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

HEROIN There were 32 heroin-related deaths in the first half of 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.

HEROIN

The rate of ED heroin mentions has remained stable since Treatment admissions have increased 33% since 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 Heroin prices seem stable.

Trends in ED mentions – ( rate per 100,000 population)

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

Addiction as a Brain Disease lProlonged drug use Pervasive changes in brain function that 4Persist after drug use stops 4Can be demonstrated at many levels VMolecular VCellular VStructural VFunctional

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: , 2000.

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

Adapted from: JAMA, Dec. 9, 1998, 280 (22), NIH Consensus Panel on Effective Medical Treatment of Opiate Addiction 12 member multi-disciplinary panel, Nov heard testimony from 25 experts reviewed 941 research reports published over the period Jan Sept “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.”

Comparing Methadone and Heroin

LAAM: Levo-Alpha Acetylmethadol A 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

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

Admission Criteria Adult 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.

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 zAdditional education, i.e., HIV/HCV, family planning

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.

Methadone Maintenance vs. 180 Day Detoxification 12 month study of 179 opioid dependent patients randomly assigned to: lMethadone Maintenance 3mean dose=85.3mg 3for 14 months l180 Day Methadone Detoxification 3mean dose=86.3 mg prior to taper at 120 days 3followed by psychosocial Tx for 8 months K.L. Sees et al., JAMA 2000

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

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

Drug Use & Length of Time in Methadone Treatment

Percentage of Patients with + U/A January – December, 2001 Van service

Adapted from: Ball & Ross, The Effects of Methadone Treatment on Crime Days 70.8% Decline in Crime Days 94% n= 617

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

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

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

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

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

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

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

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

Methadone and Criminal Justice

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

Adapted from: Marsch, L.A. Addiction 93(4), , 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: Ball & Ross, 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

Swedish Methadone Study Before Experimental Group (Methadone) Control Group (No Methadone) Gunne & Gronbladh, 1981

Swedish Methadone Study After 2 Years Experimental Group (Methadone) Control Group (No Methadone) Gunne & Gronbladh, 1981 d ab c dd a Sepsis b Sepsis and Endocarditis c Leg Amputation d In Prison

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

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

Opiate Antagonists Naloxone (NARCAN ® ) 3treatment for acute opiate overdose Naltrexone (ReVia ® ) 3detoxification from physical dependence on opiates 3opiate “blocker” - aid to maintenance of abstinence from opiates  Clonidine (Catapres ® ) - not an antagonist - suppresses withdrawal symptoms