Doctor's Column
Thanks to all of these fine doctors for participating . . .
Our Medical Advisory Board includes Dr. Vincent Dole, Rockefeller
University; Dr. Marc Shinderman, Director/Owner of Center for Addictive
Problems (CAP) in Chicago; Herman Joseph, Ph. D., Research Scientist
for the New York State Office of Alcoholism and Substance Abuse Services;
Dr. Charles Schuster, Director of the University Psychiatric Center
(UPC) and former head of NIDA, and his associate, Dr. John Hopper,
Medical Director of UPC; and Dr. Andrew Byrne, Australia, who has
written two books about methadone.
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.
To subscribe to the newsletter:
Dr. Column 3/97-9/97 / Dr. Column
10/97-3/98 / Dr. Column 4/98-10/98
Dr. Column 11/98-7/99 / Dr.
Column 8/99 - /
Breast Feeding & Y2K (July 1999, Vol IV, No.
VII)
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)
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Methadone & Pregnancy in Detroit,
Michigan
Dear Doctor:
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
Editor's Note: After receiving this letter, DONT's
secretary, Nancy Rose, called "Hospital X" and spoke with the head nurse
for about 20 minutes. The head nurse admitted that they begin dropping
the women's doses immediately upon admission to the program. She said they
do not completely detox them off but to a "very low dose" by the time the
birth is imminent.
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, Treatment of the addicted woman in pregnancy. In: Miller
NS, ed. Principles of addiction medicine. Section 16, Women, children and
addiction. Chevy Chase (MD): American Society of Addiction Medicine; c1994.
Chapter 4; [4 p.].
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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Attention: Pregnant Methadone Patients in
Michigan
by Beth Francisco
Last month, our Doctor's Column was in response to a woman's
cry for help because she did not want to go to Hospital X in Detroit, which
is where most women in Michigan are sent when their clinics discover they
are pregnant. As a result of that column, Methadone Today received
a call from Dr. Schuster, who is the Director of the UPC Jefferson Avenue
Research Clinic. He was also formerly the head of the National Institute
on Drug Abuse (NIDA). Dr. Schuster told us at DONT that he agreed
with Dr. Shinderman's answer and that we may send pregnant women to UPC
where they will be treated according to proper procedure.
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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Letter from General Practice Doctor
Reprinted from "Australian Doctor Magazine" 18 Sept '98.
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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MMT Patient Organ Donation
Dear Dr. Dole:
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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Methadone and Alcohol
Dr. Marc Shinderman
Dear Doctor:
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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Methadone, LAAM & Withdrawal
John Hopper, M.D.
Dear Dr. Hopper:
I'm now taking Orlaam (LAAM) but for two years, I was on
methadone. Though I took my medication every day, I would often go
through severe withdrawals. For a long time, I was unaware of why
I was getting sick, and none of the doctors could figure it out either.
Every 8 weeks like clockwork I'd wake up ill and vomit stomach acid every
20 minutes, usually lasting 7 days, and I wouldn't get ANY sleep.
It never occurred to me that I was withdrawing because I'd had my methadone
the previous day.
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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Methadone, Weight Gain & Reduced Sex Drive
Dear Doctor,
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
Center for Addictive Problems (CAP)
Chicago, Illinois
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Uses of Methadone for Other than Opiate Addiction
Dear Doctor,
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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Sexual Dysfunction Treatment with Bromocryptine
M. Shinderman, M.D. (ASAM) & S. Maxwell, M.D. (ASAM)
Center for Addictive Problems, Chicago, Illinois
Editor's Note: The issue of lowered libido was brought up in the
April issue of Methadone Today. Dr. Shinderman's "findings regarding
medical treatment of lowered libido in methadone maintained patients" was
presented at the American Society of Addiction Medicine [ASAM] conference
and is summarized below:
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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Breast Feeding & Y2K
Dear Doctor:
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.
============================================
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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