1. NYSDOH/AI The Role of Methadone in HIV Prevention And Treatment Sharon Stancliff, MD Medical Consultant AIDS Institute New York State Department of Health

2. NYSDOH/AI Drug Use and HIV Injection of heroin and cocaine is the driving force behind HIV in New York State

3. NYSDOH/AI Addiction Opiates interact with receptors for endogenous peptides. Short term changes in the dopamine secreting neurons, such as atrophy are documented Long term changes are suspected.

4. NYSDOH/AI Genetics Twin and adoption studies show a strong familial trend in alcoholism Addictive disorders are common among the families of heroin addicts Anthenelli

5. NYSDOH/AI “Drug Addiction is a Brain Disease” Alan Leshner, PhD National Institute of Drug Abuse Director

6. NYSDOH/AI National Institute of Health “Methadone is the most effective treatment for heroin addiction.” National Institute of Health Consensus Development Conference on the Medical Treatment of Heroin Addiction

7. NYSDOH/AI Methadone A synthetic opiate with a 24-36 hour half- life Methadone Maintenance Treatment (MMT) was first implemented by Dole and Nyswander in the 1960s as most “detoxed” addicts relapsed to heroin use

8. NYSDOH/AI Methadone Usual effective dose: 80-120 mg range:5mg- >500 Clinical response guide dose Rettig, Leavitt 80-90% of those stopping MMT will return to heroin use so treatment is long term Ball, Magura

9. NYSDOH/AI Methadone Safe during pregnancy Kandall No known long term detrimental effects Novick MMT is usually accompanied by counseling and sometimes other requirements

10. NYSDOH/AI Benefits of Methadone Maintenance

11. NYSDOH/AI Reduction in Heroin Use Given a sufficient dose virtually all heroin users will stop using heroin At lesser doses heroin use is decreased. Ball 1991

12. NYSDOH/AI MMT patients are 3-6 times less likely to become HIV positive when compared to out- of-treatment heroin users. Metzger, Drucker, Gibson, Hartel HIV Prevention

13. NYSDOH/AI Reduction in HIV seroconversion: a prospective study Comparison of opiate users in and out of methadone treatment Those out of treatment reported more risk behavior for HIV In treatment: 3.5% seroconverted, Out- of-treatment 22% seroconverted Metzger

14. NYSDOH/AI HIV positive heroin users on methadone are hospitalized less often and live longer than their counterparts who are not on methadone Weber, Newschaffer, Laine Improved outcome in HIV

15. NYSDOH/AI Other Benefits A fourfold reduction in suicide A fourfold reduction in lethal overdose Capelhorn Reductions in sex work Bellis Reduction in crime Hubbard, Appel

16. NYSDOH/AI Issues in Methadone Prescribing

17. NYSDOH/AI Over regulation Available only in methadone clinics Frequent attendance required Limited number of slots Medical maintenance has been shown to be successful outside of these constraints

18. NYSDOH/AI Under Dosing A 1995 study of selected MMTPs found an average dose of less than 59mg 2/3s of the clinics set a dose ceiling of 80- 100mgs D”Aunno

19. NYSDOH/AI Premature discharge A 1995 study found that the majority of clinics encourage detox after only 1 year of treatment Relapse can be deadly- Zanis found 8.2% mortality among 110 pts. leaving MMTP but only 1.2% among 397 remaining in treatment

20. NYSDOH/AI Misunderstandings about methadone Patients often believe that methadone causes bone or liver damage. Physicians may have misconceptions about pain management in methadone patients. It is also erroneously believed that MMT leads to cocaine use.

21. NYSDOH/AI MMT patients are judged by: Family Friends Physicians Social service providers Employers Politicians Drug users

22. NYSDOH/AI Stigmatization by drug Treatment Providers MMT patients are discouraged from speaking at Narcotics Anonymous meetings Narcotics Anonymous Bulletin Many facilities treating cocaine and alcohol abuse bar methadone

23. NYSDOH/AI Role of the Primary Care Provider Education of current and potential MMT patients and their families Understanding medical issues such as drug interactions Working with clinics to ensure the best possible care for patients

24. NYSDOH/AI Drug Interactions DRUGS WHICH MAY LOWER PLASMA LEVELS OF METHADONE Phenobarbital Carbamazepin (Tegretol) Phenytoin (Dilantin )** Ritonavir (Norvir) ** Major effect, may require large methadone dose increases Nevirapine (Viraimmune)** Rifampin** Efavirenz (Sustiva)** Abacavir ( Ziagen) ethanol (chronic use)

25. NYSDOH/AI Drug Interactions II DRUGS WHICH MAY INCREASE PLASMA LEVELS OF METHADONE (none are major problems) Amitriptyline (Elavil) Cimetidine (Tagamet) Diazepam (Valium) Ethanol ( acute use) Ketoconazole (Nizoral) Zidovudine (AZT) levels may be increased by methadone. DRUGS WHICH ARE CONTRAINDICATED Pentazocine (Talwin), Tramadol (Ultram)

26. NYSDOH/AI For more HIV-related resources, please visit www.hivguidelines.org