The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health - PowerPoint PPT Presentation

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The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health

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Title: The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health


1
The Role of Methadone in HIV Prevention And
TreatmentSharon Stancliff, MDMedical
ConsultantAIDS InstituteNew York
StateDepartment of Health
2
Drug Use and HIV
  • Injection of heroin and cocaine is the driving
    force behind HIV in New York State

3
Addiction
  • Opiates interact with receptors for endogenous
    peptides.
  • Short term changes in the dopamine secreting
    neurons, such as atrophy are documented
  • Long term changes are suspected.

4
Genetics
  • Twin and adoption studies show a strong
    familial trend in alcoholism
  • Addictive disorders are common among the
    families of heroin addicts
  • Anthenelli

5
Drug Addiction is a Brain DiseaseAlan
Leshner, PhDNational Institute of Drug
AbuseDirector
6
National Institute of Health
  • Methadone is the most effective treatment for
    heroin addiction.
  • National Institute of Health Consensus
    Development Conference on the Medical Treatment
    of Heroin Addiction

7
Methadone
  • A synthetic opiate with a 24-36 hour half-life
  • Methadone Maintenance Treatment (MMT) was
    first implemented by Dole and Nyswander in the
    1960s as most detoxed addicts relapsed to
    heroin use

8
Methadone
  • Usual effective dose 80-120 mg range5mg-
    gt500 Clinical response guide dose
  • Rettig, Leavitt
  • 80-90 of those stopping MMT will return to
    heroin use so treatment is long term
  • Ball, Magura

9
Methadone
  • Safe during pregnancy
  • Kandall
  • No known long term detrimental effects
  • Novick
  • MMT is usually accompanied by counseling and
    sometimes other requirements

10
Benefits of Methadone Maintenance
11
Reduction in Heroin Use
  • Given a sufficient dose virtually all heroin
    users will stop using heroin
  • At lesser doses heroin use is decreased.
  • Ball 1991

12
HIV Prevention
  • MMT patients are 3-6 times less likely to become
    HIV positive when compared to out-of-treatment
    heroin users.
  • Metzger, Drucker, Gibson, Hartel

13
Reduction in HIV seroconversion a prospective
study
  • Comparison of opiate users in and out of
    methadone treatment
  • Those out of treatment reported more risk
    behavior for HIV
  • In treatment 3.5 seroconverted,
    Out-of-treatment 22 seroconverted
  • Metzger

14
Improved outcome in HIV
  • HIV positive heroin users on methadone are
    hospitalized less often and live longer than
    their counterparts who are not on methadone
  • Weber, Newschaffer, Laine

15
Other Benefits
  • A fourfold reduction in suicide
  • A fourfold reduction in lethal overdose
  • Capelhorn
  • Reductions in sex work
  • Bellis
  • Reduction in crime
  • Hubbard, Appel

16
Issues in Methadone Prescribing
17
Over regulation
  • Available only in methadone clinics
  • Frequent attendance required
  • Limited number of slots
  • Medical maintenance has been shown to be
    successful outside of these constraints

18
Under Dosing
  • A 1995 study of selected MMTPs found an
    average dose of less than 59mg
  • 2/3s of the clinics set a dose ceiling of
    80-100mgs
  • DAunno

19
Premature discharge
  • A 1995 study found that the majority of
    clinics encourage detox after only 1 year of
    treatment
  • Relapse can be deadly- Zanis found 8.2
    mortality among 110 pts. leaving MMTP but only
    1.2 among 397 remaining in treatment

20
Misunderstandings about methadone
  • Patients often believe that methadone causes
    bone or liver damage.
  • Physicians may have misconceptions about pain
    management in methadone patients.
  • It is also erroneously believed that MMT leads
    to cocaine use.

21
MMT patients are judged by
  • Family
  • Friends
  • Physicians
  • Social service providers
  • Employers
  • Politicians
  • Drug users

22
Stigmatization by drug Treatment Providers
  • MMT patients are discouraged from speaking at
    Narcotics Anonymous meetings
  • Narcotics Anonymous Bulletin
  • Many facilities treating cocaine and alcohol
    abuse bar methadone

23
Role of the Primary Care Provider
  • Education of current and potential MMT
    patients and their families
  • Understanding medical issues such as drug
    interactions
  • Working with clinics to ensure the best
    possible care for patients

24
Drug Interactions
  • DRUGS WHICH MAY LOWER PLASMA LEVELS OF METHADONE
  • Phenobarbital
  • Carbamazepin (Tegretol)
  • Phenytoin (Dilantin )
  • Ritonavir (Norvir)
  • Major effect, may require large methadone dose
    increases
  • Nevirapine (Viraimmune)
  • Rifampin
  • Efavirenz (Sustiva)
  • Abacavir (Ziagen)
  • ethanol (chronic use)

25
Drug Interactions II
  • DRUGS WHICH MAY INCREASE PLASMA LEVELS OF
    METHADONE (none are major problems)
  • Amitriptyline (Elavil)
  • Cimetidine (Tagamet)
  • Diazepam (Valium)
  • Ethanol ( acute use)
  • Ketoconazole (Nizoral)
  • Zidovudine (AZT) levels may be increased by
    methadone.
  • DRUGS WHICH ARE CONTRAINDICATED
  • Pentazocine (Talwin),
  • Tramadol (Ultram)

26
For more HIV-related resources, please visit
www.hivguidelines.org
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