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

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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

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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,

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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
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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

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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

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Learning Together

• Parallel Process

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Learning Process Knowledge and Skills

• Acquisition of content
• Retention (store in memory)
• Application (retrieve and use)
• Proficiency (integrate and synthesize)

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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.

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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.

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I. The Socio-Pharmacology of Opioid Use and
Dependence
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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?

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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.

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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)

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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).

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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.

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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.

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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?

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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.

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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)

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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.

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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.

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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.

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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

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Heroin In The Brain
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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."

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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.

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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.

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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.

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Short-term Effects Of Heroin Use

• Rush
• Depressed Respiration
• Clouded Mental Functioning
• Nausea and Vomiting
• Suppression of pain
• Spontaneous abortion

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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)

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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.

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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.

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Five additional factors that originate outside
the laboratory setting in real life practice

• Set
• Setting
• Script
• Schedule (????????????? or morning shot)
• Structure

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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

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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).

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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)

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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)

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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

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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

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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

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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.

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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.

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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.

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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.

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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

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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)

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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

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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.

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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.

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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.

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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.

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Sources of Skin Infections

• Users skin and mouth (most common)
• Syringe
• Cooker
• Dissolving water
• Filter
• Drugs and contaminants

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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

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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

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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.

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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.

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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.

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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.

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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.

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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

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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

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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)

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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.

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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.

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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.

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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.

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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).

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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.

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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.

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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).

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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).

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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)

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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)

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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)

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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

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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.

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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