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Title: Oral%20Substitution%20Treatment%20for%20Opioid%20Dependence:%20A%20Training%20in%20Best%20Practices%20


1
Oral Substitution Treatment for Opioid
Dependence A Training in Best Practices
Program Design for Nepal
Day 1
March 26-28, 2006 Kathmandu, Nepal UNDP
  • Richard Elovich, MPH
  • Columbia University Mailman School of Public
    Health Medical Sociologist
  • Consultant, International Harm Reduction
    Development International Open Society Institute

2
This Training is Adapted From
  • Medication-Assisted Treatment For Opioid
    Addiction in Opioid Treatment Programs
  • CSAT/SAMSHA (Substance Abuse and Mental Health
    Services Administration Center for Substance
    Abuse Treatment)
  • Best Practices in Methadone Maintenance Treatment
  • Office of Canadas Drug Strategy
  • Addiction Treatment A Strengths Perspective
  • Katherine van Wormer and Diane Rae Davis
  • Additional Sources Robert Newman, MD, Alex
    Wodak, MD, Melinda Campopiano, M.D, Miller and
    Rollnick, Prochaska, DiClemente, and Norcross,
    Michael Smith, MD, Sharon Stancliff, MD, Ernest
    Drucker, PhD,

3
Clear Program Philosophy and Treatment Goals
Adequate Resources
Involvement Of Wider Community
Program Development And Design
Focus on Engagement and Retention
Client/Patient Involvement
A Maintenance Orientation
Integrated Comprehensive Services
A Client/Patient Centered Approach
Accessibility
4
Training Goals
  • Ideally, this training will contribute to
  • Increased knowledge, skills and best practices
    among OST practitioners and providers
  • Engagement and retention of clients/patients in
    the OST program in Kathmandu
  • Improved treatment outcomes

5
Six Training Modules
  • The Socio-Pharmacology of Opioid Use and
    Dependence
  • Introduction and background of oral substitution
    treatment
  • The pharmacology of medications used in oral
    substitution treatment
  • Information collection and service provision
    assessment-in-action
  • Pharmacotherapy and OST
  • Insights from the field

6
Learning Together
  • Parallel Process

7
Learning Process Knowledge and Skills
  • Acquisition of content
  • Retention (store in memory)
  • Application (retrieve and use)
  • Proficiency (integrate and synthesize)

8
Expectations for Certification Training Contract
  • Listening is a key to this training. Listen to
    new ideas. Listen to whats coming up inside you
    in relation to whats being presented. Try to
    put your thoughts and feelings into words instead
    of shutting down.
  • Acknowledge and respect differences. You can
    agree to disagree on a contentious point and
    move on. Participate in role plays. Everyone has
    permission to pass. Offer feedback constructively
    not personally. Try to receive feedback as a
    gift.
  • This is an 18 hour training over a 3 day period.
    Allowances have been made for your work
    schedules Noon 6 PM.
  • You must be present and participate in all 18
    hours of the training to receive certification.
    There can be no exceptions.
  • Please stay focused. Be on task because we have
    a lot of material to cover in 3 days.

9
Learning Environment
  • No cross talk. Allow one person to speak at a
    time. Equal time over time.
  • Start and end on time, including breaks. Be
    alert to tendency to fudge this.
  •  Use I statements.
  • Can everybody agree to this training contract? Is
    there anything you absolutely cannot live with?
  •  Now we are off.
  • Try to be okay with taking some learning risks.
    Stretch past your edge of what you know and what
    you are comfortable with. 
  • Confidentiality. Hold the container. Dont be
    leaky.
  • Turn off phones please.

10
I. The Socio-Pharmacology of Opioid Use and
Dependence
11
Heroin/Tidigesic/Set Use Social
  • Heroin/opiate use, though physiological and
    experienced in the body, is socially mediated.
  • What does this mean?
  • Initiation relational, social
  • Learning to use the drug.
  • Administration
  • The experience changes over time
  • Managing the experience
  • Contingencies
  • What else?

12
The production of getting off or getting
high.
  • Brainstorm components of the production.
  • List names of the social actors involved in the
    production.
  • Identify social interactions.
  • Identify cognitive and learning processes.
  • Identify strategies of the heroin user or addict.

13
What is Opioid dependence?
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Drug Use is The Root of Their Problems
  • Substance use may be an expression of a problem
    rather than its cause.
  • Rather than the cause of erratic or unhealthy
    behavior, substance use may be an adaptive
    mechanism or best solution to a range of problems
    including mental illness, abusive partner,
    homelessness, sexual abuse, poverty or other
    difficulties (Springer, 1991)

16
Bad Drug Using Women
  • A survey of crack-using women in New York, for
    example, found that nearly 1/3 had a past history
    of abuse and prior hospitalization for mental
    illness (Chavkin, 1993).
  • In another, women who were HIV, were homeless in
    the last year, and had experienced combined
    physical and sexual abuse were also those most
    likely to report exchanging sex for drugs and
    money, using injection drugs in the past year,
    and having sex in crack houses (El Bassel et al,
    2001).

17
An Addict Stays the Same or Gets Worse.
  • Addiction is cyclic and variable in intensity.
    While some addicts may follow the pattern, made
    familiar by alcoholism, of chronic, progressive
    illness, others may have periods of intense drug
    use and dysfunction followed by long periods of
    being drug free or vice versa (Kane, 1999).
  • Compare cocaine bingeing and heroin use.

18
Its Their Choice its Their Own Fault.
  • Ongoing substance use is rarely a simple question
    of choice.
  • Much as with people in abusive relationships or
    those with compulsive disorders, choice for
    substance users is shaped by perceptions of
    self-efficacy, mental health status, and social
    conditions.

19
They stopped growing. They are not themselves.
They are addicted.
  • How do we know they stop growing?
  • Who defines when people are themselves?
  • How do we define these terms? Societal or
    cultural norms?
  • How does the planet heroin story lead us to the
    disappearance of the person into the drug?
  • How are heroin users accounts of themselves
    ignored or marginalized when we make these
    assumptions based on the label addict?

20
They are manipulative. They lie.
  • Once a person is labeled a heroin addict, what
    assumptions do we make about them?
  • How are they treated by health providers?
  • Imagine yourself at your last job interview.

21
Whose Fault is it Anyway?
  • Addiction like hypertension, asthma, or
    diabetes is chronic, relapsing condition whose
    etiology frequently includes a combination of
    behavioral, genetic, and environmental factors.
  • As with substance users, only a minority of
    diabetics or hypertensives successfully abstain
    from the behaviors contributive to these
    conditions, yet these patients are not
    stigmatized, blamed for their condition, or
    denied health services (McLellelan et al, 1995)

22
1. How Do Drugs Work?
  • Drug Action Interconnection between neurology,
    the science of the nervous system, and chemistry
  • Drug Effects represents broader phenomena than
    drug and living tissue association.
  • Drug Factors, which originate outside the
    laboratory, in real life practice that shapes
    effects.

23
Drug Action I
  • In passing through the brain, a given drug (the
    key) will be attracted to, and will bind to a
    specific site in the brain (the lock).
  • The sites in the brain that control certain
    organs are rich in receptors into which specific
    drugs fit much like a key into a lock these
    same sites may lack receptors for other drugs.

24
Drug Action II
  • For instance, after heroin turns into morphine in
    the body, morphine fits into the receptors in
    the brain that control breathing and heartbeat
    rate, and hence, a sufficiently large dose of
    this drug can shut down these two functions and
    cause death by overdose.

25
Opiates Duration of action
  • Methadone 24 hours
  • Oxycontin 12 hours
  • Heroin 6-8 hours
  • Dilaudid 4-6 hours
  • Codeine 3-4 hours
  • Demerol 2-4 hours
  • Fentanyl 1-2 hours

26
Heroin In The Brain
27
Short-term Effects Of Heroin Use
  • Soon after injection (or inhalation), heroin
    crosses the blood-brain barrier.
  • In the brain, heroin is converted to morphine and
    binds rapidly to opioid receptors.
  • Abusers typically report feeling a surge of
    pleasurable sensation, a "rush."

28
Short-term Effects Of Heroin Use
  • The intensity of the rush is a function of how
    much drug is taken and how rapidly the drug
    enters the brain and binds to the natural opioid
    receptors.
  • Heroin is particularly addictive because it
    enters the brain so rapidly.

29
Short-term Effects Of Heroin Use
  • With heroin, the rush is usually accompanied by
  • A warm flushing of the skin,
  • Dry mouth, and
  • A heavy feeling in the extremities,
  • The rush may also be accompanied by
  • Nausea,
  • Vomiting, and
  • Severe itching.

30
Short-term Effects Of Heroin Use
  • After initial effects, drowsy for several hours.
  • Mental function clouded by effect on CNS.
  • Cardiac function slows.
  • Breathing severely slowed, sometimes to the point
    of death.
  • Overdose is a particular risk on the street,
    where the amount and purity of the drug cannot be
    accurately known.

31
Short-term Effects Of Heroin Use
  • Rush
  • Depressed Respiration
  • Clouded Mental Functioning
  • Nausea and Vomiting
  • Suppression of pain
  • Spontaneous abortion

32
Heroin Intoxication
  • Pupil size (pinned pupils)
  • Voice (slower, lower in tone)
  • Conversations (talkative)
  • Being high (feeling warm, euphoric, content)
  • Scratching
  • Droopy eyes
  • Itchiness?
  • Blood spots (needle marks bleed)
  • Expansive mood
  • Nodding out (sleep-like state)

33
Drug Action and Drug Effects
  • It is crucial to make a distinction between the
    specific pharmacological action of a drug, which
    is the product of a biological and chemical
    process, and drug effects.

34
Drug Effects
  • Drug effects is far more than the chemistry of a
    drug placed in the setting of living tissue.
    They represent the nonspecific factors that
    influence drug effects.
  • Six more or less pharmacological dimensions (1)
    identity and half-life in the body (2) dose (3)
    potency and purity (4) drug mixing (5) route of
    administration (6) habituation.

35
Five additional factors that originate outside
the laboratory setting in real life practice
  • Set
  • Setting
  • Script
  • Schedule (????????????? or morning shot)
  • Structure

36
Tolerance
  • Need for increased amounts of the drug to achieve
    desired effect
  • Markedly diminished effect with continued use of
    the same amount of the drug
  • Withdrawal
  • Characteristic withdrawal syndrome
  • The same (or closely related) drug is taken to
    relieve or avoid withdrawal symptoms
  • The drug is taken in larger amounts or over a
    longer period than was intended
  • There is a persistent desire or unsuccessful
    efforts to cut down or control drug use
  • A great deal of time is spent in activities
    necessary to obtain the drug
  • Important social, occupational or recreational
    activities are given up or reduced
  • Drug use is continued despite knowledge of having
    a persistent or recurrent problem that is likely
    to have been caused or exacerbated by the drug
    use

37
What is Substance Dependence
  • As the DSM IV explains, the term addiction is
    no longer widespread in the medical community,
    and has been widely replaced by the term drug
    or substance dependence. They also note that
    the term drug or substance abuse abuse is
  • a highly complex, value-laden and often
    excessively vague term that does not lend itself
    completely to any single definition.
  • Furthermore, because the term has different
    meanings for different groups of people and
    their definition of the term reflects their
    different perspectives there is often difficulty
    in drawing a line between use of substances and
    abuse of substances (Brands et al., 1998, 45).

38
Dependence Syndrome
  • Dependence syndrome consists of the particular
    behavioral, cognitive and physiological effects
    that may arise through repeated substance use.
  • Psychological characteristics include a strong
    desire to take the drug (craving), impaired
    control over its use, persistent use despite
    harmful consequences, and the prioritization of
    drug use over other activities and obligations.
  • Physical dependence comprises increased tolerance
    and a physical withdrawal reaction that occurs
    when drug use is discontinued (WHO 1984)

39
The DSM-IV Specifies Criteria for Opioid
Dependence
  • A maladaptive pattern of substance use, leading
    to clinically significant impairment or distress,
    as manifested by three (or more) of the
    following, occurring any time in the same
    12-month period
  • tolerance, as defined by either of the following
  • A need for markedly increased amounts of the
    substance to achieve intoxication or desired
    effect
  • Markedly diminished effect with continued use of
    the same amount of the substance.
  • American Psychiatric Associations Diagnostic
    and Statistical Manual of Mental Disorder (DSM-IV)

40
The DSM-IV Specifies Criteria for Opioid
Dependence
  • Withdrawal, as manifested by either of the
    following
  • The characteristic withdrawal syndrome for the
    substance
  • The same (or a closely related) substance is
    taken to relieve or avoid withdrawal symptoms
  • The substance is often taken in larger amounts or
    over a longer period than was intended
  • There is a persistent desire or unsuccessful
    efforts to cut down or control substance use

41
The DSM-IV Specifies Criteria for Opioid
Dependence
  • A great deal of time is spent in activities
    necessary to obtain the substance, use the
    substance, or recover from its effects
  • Important social, occupational, or recreational
    activities are given up or reduced because of
    substance use
  • The substance use is continued despite knowledge
    of having a persistent or recurrent physical or
    psychological problem that is likely to have been
    caused or exacerbated by the substance

42
Perspectives on Drug Dependence
  • The unfolding nature of heroin dependence
  • Different types of dependencies and patterns of
    practices. Drug dependence is complex and
    variable but literature speaks in absolutes
  • Fluid phenomenon movable famine
  • Drug users are thinking, strategizing
  • Range of different therapies/services for
    multiple and incremental outcomes

43
Tolerance and Habituation
  • When a person uses heroin regularly, they
    develop a tolerance they have to use more heroin
    to get the same effects. The greater the amount
    and frequency of their use, the faster they
    become tolerant.
  • Some people try to chip or use only
    occasionally, avoiding two days in a row.
  • Others try to manage their habits by using a
    little less for a day or two to lower their
    tolerance, allowing them to decrease the amount
    needed to get high-- or well.

44
Overdose
  • Overdose is a serious health risk for heroin
    users.
  • Heroin slows down the heart rate and breathing
    someone who overdoses may eventually stop
    breathing altogether.
  • Mixing heroin with other drugs (valium, alcohol,
    cocaine) significantly increases risk of
    overdosing, especially alcohol.

45
Active Drug users can be approached about
overdosing
  • Avoid mixing heroin with other drugs, especially
    benzos (Xanax, Clonopin, Ativan, Valium), other
    downs (Seconal, Elavil, Placidyl) or alcohol.
  • Many drug users overdose after coming out of jail
    because their tolerance has fallen. Users should
    do a tester shot if it is from a new source or
    they have not used in a while.

46
Overdose are very serious but do not have to be
fatal
  • Drug users should talk with using partners and
    make a plan for dealing with ODs. If they have
    thought it through, they are less likely to panic
    or freeze up in the event of an actual OD.
  • Drug users should know about Naloxone, what
    paramedics use, and can call 1 866 STOP ODS for
    more information.
  • Drug users can learn rescue (mouth to mouth)
    breathing, which is the most important thing they
    can do to help someone survive an overdose.

47
Heroin Withdrawal (1 of 2)
  • Elevated Blood Pressure Pulse
  • Insomnia (can last for days or weeks)
  • Restlessness
  • Anxiety (confusion, exaggerated startle reflex)
  • Irritability
  • Body aches
  • Lacrimation
  • Sneezing

48
Heroin Withdrawal (2 of 2)
  • Runny nose
  • Piloerection (body hair stands up)
  • Nausea and vomiting (can lead to dehydration)
  • Sweating
  • Diarrhea
  • Deep muscle twitch
  • Spontaneous erection or ejaculation (due to
    hypersensitivity)
  • Pupil dilation (enlarged pupils)

49
Long-term Effects Of Heroin Use
  • Dependence
  • Infectious Diseases HIV/AIDS, Hepatitis B C
  • Collapsed veins
  • Bacterial Infections
  • Abscesses
  • Infection of heart lining and valves
  • Arthritis and other rheumatologic problems

50
Long-term Effects Of Heroin Use
  • Physical dependence develops with higher doses of
    the drug.
  • The body adapts to the presence of the drug and
    withdrawal symptoms occur if use is reduced
    abruptly.
  • Withdrawal may occur within a few hours after the
    last time the drug is taken.

51
Long-term Effects Of Heroin Use
  • Symptoms of withdrawal include
  • Restlessness
  • Muscle and bone pain
  • Insomnia
  • Diarrhea
  • Vomiting
  • Cold flashes with goose bumps ("cold turkey")
  • Leg movements.

52
Long-term Effects Of Heroin Use
  • Major withdrawal symptoms peak 24 - 48 hours
    after the last dose of heroin and subside after
    about a week.
  • Some people have shown persistent withdrawal
    signs for many months.
  • Heroin withdrawal is never fatal to otherwise
    healthy adults, but it can cause death to the
    fetus of a pregnant addict.

53
Chronic Use Medical Complications
  • Scarred and/or collapsed veins
  • Bacterial infections of blood vessels and heart
    valves
  • Abscesses (boils) and other soft-tissue
    infections
  • Liver or kidney disease
  • Lung complications (e.g., pneumonia, TB) may
    result from the poor health condition of the
    abuser as well as from heroin's depressing
    effects on respiration.

54
Sources of Skin Infections
  • Users skin and mouth (most common)
  • Syringe
  • Cooker
  • Dissolving water
  • Filter
  • Drugs and contaminants

55
Danger Signs
  • Fever and chills
  • Increased pulse
  • Difficulty breathing
  • Altered mental status/confusion
  • Can progress to
  • Sepsis
  • Necrotizing fascitis (gangrene, streptococcus)
  • Wound botulism or tetanus

56
Prevention of Infection
  • New needle for each injection or reduction in
    reuse
  • Site rotation
  • Alcohol wipes or soap and water for at least one
    minute
  • Cook heroin until it bubbles
  • Plan for missing the vein

57
Chronic Use Medical Complications
  • Clogging of blood vessels that lead to the lungs,
    liver, kidneys, or brain (due to the many
    additives in street heroin which may not readily
    dissolve) resulting in infection or even death of
    small patches of cells in vital organs.
  • Immune reactions to these or other contaminants
    can cause arthritis or other rheumatologic
    problems.

58
Chronic Use Medical Complications
  • Sharing works or fluids can lead to some of the
    most severe consequences of heroin
    abuse-infections with hepatitis B and C, HIV, and
    a host of other blood-borne viruses, which drug
    abusers can then pass on to their sexual partners
    and children.

59
Heroin Abuse Pregnancy
  • Heroin abuse can cause serious complications
    during pregnancy, including miscarriage and
    premature delivery.
  • Children born to addicted mothers are at greater
    risk of SIDS (Sudden Infant Death Syndrome), as
    well.

60
Heroin Abuse Pregnancy
  • Pregnant women should not be detoxified from
    opiates because of the increased risk of
    spontaneous abortion or premature delivery
    rather, treatment with methadone is strongly
    advised.
  • Infants born to mothers taking prescribed
    methadone may show signs of physical dependence
    but they can be treated easily and safely in the
    nursery.
  • Research has demonstrated also that the effects
    of in utero exposure to methadone are relatively
    benign.

61
Heroin Use Blood-borne Diseases
  • At risk for contracting HIV, hepatitis C, and
    other infectious diseases through sharing and
    reusing syringes and injection paraphernalia that
    have been used by infected individuals.
  • They may also become infected with HIV and,
    although less often, to hepatitis C through
    unprotected sexual contact with an infected
    person.
  • Injection drug use has been a factor in an
    estimated one-third of all HIV and more than half
    of all hepatitis C cases in the Nation.

62
Heroin Use Blood-borne Diseases
  • Users can change the behaviors that put them at
    risk for contracting HIV, through drug abuse
    treatment, prevention, and community-based
    outreach programs, including harm reduction.
  • Users can reduce or eliminate the risk of
    exposure to HIV/AIDS and other infectious
    diseases by decreasing/eliminating
  • drug use
  • Injection drug use
  • drug-related risk behaviors such as needle
    sharing
  • unsafe sexual practices

63
II. Introduction and background of oral
substitution treatment
  • What is Oral Substitution Therapy (OST)?
  • How does Methadone Work?
  • Rationale for and Uses of OST
  • What types of OST are Most Effective?
  • Increasing Access to OST in Nepal Identifying
    and Overcoming Barriers
  • Developing a Continuum of MMT Program Delivery

64
Vernacular Formulations of Substitution Therapies
  • Irregular supply, fluctuations in price and
    purity mean dangers for drug users and others
  • Drug users are already creating their own forms
    of replacement therapy
  • Although we call it methadone maintenance, it
    is a form of drug treatment

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The Basic Orientation
  • THE PATIENT like all other patients
  • THE CONDITION like all other chronic medical
    conditions
  • THE MEDICATION like all others used in medicine

The Baron Edmond de Rothschild Chemical
Dependency Institute
CHINA VISIT APRIL 7-14, 2005
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What is Methadone?
  • Formulation Oral solution, liquid concentrate,
    tablet/diskette, and powder
  • Receptor Pharmacology Full mu, opioid agonist
  • Regulation Proscriptive regulations fail to
    leave room for treatment flexibility and
    innovation (SAMSHA, U.S. Department of Health and
    Human Services Treatment Improvement Protocol
    43 22)

83
How Does Methadone Work? 1
  • Opiate agonists bind to the mu opiate receptors
    on the surfaces of brain cells, which mediate the
    analgesic and other effects of opioids.
  • Methadone produces a range of mu agonist effects
    similar to those of short-acting opioids.

84
How Does Methadone Work? 2
  • Therapeutically appropriate doses of this agonist
    medication produce cross-tolerance for short
    acting opioids such as morphine and heroin,
    thereby suppressing withdrawal symptoms and
    opioid craving as a short-acting opioid is
    eliminated from the body. The dose needed to
    produce cross-tolerance depends on the individual
    patients level of tolerance for short-acting
    opioids.

85
How Does Methadone Work? 3
  • When given intramuscularly or orally, methadone
    suppresses pain for 4 to 6 hours. Intramuscular
    is used only for patients who cannot take oral
    methadone, for example, patients in
    medication-assisted treatment for opioid
    dependence who are admitted to a hospital for
    emergency medical procedures.

86
How Does Methadone Work? 4
  • Methadone is metabolized chiefly by the
    cytochrome P3A4 (CYP3A4) enzyme system (Oda and
    Kharasch 2001), which is significant when
    methadone is co-administered with other
    medication that also operate along this metabolic
    pathway.

87
How Does Methadone Work? 5
  • After patient induction into methadone
    pharmacotherapy, a steady-state concentration
    (i.e., the level at which the amount of drug
    entering the body equals the amount being
    excreted) of methadone usually is achieved in 5
    to 7.5 days (four to five half-lives of the
    drug).

88
How Does Methadone Work? 6
  • Methadones pharmacological profile supports
    sustained activity at the mu opiate receptors,
    which allows substantial normalization of many
    physiological disturbances resulting from the
    repeated cycles of intoxication and withdrawal
    associated with dependence on short-acting
    opioids.

89
How Does Methadone Work? 7
  • Therapeutically appropriate doses of methadone
    also attenuate or block the euphoric of heroin
    and other opioids.
  • When opiate medication dosage must be adjusted to
    compensate for the effects of interacting drugs
    (e.g., Rifampin for TB), observe patients for
    signs or symptoms of opioid withdrawal or
    sedation to determine whether they are under
    medicated or overmedicated.

90
How Does Methadone Work? 8
  • Methadone is up to 80 orally bioavailable, and
    its elimination half-life ranges from 24 to 36
    hours. When methadone is administered daily in
    steady oral doses, its level in blood should
    maintain a 24-hour asymptomatic state, without
    episodes of overmedication or withdrawal (Payte
    and Zweben 1998).

91
How Does Methadone Work? 9
  • Methadones body clearance rate varies
    considerably between individuals. The serum
    methadone level (SML) and elimination half-life
    are influenced by several factors including
    pregnancy and a patients absorption, metabolism
    and protein binding, changes in urinary pH, use
    of other medications, diet, physical conditions,
    age, and use of vitamin and herbal products
    (Payte and Zweben 1998).

92
Early Research Findings Vincent P. Dole 1980, 1988
  • Patients do not experience euphoric,
    tranquilizing, or analgesic effects. Their affect
    and consciousness were normal. Therefore, they
    could socialize and work normally without the
    incapacitating effects of short-acting opioids
    such as morphine or heroin
  • (SAMSHA, U.S. Department of Health and Human
    Services Treatment Improvement Protocol 43
    17-18)

93
Early Research Findings Vincent P. Dole 1980, 1988
  • A therapeutic, appropriate dose of methadone
    reduced or blocked the euphoric and tranquilizing
    effects of all opioid drugs examined, regardless
    of whether a patient injected or smoked the drugs
    (e.g., morphine, heroin, opium, etc.)
  • (SAMSHA, U.S. Department of Health and Human
    Services Treatment Improvement Protocol 43
    17-18)

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Early Research Findings Vincent P. Dole 1980, 1988
  • No change usually occurred in tolerance levels
    for methadone over time, unlike for morphine and
    other opioids therefore, a dose could be held
    constant for extended periods (more than 20 years
    in some cases.)
  • Methadone was effective when administered
    orally. Because it has a half-life of 24-36
    hours, patients could take it once a day without
    a syringe. (SAMSHA, U.S. Department of Health and
    Human Services Treatment Improvement Protocol
    43 17-18)

95
Early Research Findings Vincent P. Dole 1980, 1988
  • Methadone relieved the opioid craving or hunger
    that patients with addiction described as a major
    factor in relapse and continued illegal use
  • Methadone, like most-opioid class drugs, caused
    what were considered minimal side effects, and
    research indicated that methadone was medically
    safe and nontoxic.
  • (SAMSHA, U.S. Department of Health and Human
    Services Treatment Improvement Protocol 43 22)

96
Expansion of Methadone from Research to Public
Health Program
  • Most patients were stabilized on methadone doses
    of 80 to 120 mg/day.
  • Most patients who remained in treatment
    subsequently eliminated illicit-opioid use.
  • In general, the team found that patients social
    functioning improved with time in treatment, as
    measured by elimination of illicit-opioid use and
    better outcomes in employment, school attendance,
    and domestic relations.
  • Columbia University School of Public Health, Dr.
    Frances Rowe Gearing, 1974

97
Poly Substance Use and Abuse
  • However, 20 percent of more of these patients
    also had entered treatment with alcohol and poly
    substance abuse problems., despite intake
    screening that attempted to eliminate these
    patients from treatment. (Gearing and Schweitzer
    1974)
  • Methadone treatment was continued for these
    patients, along with attempts to treat their
    alcoholism and polysubstance abuse.

98
MMTP Becomes A Major Public Health Initiative in
the U.S.
  • Methadone maintenance became a major public
    health initiative to treat opioid dependence
    under the leadership of Dr. Jerome Jaffe, who
    headed the special Action Office for Drug Abuse
    Prevention in the Executive Office of the White
    House in the early 1970s.
  • Dr. Jaffes office oversaw the creation of a
    nationwide , publicly funded system of treatment
    programs for opioid dependence

99
The pharmacotherapy of opiate dependence

Robert Newman, MD, Director, Baron Edmond de
Rothschild Chemical Dependency Institute Beth
Israel Medical Center, NYC
Presented _at_ the 15th INTERNATIONAL CONFERENCE ON
THE REDUCTION OF DRUG RELATED HARM, Melbourne,
Australia, 20-24 April, 2004
The Baron Edmond de Rothschild Chemical
Dependency Institute
100
Methadone Maintenance (MMT).Dole and Nyswander,
1964
  • Their goal to look for some medication to
    permit addicts to live as normally as possible
  • Initial study with 22 subjects
  • Maintenance dose ranged from 10-180mg
  • No reference to any preferred duration of
    treatment
  • Dole and Nyswander. JAMA 193(8) 646-650,
    1965
  • Dole, Nyswander and Kreek. Arch. Int.
    Medicine. 118(4)304-309, 1966

101
Methadone seeking to explain successDole and
Nyswander, 1967
  • The unexpected response to a simple medical
    program forced us to re-examine our assumptions
  • We had been misled by traditional theories based
    on weaknesses of character.
  • Dole and Nyswander. Arch. Int. Medicine.
    120(1)19-24, 1967

102
Addiction A theoryDole, 1970
  • Persistent physiological changes contribute
    somehow! to relapse tendency after abstinence
    has been achieved.
  • Dole. Ann. Rev. Biochem. 30821-840, 1970

103
1973 - support for the theory Opiate
receptors/peptides in brain
  • Identification of opiate receptors provides
    insight into mechanism of action of opiates.
  • Brain contains substances with morphine-like
    activity
  • Pert and Snyder Science 179(4077)1011-1014,
    1973
  • Guillemin Science 202(4366)390-402, 1978

104
High on methadone? No!
  • We have not been able to find a medical or
    psychological test capable of identifying
    patients on methadone.
  • When given placebo patients were unaware that
    the medication had been changed until withdrawal
    began
  • Methadone given in constant daily doses causes
    no euphoria, abstinence symptoms or demand for
    escalation of dose.
  • Dole and Nyswander. JAMA. 193(8)646-650, 1965
  • Dole and Nyswander. NY State J of Med.
    66(15)2011-2017, 1966

105
Methadone effectiveness and safety US
Government assessment, 1983
  • Retains more patients, longer, than any other
    treatment
  • Heroin use and criminal activity significantly
    reduced
  • Employment increases
  • Marked improvement in health status
  • No major adverse consequences
  • Dosage/duration limits therapeutically
    unjustified
  • US National Institute on Drug Abuse DHHS
    publication (ADM)831281, 1983

106
US Government on Methadone consistency!
1983-2004
  • 1997 Methadone significantly lowers illicit
    opiate use and related illness and death, reduces
    crime, enhances social responsibility.
  • 2004 Methadone continues to be a safe and
    effective treatment for addiction to heroin.
    NIDA Notes, 1997, http//www.drugabuse.gov/NIDA_
    Notes/NNVol12/NIPanel.html
  • Subst. Abuse and Ment. Heath Services Admin.,
    News release 6 Feb 2004

107
United Nations on harm reduction and methadone,
2003
  • UNODC is particularly committed to programmes
    that reduce harm from drug abuse.
  • It is important to implement methadone
    programmes urgently.
  • Speech by Dr. Sandro Calvani, UNODC Regional
    Representative for East Asia and the Pacific,
    given in Hong Kong 22 Oct. 2003

108
WHO/UNODC/UNAIDSPosition paper on
substitution, 2004
  • Maintenance treatment is an effective, safe,
    cost-effective modality.
  • Available on line http//www.who.int/substance_a
    buse/

109
When theres commitment . . . Hong Kong, 1975-76
  • End 1974 one pilot programme, 500 patients
  • End 1975 approximately 2,000 enrolled
  • End 1976 approximately 10,000 enrolled
  • Admissions to voluntary in-patient drug-free
    programmes stable 1974-76 2,300-2,500/year
  • Newman J. Pub. Health Policy 6(4)526-538 (1985)

110
Roughly For a problem with heroin, call this
number for same-day help!
111
Risk of HIV Infection in Hong Kong (1984-2002)
Source HIV Surveillance Report 2002 Update (Dept
of Health, Hong Kong S.A.R., Nov 2003)
112
When theres commitment . . . Croatia
1991-present
  • Treatment started 1991 GPs mainstay of MMT
  • Of 2,400 GPs nationally, over 1,000 provide MMT
  • High retention 70-80
  • Estimated 15,000 heroin addicts 7,000 get Rx
  • Ivancic SEEA Addiction 4(1-2)15-17, 2003

113
Estimated number of patients receiving methadone
buprenorphine in France, 1996-2001
Source on web at http//www.drogues.gouv.fr/fr/pr
ofessionnels/etdues_recherches/IT-4b.pdf
114
Ancient historyDr. Ernest Bishop (NYC), 1920
  • We have regarded failure to abstain from
    narcotics as evidence of weak will-power.
  • We have prayed over our addicts, cajoled them,
    exhorted them, imprisoned them, treated them as
    insane and made them social outcasts and weve
    consistently failed!
  • Bishop, The Narcotic Drug Problem. Macmillan NY
    1920

115
Stepped Approach vs. All or Nothing Approach
  • Optimal drug cessation
  • Reduce drug use
  • Increased control of drug use
  • Alternative to injecting
  • Alternative to sharing
  • Reduce harm related to sharing and safer sex
    practices

116
The Context for OST in Nepal
  • Heroin
  • Tidigesic (Buprenorphine)
  • The Set
  • Norphine
  • Diazapam
  • Avil
  • The Subjective Meanings of Injecting
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