Methadone Today

Narcotic Blockade - by Joycelyn Woods, Executive V.P. - NAMA

The Good News Is. . . .Nancy R. (Detroit)

The Bad News Is. . . .Nancy R. (Detroit)

Hepatitis C - by Beth Francisco

DEA - Jennifer McNeely (Lindesmith Center)

Drugs Which May Lower Methadone Serum Blood Levels - Nancy R. (Detroit)

I Have A Vision - by Michael Habenstreit - Reprinted from Methadone Awareness

Briefly Speaking - Short items about drugs in history

Back Page - Short items, i.e corrections, news, etc.

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There is a saturation point of the opiate receptors, which is the concept of blockade. Theoretically, you are saturating the opiate receptors with methadone, which is longer acting than heroin, AND here is another property of methadone that makes it somewhat different than other opiates--it has specificity to the mu2 receptor which is the receptor involved in euphoria and, as I recall, respiratory depression. Other opiates do not have the specificity of methadone--while certainly they prefer a receptor (heroin and morphine prefer mu2), they will fit in any opiate receptor around.

Since methadone is longer acting, has a higher affinity for, and has a specificity to the mu2 receptor, it fills them up. Now lets make this simple--suppose you had 100 mu2 receptors in your brain (fortunately we don't), your dose was 100 mgs a day and, on the average, 90 receptors are filled (or 90%). Since methadone will stick to that receptor for around 24 hours, you could shoot all the heroin in the world, and the most receptors you can fill would be 10, or 10%. Considering that, you probably would not feel anything.

BUT, the brain isn't that simple; we do not have a set number of opiate receptors. For example, cocaine increases opiate receptors, which kind of makes sense since patients will say that cocaine eats up methadone. What is happening is that the receptors are increasing, and ratios are probably more important than exact numbers. So, if you had 100 opiate receptors in your brain and were on 100 mg. which, on average, filled 90 receptors, then used cocaine, and the receptors were increased to 120, now you only have 75% of the receptors filled with 100 mgs. instead of the 90% you are used to. You would feel uncomfortable, feel like the cocaine was eating up your methadone, and ask for a raise like most patients would.

BUT back to the brain not being so simple. It is kind of like a soup of peptides and transmitters and all kinds of things like little molecules floating around (there are neurotransmitter systems impinging on the endorphin system, and all this is in the sea of neurotransmitter juice). You also metabolize differently throughout the day--some fast metabolizers may never be able to achieve blockade. So there are many other factors playing on this, which may be the reason that some patients can shoot over their dose. However, usually the effects of heroin are dulled somewhat. (Please remember, this is a very simplified model and the brain does not work in exactly this way).

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Hepatitis C has grown to epidemic proportions, with some areas reporting that as many as 95% of new methadone patients test positive for the virus. At one time called non-A, non-B, there is still very little known about it. About 3.5 million Americans already have Hepatitis C (HCV), and there are about 180,000 new cases each year; at least one-half will develop into a chronic condition.

Hepatitis C is a blood-borne disease and can be easily transmitted through shared needles, tattoos, and blood transfusions. HCV cannot be killed with bleach as HIV can. Other ways to become infected are by sexual contact, using another person's toothbrush or razor, and health care workers are easily infected by pricking themselves with an infected needle or by transmission through a small cut on their hands, etc.

Symptoms of HCV may include fatigue and depression, flu-like aches and pains such as vomiting and diarrhea, loss of appetite, elevated liver enzymes, and the urine may look dark; the later stages may include internal bleeding and swelling of hands and feet (edema).

Hepatitis C causes cirrhosis, liver damage, liver cancer, and eventually liver failure. It is one of the two most common reasons for liver transplants--the other is cirrhosis resulting from alcoholism. A lot of people have Hepatitis C and do not know it, nor do they know where the transmission occurred.

Some lifestyle changes are necessary, and may save your life. Avoid alcohol, do not use any powdered drugs--cocaine, crack or those used in cold preparations, etc. There is evidence that alcohol and stimulants may speed the degenerative nature of the virus. Eat nutritionally sound meals, and brush your teeth just as soon as you are done eating.

Good personal hygiene is essential--a bath or a shower daily is a must. With Hepatitis C, the cleaner you keep your body, the better chance you have of surviving.

If you have not been checked for this virus, please do so. As with most diseases, the earlier it is detected, the better the prognosis. Interferon is the only treatment available to date.

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At the present time, except for New York's KEEP Program (story next month in Methadone Today) at Riker's Island, anyone who is prescribed methadone is at the mercy of their jailers when the patient is locked up. However, we occasionally hear good news:

A patient from an area clinic was locked up in Northern Michigan for non-payment of child support and another was locked up downriver for a traffic ticket. In each case, the police drove the patient/prisoner to the clinic to pick up their daily dose! Plus, the clinic and police arranged to have as many doses available as needed to cover the number of days each patient would be locked up. We would like to thank the police agencies, jails and owners/staff of the clinic involved. We hope other clinics and law enforcement agencies will be as ethical and caring when a set of circumstances such as these present themselves.

If anybody has a good story (or bad story, whichever the case may be), let me know; send it to us at Methadone Today, P.O. Box 164, Davison, MI 48423-0164.

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A patient was locked up in Macomb County for the weekend (Friday night through Sunday, 8 p.m.) for driving under the influence (DUI). Macomb County Jail would not let the patient dose even though take-home bottles for the weekend were available. They did not even have to drive the patient to the clinic; the patient had the bottles with them! A clinic employee called Macomb County Jail on the patient's behalf, but the jail refused to cooperate.

We hope the day comes soon when all law enforcement personnel realizes that a methadone patient is a patient, prescribed a legal medication by a physician, and it is dangerous physically (not to mention extremely inhumane) to deny a patient his or her medication. A patient who is prescribed insulin or blood pressure pills would not be denied those medications. Likewise, methadone should not be denied to a patient.

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While it's true that most of the public and the medical profession think poorly of drug users and methadone patients, the greatest barrier to change right now is the DEA, and we should focus on them equally, if not give them priority, when we advocate for a more sensible methadone treatment policy. There are doctors out there who would prescribe methadone today, but the DEA keeps them from doing it by continuing to misrepresent the numbers of methadone deaths and exaggerating methadone's presence on the black market.

When an emergency room patient dies of a heart-attack or a heroin overdose, if methadone is in the blood, the DEA counts it as a methadone death. In reality, more deaths are caused by acetaminophen (Tylenol) than by methadone alone. Heroin overdose deaths, which methadone treatment can prevent, outnumbered methadone deaths by 16 to 1 in 1994.

It's extremely important for patients to speak up when people try to demonize and de-legitimize methadone, and it is important to bring more attention to the way that methadone patients and drug users are mistreated (or just not treated) by physicians. But we also have to make sure that we talk about the DEA and reveal their misrepresentations of the facts about dangers of methadone diversion. Until they back down, even good doctors will continue to have their hands tied on methadone.

Note: Jennifer is going to medical school but is still affiliated with the Lindesmith Center. We wish her well; she has been an inspiration to us.

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Do you, as a methadone patient, ever notice that on some days your methadone seems to "hold" you just fine, and on other days, it doesn't? There are a number of possible reasons for this. Taking certain over-the-counter medications, vitamins, or even grapefruit juice may affect your methadone blood level.

Sometimes methadone patients are prescribed other medications by their physicians. There are several which may interact with methadone causing withdrawal symptoms. These particular drugs actually lower the methadone plasma blood level, or decrease methadone's effects.

The following list of drugs and other substances which may cause withdrawal symptoms was given in the Addiction Treatment Forum (Vol. VI, #2, Spring 1997):

Drugs Which Are Contraindicated/Which May Precipitate Withdrawal
ReVia™ (generic name - naltrexone)
Certain pain relievers with opioid-antagonist activity, such as Buprenex®, Stado®, Dalganr®, Nubain®, Talwin® (generic names - buprenorphine, butorphanol, dezocine, nalbuphine, pentazocine)
Certain pain relievers (not considered opioid antagonists), such as Ultram® (generic name - tramadol)
Revex™ and Narcan® (generic names - nalmefene and naloxone)

Drugs Which May Lower Methadone Blood Levels
Certain barbiturate sedatives and/or hypnotics, such as Bitosol Sodium®, Nembutal®, Phenobarbital, Seconal®
Anticonvulsants for epilepsy and trigeminal neuralgia, such as Atretol®, Tegretol, and Dilantin®
Rifadin®, Rifamate®, Rifater®, Rimactane® (generic name rifampin), which is used in treatment of pulmonary tuberculosis
Vitamin C, K-Phos® (large doses), (generic name - ascorbic acid, urinary acidifiers)
Wine, beer, whiskey (chronic use), (generic - Ethanol)

Drugs Whose Pharmacokinetics May Be Altered by Methadone
Norpramin® (generic name - desipramine), used as an antidepressive
Retrovir®, AZT combinations (generic name zidovudine)

Some over-the-counter drugs, such as Tylenol® and Excedrin® may affect methadone blood levels, as well as protease inhibitors used for HIV treatment. For further information on protease inhibitors and methadone, see Methadone Today, Vol. II, Issue VI, June 1997.

Certain substances/drugs may increase methadone blood levels. Drugs used in the treatment of depression and anxiety, such as Elavil®, Triavil®, Endep®, and Limbitrol® (generic name - amitriptyline) may increase plasma levels of methadone, along with Tagamet® (cimetidine), which is used in the treatment of gastric and duodenal ulcers. Drugs used in the treatment of anxiety, such as Valium® may also have this effect.

We feel methadone patients and physicians should be made aware of the substances and drugs which may affect a methadone patient's serum levels. While the list of substances mentioned above is not a complete listing, it will hopefully help make patients, physicians, dentists, and any other health-care professionals who prescribe drugs aware of the interaction between other drugs methadone serum levels. And, when you, the patient, feel your methadone is too strong or is not holding you, it just may not be "all in your head." That's the unprofessional, lazy man's answer.

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After spending over one decade and getting close to my second decade on methadone maintenance treatment, you can imagine the disrespect, humiliation, and heartbreak I have been through. I have been on five different clinics in Massachusetts and Rhode Island.

It is now the late 1990's--isn't it about time for a new methadone treatment system? Computers are everywhere now--why not let us have a new system, with a card like the welfare and public assistance organizations use. It would have a magnetic-encoded strip on one side, with your own PIN (personal identification number), and maybe your social security number. And, on the other side, it would have your dose in milligrams and your picture--hologram style.

Then, methadone patients, and especially the people who live 50-100 miles away from the nearest clinic, could go to their local pharmacy and get their dose. The pharmacy would have to install an infrared reader hooked up to a modem, which would go directly to the State Methadose main computer. The computer would recognize your card and okay the pharmacist to give you your dose. And, no one, the other customers in line, would even know it was methadone you were getting. Once or twice a month, the local hospital in your area could do a urine or blood test.

Why should we be treated any differently from the diabetic or pain clinic patient? I would even say you should receive this privilege only after at least a year of putting up with a clinic's rules--follow them, and one day your future on methadone maintenance may be humane treatment!

This system, if done properly, could even save money! I have thought up all sorts of ways we could stay within the Federal and State guidelines and do away with the hassle of clinics and clinic regulations. I hope to change my world and yours for the better, and with all of the advocacy groups that are springing up, it looks like things will change for the better in the future!

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1906 - The first Pure Food and Drug Act becomes law; until its enactment, it was possible to buy, in stores or by mail order, medicines containing morphine, cocaine, or heroin, and without their being so labeled (Szasz. T. (1975) Ceremonial Chemistry. New York: Doubleday/Anchor).

1920-33 - The use of alcohol is prohibited in the U.S. In 1932 alone, approximately 45,000 persons receive jail sentences for alcohol offenses. During the first eleven years of he Volstead Act, 17,971 persons are appointed to the Prohibition Bureau; 11,982 are terminated "without prejudice," and 1,604 are dismissed for bribery, extortion, theft, falsification of records, conspiracy, forgery, and perjury. (Fort, Joel, The Pleasure Seekers, p. 69).

Prohibition will never, ever work--never! There is too much money involved in bribery, extortion, corruption, and you name the rest.

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ADDITION - Last month's Methadone Today, July 1997, "When the Dose is Not Holding the Patient" was taken from Treatment Improvement Protocol (TIP) Series #1, State Methadone Treatment Guidelines. To order call (800) SAY NOTO; it will be sent to you free of charge.

CONNECTICUT STATE SENATE decided the State Corrections Commissioner could establish a methadone program for drug-dependent inmates as a pilot program, and licensed physicians would be allowed to prescribe methadone for heroin users in one geographical area of the state as long as there is community approval and funds available. It's a beginning!

MORE BAD NEWS - At the end of June, after the July newsletter went to press, we were informed that Pete Seal, President of SCA-NAMA, passed away in April of an overdose. As many of you may know, Pete wrote the article, "It's Only In Your Head", which was published in the Ombudsman and reprinted in Methadone Today. It is a great loss since he had worked and trained others to work in the field for years, and when he needed help, he received humiliation and bias.

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