If you have any questions you need answered by the doctors about methadone, here is the place to send them. yourtype@tir.com     However, please read this first, or your question may not be answered.
 

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Sexual Dysfunction Treatment with Bromocryptine  (June 1999, Vol. IV, No. VI)

Uses of Methadone for Other Than Opiate Addiction (May 1999, Vol. IV, No. V)
 
Methadone, Weight Gain & Reduced Sex Drive (April 1999, Vol. IV, No. IV)

Methadone, LAAM & Withdrawal - (March 1999, Vol. IV, No. III)

Methadone & Alcohol - (February 1999, Vol. IV, No. II)

MMT Patient Organ Donation - (January 1999, Vol. IV, No. I)

 Letter from General Practice Doctor  - (December 1998, Vol. III, No. XII)

Methadone & Pregnancy in Detroit, Michigan - (November 1998, Vol. III, No. XI)

Attention:  Pregnant Methadone Patients in Michigan - (December 1998, Vol. III, No. XII)

 I am a pregnant methadone patient, on 120 mg, and my urines have been clean for the past seven years.

 I live in Detroit, Michigan, and I have been hiding my pregnancy at my clinic.   They and, as far as I know, every other clinic in the Detroit area MAKES their patients go to "Hospital X" when their pregnancy is discovered.  I had my first baby eight years ago through this hospital and had a horrible experience!

 Every pregnant patient I have talked to tells me that this hospital has not changed their practice from that of what I experienced eight years ago.  They decrease patients' doses whether they like it or not or start using again! "X" makes every patient come in seven days a week; they allow NO takehomes no matter what your status was at your previous clinic. They don't open until 9 am, and I have been used to dosing at 5:30 to 6 am for the past 7 years.

 When I was pregnant with my daughter 8 years ago and forced to go to Hospital "X", I had been clean for several months.  But, "X" forced me to detox to a VERY low dose (it was all BLIND dosing).  I couldn't handle the detox.  I began buying "street" methadone, and when that got too expensive, I started buying heroin.  Hospital "X" doesn't seem to care if the women can't deal with the detox and start using again! They just keep on dropping that dose, claiming its best for the baby.  How can it be better for the baby if the mother starts using heroin again!?

 Luckily, my daughter was born healthy, although she was one month premature and only weighed 4 lbs. I think it's a miracle, since I was using heroin EVERY day in my 7th & 8th months.  I HAD TO, doctor, because I was so sick from withdrawals, I just couldn't stand it!  I hope you understand.

 Over the past 20 years I have been an addict, I have had many girlfriends and known other women who were pregnant and hid it from their clinics as long as they could because they were absolutely TERRIFIED about going to "Hospital X!"  After buying a subscription to Methadone Today, I learned that addictionologists, including the ones who write the TIP and TAP books, recommend completely the opposite of what "Hospital X" is doing to women.  Can't someone make them stop!? Or why can't the other methadone clinics in the Detroit area give pregnant patients a choice whether to stay at their clinic or to go to "X"?  -  A Very Worried Patient (With Not Much Time Left Before I Start Showing)

Dear Worried:

 The mistreatment which you suffered eight years ago that resulted in your child's low birth weight and premature birth is now subject to a claim of malpractice due to the clinical research and practice guidelines that attest to the following:

 Methadone should be increased, commonly as much as 30 percent, during pregnancy.  Failure to medicate adequately increases fetal distress, prematurity and spontaneous abortion.  Methadone maintenance, when adequate to suppress the need for illicit drug abuse, results in healthier, higher birth weight newborns compared with mothers who continue to use heroin.  Infants born to methadone-maintained mothers do not over time differ significantly from those born to non-dependent mothers in ways that can be attributed to methadone.

 Management of neonatal opioid withdrawal is a safe procedure and not to be feared, especially compared to the risks of underdosing pregnant patients who relapse as a result.  Many of the infants of methadone maintained mothers may not require much in the way of management of neonatal abstinence, but it is almost impossible to predict for an individual case (at CAP clinics, there was at least one infant whose mother delivered at a maintenance dose of 180 mg/d whose abstinence syndrome was easily managed).

 "Blind" dosage should never be practiced when not requested by the patient.  It is demeaning, unsafe, anxiety provoking, and encourages diversion among nursing staff.  It is a sign of a punitive and non-medically oriented program where administration has little understanding of the disease of addiction and even less empathy for the patients whom they serve.  Run, do not walk, from such a facility.

 I have no idea why pregnant patients should be banned from MMT programs and will not comment on this bizarre practice, which you describe, of herding them all into a single clinic.  It is not done anywhere else in the world in my experience.

 There are guidelines about monitoring prenatal care that all clinics must observe in the federal regulations.  This implies that pregnant women should be served.  Depriving women of the option of attending the clinic of their choice should be addressed with the State of Michigan or with the agencies who license or fund these no-service clinics.

 Providing care to pregnant women should be a primary requirement for licensing or funding in my opinion.  It is one of the truly critical health care interventions that MMT clinics can do better than any other facility.  The federal rule regarding admission criteria for pregnant addicts is minimal compared with those for others and reflects the government's expectation that licensed clinics should serve this population ahead of everyone else and certainly not have the option of excluding it.

Dr. Marc Shinderman

Center for Addictive  Problems (CAP)

Chicago, Illinois

 Nancy asked the head nurse, "What dose would that be?"

 The nurse wouldn't tell Nancy, but her response was very "telling", "Well, we HAVE to drop their doses! Some of these women come in here on high doses, like 50 mg!"

  Nancy then asked if the nurse and/or medical director had read the TIP/TAP books. The nurse said that they had, but they had to do "what was best for the baby".

 Nancy asked, "But isn't it better for the baby to be born on methadone than on HEROIN?"  and the head nurse indignantly replied, "Well, these women have to take SOME responsibility!"

 We, at DONT, believe that pregnant patients should have a choice of where to go for treatment just like any other patient.  We find it appalling that this hospital's program goes against the treatment protocols well known in the field of addiction medicine and that pregnant patients have no alternatives.

NOTE:  PREGNANT PATIENTS IN SOUTHEASTERN MICHIGAN WHO WANT AN ALTERNATIVE TO "HOSPITAL X" FOR METHADONE TREATMENT, PLEASE CALL DONT AT (810) 658-9064.

 For further information, read the TIP/TAP column in the September 1998 issue of Methadone Today, "Treating Pregnant MMT Patients" or order  (1-800-SAY-NOTO) a FREE copy of TIP 2, "Pregnant, Substance-Using Women" and TIP 5, "Improving Treatment for Drug-Exposed Infants .
 

See also:

 Mitchell JL, Brown G., Physiological effects of cocaine, heroin and methadone. In: Engs RC, ed. Women: alcohol and other drugs. Dubuque (IA): Kendall/Hunt; c1990. p. 53-60.

 Finnegan LP, Hagan T, Kaltenbach KA. Scientific foundation of clinical practice: opiate use in pregnant women.  Bull N Y Acad Med 1991 May-Jun;  67(3):223-39.

 Finnegan LP, Kaltenbach K. Neonatal abstinence syndrome. In: Hoekelman RA, ed. Primary pediatric care. 2nd ed.  St. Louis:  Mosby-Year Book; c1992. p. 1367-78.

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 UPC accepts third-party payments (insurance) and Medicaid.  During the first part of November, DONT told a few women that there were no additional slots available at UPC for Medicaid.  However, that problem has been resolved, and there is now money to accept additional Medicaid patients.

 UPC treats other specialty patients besides pregnant women.  They have a Medical Director and Psychiatric Director, and it seems that they take a holistic approach to the treatment of addiction.

 For pregnant patients, or anyone else, interested in this program, following is contact information:  UPC Jefferson Avenue Research Clinic, 2761 East Jefferson; Detroit, Mi 48207; (313) 993-1363.  If you have further questions,   they will be happy to answer them for you.

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Dear Editor,

        After doing a one-day methadone prescriber's course two years ago and attending Blacktown Clinic, I obtained authority to prescribe for 25 patients and started slowly with a few stable ones.  Since then I have increased my number to 76 in all stages of dependency.

        Even though I treat mainly regular general practice patients, I have found that dependency patients have not caused any serious problems in my surgery.  Their attitude and behaviour has in fact improved since attending a general practice and it is gratifying to see progress in most of the patients  I treat.  This is reflected in their ability to get employment, their general health care and in turn the health of their children.

        Since I have been their prescriber, 11 have obtained full-time work, six part-time and two are doing TAFE courses.  Over the years many of my patients have neglected illnesses such as asthma, hypertension, diabetes and anemia and now in the setting of a general practice are much better managed.

   Six patients with long-term dependency on benzodiazepines have been withdrawn from their pills and now repeatedly have clean urines.  Just one has given up smoking (cigarettes) for over six  months and two have reduced and finally ceased their methadone and are now completely drug-free.

        Although these numbers may be small they are very significant in such a disadvantaged group and it is satisfying to see the progress they have made.

        I would urge colleagues to consider methadone prescribing as I have done.  If the methadone maintenance guidelines are strictly adhered to, there is little scope for abuse.

Dr. Lynette McDonald
North Rocks, NSW

Re-posted on GP-net by Andrew Byrne

 One has to admire Dr. McDonald as a Sydney solo female GP for  taking on such challenging patients and reporting her largely positive experiences.  It certainly  parallels my own practice findings.
  ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
          Dr. Andrew Byrne
          General Practitioner, Drug and Alcohol
          75 Redfern Street
          Redfern
          New South Wales, 2016
          Australia
          Tel (61 - 2) 9319 5524  Fax 9318 0631
          E-mail  ajbyrne@ozemail.com.au
  ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

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 Hello! I am a 23-year methadone maintenance patient (age 45), and I have a question that I felt I should and could direct only to you.

 First, I'll explain briefly -- my name is Nancy Rose, and I work closely with Beth Francisco, the Editor of Methadone Today newsletter and President of DONT in Michigan.  I am the Secretary and Assistant Vice President of DONT.  I've been active in methadone patient advocacy since our group began in 1995.

 I, along with just about all methadone patients, recognize you as the "father" of methadone maintenance treatment (along with your late wife, Dr. Marie  Nyswander), and respect both of you for the dedication and caring attitude displayed toward MMT patients. I really enjoyed hearing you speak in person at the Methadone Advocacy Conference in New York at the AMTA Conference in September!

 To keep this brief, I'll get to the point. I had always planned to have my organs donated upon my death. But, recently, I have decided that I would be willing to donate my body upon my death IF there is anyone or any group that would be interested in studying the body of a methadone patient (or addict), particularly to study the effects of long-term methadone use.

 I have no idea if there is anyone interested in this. I thought if anyone knows if there is, it would be you! Since I have already decided to dedicate my life to the cause of methadone patient advocacy, I am certainly willing to donate my body upon death to further the cause!

 I am looking forward to your response.

Sincerely, Nancy Rose
 
Dear Nancy. . . . .

        I am moved by your dedication. . .

        The answer to your question is NO,  and for a very good reason:

           Your body is too normal to reveal anything new about addiction.  As a methadone patient in good health now (I hope), you have a normal life expectation provided that you continue to live a healthy life. . . When your time comes, an autopsy would show only the immediate cause of death but nothing diagnostic of past addiction or methadone maintenance. . .

         But you can do much good while you are alive:

       Continue to work for recognition of patients' rights. . . This is the most important activity today, and it is succeeding!

                        All best wishes,  Vincent Dole

 Vincent Dole, MD

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 I have heard people say that methadone keeps them from drinking.  Is that possible and if so, how?

Dear Emily,

 Alcohol interacts with the same endorphin receptors that methadone and other opioid drugs affect.  Filling up these receptors with another substance, whether it blocks (like naltrexone) or stimulates (as with methadone), diminishes the amount that alcohol abusing rats or humans will drink. (You can look this up in Medline. J. David Sinclair, Ph.D., is usually one of the authors.  The  work goes back to the 70's, I am guessing).

 Alcohol-preferring rats given morphine will take it the exclusion of alcohol, after a while.  In the absence of morphine,  opioid-dependent rats allowed access to alcohol will cross over to alcohol dependence. They will cross back to morphine, if  given the opportunity.

 A heroin addict who cannot get enough heroin  may use alcohol.   If he gets enough heroin, he will not use it at all.  Some never get enough.

 After dependence and tolerance are developed to alcohol and/or opiates, the craving and associated behaviors are, in our experience, completely diminished by adequate doses of methadone with good results in all areas of function.

 Very few previously dually-dependent patients choose to replace opiates with alcohol once having enjoyed the benefits of having their endorphin dysfunction stabilized with opiates.  Methadone and LAAM are the ones that we use.

 There may be  exceptions, but  in our clinics I cannot recall any patients who abused alcohol after getting an adequate methadone dose.  Those who do abuse it  usually have serious problems such as rapid progression of HepCV-related illness and/or overdose.

Dr. Marc Shinderman
CAP
Chicago, IL

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 Finally, one day when I couldn't make it to my clinic, I did manage to get some heroin, and within ten minutes of snorting it, I was like a brand new person.  I went from my deathbed to cleaning my house in a matter of mere minutes!  From that point on, whenever I got this horrible sickness, I'd buy street drugs and almost instantly, I'd be 100% better.  I've been taking Orlaam for four months now, and while I haven't had the identical problem, I'm still having withdrawals.  Two times now I've thrown up the Orlaam within 15 minutes of taking it (due to nausea), and I IMMEDIATELY go into withdrawal.  I'm certain my dose is sufficient, as I never have cravings and haven't used since being on it.

 The only time I have withdrawals are the days I've vomited before it was absorbed in my system....but why do I go into immediate and severe withdrawal?  I've felt fine before taking it--not a hint of illness or withdrawal at all.  But vomiting the Orlaam seems to set the stage for the rest of the day or at least until I can get some other kind of opiate in me.  I could fully understand having withdrawals later that day or night if I vomit soon after taking it...what I don't understand is INSTANTLY going into withdrawal when there was no sign of it before taking the Orlaam!

 These withdrawals are so severe, so utterly debilitating, that I'm a nervous wreck the night before I'm due for another dose.  I'm so afraid it'll wear off and I'll withdraw--I'd rather have surgery without anesthesia than go through withdrawal.

 I'm thinking about going back to methadone, but I'm concerned that I'll have the same 'sick every 8 weeks' problem.  Do you have any suggestions as to what might cause this?  What can I do?  Why is this happening?  Thank you for your time.

Dear Withdrawing:

 Feeling very ill right at the time of dosing does happen once in a while.  How this cycle gets started is usually a mystery, but there may be some ways to break the cycle.  Although I have not found any published literature on your problem, we do see this once in a while and I hope these suggestions help.

 Much of what you're describing now may be a response to feeling nauseated at the time of dosing.  The next time you go to dose, your mind and body remember how bad you felt last time, and you begin to feel sick even before you get to the window.  When you finally get the taste of the dose it sets up an immediate memory of illness, and you become sick with the symptoms you describe.  Now you've unconsciously 'learned" that the dose makes you sick and even thinking about dosing can set this off.

 It's important to make sure that there isn't some medical reason for you to be more sensitive to the possibility of nausea and vomiting.  Pregnancy, liver disease, kidney problems, and tumors are just a few of the many medical problems that could make this cycle develop.  It would be worth getting these things checked out with a primary health-care-provider.

 Assuming you're healthy, it is still possible that the withdrawal you are experiencing is from an inadequate dose, or inadequate absorption of the dose (due to vomiting).  A small increase could help.  Somehow you and your program physician need to figure out a way that you won't feel sick just thinking about dosing.  Things that we have used include: changing the time of dosing, eating more or less before dosing, adding more water to the dose, drinking juice or eating crackers right after the dose, relaxation techniques before or after dosing, and more.  If you can imagine yourself dosing and feeling well through the process, I believe it will help.  If you found that the smell or taste of the medication bothered you, trying to drink it quickly might help.  An antacid or anti-nausea medication before dosing could help as well.

 You may me able to come up with some other ideas of how to break this cycle.  It sounds like this has been going on for a little while so it may take some time to resolve.  My guess is that a change back to methadone would not help much, so would only consider this as a last resort.  Please let us know of any changes.

- John Hopper, M.D.
University Psychiatric Center

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 I've been unable to find any books or articles on methadone.  I've found several books that mention methadone but everything written about it was extremely negative.  The only problem I have is extreme weight gain, and reduced sex drive is creating a problem with my significant other.  Can you help?

Answer:

 The toll that lack of sexual interest can have on relationships and to one's sense of well being is obvious.  Loss of sexual drive can occur as a side effect of chronic opioid use, including methadone maintenance.  Weight gain, another frequent topic of discussion, here, probably has the same endocrinological basis. Seeing  many patients at the Center for Addictive Problems lower their agonist medication (methadone or LAAM) in order to  diminish their weight gain or increase their sexual interest, only to relapse or become depressed, motivated  me to search for a solution to these problems.

 It appears that all this  may have been avoidable, for the last 15 years.  Enough information was available for clinicians to have developed an effective treatment response to these very real complaints by MMT patients and others.

 What is worse, a mythology supporting the concept that MMT had nothing to do with these things has been elevated to a religion, in some circles.  I base  my statements on the 70 percent positive response experienced among the 30 or so patients treated at the Center for Addictive Problems for these complaints, as well as the body of literature which supports the intervention, at least in theory.  If our theory about the mechanism of action is wrong, it is still all good news; the treatment works.  Since we did not use sophisticated experimental protocols for this treatment, all of our good results could be attributed to some other factor, but I doubt it.

 I will be presenting my findings regarding medical treatment of lowered libido in methadone maintained patients in April, at the next Amercan Society of Addiction Medicine conference. Weight loss was not a focus of the abstract which we presented to ASAM, last fall, but it is now apparent that the same treatment has resulted in weight loss for some patients who have taken the medication daily and for a few months. There might even be a positive effect on mood and concentration, but that is less certain, at this time.

 The medication is costly and there are some side effects and contraindications.  Doctors interested in helping patients with sexual dysfunction and/or weight gain due to MMT are welcome to contact me by email or through the clinic, in Chicago (Methadone Today will pass along any correspondence.
 

Dr. Marc Shinderman

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 I would like to know if you have any information regarding the use of methadone in pediatric burn patients.  Please send me any information you have.  Thank you very much.
 
Answer:

Methadone has been used for the treatment of chronic pain in children with malignancies.  A recent paper on hospitalized children is, "Oral Methadone for the Treatment of Severe Pain in Hospitalized children:  A Report of Five Cases," by Shir Y, et al.  Clin J Pain.  1998 Dec; 14(4):  350-353.  Methadone has been used in adult burn patients as well.  A typical starting dose for severe pediatric pain is 0.7 mg/kg/day divided q 4-6 hours.

- John Hopper, M.D.
University Psychiatric Center

Editor's note:  Many people are unaware that methadone has uses aside from the treatment of opiate addiction, such as treatment of chronic pain.  As a result, chronic pain patients suffer  the same stigma and discrimination to which methadone maintenance treatment patients are subjected.
 
 

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 Diminished sexual interest and function due to methadone maintenance treatment (MMT) is a common complaint among our MMT patients, which sometimes adversely affects treatment outcome.  Lowering of methadone (or LAAM) dosage and/or stimulant (cocaine) abuse are examples of strategies reported by our patients in attempts to restore lost libido.  We were aware that MMT patients demonstrate elevated prolactin levels.  Non-opioid dependent individuals who develop hyperprolactinemia from prolactinoma (benign pituitary tumor) or taking antipsychotic medications demonstrate an array of sexual dysfunction signs and symptoms as well as weight changes.  In men, decreased libido and impotence are the main presenting complaints.  Hyperprolactinemic women commonly experience cessation of menstruation, galactorrhea and infertility, as well as diminished libido and inorgasmia.  The treatment of these symptoms, for decades, was Bromocryptine (BRC), which decreases prolactin by enhancing dopaminergic tone.  Decreased prolactin levels in BRC treated patients are correlated with normalization of decreased testosterone and other hormonal abnormalities, resumption of menses, as well as restoration of libido and erectile function.  A colleague, A. Tagliamonte, M.D., of Cagliari, Italy, advised us of 17 male MMT patients of his who complained of loss of libido, had high prolactin levels and whose symptoms responded to Bromocryptine therapy.

 We hypothesized that the increased prolactin levels in MMT patients reduced libido through anterior pituitary-gonadal interaction, as in these other conditions.  We prescribed BRC to 19 patients (13 male and 6 female) in methadone maintenance treatment who had reported some sexual dysfunction.  These problems included loss of sexual interest, absent or delayed orgasm, and (for males) erectile dysfunction.

 Overall, the results indicate that approximately half of the patients who had reported some impairment in sexual function experienced a significant improvement following treatment with BRC.  Among the female patients, half (3 out of 6) reported a significant increase in sexual interest.  Among the 13 males who had reported a complaint, 70 percent reported a moderate or better increase in sexual interest, 57 percent reported a moderate or better improvement in orgasmic dysfunction, and 50 percent reported a moderate or better improvement in erectile function.  No apparent differences between responders and non-responders were evident in regard to age, time in treatment or methadone dose.

 Our study does not demonstrate that increased prolactin levels in MMT patients cause diminished sexual desire and function.  Obtaining prolactin levels prior to treatment and monitoring changes would have helped to clarify this issue.  The purpose of our intervention was to find a treatment that alleviated our patients' complaints.  Our results suggest that any strategy that increases dopaminergic tone might be useful in treating sexual dysfunction in this population.  Medications with lower side effect profiles, such as cabergoline, a newer dopamine agonist requiring only twice weekly administration, or bupropion, might be better choices than Bromocryptine for most patients.

 We believed that the dramatic weight gain seen in some MMT patients might be linked to prolactin levels but were unable to demonstrate this because most of the patients took medication sporadically.  Patients who become obese in treatment frequently associate it with methadone, as do those with sexual dysfunction.  Of the few patients who took BRC daily for a period of more than 90 days, one female showed a 20-pound weight loss.  In MMT patients with complaints of obesity or sexual dysfunction, hyperprolactinemia should probably be considered among the causes.
 

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 I overheard an expectant mother saying that she would breast feed her baby while still on methadone—couldn't this harm the baby or make the baby experience withdrawal symptoms once nursing is discontinued?  Why should a mother on methadone risk breast feeding when she could just as well feed her baby formula?

Answer:

 Breast feeding is not contraindicated due to a mother's being maintained on methadone.  Breast feeding is no different for a methadone patient than for any other mother, and methadone dose has no effect on this whatsoever.

Dr. Marc Shinderman, M.D.
Center for Addictive Problems (CAP), Chicago, Illinois

Editor's Note:  At one time, doctors recommended that methadone patients avoid breast feeding because no studies or research had been done to determine if breast feeding while on methadone could be harmful to the baby.  Since then, many studies have been conducted, and researchers have determined that breast feeding by a mother that's being maintained on methadone is not harmful to the baby.

 The Center for Substance Abuse Treatment (CSAT) encourages methadone treatment providers to recommend breast feeding among mothers being maintained on methadone.  TIP (Treatment Improvement Protocol) Series No. 5, page 13 states:

  Breast feeding is not contraindicated if the woman is methadone maintained.  Thus, if they are HIV-negative and free of other drug use, women on methadone can be encouraged to breast-feed their babies.  Given the well-established importance of breast feeding in the mother-infant bonding process, the fact that methadone-maintained women can often breast-feed their infants is of vital significance.  This advantage to methadone should be emphasized by providers when assisting women in the decision-making process regarding whether to begin methadone maintenance.
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Dear Doctor:

 What, if anything, should methadone clinics be doing to prevent the Y2K problem* (see related article on page 3) from affecting their patients?  For example, suppose the drug company supplying the methadone has problems delivering around the first of next year; will your clinic "stock up" in advance to avoid any possible problems?

Concerned Patient

Dear Concerned:

 This issue needs to be addressed by all businesses, no less treatment services of all kinds.  Most clinics can and do operate manually without computer back up if there are power failures.  Any such eventualities due to the millennium bug should cause no more than minor delays and inconvenience.

 All clinics should stock up on extra methadone at holiday times.  January 1, 2000 should be no different.  My advice is to double normal stocks if possible which may be up to two weeks' supply.  Some clinics may also stock up on the powder concentrate which is much easier to store and could account for another week's supply.

 Blizzards, earthquakes, fires and tidal waves could affect smooth operations of medical facilities.  These things may sound far-fetched, but people in Belgrade and Oklahoma may have thought that a year ago too.  Hence, all clinics should have a backup plan for such emergencies.  This requires a computer disk, suitably encrypted, which could be used by a "sister" clinic which could dose patients if arranged.  We have such an arrangement with our local pharmacy which is open from 8 a.m. to 9 p.m. seven days per week.

 I hope we can look into these issues sensibly in an effort to reassure our patients that they will be looked after.

Dr. Andrew Byrne, M.D.

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