Opiate Substitution Treatment: An Overview

1. Opiate Substitution Treatment:An Overview Ron Jackson, M.S.W. Evergreen Treatment Services Seattle, WA

2. HEROIN • There were 32 heroin-related deaths in the first half of 2001. • These represent 37% of all drug deaths. • Of the heroin-related drug deaths: • 27 (84.4%) had one or more other drugs in their system at the time of death. • 72% of decedents were male; 94% Caucasian; 3% African-American; 3% Hispanic.

3. HEROIN

4. HEROIN • The rate of ED heroin mentions has remained stable since 1998. • Treatment admissions have increased 33% since 1998. • ADAM data showed male arrestees tested positive for opiates at the rate of 9.9% in 2000 and 11.7% in the first quarter of 2001. • Heroin prices seem stable.

5. Trends in ED mentions – 1988-2000(rate per 100,000 population)

6. ADDICTION “Addiction is a brain disease shaped by behavioral and social context.” Dr. Alan Leshner, Director National Institute on Drug Abuse “It’s like I’ve got a shotgun in my mouth, my finger’s on the trigger and I like the taste of gun metal.” Robert Downey, Jr. Actor

7. Addiction as a Brain Disease • Prolonged drug use Pervasive changes in brain function that • Persist after drug use stops • Can be demonstrated at many levels • Molecular • Cellular • Structural • Functional

8. Drug Dependence:A Chronic Medical Illness • Genetic Heritability – twin studies • Hypertension – 25-50% • Diabetes – Type 1: 30-55%; Type 2: 80% • Asthma – 36-70% • Nicotine – 61% (both sexes) • Alcohol – 55% (males) • Marijuana – 52% (females) • Heroin –34% (males) • Voluntary Choice – shaped by personality and environment • Pathophysiology – neurochemical adaptations • Treatment Response • Medications – effectiveness and compliance • Behavioral interventions McLellan, A.T., et.al., Drug Dependence, a Chronic Medical Illness Journal of the American Medical Association 284:1689-1695, 2000.

9. 581 Male Heroin Addicts Followed for 33 Years Hser et al., 2001

10. NIH Consensus Panel onEffective Medical Treatment of Opiate Addiction • 12 member multi-disciplinary panel, Nov. 1997 • heard testimony from 25 experts • reviewed 941 research reports published over the period Jan. 1994 - Sept. 1997 “Of the various treatments available, MMT, combined with attention to medical, psychiatric, and socioeconomic issues, as well as drug counseling, has the highest probability of being effective.” Adapted from: JAMA, Dec. 9, 1998, 280 (22), 1936-1943

11. Comparing Methadone and Heroin

12. LAAM: Levo-Alpha AcetylmethadolA Long-Acting Opiate Agonist • Pharmacological Action • Metabolites more active than parent drug • Advantages • One dose lasts 48 to 72 hours • Fewer trips to the clinic • Better heroin blockage • Disadvantage • Cardiac complications

13. Methadone Dose:How much is enough? Leavitt, SB, et.al., When “Enough” is Not Enough. Mt Sinai Journal of Medicine 2000: 67(5&6): 404-411.

14. Admission Criteria • Adult • 16-17 y.o. needs parental/guardian permission • Currently physiologically dependent on an opiate • Exceptions for incarcerated persons and for those who had previously successfully completed treatment • Current dependence on other drugs doesn’t disqualify • If in treatment more than 180 days, patient needs documentation of at least one year’s history of opiate dependence.

15. Treatment Requirements • Attendance for observed dosing 6 days a week for the first 90 days (methadone); 3 days a week indefinitely (LAAM) • Take-home doses permitted after 90 days but only to those patients meeting a number of criteria • At least once per month observed urinalysis • Some clinics have contingencies; some don’t • Some agencies administer alcohol breath tests; some don’t • Primary counselor assigned; weekly counseling for at least the first 90 days • Additional education, i.e., HIV/HCV, family planning

16. Opiate Substitution Treatment Goals • Primary Goals: • Reduction in of illicit opiate use. • Retention in treatment for 1-2 years or more. • Secondary Goals: • Reduction in cocaine, alcohol, and other drug abuse. • Reduction in transmission of infectious diseases by unsterile injection equipment. • Reduction in criminal activity. • Increase in pro-social activity — employment, education, child care, etc.

17. Methadone Maintenance vs.180 Day Detoxification 12 month study of 179 opioid dependent patients randomly assigned to: • Methadone Maintenance • mean dose=85.3mg • for 14 months • 180 Day Methadone Detoxification • mean dose=86.3 mg prior to taper at 120 days • followed by psychosocial Tx for 8 months K.L. Sees et al., JAMA 2000

18. Reduction of Heroin Use By Length of Stay in Methadone Treatment Admission: < 6 months stay Average Stay: 6 to 54 months Long-term: > 54 months Pre- treatment Adapted from: Ball & Ross, 1991.

19. Frequency of Heroin Use & Methadone Dose Level Adapted from V. Dole (1989) JAMA, 282, p. 1881

20. Drug Use & Length of Time in Methadone Treatment

21. Percentage of Patients with + U/AJanuary – December, 2001 Van service

22. The Effects of Methadone Treatment on Crime Days • n= 617 70.8%Decline in Crime Days94% Adapted from: Ball & Ross, 1991.

23. Changes in Illegal Activity Preliminary findings, DASA, Washington State Outcomes Project, 2002

24. Changes in Illegal Activity Preliminary findings, DASA, Washington State Outcomes Project, 2002

25. Comparing RetentionMethadone (6 mos.) vs. “Drug-free” (3 mos.) Preliminary findings, DASA, Washington State Outcomes Project, 2002

26. Comparing 6 month OutcomesMethadone vs. “Drug-free” Preliminary findings, DASA, Washington State Outcomes Project, 2002

27. Determining the Value of Opiate Substitution Treatment Washington State DASA, Management Report, December, 2001 1 n=726 2 n=363

28. Initial & 18 Month Self-Report Data From 78 Methadone Patients from D. Calsyn, NIDA Grant # R18DA06104

29. Comparing RetentionMethadone (6 mos.) vs. “Drug-free” (3 mos.) Preliminary findings, DASA, Washington State Outcomes Project, 2001

30. Comparing 6 month OutcomesMethadone vs. “Drug-free” Preliminary findings, DASA, Washington State Outcomes Project, 2001

31. Women in Methadone Treatment: Reduction in Prostitution 28% 13% 0% % of women admitting to prostitution in previous 6 months from D. A. Calsyn, NIDA Grant # RA18 DA 06104

32. Efficacy of Methadone Maintenance:A meta-analysis Estimation of Results with Intervention* * based on the effect sizes observed in meta-analysis (# of studies) Adapted from: Marsch, L.A. Addiction 93(4), 515-532, 1998.

33. Characteristics of Successful Methadone Treatment Programs • Adequate Dosing Policies • Average Dose Between 60 & 120mg. • Comprehensive Services • Well-trained & Stable Staff • Individualized Treatment • Coordinated Services • Medical, Counseling & Administration Adapted from: Ball & Ross, 1991.

34. Swedish Methadone StudyBefore Experimental Group(Methadone) Control Group(No Methadone) Gunne & Gronbladh, 1981

35. Swedish Methadone StudyAfter 2 Years Experimental Group(Methadone) Control Group(No Methadone) a b c d d d a Sepsisb Sepsis and Endocarditisc Leg Amputationd In Prison Gunne & Gronbladh, 1981

36. Return to I.V. Drug Use Following Premature Termination of Treatment % IV USERS Months Since Dropout Adapted from: Ball & Ross, 1991.

37. BUPRENORPHINE • Partial agonist at Mu-opiate receptor • less subjective “high” • Slowly dissociates from those receptors • slow onset & offset • Once-a-day dosing • Sublingual administration • compounded with naloxone (BUP/NX) which will precipitate abrupt withdrawal if injected

38. Opiate Antagonists • Naloxone (NARCAN®) • treatment for acute opiate overdose • Naltrexone (ReVia®) • detoxification from physical dependence on opiates • opiate “blocker” - aid to maintenance of abstinence from opiates • Clonidine (Catapres®) - not an antagonist - suppresses withdrawal symptoms