Contents
Interview With Vincent P. Dole
Medical Model
Medical Treatments Before And Since
2. Theories Behind Methadone Treatment
Rationale For Treatment
Why Methadone?
Research Basis For Current Practice
Methadone Myths
Goals Of Treatment
3. Commencement Of Treatment
Essentials Prior To Treatment
Physical Examination And Assessment
Blood Testing
How Much Heroin Are They Using?
How Much Methadone To Give?
Finances - Private Or Public?
When To Review In Early Treatment?
4. Routine Methadone Maintenance
Who Is Doing Well? How Often To Consult?
Consultation Content: 'Counselling'
Take-Home Dosing
Urine Testing And Review
5. Problems After The 'Honeymoon'
Clues To Instability, Dose Adjustment
Continued Use Of Non-Opiates
Attitude To Heroin And Methadone
Feelings Of Guilt
Is It Watered Down?
Rapport When The Chips Are Down
'Side Effects'
6. 'I Want Out'
Why Cut Down?
When To Reduce?
Reduction Versus Transfer
Ways Of Easing Reductions
Physical And Chemical Assistance
'Plan B'
7. Patients With Other Medical Conditions
Pregnancy And Breastfeeding
Viral Infections
Gastro-Intestinal Disturbances
Musculo-Skeletal Symptoms
Psychiatric And Neurological Diseases
Tuberculosis
Iatrogenic Addiction
8. Life After Methadone
The Last Dose
On-Going Reviews
Once An Addict
9. Dispensing Methadone
Hardware And Software
Common Problems
Numbers And Appointments
Missed Doses
Overdose
Identity Documents And Transfers
10. People Issues
Relatives
Neighbours
Police
Disputes Between Patients
Tensions With Staff
The Unhappy Doctor
11. Case Histories
Appendices
1 Legal Reports And Certificates
2 Post Operative And General Pain Relief
3 A Glossary Of Terms
Selected Reading
References
Index
This work is copyright. Apart from any fair dealing for the purposes
of private study, research, criticism or review, as permitted
under copyright law, no part may be reproduced by any process
without written permission from the publishers.
Dedicated to my many patients who have educated me about addiction,
and especially to those who have suffered from HIV, overdose and
other complications which may have been avoided had methadone
treatment been more widely available.
Thanks are due to Dr Alex Wodak of Sydney who first kindled
my interest in this field and to Dr Robert G. Newman of New York
for encouraging my first foray into research. My gratitude also
to the many people from both private and public practice who made
helpful suggestions during the book's genesis. Anne Love and Allan
Gill also deserve special thanks for their tireless work on the
manuscript.
Andrew Byrne is a third generation medical practitioner from
Sydney. Following six years working in inner city hospitals, he
went into general practice where he first treated drug addicts
in 1984. He was the first general practitioner in New South Wales
approved to prescribe methadone for addiction and has treated
up to 120 patients at a time over a ten year period. Having studied
methadone treatment facilities in Brighton (England), Hong Kong,
New York and San Francisco, he has developed a successful rehabilitation
strategy based on the medical model originally proposed by Dole
in 1965. The general practice setting has allowed observation
of long-term outcomes in patients who have completed methadone
treatment. Dr Byrne presented his practice profile to the National
Methadone Conference in Sydney in November 1994. He has been published
widely in Australian medical journals on various drug and alcohol
issues including the use of nicotine patches, benzodiazepine addiction
as well as politically viable alternatives to the prohibition
of drugs.
FOREWORD
This book is intended for the practising physician wishing
to prescribe methadone in the treatment of heroin addiction. It
contains the lessons learned by a general practitioner during
ten years of practice in this field. Far from being the last word
on treatment, it merely represents one physician's approach to
a complex problem.
While many doctors have ambivalent views of methadone treatment,
most are aware of some patients who have functioned normally in
society for extended periods while taking the drug. Rather than
being exceptions, such patients may represent the majority. The
conspicuous few who continue to use illicit drugs create a slanted
impression of this treatment. With society's consequent prejudice,
those who are leading normal lives are unlikely to advertise the
fact that they take methadone.
It has been well documented that much methadone treatment provided
is still inadequate and difficult to access. One patient found
it more convenient to fly from Boston to New York every two weeks
to collect her methadone doses, rather than suffer the rigours
of the local treatment program. It has also been shown that improvements
in the delivery of methadone are associated with improvements
in outcomes. Professor Dole now states that by providing good
quality methadone treatment, complete abstinence from heroin can
be achieved by 95% of patients. The HIV epidemic has made this
goal even more relevant.
Undergraduate teaching still has inadequate drug and alcohol
content, and this 'primer' is intended to help bridge that gap.
Although methadone has often been provided in large clinics, its
use has always been based on the ethical and legal framework of
other medical treatments. Many authorities now believe that this
form of treatment is not fundamentally different from other areas
of medical practice, where accurate diagnosis, advice and judicious
prescribing with appropriate supportive measures are associated
with predictably favourable outcomes.
There are some reports of general practitioners treating numbers
of such patients without disrupting the smooth running of their
medical practices. Two Australian States, Victoria and
South Australia have recently permitted methadone prescription
from private doctors offices. Belgium, France and Germany have
also recently introduced this form of treatment after many years
of virtual prohibition.
The challenging field of drug and alcohol medicine can be as
rewarding as any medical endeavour. The use of methadone should
be taken up by general physicians who are best placed to optimise
its use. Indeed, it is intrinsic to the Hippocratic philosophy
to utilise every available modality in our patients' interests.
Chapter 1 — A New Treatment
Interview with Vincent P. Dole
On my pilgrimage to The Rockefeller University, I asked the old
professor, "Whatever made you give methadone to heroin addicts?"
He replied, with a grandfatherly smoothness, that he and his wife,
Marie Nyswander, had observed the sad results of alcoholism and
drug addiction near the 125th Street station in New York. "We
just decided that we would keep working on the problem, rather
than leaving it to somebody else."
As a psychiatrist, Marie Nyswander had worked with drug addicts
during the 1950s, observing the limited results of abstinence
orientated treatments. Vincent Dole was a researcher in biochemistry.
Both had noted the limited results of available treatment and
they believed that there was a medical basis for the compulsive,
anti-social behaviour of heroin users.
Dole and Nyswander also believed passionately in the science as
well as the art of medicine. In their crusade they sacrificed
simpler and more comfortable pursuits.
They obtained permission to treat a group of heroin addicts with
certain narcotics in a formal trial setting. After trying numerous
short acting drugs, daily administration of methadone was found
to enable patients to curtail heroin use and return to a normal
life in a majority cases. The collaboration changed not only their
lives, but also the lives of countless others around the globe.
Medical Model
While the trial results reported in 1965 were favourable, law
enforcement authorities were not supportive. The prompt and detailed
documentation of the research findings in the Journal of the American
Medical Association made a good case for this becoming 'normal
medical treatment', and thus outside the province of the police.
Subsequent laws banning the use of methadone, even in 'normal
medical practice' showed that the latter-day prohibitionist sentiments
came from the law makers as well as the law enforcement agencies.
Like other successful medical interventions, the 'miracle' of
methadone has to be witnessed to be fully appreciated. The transformation
of the addict is often dramatic. There are improvements in appearance,
attitude and general health. Thanks to the foresight and courage
of these pioneers, this option is now available in many developed
countries where heroin injecting has become prevalent. It is also
being used in some developing countries, with benefits for the
addicted citizens as well as for society generally.
Extending the availability of methadone treatment has been a slow
process, but the HIV epidemic of the 1980s made public health
authorities reassess this modality. There has only been limited
success with other manoeuvres such as behavioural therapies, self-help
groups and residential rehabilitation. Other failed measures include
laws aimed at the drug itself such as stronger penalties for drug
possession and trafficking; increasing customs controls; spraying
of crops in the third world and the use of diplomatic pressure
on poor, impotent or corrupt regimes in producer countries.
Prohibition of heroin has not stopped it being widely available
in most western countries. Telephone orders and home deliveries
of heroin are commonplace. In places where import restrictions
are relatively effective, such as New Zealand and Western
Australia, consumers have made their own heroin substitute from
codeine. Called 'homebake', this mixture contains monoacetyl morphine
which is just as addictive as heroin.
The repeated failure of the prohibition of narcotics, however,
does not justify the uncontrolled supply of opioids which some
authorities have advocated. However, such drugs, including methadone,
should be available to all those who need them, under a coherent
plan of medical management, based upon established principles,
or as a part of on-going research. Even in places with limited
access to trained medical and nursing staff such as Hong Kong,
it is possible for good quality methadone treatment to be made
available on a broad scale.
Dole's original work was twenty years after the La Guardia Congressional
Commission on drugs, and another twenty years before the appearance
of HIV. The reduction in the use of needles and syringes was noted
after the commencement of methadone treatment. Some of Dole's
original ideas went out of favour, but most have since been shown
to be correct, and reintroduced into clinical practice. These
include the use of high dose methadone (>100mg daily) where
necessary, the selective use of supervised urine tests, the use
of intensive psychosocial assistance as well as lengthy or even
indefinite periods in treatment. The drug was initially administered
in the traditional setting of a hospital ward and subsequently
from outpatients. Many controlled trials have since supported
these foundations of methadone treatment.
While now retired from clinical practice, Dole leaves us with
some important principles, based on sound Hippocratic practice.
Quality research should dictate the direction of ethical practice
and professional solidarity should ensure its continued availability,
even when our patients may not always be held in society's highest
regard.
This field has little of the glamour seen in other medical specialties.
Along with indigenous people's health and geriatrics, this field
relies upon a combined approach between the affected families,
professionals in the field and the goodwill of funding agencies
and government. Few patients are prepared to go public with grievances
or consumer action, preferring to maintain their privacy. Those
who do go public are not always representative of the group as
a whole.
Comparable Treatments Before and Since
Just how radical was the plan to give methadone to addicts? Heroin
was invented by the Bayer Company in 1898 and marketed as a non-addictive
analgesic which was suitable for children and also a 'cure
for morphinism'. It was not realised for ten years that it was
just as addictive as morphine.
Like chariots, rockets and penicillin, methadone came about due
to the pressure of war-time. German chemists were working on synthetic
opioids because the allied war effort threatened the traditional
middle-eastern sources of opium. The new drug was recognised as
having strong analgesic properties, and a long duration of action.
It has been marketed since under several names, including Dolophine,
Amidone, Phenadone and Physeptone. The name methadone is
a contraction of the complex chemical name, 6-dimethylamino-4,4-diphenyl-heptan-3-one
hydrochloride (C21H27NO,HCl).
Narcotics are among the most efficacious drugs in the traditional
pharmacopoeia. Opium was called thebacium in Latin, after
the fabled city of Thebes. Galen was aware of its addictive properties
when he prescribed it to Roman Emperor Marcus Aurelius who suffered
from joint pains, possibly gout. Laudanum (tincture of
opium) was popular with both doctors and patients in Victorian
times.
It was not altogether new for physicians to prescribe narcotics
for opioid addiction. Morphine has been prescribed for many years
to addicts, many of whom have functioned well in society. A number
were physicians themselves, such as William Halsted, the originator
of the cancer curing operation. Many pharmaceutical opioids apart
from heroin were also introduced as having non-addictive
properties, only to prove habit-forming in subsequent clinical
practice.
Other narcotic drugs have been used in the treatment of heroin
addiction, both formally and de facto. Buprenorphine has
been trialed as sublingual tablets. Levomethadyl acetate (levo-alpha-acetylmethadol,
LAAM, also called 'long acting methadone'), dihydrocodeine, codeine,
propoxyphene, dextromoromide and intravenous heroin itself have
also been used. Transdermal patches are being trialed in palliative
care and may also prove useful for drug addiction treatment. No
other intervention has thus far proven to be superior to methadone
hydrochloride.
Naltrexone, an orally absorbed, long-acting narcotic antagonist,
has been reported to be effective both for rapid detoxification
under anaesthetic as well as for preventing relapse once maintenance
treatment has ceased. It also has been used in the treatment of
alcoholism and other forms of drug abuse, but formal evidence
is awaited.
A Note to the Reader
While every care has been taken to ensure that the content of
this book is accurate, the author and publisher do not accept
legal liability for any problems arising from the implementation
of the various treatment strategies outlined therein. The mortality
amongst street drug users is such that deaths are occasionally
encountered in this type of practice. The aim of this work is
to assist physicians and others working in the field to ease the
suffering of those affected by heroin addiction and to reduce
this mortality as far as possible.
