Doctor's Column
Thanks to all of these fine doctors for participating . . .
Our Medical Advisory Board includes Dr. Vincent Dole, Rockefeller
University; 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; Dr. Marc Shinderman, Director/Owner of Center for Addictive
Problems (CAP) in Chicago; 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 - /
More on Serum Levels - (October 1998, Vol. III,
No. X)
Naltrexone-Related Deaths - (September
1998, Vol. III, No. IX)
Reluctant to Tell Employer About MMT - (August
1998, Vol. III, No. VIII)
Forced Withdrawal Letter - J. Thomas Payte,
M.D. - (July 1998, Vol. III, No. VII)
Daughter on Methadone isTired & Anxious
- (June 1998, Vol. III, No. VI)
Addiction vs Dependence - (May 1998,
Vol. III, No. V)
What to tell friends and family regarding
MMT - (April 1998, Vol. III, No. IV)
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What to tell friends and family regarding
MMT
Tell them as little as possible. Few can understand it, and most will not
be supportive. Many "straight" people will reject you if they learn that
you take methadone. They will immediately harp on you to be through with
methadone at some point, which will have nothing to do with your capacity
to do so without relapsing. If they are addicts, they will be jealous of
your independence from them and the routine.
Do not discuss your dose--ever. It is no one's business. It will come
back to haunt you one way or another. Tell them you do not want to know
and you do not want anyone else to know. It does not mean anything. How
you handle your life is what counts.
If you must discuss your treatment at all, discuss it in terms of your
goals and progress (i.e. health, not using heroin, being pain free, school
and vocational issues, improved relationships, etc.). If you must tell
anyone, use the word "medication" and not "methadone." Bashing opiate use
is a natural reflex for the ignorant; they cannot help themselves. Do not
get into emotional arguments about "methadone." It does no good.
Sample Q&As
Q: When are you going to get off methadone?
A: When they find a better treatment or cure for heroin addiction. Research
shows that those who withdraw from medication are dead, in jail or using
heroin within 18 months. Why would anyone want to take those risks?
Q: Does that mean you will never get off of methadone?
A: My goals are (fill in the blank). Withdrawing from the treatment
which gives me the opportunity to realize these goals seems self destructive
to me. I know what life was like without medication; I may feel differently
in the future. Who knows, maybe there will be something better than this
medication one day? We can both look forward to that.
When others become animated and angry about it, and they will, do not
get defensive. Just say, "I would have agreed with you before learning
what I have and before experiencing the benefits of treatment." Offer to
refer them to clinical research literature, addiction professionals who
prescribe methadone, or personnel at your clinic or doctor's office if
they want more answers beyond your little testimonial. Stick to what you
know, which should be that your treatment is "a lifesaver for me personally.
Isn't that wonderful?" If they are not willing to do any of these things
and continue to pry and complain, you can observe (aloud or to yourself)
that such persons' real interest is in your behaving like an addict again.
You do not have to accommodate them.
Regarding being off heroin, no one wants to hear that you were ever
ON HEROIN, in the first place. You do not get a gold star for publicly
being off it. "I don't need it, why should you?" is their attitude. Everyone
is vigilant for signs of your relapse once they know about your addiction
history.
Many people actually think that it is a great idea to tell people about
their methadone treatment. No one will really give a damn except to put
you down for being an addict or worse if you are on methadone. All they
care about is that you do not rock their boat with different ideas and
new behaviors and that you continue to play out a role that confirms their
microscopic egocentric world view. "Methadone Works!" does not do that
for either the devoted addict or someone who has never had a problem with
drugs. "Methadone doesn't Work!", confirmed by your dropping dead or being
a failure, is much more self-affirming for both viewpoints. Some of these
folks will subconsciously push and undermine you until you satisfy their
limited expectations.
There are exceptions, of course. Use these guidelines always at first,
and then choose whom you tell and what you tell carefully after you have
stabilized in treatment and are feeling good about your progress. This
is seldom before a year or two into treatment, in most cases.
Dr. Marc Shinderman
Center for Addictive Problems (CAP)
Chicago, Illinois
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Dependence vs Addiction
PHYSICAL DEPENDENCE DOES NOT CAUSE ADDICTION.
ABSTINENCE DOES NOT CURE ADDICTION.
NALTREXONE IMPLANTS AND DEPOT FORMULATIONS
MAY NOT BE THE BEST WAY TO GO
Many believe that addiction and physical dependence are the same thing.
They are two very different issues. This has been demonstrated repeatedly
in animal and human studies. Physical dependence may be a side effect from
substance use, licit or illicit, taken for medical or recreational, self-medication
purposes. It RARELY leads to addiction, which has to do with obsessive
pursuit and abuse in the face of self-destructive consequences.
Neither many patients made physically dependent in the course of medical
treatment nor lab animals that we make physically dependent in experiments,
who do not have the "right stuff " (genetics or high stress environment),
ultimately behave as addicts.
Physical dependence can be medically managed, fairly easily and inexpensively,
if done so slowly, by most experts on an outpatient basis. Hospital treatment
is usually not necessary. In addiction, it is usually not very effective
for long.
NALTREXONE, Alcohol and Opiate abuse
Blocking development of physical dependence or some other responses
that depend on stimulation of opiate (opioid) receptors in the brain with
naltrexone is an attractive idea to many people. While it is common sense,
addiction isn't that simple.
Naltrexone is a useful tool in the treatment of alcohol abuse. It might
be useful in the treatment of some heroin addicts. It must be used in ways
which protect patients from overdose and creation of high levels of drug
craving, depression and diminished sexual interest, in my (research informed)
opinion. Chronic administration may not be the way to accomplish all these
goals.
Administration of naltrexone on a daily basis, for long periods, as
is now possible through implants, depot injection or direct observation
of oral dosing, will prevent physical dependence on opiates and many of
the effects of alcohol that result in abuse. Used in this manner, it leads
to increased craving and increased reaction to alcohol or opiates when
the blockade is stopped. This means that a little will go a very long way,
leading to disinhibited behavior, blackout in the case of alcoholism, or
death, in the case of heroin, on very low doses of drug, once naltrexone
blockade is removed. Long-term daily (or depot) use of naltrexone in alcohol
treatment is inferior in these respects compared to its intermittent use,
and I am wondering whether this might be the case in regard to the treatment
of heroin addiction. The short term results might be better for chronic
uninterrupted blockade, but the long term results may prove otherwise.
It is something to watch. Frankly, I hope that I am wrong about this. If
this chronic endorphin blockade does turn out to be a good intervention
after all, using the depot injection, recently available somewhere (Naltrem)
would be a simple procedure.
Dr. Marc Shinderman
Center for Addictive Problems (CAP)
Chicago, Illinois
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Daughter on Methadone isTired & Anxious
Dear Doctor,
My 24-year-old daughter has been on methadone for 6 months; her dose
is 60-70. She is doing very well, but she is very tired all the time &
has had problems staying up especially when she is in class. Are there
any vitamins or nutritional programs to help her? She also has anxiety
attacks when she sees people who she knew prior to her addiction; are there
any anti-anxiety meds you would recommend? Thanks for your help.
Dear Mrs X,
Your daughter needs no special diet. She should have the same advice
as any student in a similar position--good food, enough exercise, sound
sleep and healthy social life are all important.
A certain level of anxiety in these circumstances is absolutely normal,
and the best approach is to try to avoid the parties involved from her
past life. In six months, she has apparently radically and successfully
altered her lifestyle.
Drugs used for anxiety are often ineffective and some, like Valium,
are habit forming and should be used with caution by people with addictive
tendencies. If she has an underlying depression or other condition, she
may need specific medication, and for this reason, she should consult with
a physician who is familiar with dependency.
A full history and physical examination may reveal something which can
be addressed to improve the anxiety. Some such problems are sometimes best
not discussed with loved ones.
The dose is a technical matter between patient and doctor. A higher
dose may help anxiety, but it may also worsen her lethargy or other effects.
It is "always" possible to find a 'happy medium', but it may take some
fine tuning. The "average" dose in good clinics around the world is now
close to 100mg, so your daughter's dose of around 70mg is still in the
low range. The maximum I use is 350 mg daily.
The use of other drugs is also important - with amphetamines, cocaine
and alcohol being particular concerns in cases like this, whereas cannabis
and tobacco seem to be less of a problem in such circumstances. This is
not to say the latter should not be discouraged, as they should. Your daughter
is now likely to lead a normal life as long as she treats her dependency
seriously, seeking advice at the right time and getting the help she needs.
She is likely to need methadone for certain periods, and she may be off
methadone at other times.
You should treat her no differently than if she had high blood pressure,
diabetes or another long-term condition. The one thing you must not do
is pressure her to change her dose. If you are concerned about her condition,
a second professional opinion is the most logical step, even if it means
traveling to the next town.
I hope this is of assistance.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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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Forced Withdrawal Letter
Sample letter to respond to efforts
to force a probation/parole methadone patient into withdrawal solely for
being on methadone. This letter may be used in response to a threat
that a patient must "detox" or be "revoked" and incarcerated.
Such efforts are based on ignorance
of the facts, leading to bias and serious discrimination. Other issues
involve forced medical decisions (practice of medicine), violations of
civil rights, and denial of appropriate treatment for a medical disorder.
The letter can be adapted and is intended to educate and intimidate
.
Re: Forced
disruption of methadone maintenance treatment by mandatory withdrawal
Patient: John Doe
Dear PO:
On numerous occasions in the past,
I have had patients who were in treatment for chronic opioid addiction
involving the use of opioid agonists drugs such as methadone and LAAM,
who were also on probation or parole. In some cases continued treatment
is incorporated into the terms and conditions of probation or parole to
ensure continued medical treatment, supervision, and appropriate reporting
to ensure compliance. Experienced officers are often well aware of
the advantages of maintenance pharmacotherapy in terms of fostering employment,
elimination of criminal activities, drug use, improved health, and lowered
rates of relapse and recidivism.
However some officers may not be
familiar with the considerable body of knowledge, scientific and clinical
research that establish opioid maintenance pharmacotherapy as the most
effective treatment for chronic opioid addiction. Addiction has been
clearly demonstrated to be a chronic, progressive, relapsing and often
(if untreated) fatal disease. Opioid maintenance is a medical treatment
utilizing effective pharmacological agents (medications, primarily methadone
and LAAM) to correct, stabilize, and normalize the disease process
but not to "cure" the disease. opioid maintenance treatment has been
shown to be safe and effective in terms of dramatic reduction in death
rates, stopping illicit drug use, elimination of criminal activity, reduction
in spread of hepatitis B and C as well as HIV disease. Social function,
mental and physical health, and employment are enhanced.
Forced withdrawal from opioid maintenance treatment is associated
with a greater than 90% relapse rate to illicit opioid drug use.
Relapse carries added risks of overdose, HIV infection, hepatitis, return
to criminal activities, as well as the violation of specific terms of probation
or parole. The choice of opioid maintenance treatment as a treatment
modality is a medical decision made by the physician in consultation with
the patient. Any decision to withdraw from methadone is also a medical
decision made with considerable caution based on the patient's strong wishes
to withdraw as well as progress in treatment and the degree of stability
in such domains as employment, social stability, etc. that will support
ongoing recovery and abstinence.
At times opioid maintenance treatment patients who are doing well
in treatment and not otherwise in any violation of terms and conditions,
are subject to efforts to force discontinuation of treatment for their
addiction with threats to revoke and send them to prison. These efforts
appear to be based on bias and prejudice toward opioid maintenance treatment
fostered by a lack of knowledge relating to addictive disease and the various
treatment modalities, including opioid maintenance treatment.
Being in opioid maintenance treatment does not constitute a basis
for relaxation of any standards in relation to specific terms and conditions
of probation/parole. Those in violation and facing revocation will
be afforded withdrawal based on conditions in effect. My concern
is in the cases where continued effective and essential treatment is threatened
based on objections to the treatment modality. The objection appears
to be based on the use of a medication (in this case an orally effective,
long-acting opioid agonist such as methadone or LAAM) to relieve or correct
a neuro-biological defect that does not lead to a "cure." There are
many examples in the practice of medicine where treatments of a host of
disorders, such as diabetes, hypertension, allergies, hormone deficiencies
involving medication that stabilize, comfort and relieve but do not "cure."
I view these efforts with considerable alarm over the exertion
of very questionable authority to deny an individual with a medical disease
(chronic opioid addiction) the right to get the most effective, safe and
legitimate treatment available. This may be seen as a violation of
civil rights and provisions of the Americans with Disabilities Act that
comes dangerously close to the practice of medicine without a license.
The disruption of treatment carries very real risks and potential harm
and very significant losses, far beyond the relapse to illicit drug use
with impact on the individual, his family, and the community at large.
Medically supervised withdrawal (MSW) from methadone maintenance
is a medical procedure that must be ordered by a physician and done with
full informed consent of the patient. MSW cannot be mandated in disregard
of the health and safety of the individual and the community. On
grounds of medical judgment, I refuse to perform this procedure in the
absence of sound indications that would support a reasonable chance of
a successful outcome.
By Federal law, patients have the right to a MSW on request.
This procedure is allowed when evidence suggests that the patient strongly
desires the procedure and understands the risks. When the patient's
request for MSW is in response to external pressures and/or threats the
procedure is done only against medical advice (AMA) with full documentation
of the circumstances. The patient signs a form acknowledging the
AMA conditions, that there is pressure to stop opioid maintenance treatment,
and that the patient is aware of the risks and consequences of this procedure
.
Consultation with legal counsel has assured me that any restrictions
imposed upon an opioid maintenance treatment patient by individual officers
of probation or parole departments may be seen as a violation of constitutional
rights under US Section 1983 and the Americans with Disabilities Act, among
others.
If continued appropriate treatment for his chronic opioid addiction
is assured, our program will cooperate fully with officials to ensure compliance
and his participation in treatment to facilitate rehabilitation and development
as a responsible, productive, and law-abiding citizen.
The treatment proposed is continued methadone or other agonist
treatment for as long as the patient continues to benefit from treatment,
is at risk of relapse, and desires to continue. Getting off methadone
is never a criterion of success. However, periodic evaluations are
made to determine the feasibility of a change to a maintenance-to- abstinence"
track when appropriate and strongly desired by the patient. In many
cases two or more years are needed for stabilization and to reach
a point where withdrawal from methadone can be accomplished and the resources
are in place to maintain a drug-free life. Some patients will require
very long term if not life-long treatment, while others are candidates
for abstinence based continuing care.
Editor's Note: I have had several people ask what
they can do when a probation/parole officer tells them to get off methadone.
Sincere thanks to Dr. J. Thomas Payte for allowing us to
reprint this excellent letter to help them out.
For those of you who have internet access, Dr. Payte has a web
site at: http://home.swbell.net/jtpayte/
It is well worth checking out, if only for the letters he has online.
To mention just a couple of items to his credit, Dr. Payte was
a recipient of the Nyswander-Dole Award (The Marie Award) in 1992, he is
the editor of the recent Journal of Maintenance in the Addictions
published by the Haworth Press, and he has a patient-oriented methadone
maintenance clinic: 3701 W. Commerce Street, San Antonio TX 78207
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Reluctant to Tell Prospective Employer About
MMT
Dear Doctor,
I have been on methadone since September 1997. It has worked
FANTASTICALLY!! I have not used even once since I started.
We just bought a new home, and I am ready to start looking for a part time
job to help out with the bills. I am very reluctant to tell any prospective
employer that I am on the program.
My question is this: what socially-accepted affliction can
I tell them I have that requires me to go to the clinic every morning as
well as group every Tuesday afternoon. I am not willing to give up
my Tuesday groups. I have made very good friends with them and the
counselor. I was thinking I could say I have diabetes, but they would
see me eating candy and especially drinking chocolate milk (which I now
crave). Any thoughts?
Thanks, DS
Dear DS,
Frankly, I would not lie. I would not tell them anything,
personally. If you must lie, make it a whopper. You might say
that this is a religious meeting. Religion is not discussed and judged
as much as are medical issues. A religious excuse might be
perceived as something both benign and not to be messed with by an employer.
The other lie that you might like is "eating disorder" treatment.
Good Luck.
Dr. Marc Shinderman
Center for Addictive Problems (CAP)
Chicago, Illinois
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Naltrexone-Related Deaths
Dr. Andrew Byrne
In June, I learned of three Sydney drug users who had been through
rapid detox and then died afterwards. All three stopped their naltrexone
and overdosed on narcotics. I know that two of these cases will be
referred to the coroner. One may have been an intentional suicide.
It is very worrying to have three deaths in such a short
period and in the one small area. I am concerned that these may not
be isolated. All of these patients were repeatedly informed of the
dangers of using even small amounts of heroin after the rapid detox procedure.
At least two signed consent forms to this effect. Depression played
a role in at least two of these patients who were both originally treated
in different cities to their place of residence. Only one patient
was in a funded trial supervised by an ethics committee, while the others
paid for private treatment elsewhere in Australia and overseas.
One patient died 10 days after the procedure, one 6 months and
the third an unknown 'number of weeks' after detox. One had a general
anaesthetic while the other two had sedation. One patient was a 40-year-old
registered nurse who had been stable on methadone for 8 years previously.
We must all advise extreme caution when dealing with a modality
which is not yet established. Would we allow a relative to be treated
with a new intervention of unknown safety or effectiveness? My feeling
is that more information needs to be obtained on the patients who have
already been treated before embarking on further trials of this manoeuvre.
It may be that Miotto's study published last year was not exceptional.
They found that of 81 traditional detox patients who were prescribed naltrexone,
13 had overdosed within a year and 4 were dead. Another patient had
attempted suicide by jumping from a moving vehicle.
There are still many unanswered questions about naltrexone, the
most pertinent being, "is it safe and is it effective." The evidence
in favour2 of these is still very slender. A recent review of a large
number of studies3 provides little encouragement for those who believe
that this is a major advance.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
1Miotto K, McCann MJ, Rawson RA, Frosch D, Ling W.
Overdose, suicide attempts and death among a cohort of naltrexone- treated
opioid addicts. Drug and Alcohol Dependence (1997) 45:131-134.
2Spelling is correct--Australia
3O'Connor PG, Kosten TR. Rapid and Ultrarapid Opioid Detoxification
Techniques. 1998 JAMA 279;3:229-234.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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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More on Serum Levels
Serum Levels
Active & Inactive Methadone
People are always asking me about serum levels. Usually
they tell you something useful, but not always. . .
American methadone is a 50/50 mixture of active and inactive forms.
Swiss sometimes use the pure form that has only active methadone, as well
as the mixed (racemic) product used for maintenance in the US.
These are called different names in different languages but are
named for the right-handed or left-handed nature of the way the molecule
transmits light. What is important is that only one of these methadone
forms is biologically active.
Our traditional serum level lab tests are based on adding the
total methadone, both right- and left-handed. Combined values, which
equal 450 ng/ml or greater are cited as being the minimum necessary for
good treatment and abolishing craving.
The problem is that some patients metabolize methadone in
a way that allows the 50/50 ratio of inactive/active methadone to vary
widely. Some patients can have far too little of active methadone
("R" methadone) but still have serum levels in the normal range.
Others can be comfortable with low serum methadone test results
because they have larger than average "R" methadone fractions in their
system. In patients whose active/inactive (R/S) methadone ratio is
less than .67 (=40 percent active methadone), Swiss clinicians (JJD) have
observed signs and symptoms of withdrawal and emergence of craving although
their total methadone serum level would appear to be adequate.
In the US, we need to medicate patients based on clinical signs
and symptoms more than on serum levels. Tests which measure the two
isomers are now expensive, and our literature does not yet reflect broad
clinical experience with their use. Pure "active" methadone, which
is usually dosed at fifty percent of the dose of our methadone, is unavailable
here (and costly, if it were).
Abstract information: European Journal of Clinical Pharmacology
ISSN: 0031-6970 (printed version) ISSN: 1432-1041 (electronic version).
Conclusion:
Although of small amplitude (16%), this decrease confirms previously
described adaptive changes in methadone pharmacokinetics during racemic
methadone maintenance treatment and may necessitate, in some patients,
a dose adjustment.
Dr. Marc Shinderman
Center for Addictive Problems (CAP)
Chicago, Illinois
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