Treatment Of Heroin Addiction Research Articles

Fiscal Strain and Access to Opiate Substitution Therapy at Department of Veterans Affairs Medical Centers

This study examines the relationship between institutional fiscal strain and the availability of opiate substitution therapy (eg, methadone maintenance), an effective but relatively expensive treatment for heroin addiction. An observational design was used to examine the association of changes in funding and changes in provision for treating opiate addiction at 29 VA Medical Centers (VAMCs). We hypothesized that VAMCs experiencing greater fiscal strain would show reduced availability of opiate substitution treatment. Administrative records from each of 29 VAMCs that provided opiate substitution therapy in both Fiscal Year (FY) 1995 and FY 1999 were used to measure changes in the availability of this service, ie, the percent change in total patients treated, annual visits per patient, and total services delivered. Institutional fiscal strain was measured by the percent decline in per capita funding at four levels at each VAMC: the entire medical center, all mental health programs, all substance abuse programs (inpatient and outpatient), and outpatient substance abuse programs alone. The total number of patients receiving opiate substitution increased from 5,549 in FY 1995 to 6,884 in FY 1999 (24%), annual visits per patient decreased by 16%, and the total number of units of services increased by 4%. There were no significant relationships between changes in the delivery of opiate substitution services and changes in per capita funding at any of the four institutional levels. No new programs were started during these years. Although no new programs were started, the availability of opiate substitution therapy at VA facilities with existing programs was maintained over a five-year period regardless of local funding changes, although at somewhat reduced intensity.

Naltrexone maintenance treatment for opioid dependence.

Despite widespread use of naltrexone maintenance in many countries for more than a decade, the evidence of its effects has not yet been systematically evaluated. To evaluate the effects of naltrexone maintenance treatment in preventing relapse in opioid addicts after detoxification. We searched MEDLINE (1973-first year of naltrexone use in humans-July 2000), EMBASE (1974-July 2000), Cochrane Controlled Trials Register (Cochrane Library issue 2000, 3) and handsearched the "Bolletino per le Farmacodipendenze e l'Alcolismo" (1978 to 1997) and reference lists of relevant articles. We contacted pharmaceutical producers of naltrexone, authors and other Cochrane review groups. Date of most recent searches: July 2000. All controlled studies of naltrexone; treatment of heroin addicts after detoxification. Reviewers evaluated data independently and analysed outcome measures taking into consideration adherence to and success of the study intervention. Data was extracted and analysed stratifying for the three categories of study quality. Where possible, meta-analysis was performed. Eleven studies met the criteria for inclusion in this review, even if not all of them were randomised. The methodological quality of the included study varied, but was generally poor. Meta-analysis could be performed to a very low degree only, because the studies and their outcome measures were very heterogeneous. A statistically significant reduction of (re-)incarcerations was found for patients treated with naltrexone and behaviour therapy respect to those treated with behaviour therapy only. The other outcomes considered in the meta-analysis did not yield any significant results. Final conclusions on whether naltrexone treatment may be considered effective in maintenance therapy cannot be drawn from the clinical trials available so far. The available trials do not allow a final evaluation of naltrexone maintenance treatment yet. A trend in favour of treatment with naltrexone was observed for certain target groups (particularly people who are highly motivated), as has been previously described in the literature.

Feasibility of referring drug users from a needle exchange program into an addiction treatment program: Experience with a mobile treatment van and LAAM maintenance

We evaluated program entry, retention, and early treatment response of needle exchange program (NEP) attenders referred to a drug treatment program using levomethadyl acetate hydrochloride (LAAM). Of 163 referrals, 114 (70%) entered the program, and 84% were retained for at least 90 days. Comparing baseline and follow-up visits after 1 month, there were significant reductions in the Addiction Severity Index subscale scores for drug and alcohol use and legal situation. We observed a 31% and 22% reduction in heroin- and cocaine-positive urine tests, respectively ( p < .0001). Although LAAM is no longer considered a first line treatment for heroin addiction, these results demonstrate the feasibility of utilizing long-acting agonist therapies such as LAAM to treat opioid dependence among NEP attenders.

Beliefs About Methadone in an Inner-City Methadone Clinic

Despite being considered both the most effective treatment for heroin addiction and an essential tool in the prevention of human immunodeficiency virus (HIV), methadone maintenance (MM) is often held in low esteem by heroin addicts-even those in MM treatment. This survey examined current beliefs and attitudes about MM of patients at an inner-city clinic, and the personal experience and attitudes of these patients with this treatment. Consenting patients in a methadone clinic serving a poor population with high rates of human immunodeficiency virus infection were queried about their attitudes toward and beliefs about methadone using a 16-item questionnaire. Over 2 days, 315 questionnaires were completed (acceptance rate 40%), totaling 32% of the 1,000 clinic patients. Nearly 80% believed that methadone had a positive effect on his or her life, but 80% were certain or unsure as to whether methadone is bad for one's health, and a similar percentage (80%) believed that discontinuing methadone was an important goal. Patients continue to have strongly negative attitudes toward and beliefs about methadone despite their acknowledgement that methadone has been very positive for them as individuals. As a result, many patients leave MM treatment prematurely, and there are usually unfilled slots in MM programs in New York City, even while continued need exists (e.g., less than 25% of the heroin addicts in the city are in treatment). The restrictive nature of many MM programs may account for these attitudes and beliefs.

A new series of 13 buprenorphine-related deaths

Objectives: Buprenorphine at high dosage became available in France in 1996, as a substitution treatment for heroin addicts. Since this date, numerous deaths were attributed to this drug. This paper reports a new series of 13 fatalities involving buprenorphine observed at the Institute of Legal Medicine of Strasbourg, between August 2000 to October 2001. Design and methods: During the mentioned period, about 800 forensic cases were screened at the laboratory. Buprenorphine and its primary metabolite norbuprenophine were assayed in postmortem specimens by HPLC/MS. From these 13 subjects, 11 were male. Blood levels ranged from 0.3 to 7.7 ng/mL (mean 3.5 ng/mL) and 0.3 to 16.2 ng/mL (mean 2.9 ng/mL) for buprenorphine and norbuprenorphine, respectively. The mean values appear to be within the therapeutic range. Conclusions: IV injection of crushed tablets, a concomitant intake of psychotropics (especially benzodiazepines and neuroleptics) and the high dosage of the buprenorphine formulation available in France appear as the major risk factors for such fatalities.

Narcotic-Induced Hypogonadism During Therapy for Heroin Addiction

ABSTRACT Many patients receiving sustained-action narcotics during therapy for heroin addiction have symptoms of fatigue, depression, diminished libido, and impaired sexual function. They are rarely, however, evaluated for narcotic-induced hypogonadism, or treated with sex-hormone replacement. Studies are reviewed examining the influence of narcotic administration on sex-hormone levels. These document frequent, sometimes profound, deficiencies in many men and women treated with narcotics. We have documented improved quality of life during sex-hormone replacement therapy in patients with narcotic-induced hypogonadism, most of whom were receiving their narcotics for control of chronic pain. These studies suggest that similar hormone replacement therapy may assist patients receiving narcotics for treatment of heroin addiction.

Drug addicts in therapy—changes in life space in the course of one year

AbstractIn a residential community treatment setting, moods and emotional states of drug addicts were explored over a 1‐year period. The specific form of treatment of heroin addiction employed in the communities is based on the importance of interpersonal relationships for psychosocial transition. Twenty‐nine participants reported current mood, emotions, attributions, and motive activation using a time‐sampling diary for 2 weeks at the beginning of the treatment, and 6 and 12 months later. Results show an increase in positive emotions, and in subjective strength and freedom. Furthermore, participants report higher self‐esteem and use less fatalistic attributions. This is interpreted as indicating successful transition processes in terms of higher autonomy, a more extended life space and increased levels of realism. Copyright © 2002 John Wiley &amp; Sons, Ltd.

Some People Come Equipped With Addiction-Fighting Gene

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessSome People Come Equipped With Addiction-Fighting GeneJim RosackJim RosackSearch for more papers by this authorPublished Online:7 Jun 2002https://doi.org/10.1176/pn.37.11.0016Pharmacologically speaking, cocaine has been well characterized as one of the most—if not the most—addictive substances studied to date. Yet rare but consistent anecdotal accounts of “casual” cocaine use without addiction do exist. New research may now offer an explanation.A report from the Laboratory of Biology of Addictive Diseases at Rockefeller University says that some people carry their own genetically based defense mechanism that helps to prevent the development of addictive behavior. The report appeared in the Neuropsychiatric Genetics section of the May 8 issue of the American Journal of Medical Genetics.Mary Jeanne Kreek, M.D., a professor of psychiatry and director of the lab, presented evidence that a genetic variance that results in increased production of the naturally occurring brain opiate dynorphin may serve as an effective antidote to counter the pleasurable effects of cocaine.Dynorphin, one of the body’s endogenous opiates, is thought to play a role in numbing pain, creating feelings of euphoria and well-being, and increasing energy. Endogenous opiates also help the body modulate its response to stress. Addictive opiates, such as heroin and morphine, as well as synthetic opiates like oxycodone (the active ingredient in OxyContin), mimic the actions of endogenous opiates in the body.Kreek and her colleagues studied the association between the gene mutation coding for the “up-regulation” of dynorphin and dependence or abuse by analyzing DNA samples from 174 people, 83 of whom had been previously diagnosed with cocaine dependence or abuse, and 91 control subjects with no history of any substance abuse. Kreek is often referred to as “the mother of methadone” because she, along with Rockefeller Professor Emeritus Vincent Dole, M.D., and his now deceased wife, Marie Nyswander, pioneered methadone treatment for heroin addiction in the 1960s.The current work was funded by grants from the National Institute on Drug Abuse and the National Institutes of Health.The results of the study suggest that individuals who harbor the “high-output” form of the gene that codes for dynorphin have a significantly lower risk of becoming dependent on or developing addiction to cocaine compared with persons with the “low output,” more common, form of the gene.“These results are preliminary but do suggest that genetic differences in the gene are correlated with individual variations of vulnerability to cocaine abuse,” Kreek said in a press release.Previous studies from Kreek’s lab as well as others have indicated that cocaine triggers a flood of dopamine release in the brain, which in turn leads to its characteristic high. This onslaught of dopamine can be toxic to brain tissues, causing permanent damage, Kreek said.In apparent response to increasing levels of dopamine, dynorphin production picks up as well. Kreek and her colleagues believe that dynorphin acts like an “antitoxin” to neutralize the destructive effects of cocaine. As such, a person who carries a gene that leads to increased baseline levels of dynorphin in the brain might then be “protected” against cocaine-induced brain damage.Studies have shown that the dynorphin gene is present as a “multiple” or “repeat”—that is, individuals may have one, two, three, or four copies. Having more copies of the gene presumably leads to increased levels of dynorphin.Kreek’s lab showed that there is a definite correlation between having three or four copies of the repeat and having a significantly lowered risk of becoming addicted to cocaine.“Knowing how this genetic variation could potentially modulate the effects of cocaine lends weight to our results,” commented lead author Andrew Chen, M.D., Ph.D., a research associate professor at Rockefeller. Chen cautioned, however, that the team’s sample size was small, and further follow-up work needs to be done to confirm the results.An abstract of the study, “Potentially Functional Polymorphism in the Promoter Region of Prodynorphin Gene May Be Associated With Protection Against Cocaine Dependence or Abuse,” is posted on the Web at www3.interscience.wiley.com/cgi-bin/abstract/93514787/START. ▪ ISSUES NewArchived

Auricular Acupuncture As a Treatment of Cocaine, Heroin, and Alcohol Addiction: A Pilot Study

Objectives In the United States, outpatient acupuncture treatment of patients with drug and alcohol addictions has been provided for more than 20 years. Although positive effects were shown in control studies, the effectiveness of acupuncture treatment in drug addiction is not well-established and is still disputed. During the past few years, interest in acupuncture treatment has increased in Germany. It is occasionally provided in inpatient and outpatient settings for detoxification purposes. Methods This longitudinal study evaluates a low-threshold outpatient acupuncture treatment project in Hamburg. During 8 months of documentation, 159 patients were included in the study—96% of all the patients being treated. The majority participated in only a few acupuncture visits. After 2 weeks, half of the patients had already finished treatment. This study focused on 30 patients who participated in at least four follow-up assessments during the treatment. Results The results show a significant decrease of withdrawal symptoms, a slight improvement of the physical and mental state, and a reduction of alcohol and cocaine consumption. Conclusions Because of the great number of patients who dropped out soon after the beginning of acupuncture treatment, the sample size is rather low. Therefore, this study only shows preliminary results regarding the efficiency of acupuncture treatment of patients with drug and alcohol addictions. However, there is some evidence that acupuncture might be an effective form of therapy, especially for patients with problematic cocaine use.

Policy Progress for Physician Treatment of Opiate Addiction

Medical treatment of heroin addiction with methadone and other pharmacotherapies has important benefits for individuals and society. However, regulatory policies have separated this treatment from the medical care system, limiting access to care and contributing to the social stigma of even effective addiction pharmacotherapy. Increasing problems caused by heroin addiction have added urgency to the search for policies and programs that improve the access to and quality of opiate addiction treatment. Recent initiatives aiming to reintegrate methadone maintenance and other addiction pharmacotherapies into medical practice may promote both expanded treatment capacity and increased physician expertise in addiction medicine. These initiatives include changes in federal oversight of the opiate addiction treatment system, the approval of physician office-based methadone maintenance programs for stabilized patients, and federal legislation that could enable physicians to treat opiate addiction with new medications in regular medical practice.

Cynthia's Dilemma: Consenting to Heroin Prescription

Heroin prescription involves the medical provision of heroin in the treatment of heroin addiction. Rudimentary clinical trials on that treatment modality have been carried out and others are currently underway or in development. However, it is questionable whether subjects considered for such trials are mentally competent to consent to them. The problem has not been sufficiently appreciated in ethical and clinical discussions of the topic. The challenges involved throw new light on the role of value and accountability in contemporary discussions of mental competence.

Alternative Medicine

Ancient Chinese Recipe Good for Colds, Cancer. The Shanghai University of Traditional Chinese Medicine. Chinese Doctor Invents Acupuncture Treatment for Heroin Addicts. From Quack Medicine to Bona Fide Cures — An Introduction to Mongolian Medicine. Hong Kong to Hold TCM Conference.

Treatment of heroin (diamorphine) addiction: current approaches and future prospects.

New pharmacological treatments for heroin (diamorphine) addiction include drugs that reduce opiate withdrawal symptoms and agents that are given during the maintenance phase of treatment. A variety of different types of pharmacological agents (opioid agonists, partial opioid agonists, opioid antagonists and alpha(2)-adrenoreceptor agonists) are reviewed and the evidence of their use during managed withdrawal and maintenance are presented. Experimental approaches attempting to reduce the time of opiate withdrawal and to accelerate the transition to abstinence are being developed. The combination tablet of buprenorphine and naloxone that is to be introduced for office-based maintenance is currently undergoing intense evaluation in the US. This new approach may facilitate the expansion of treatment while reducing the potential for medication diversion and intravenous use.

SUBSTITUTION THERAPY FOR HEROIN ADDICTION

Substitution treatment for heroin addiction, defined here as maintenance prescribing of opioid agonist drugs to opioid dependent subjects, has increased in the last decade. The recent history of substitution treatment in five countries—Canada, the U.K., Australia, Israel, and France—is reviewed. In all five countries, the critical issues around substitution treatment are similar. The first key issue concerns the balance between making treatment accessible and attractive, and minimizing diversion to the black market. The second issue concerns the role of primary health care in delivering MMT. In general, there has been increasing involvement of primary health care, with training and support for practitioners. However, there remains uncertainty and official ambivalence over whether treatment should be restricted to specialist clinics and practitioners, or available through primary care. Most importantly, underlying these issues is the problem of stigma being associated with both addiction, and with substitution treatment. The underlying problem that treatment is often at odds with community values places enormous strains on substitution treatment, and makes the treatment system vulnerable to shifting community support and abrupt, politically-driven changes in policy.

Buprenorphine Taken Three Times per Week Is as Effective as Daily Doses in Treating Heroin Addiction

Buprenorphine Taken Three Times per Week Is as Effective as Daily Doses in Treating Heroin Addiction

Deaths involving buprenorphine: a compendium of French cases

Buprenorphine at high dosage became available in France in 1996, as a substitution treatment for heroin addicts. Since this date, numerous deaths were attributed to this drug. This paper reports two original series of 39 and 78 fatalities involving buprenorphine observed at the Institute of Legal Medicine of Strasbourg and at 13 other French forensic centers, respectively. The files were recorded from January 1996–May 2000. The first 20 fatalities that were previously published were excluded from this epidemiological study. From these 117 subjects, 96 were male (82%). Buprenorphine and its primary metabolite norbuprenophine were assayed in post-mortem blood by HPLC/MS ( n=11 labs) or by GC/MS ( n=3 labs). Blood levels for buprenorphine ranged from 0.5 to 51.0 ng/ml (mean 10.2 ng/ml) and 0.1 to 76 ng/ml (mean 12.6 ng/ml) in Strasbourg and the other centers, respectively. Blood levels for norbuprenorphine ranged from 0.2 to 47.1 ng/ml (mean 8.2 ng/ml) and <0.1 to 65 ng/ml (mean 10.6 ng/ml) in Strasbourg and the other centers, respectively. The mean values appear to be within the therapeutic range. Buprenorphine was identified in 24 of the 26 hair samples assayed in Strasbourg, at concentrations ranging from 10 to 1080 pg/mg. Intravenous injection of crushed tablets, a concomitant intake of psychotropics (especially benzodiazepines and neuroleptics) and the high dosage of the buprenorphine formulation available in France appear as the major risk factors for such fatalities. In addition, two suicide-related deaths were also observed, with blood buprenorphine concentrations at 144 and 3276 ng/ml.

Lack of effect of single high doses of buprenorphine on arterial blood gases in the rat.

High dose buprenorphine, a potent semisynthetic agonist-antagonist for opiate receptors, is now used in substitution treatment of human heroin addiction. Deaths have been reported in addicts misusing buprenorphine. We determined the median lethal dose (LD(50)) and studied the effects of high doses of intravenous buprenorphine on arterial blood gases in rats. Male Sprague-Dawley rats were administered buprenorphine intravenously to determine the LD(50) using the up-and-down method. Subsequently, catheterized groups of 10 restrained rats received no drug, saline, acid-alcohol aqueous solvent (required to dissolve buprenorphine at a high concentration), or 3, 30, or 90 mg/kg of buprenorphine intravenously. Serial arterial blood gases were obtained over 3 h. The LD(50) determined in triplicate was 146.5 mg/kg (median of 3 series, range: 142.6-176.5). The mean dose received by surviving animals was 96.9 +/- 46.7 mg/kg. There was a significant effect of the acid-alcohol aqueous solvent on arterial blood gases. Excluding the solvent effect, 3, 30, and 90-mg/kg buprenorphine doses had no significant effects on arterial blood gases. The toxicity of intravenous buprenorphine in adult rats, assessed by the LD(50), is low. These data are consistent with a wide margin of safety of buprenorphine. The mechanism of death after the intravenous administration of a lethal dose of buprenorphine remains to be determined.

Gamma-vinyl GABA (GVG) blocks expression of the conditioned place preference response to heroin in rats.

We examined the effect of gamma-vinyl GABA (GVG) on the expression of the conditioned place preference response to intraperitoneally (i.p.) administered heroin in rats. Heroin, but not vehicle, produced a significant conditioned place preference response. Pretreatment of animals with 300 mg/kg of GVG significantly attenuated the expression of the heroin-induced conditioned place preference response. These results are the first to suggest that systemic GVG may provide an effective alternative to methadone maintenance in the treatment of heroin addiction, since it is without abuse potential and can be used for treatment outside an institutional setting.

Determination of methadone in urine using ion trap GC/MS in positive ion chemical ionization mode

Methadone is a potent analgesic and sedative. It is widely used in the treatment of heroin addiction and is often encountered in forensic specimens. In electron impact (EI) gas chromatography/mass spectrometry (GC/MS) mode, methadone produces predominantly a m/ z 72 ion, which is not sufficiently characteristic for identification. Determination of the molecular ion, which can be achieved using chemical ionization (CI) provides diagnostic information and better identification of the drug. This paper describes the development of a positive ion CI GC/MS procedure, using a liquid reagent gas and ion trap instrumentation, for the determination of methadone and its metabolites in urine. CI generally produces a single molecular ion spectrum, but optimization of the reagent gas parameters increases the fragmentation of the molecule, allowing determination of ion ratios if required. The procedure is sensitive, diagnostic and is currently in routine use in our laboratory.

Welcome to methadonia: a social worker's candid account of life in a methadone clinic

Rachel Greene Baldino embarked on a year-long journey as a new professional in a methadone clinic. She was ecstatic that she would be her career in a full-fledged counselor's position. But was she prepared for what lay ahead? Her personal account of the year that followed will give you an eye-opening glimpse into the sights, sounds, smells, and emotions she experienced. The author honestly and openly describes her feelings about the work and the people, and describes in graphic terms what she observed during her year in a methadone clinic. This is a personal account of one person's story--that of a neophyte professional. As such, it does not describe all methadone treatment or all methadone clinics--only one person's observations in one setting. While it does outline the benefits of methadone treatment and its life-saving effect on many people, it is not a research-oriented book and does not present the many years of research findings on this treatment. It does provide insight into one new professional's experience, including such issues as vicarious traumatization, and it bravely reveals her weaknesses as a new professional in a highly specialized field. Besides chronicling her year as a counselor in a methadone setting, Baldino makes recommendations for changes to the treatment system--recommendations she sees as a starting point for discussion among those who are in and associated with the field. A glossary is provided to help readers quickly identify and define key terms associated with heroin addiction and methadone treatment.