public officials who would otherwise do more to make treatment readily accessible.[3] However, the facts seem clear: addiction treatment reduces costs while resurrecting the lives of addicts and their families. Society at large benefits from winning back responsible, productive, tax- paying citizens.

1. Substance Abuse in Brief. Rockville, MD: Center for Substance Abuse Treatment; January 1999.
2. Matching Treatment to Patients’ Needs in Opioid Substitution Therapy. Treatment Improvement Protocol (TIP) Series 20. Rockville, MD: Center for Substance Abuse Treatment; 1995. DHHS publication (SMA)95-3049.
3. Lewis D. Treatment works – the truth please. Brown University Digest of Addiction Theory & Applications. 1998;17(4).
4. Fast facts on drug treatment. Office of National Drug Control Policy. Available at: http://www.whitehouse drugpolicy.gov. Accessed February 10, 1999.
5. Graham P. Drug treatment cuts crime, saves money [news report]. Associated Press. April 21, 1999.
6. Methadone treatment survey reveals 56% more patients enrolled in methadone treatment than previously reported [press release]. New York: American Methadone Treatment Association; April 8, 1999.
7. Harwood, et al. The Costs of Crime and the Benefits of Drug Abuse Treatment. NIDA Monograph Series 86. Department of Health and Human Services, 1988.
8. How MMT saves money. Addiction Treatment Forum. 1999;VIII(1):1.
9. McLellan T. Compliance and “relapse” in selected medical disorders. Physician Leadership on National Drug Policy (PLNDP). Available at http://www.caas.brown.edu/plndp/akit/pl24.gif. Accessed May 18, 1999.

Clinical Concepts

Why Measure Methadone Blood Levels?

“I’ve been on 100 mg/day of methadone for almost two years, but I wake up in withdrawal every morning. My clinic recently gave me something called a ‘trough test.’ They never told me what that meant, but it justified their raising my dose. I thought 100 mg/day was the highest one could go. Now I’m up to 130 mg/day and I feel a little better but am still doing poorly every morning. What could be the matter with me?” – via e-mail to AT Forum.

What is the “trough test”? Why and when should it be used? How can it help?

Patients in methadone maintenance treatment programs sometimes complain of problems with a given dose of methadone: “My dose isn’t holding me”; “I get sleepy at work”; or, “I wake up sick in the morning” (in our reader’s case). Certainly, there is some variation in how patients react to methadone, and blood level measurements can be very useful when the clinical picture does not agree with the typical or expected response to a given dose of methadone.[1]

Peaks & Troughs

Methadone, administered daily at a steady dose, should be present in the blood in levels sufficient to maintain “normalcy” over a 24-hour period. That is, the patient should not feel drugged or “high,” or have withdrawal symptoms (abstinence syndrome) during that time.

Measuring levels of methadone in the blood – in terms of nanograms per milliliter or ng/mL – is helpful in determining how much of the medication is circulating in the patient’s system. Typically, the blood level reaches a high point, or “peak,” about 3 to 4 hours after taking the dose. There is a gradual decline over the remainder of the 24-hour period to a low point or “trough” level.

Blood levels are interpreted in the context of the patient’s clinical presentation; the lab values help in making dosing decisions when faced with challenging cases. The trough level at 24 hours should be at least 150 to 200 ng/mL, or 400 ng/mL to achieve cross-tolerance, thereby making ordinary doses of IV heroin ineffective.[1]

In practice, serum methadone levels are sometimes more helpful in confirming inadequate dose than in determining optimum dose. Clinicians Sarz Maxwell, MD and Marc Shinderman, MD recommend that a minimum of 400 ng/mL (trough level) is usually effective for alleviating objective signs and subjective symptoms of opioid abstinence syndrome.[2]

The peak level at 3 to 4 hours should be no more than twice the trough level, giving an ideal peak/trough ratio of 2 or less. This rate-of-change ratio can be of more clinical value than the actual levels. A ratio of 3.5 would indicate rapid metabolism (early peaking) possibly leading to unexpected withdrawal symptoms, whereas 1.7 might suggest normal metabolism. A trough level alone, although useful, does not indicate the rate of change over the time-course of a dose.[1]

Methadone peak, trough, and average levels and the rate of elimination (half-life) may be influenced by several factors: metabolism, poor absorption, changes in urinary pH, concomitant medications or drug abuse, diet, physical condition, pregnancy, even vitamins.[1,3,4] Research also shows that two equally occurring forms of the methadone molecule (enantiomers) in the medication – one active, the other inactive – are metabolized at unequal rates in some patients. The amount of active methadone can vary greatly between two patients at the same serum level; one will be comfortable while the other is not. [2,5] However, the clinical utility of this has not yet been established and testing for the ratio of active to inactive methadone in serum is not commonly available.

Broad Ranges

According to Mitchell Bradbury, PhD, opiate toxicology and patient self-reports are the most commonly used indicators of appropriate methadone dose, but they can be misleading without also assessing plasma levels.[6] Bradbury and Philip Paris, MD have reported on 55 patients evaluated for methadone dose/opiate withdrawal-related problems, with trough methadone plasma levels obtained on all patients upon entry into the study.[3]

Of interest, there was a wide range of plasma levels at each daily methadone dose. For example, among 4 patients receiving 60 mg/d (milligrams per day), trough levels ranged 10-170 ng/mL; 20 patients receiving 100 mg/d ranged 90-520 ng/mL; and for 10 patients at 120 mg/d the range was 10-440 ng/mL. At each methadone dose there were patients well below optimum trough levels.[3]

Positive correlations have been found between opiate-positive urines and patients with psychiatric diagnoses taking psychotropic medications. These patients benefit from higher methadone doses, and serum levels may be especially helpful since they may not stabilize as quickly or effectively as other patients. There also may be limitations in their psychosocial coping mechanisms, or drug interactions with the prescribed medications.[2,3]

Curiously, in the Bradbury/Paris research, there also was a strong positive correlation between patient weight and methadone plasma level. Heavier patients had higher trough levels.[3] Bradbury notes the reasons for this aren’t clear and further research is needed.[6]

From Australia, addiction specialist Andrew Byrne, MB, BS reported on trough level studies in 56 patients who were unstable (using illicit opioids) despite receiving up to 150 mg/d of methadone. Serum level findings ranged from 35-330 ng/mL, with an average of 250±150 ng/mL. Weekly methadone dose increases of 15 mg/d up to a maximum of 350 mg daily resulted in considerable improvements, with reduction or elimination of heroin use and enhanced self-reported well-being.[6,7]

However, one patient in this study had a trough level of 700 ng/mL and exhibited excessive sedation with small pupils, so dose was accordingly adjusted downward. Byrne recommends examining all high-dose patients three hours after witnessed dosing to exclude clinical toxicity.[6]

Clinical Challenges

Blood level testing must be considered in the total context of the patient’s physical and mental condition. Bradbury and Paris presented some telling examples: [3]

A woman was transferred from an MMT program where she was told that her 100 mg/d dose was plenty (as with our write-in reader above). On the new program her dose was raised to 120 mg/d, but the plasma level was still low (130 ng/mL). The dose was titrated upward to 180 mg/d, relieving her withdrawal symptoms as methadone trough blood level reached 250 ng/mL.
A male patient was stable and free of illicit drugs at 100 mg/d, but insisted on a dose reduction. He soon developed withdrawal symptoms. His blood level tested at a low 100 ng/mL, convincing him he needed to return to the original dose.
A patient taking several psychiatric medications and 80 mg/d of methadone was experiencing severe withdrawal symptoms. Her methadone trough plasma level was non-detectable. However, at 140 mg/d she experienced sedation after taking her methadone and opiate withdrawal at night [peak/trough ratio very high]. Splitting the dose – 70 mg morning/70 mg night – eliminated both sedation and withdrawal feelings.

Each patient presents a unique clinical challenge. Byrne suggests, “If the patient or doctor is reluctant to move to a higher methadone dose on clinical grounds alone, a blood level test can be quite revealing; it is usually quite low. This will give both parties confidence in trying a higher dose. If the results are then between 200-500 ng/mL, a higher dose may still be needed but clinical signs become particularly important and increments should be modest (5 mg/d increases per week).”[6]

Treat Patients Not Numbers

Bradbury believes methadone blood levels should be used routinely, bringing respectability to methadone dosing practices just as with other medications. “You wouldn’t give somebody insulin and say, ‘Let me know when the dose feels OK.'”[6] Byrne compared methadone dosing to lithium, digoxin, and anticonvulsant therapy where blood levels are critical for clinical management.[7]

As for the economics of blood level testing, Byrne indicates that the test is relatively inexpensive compared to the “cost” of giving someone inadequate doses of a drug for months or years. “Unfortunately,” he says, “the doctor who is disinclined to order a test may also be disinclined to order a higher dose. Patients should never be denied the right dose because of a doctor’s ignorance, bias, or prejudice.”[6]

At the same time, Byrne cautions, “We must never make the mistake of treating the test but ignoring the patient.”

Still, as the limited research on blood level testing demonstrates, there is no way of prescribing a single best dose to achieve a specific blood level as a “gold standard” for all patients. Providing effective treatment and comfort for patients by making flexible dosing decisions supported by appropriate laboratory procedures can be crucial. This also supports the premise that setting methadone doses by policy or regulation alone is simply not good science.

1. Payte JT, Zweben JE. Opioid Maintenance Therapies. In: Graham AW, Schultz TK, eds. Principles of Addiction Medicine. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine; 1998:557-570.
2. Maxwell S, Shinderman M. Optimizing response to methadone maintenance treatment: use of higher-dose methadone. J Psychoactive Drugs. 1999;31(2). In press.
3. Bradbury M, Paris P. Exploring serum methadone levels as a tool to enhance methadone treatment efficacy. Presented at: American Methadone Treatment Association Conference; September 1998; New York, NY.
4. See also: Methadone at work. AT Forum. 1997;4(2). (Available online at: http:// www.atforum.com.)
5. Eap CB, et al. Replacement of R-methadone by double dose of R, S-methadone in addicts: Interindividual vari- ability of the R/S ratios and evidence of adaptive changes in methadone pharmacokinetics. Eur J Clin Pharm. 1996;50:385-389.
6. In personal communication with AT Forum.
7. Byrne A. Use of serum levels for optimizing doses in methadone maintenance treatment. J Maint Addic. 1998;1(3):13-14.

From the Editor

Disturbing Legislative Trend Sends Warning

Politicians Practicing Medicine

Last summer (July 1998) New York Mayor Rudolph Giuliani’s plan to scuttle city-sponsored methadone maintenance treatment (MMT) programs shocked addiction experts and federal drug officials. Giuliani said heroin addicts should learn to recover without the help of medication.
Then, last February (1999), Sen. John McCain (R-AZ) introduced Senate bill S-423 – the “Addiction Free Treatment Act” – which would curtail all federal funding for methadone and LAAM maintenance programs. The legislation stated that the federal government should adopt a zero-tolerance, non-pharmacological policy with the objective of independence from addiction. It also proclaimed, “[methadone] results in the transfer of addiction from one narcotic to another.”
This past May, there was a flap over two proposed Congressional bills mandating private insurers to cover addiction treatment on a par with other health coverage. Unfortunately, it seems one version of the bill would support all treatment modalities, whereas the second would endorse only abstinence-based treatment, leaving MMT patients out in the cold.
At the state level, a Pennsylvania legislature bill submitted last spring would authorize any municipal government to bar methadone clinics on the grounds they could “jeopardize the public health, safety, or welfare.”


Is Anybody Listening?

One wonders where the politicians were getting their information? They seemed to misunderstand both drug addiction and its medical treatment.
To his credit, Giuliani admitted his plan was “maybe somewhat unrealistic” and recanted his position last winter. Perhaps he was influenced by U.S. Drug Czar Barry McCaffrey’s pronouncements that methadone treatment had not gone far enough in this country, pointing the finger of blame at ignorance, and his advocacy of wider distribution of methadone, not less.
Professional groups, like the American Society of Addiction Medicine, called upon their members to actively oppose any legislation that would disenfranchise patients receiving non-abstinence-based treatments, such as with methadone, LAAM, or other medications.
Whatever the outcomes of the various federal and state bills, the disturbing trend is that politicians appear to be rendering opinions cum laws regarding the validity, efficacy, and applicability of treatments for addictive disorders. As articles in this issue of AT Forum discuss, there is a broad body of scientific evidence and expert medical advice regarding what addiction is all about and the effectiveness of various treatments. Will the politicos pay attention to the experts?


Reader Survey – Measure Methadone Blood Levels?

As a follow-up to our article in this issue regarding the merits of measuring methadone blood levels, please respond to the following:
1. Does your clinic measure methadone blood levels?
Often;
Occasionally;
Rarely;
Never
2. How are the results used?
Guide routine methadone dose adjustments;
Analyze dosing problems;
Overcome patient resistance to dose change;
Other: ______________
3. How much do you pay for the lab test? $_______
4. Who pays for the test? ________

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 also help us 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

August 1999

3rd Annual HCV Conference
The World & Hepatitis C
August 21-23, 1999
Oakland, CA
Contact: 415-920-7000

Advanced School of Addiction Studies
August 24-27, 1999
Waterville Valley, New Hampshire
Contact: 207-621-2549, or neias@agate.net

National HIV Prevention Conference
August 29 – September 1, 1999
Atlanta, GA
Contact: 404-639-1942, or 99hivconf@cdc.gov
www.cdc.gov/nchstp/hiv_aids/conferences/nhpc99.htm

September 1999

12th National Prevention Network Research Conference
September 13-15, 1999
Buffalo, NY
Contact: Sue Carlson 405-325-1447, or scarlson@ou.edu
www.ccfd.com/NPN

Increasing the Effectiveness of Counseling
September 23-25, 1999
Las Vegas, NV
Contact: Lorrie Keip 800-441-5569, or lorriek@hcibooks

Great Lakes Conference on Addictions & Mental Health
September 26-29, 1999
Indianapolis, IN
Contact: Dennis S. Miller 317-283-8315, or gr8lakestr@aol.com

October 1999

NYSAASAP-3rd Annual Conference
Oct. 21-23, 1999
Rye Brook, NY
Contact: 518-426-3122, or NYSAASAP@Albany.net

November 1999

ASAM MRO Training Course
November 12-14, 1999
Lake Buena Vista, Florida
Contact: Sandy Metcalfe 301-656-3920, or email@asam.org
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

Addiction Treatment “Bible”

Principles of Addiction Medicine/ Second Edition is an extensively revised version of the original 1994 landmark publication from the American Society of Addiction Treatment. This edition includes over 100 updated chapters (17 completely new) offering a complete cross-section of core topics, including: medical disorders in the addicted patient, clinical diagnosis and assessment, the pharmacology of addictive drugs, twelve-step programs, behavioral therapies for addiction and pain management, and much more.

With this new edition, the definition of addiction medicine has been refined and enriched, the neuroscientific foundations of addictions have been described, and the most effective techniques and concepts related to addiction treatment have been reviewed. There are also 7,000 references for further inquiry.

This comprehensive text belongs on the reference shelves of all physicians, counselors, and other health care professionals concerned with addiction. Make that a sturdy shelf; with nearly 1,400 pages, it weighs close to 7 pounds. Every treatment clinic would find at least one copy for staff use well worth the investment – $155 ($130 ASAM members) + shipping.

ISBN 1880425041; available from ASAM at 1-800-844-8948 (Fax 1-301-206-9789), or online at www.amazon.com.

Updated Medicine Manual

The Merck Manual – Centennial Edition marks the 17th revision of this classic reference spanning 100 years. It’s the most widely used medical text in the world and the “hypochondriac’s hymnal.”

The 1999 Merck has updated lowdown on the vast expanse of human diseases, disorders, and injuries, as well as their symptoms and recommended therapy. It takes essential information from hundreds of references and squeezes it into one book; the type is tiny on its 2,800+ pages.

At $35.00, the cost is certainly reasonable. Plus, this Centennial package includes a separate reprint of the 192 page first edition, Merck’s Materia Medica, based on the U.S. Pharmacopoeia of 1899. Imagine arsenic as a nostrum for alcoholism?! That’s what it says.

ISBN 0911910107, Merck Research Laboratories. Available at most walk-in and online bookstores.Monte_Bryant@brown.edu.

Readers Survey – MMT Clinic Challenges?

Silent Epidemic

In the Spring 1999 edition of A.T. Forum, readers were asked to identify the single most critical challenge facing methadone maintenance treatment (MMT) clinics. There were 275 responses, either via mail or at our Web site.

Readers were asked to indicate one of eight choices or to write in their own entries. The percent responding to each item was:

· Funding for ongoing or expanding operations – 18%
· Recruiting new patients – 17%
· Hiring and training good staff – 16%
· Dealing with local community politics – 16%
· Retaining patients in treatment – 9%
· Complying with state and/or federal regulations – 5.5%
· Controlling methadone diversion – 5.5%
· Developing proposals for research grants – 1%
· Other – 12%

Stigma Stifles Treatment

Many reader comments related to the stigma surrounding MMT, which would also seem to negatively impact the top four ranked issues of funding, recruiting patients, staffing, and politics. Recently proposed federal legislation and local initiatives viewed as anti-methadone were of much concern (see also, “Straight Talk from the Editor” in this edition).

A few readers pointed to the ongoing need for educating the public, politicians, and medical professionals about the benefits of methadone treatment. One wrote: “Educating other behavioral health care providers of the efficacy of methadone treatment, especially other substance abuse treatment providers, presents a serious challenge.”

Greater Access Needed

One survey respondent simply noted: “The greatest challenge is making sure that everyone who needs MMT gets it.” Treatment should be available on demand, at a reasonable cost, and with sufficient slots to accommodate community needs.

There also needs to be a shift away from treatment as punishment, with modifications of regulations allowing patients to develop improved self-esteem. A reader commented, “Over time, patients should be able to decrease their attachments to clinics.” Medical maintenance or physician office-based treatment programs were mentioned as important for fostering long-term recovery and reintegrating patients into drug-free lifestyles.

While opening new clinics and expanding patient enrollments at existing facilities were deemed critical needs, hiring, training, and retaining good staff were viewed of equal importance. Along these lines, a more humane treatment atmosphere and organizational professionalism in clinics were mentioned as positive factors. One reader noted that resolving issues of overworked personnel and safety were critical for recruiting and retaining good staff.

Regulation, Diversion Manageable

Complying with regulations and controlling methadone diversion would seem to go together and were ranked fairly low on the agenda of critical challenges. Most respondents agreed that these are less problematic concerns, and are manageable.

Although one reader noted that there is still a need for “modifying clinic rules and regulations,” most clinic operators have accepted regulation as a daily part of doing business. Methadone diversion is periodically decried by the mass media and some government agencies; however, clinic personnel agreed that this is less common than many believe. “Successful long-term abstinence from all substances during and after MMT is the real challenge,” wrote one respondent, “and that is where our efforts should focus.”

Where’s The Money?

It is interesting to observe that, although program funding was ranked as the top challenge in our survey, developing research grant proposals was lowest in priority. Yet, such grants can be viable sources of funding.

Perhaps clinics are unaware of available grants, or the time and effort required for the application process are viewed as prohibitive obstacles. However, some clinics, such as El Rincon in Chicago, have been extremely successful in expanding operations via grants (A.T. Forum, Fall 1998). This should be an area of exploration for all clinics.

Brainstorm: Exploring the Body, Mind & Soul of Addiction

Part 1: The Blind Men & The Elephant

As the old fable goes, six blind men came upon an elephant.

Approaching the elephant’s massive side, the first blind man proclaimed the beast to be a wall. · The second man, feeling the tusk, said the animal was more like a spear. · Then, the third took the squirming trunk in his hands and declared the elephant was certainly a snake. · The fourth blind man reached out a hand and felt about the knee; “This beast is a tree!” he shouted. · The fifth man touched the ear and argued the elephant was nothing but a fan. · The last man, seizing the slender swinging tail, scoffed the elephant was just a rope.

These wise men disputed long and hard, each in his own opinion. And though each was partly right, they all were in the wrong. (See page 7 for their vision.)

The Beast of Addiction

And so it seems today, as scientists, therapists, clinicians, theologians, politicians, policy makers, law enforcers, and the public at large each have their respective perspectives on the beast called “drug addiction.” The fable reminds us that current views of addiction are often built upon quite different experiences, leading to dissimilar conclusions acting as barriers to a common understanding.

Psychiatrist Joseph Dubey notes: “There are more theories about why we use drugs than there are drugs. We avoid reality, abandon morality, suppress hunger pains or other unpleasantness, or turn away from God. We sell drugs out of greed or for upward mobility. Drugs cause brain damage, cancer, personality change, constipation, incite police corruption and political upheaval. We make drugs illegal in order to protect children or to support the underworld markets. Every theory grinds the axe of its proponent.”[1]

Science Versus Ideology

To sober-minded citizens, the pervasiveness of drugs, alcohol, and cigarettes in society is a source of much angst and consternation. Drugs become imbued with powers of good or evil: they can be life-sustaining in the case of antibiotics or ruinous as with cocaine or heroin.

It is easy to forget that good and evil are not attributes of drug molecules. In the hands of the wise, poison can be medicine; in the hands of fools, medicine can become poison.[1]

But, why would people choose to take potentially harmful drugs?

Alan Leshner, PhD, director of the National Institute on Drug Abuse (NIDA), boils down the answer to two reasons: to feel good (sensation seeking); and, then, to feel better (self-medicating). He acknowledges that there are over 70 risk factors for substance abuse and addiction, and the person moves quickly from a voluntary decision to use drugs to a state of compulsive behavior motivated by craving. “It’s as if a switch has been flipped on and there is now a brain disease.”[2]

However, Leshner concedes that accepting addiction as a chronic, relapsing disease of the brain is still a new concept for the general public, for many policy makers, and even for many health care professionals. “It is time to replace ideology with science. . If we understand addiction as a prototypical psychological illness, with critical biological, behavioral, and social-context components, our treatment strategies must include biological, behavioral, and social-context elements.”[3]

Theories on the causes and treatment of drug addiction have risen and fallen in prominence for as long as the ancient problem has plagued mankind. Yet, in many ways, addiction remains an enigma, and many Western nations are just now increasing investments in research directed at understanding, treating, and preventing addiction.

Defining Addiction

Diagnostic criteria defining drug abuse and dependence have evolved and changed over time, leaving some confusion in their wake. At least 39 diagnostic approaches had been defined for alcoholism alone prior to 1940.[4] Since then, the terms use, abuse, dependence, and addiction have been variously applied to the self-administration of myriad mind-altering (psychotropic or psychoactive) substances.

Today, researchers, clinicians, treatment programs, and insurance companies in the U.S. usually rely on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) from the American Psychiatric Association, published in 1994.[5] The World Health Organization published a comparable manual in 1992: International Classification of Diseases (ICD-10).

In DSM-IV, substance dependence includes physiological aspects – withdrawal (abstinence syndrome) and tolerance (more drug required for same effect) – plus behavioral components: a) compulsive drug seeking and use; b) loss of control over such use; c) continued use even in the face of negative health and social consequences. In all, there are 7 criteria and a person only has to meet 3 to be defined as substance dependent. Dependence is subtyped as being with or without the physiological features of withdrawal/tolerance.[5,6]

Addiction is sometimes colloquially used interchangeably with drug dependence. However, addiction (and alcoholism) most aptly applies to the subtype of someone having drug dependence including physiological features of drug withdrawal and/or tolerance.[6]

This distinguishes medical patients – who might naturally became physiologically dependent on certain drugs (e.g. some analgesics) but do not exhibit uncontrolled, compulsive drug-related behaviors – from drug-addicted persons.[6]

Substance abuse pertains only to criteria signifying problematic or hazardous use of drugs, without compulsive use, loss of control, tolerance, or withdrawal.[6] Just where or when a person might cross an imaginary line from abuse into dependency may be difficult to identify in some cases.

Integration of Biology/Behavior

Leshner writes, “I would argue that it actually does not matter what physical symptoms occur, only whether the drug causes compulsive drug use without medical purpose and in the face of negative consequences.”[7] He proposes that scientific advances over the past 20 years have shown that drug addiction is a chronic, relapsing disease resulting from the prolonged effects of drugs on the brain. The brains of addicts are different.[3]

However, in qualifying his perspective, Leshner concedes that addiction is more than just a brain disease; rather, it occurs in environmental, historical, and physiological contexts affecting the way drug use interacts with the brain. Biological and behavioral concepts are not separable in Leshner’s opinion, “The notion of mind-body dualism is a thing of the past.”[7]

The Body on Drugs

The role of the brain in addiction has been a source of enlightening discoveries tempered by shifting opinions.

Experts believe that all addictive drugs have common effects, directly or indirectly, via reward pathways deep within the brain. Activation of this system keeps users taking drugs, and the addicted brain becomes remarkably different from normal, as manifested by changes in metabolism, receptor availability, gene expression, and responsiveness to environmental cues.[3]

The brain neurotransmitter dopamine, discovered in 1957, has been pursued as the “master molecule” of addiction, partly because all addictive substances seem to cause surges of this chemical in the brain’s reward center, the nucleus accumbens. Now, new research suggests that dopamine may not be the brain’s chief “feel-good” chemical after all; that it is only one of several messengers playing a role in the pleasure process.[8]

Glutamate may have a greater influence than dopamine. Brain structures relying on this neurotransmitter contribute to learning experiences that seem to play an important part in developing drug cravings elicited by external cues – thus, “teaching the brain to take drugs.”[9]

From a “Darwinian medicine” perspective, looking at how the brain has evolved, researchers Randolph Nesse and Kent Berridge believe serotonin and norepinephrine also play pivotal roles in behavior-conditioned responses to drugs. They claim there always will be a “mismatch between our bodies and our modern environment . our brains are not designed to cope with pure drugs, video games, and snack foods . it’s not surprising at all that people use drugs. In fact its quite remarkable that more people don’t.”[10]

The Mind Over Chemistry

Just where the brain leaves off and the mind (cognition) takes command is a matter of some contention.

One researcher proposes, “To the brain, an addictive drug is an evil tutor. Its lesson: The brain should want more of the drug and should direct the body to get it – whatever the costs.”[9] However, according to neuroscientist Michael Gazzaniga, “The mere taking of drugs does not mean that the user is on the slippery slope to doom; most people eventually walk away from the hedonistic pleasures of illicit drugs.”[11]

Gazzaniga believes cognition is central to the problem – education, alternative choices, and competing temptations play roles in seeking casual reinforcement from drugs versus lapsing into chronic use. “Fixing body chemistry does not fix these cognitive patterns and beliefs.” And once addicted, abstinence from drugs alone is not a complete solution.[11]

The Interacting Soul

Considering the prominence of spirituality in the human experience, many in the addiction field believe treatment professionals have not granted spiritual issues the attention warranted in clinical practice. Yet, throughout medicine, there is increased interest in how the realm of the soul interacts with body and mind in the management of and recovery from various illnesses.

Author Aldous Huxley warns in his book on drugs and man, The Doors of Perception, that a principal appetite of the human soul is to transcend itself. And when by means of good works, worship, or spiritual exercises people fail, they may resort to psychotropic drugs as “religion’s chemical surrogates.”

Further Brainstorming

The addiction treatment field has come a long way, and the vistas of addiction science seem limitless. However, psychiatrist Peter Kramer offers this humbling message in Listening to Prozac: “If the human brain were simple enough to completely understand, we would be too simple to understand it.”

Still, an ancient adage beckons, “Our reach must exceed our grasp, or what’s a heaven for?”

And so, we embark on this series of explorations called “Brainstorms” – having the dual meaning of clever ideas (of which the field abounds) and disturbances of the mind (emblematic of the addiction process). Upcoming topics include: the neurobiology of drug craving and relapse, self-medication hypotheses of addictive behaviors, spiritual pathways to recovery, and much more.

1. Dubey J. Drugs on our minds: perspectives on ‘modifiers of affect.’ Psychiatry Times. July 1997:52-54.
2. Leshner A. Presentation at: American Methadone Treatment Association, 1998 Conference; September 1998; New York, NY.
3. Leshner A. Addiction is a brain disease, and it matters. Science. 1997;278:45-47.
4. Diagnostic criteria for alcohol abuse and dependence. Alcohol Alert. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism; October 1995. Publication 30PH359.
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association Press; 1994.
6. Matching Treatment to Patients’ Needs in Opioid Substitution Therapy. Treatment Improvement Protocol (TIP) Series 20. Rockville, MD: Center for Substance Abuse Treatment;1995. DHHS publication (SMA)95-3049.
7. Leshner A. Drug abuse and addiction are biomedical problems. Hospital Practice. April 1997:2-4.
8. Dopamine’s activity in brain may be overstated. Chicago Tribune. March 4, 1999;sect 1:13.
9. Wickelgren I. Teaching the brain to take drugs. Science. 1998;280(5372):2046.
10. Nesse RM, Berridge, KC. Psychoactive drug use in evolutionary perspective. Science. 1997;278:63-66.
11. Gazzaniga MS. [Commentary.] Science. 1997;275(5299):459-460.