medical issues about methadone : what the counselor needs to know
DESCRIPTION
Medical issues about Methadone : What the counselor needs to know. Judith Martin, MD Medical Director The 14 th Street Clinic, Oakland, CA www.14thstreetclinic.org. Counseling Staff. THE DOSING WINDOW. Epidemiology. Opioid dependence Office of National Drug Control Policy (1999) - PowerPoint PPT PresentationTRANSCRIPT
Medical issues about Methadone :What the counselor needs to know
Judith Martin, MD
Medical Director
The 14th Street Clinic,
Oakland, CA
www.14thstreetclinic.org
Counseling Staff
THE DOSING WINDOW
Epidemiology
Opioid dependence Office of National Drug Control Policy (1999)
810,000 persons Only 170,000 receiving medication treatment
Cost $20 billion per year total costs (NIDA 1992) $9.6 billion spent on heroin (ONDCP 1988-1995) $1.2 billion per year health care costs (NIDA
1992)
Prescription opioid abuse epidemiology
Prescription opioid use (2001), ED reports: 90,000+ (DAWN)Reports of oxycodone abuse:18,000+Reports hydrocodone abuse: 21,000+Reports methadone abuse: 10,000+
1994- 2002, oxycodone 450% increase!
Bottom line: big street value!
Number of new non-medical users of therapeutics
(NSDUH, 2002)
Diacetylmorphine (Heroin)
Hydromorphone (Dilaudid)
Oxycodone (OxyContin, Percodan, Percocet, Tylox)
Meperidine (Demerol)
Hydrocodone (Lortab, Vicodin)
Commonly Abused Opioids
Morphine (MS Contin, Oramorph)
Fentanyl (Sublimaze)
Propoxyphene (Darvon)
Methadone (Dolophine)
Codeine
Opium
Commonly Abused Opioids (continued)
0%
25%
50%
75%
100%
1992 1993 1994 1995 1996 1997
Route of heroin administrationTreatment Entry Data System 1992-1997
Injection Inhalation Smoking Other
Four questions patients ask:
How is methadone better for me than heroin?
What is the right dose of methadone for me?
How long should I stay on methadone?
What are the side effects of methadone?
Talking to patients about addiction treatment
models
Recovery
Psychodynamic Behavioral
Spiritual
Medical
ADDICTION AS A CHRONIC ILLNESS
Chronic relapsing condition which untreatedmay lead to severe complications and death.
ADDICTION AS CHRONIC DISEASE: IMPLICATIONSIt is treatable but not curable.
Adjustment to diagnosis is part of patient’s task.
There is a wide spectrum of severity.
Retention in treatment is key.
Best treatment is integrated.
Four questions patients ask:
• How is methadone better for me than heroin?
• What is the right dose of methadone for me?
• How long should I stay on methadone?
• What are the side effects of methadone?
How is methadone better than heroin?
Legal
Avoids needles
Known amount ingested
Opiate effects, physical
Predictable physical effects of administering opiates:Tolerance: the body becomes efficient in
processing the drug and requires ever higher doses to produce the desired effect.
Dependence: when the drug is discontinued there are typical withdrawal signs and symptoms.
IDU, pattern of heroin injection over 3 days
From Dole, Nyswander and Kreek, 1966
Do
se R
esp
on
se
Time
“Loaded” “High”
Normal Range“Comfort Zone”
“Sick”
Methadone Simulated 24 Hr. Dose/ResponseAt steady-state in tolerant patient
0 hrs.
24 hrs.
“Abnormal Normality”
Subjective w/d
Objective w/d
Opioid Agonist Treatment of Addiction - Payte - 1998
How is methadone better than heroin?
• Legal
• Avoids needles
• Known amount ingested
• Slow onset: no “rush”
• Long acting: can maintain “comfort” or normal brain function
• Stabilized physiology, hormones, tolerance
Four questions patients ask:
• How is methadone better for me than heroin?
• What is the right dose of methadone for me?
• How long should I stay on methadone?
• What are the side effects of methadone?
Do
se R
esp
on
se
Time
“Loaded” “High”
Normal Range“Comfort Zone”
“Sick”
Methadone Simulated 24 Hr. Dose/ResponseAt steady-state in tolerant patient
0 hrs.
24 hrs.
“Abnormal Normality”
Subjective w/d
Objective w/d
Opioid Agonist Treatment of Addiction - Payte - 1998
trough
What is the right dose?
Eliminate physical withdrawal
Eliminate ‘craving’
Comfort/function: usually trough is 400-600 ng/ml, peak no more than twice the trough.
Not oversedated
Blocking dose
“How Much????
Enough!!!”Tom Payte, MD
Recent Heroin Use by Current Methadone Dose
0
20
40
60
80
100
0 10 20 30 40 50 60 70 80 90 100
Methadone Dose, in mg.
% H
eroi
n U
se
Ref: J. C. Ball, November 18, 1988Slide adapted from Tom Payte
Four questions patients ask:
• How is methadone better for me than heroin?
• What is the right dose of methadone for me?
• How long should I stay on methadone?
• What are the side effects of methadone?
Relapse to IV drug use after MMT105 male patients who left treatment
28.9
45.5
57.6
72.282.1
0
20
40
60
80
100
IN 1 to 3 4 to 6 7 to 9 10 to 12
Pe
rce
nt
IV U
se
rs
Treatment Months Since Stopping Treatment
Opioid Agonist Treatment of Addiction - Payte - 1998
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991
“How Long???
Long Enough!!”Tom Payte, MD
Four questions patients ask:
• How is methadone better for me than heroin?
• What is the right dose of methadone for me?
• How long should I stay on methadone?
• What are the side effects of methadone?
Side effects of methadone:
General opiate effects: Sedation/stimulation Maintained phys. dependence (stable) hypogonadism (not as severe as with heroin, may
be dose dependent)
ConstipationSlight QTc prolongation on ECG (Martell etal)SweatingMethadone treatment tied to regulated clinic
Treatment Outcome Data
Treatment Outcome Data
8-10 fold reduction in death rate
reduction of drug use
reduction of criminal activity
engagement in socially productive roles
reduced spread of HIV
excellent retention
Crime among 491 patients before and during MMT at 6 programs
0
50
100
150
200
250
300
A B C D E F
Before TX
During TX
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991
Cri
me
Day
s P
er Y
ear
Opioid Agonist Treatment of Addiction - Payte - 1998
HIV CONVERSION IN TREATMENT
0%
5%
10%
15%
20%
25%
30%
35%
Base line 6 Month 12 Month 18 Month
ITOT
HIV infection rates by baseline treatment status. In treatment (IT) n=138, not in treatment (OT) n=88Source: Metzger, D. et. al. J of AIDS 6:1993. p.1052
Opioid Maintenance Pharmacotherapy - A Course for Clinicians - 1997
A FEW WORDS ABOUT BUPRENORPHINE
“Ceiling effect” and safety
Displaced other opiates: withdrawal on induction
Less agonist strength
Schedule 3(methadone is 2)
One form combined with naloxone
Office – based use available
Partial vs Full Opiate Mu Agonist
Dose of Opiate
OpiateEffect
death
Full Agonist(e.g., methadone)
Partial Agonist(e.g. buprenorphine)
Credit: Don Wesson, MD
Buprenorphine, Methadone, LAAM:
Treatment Retention
Per
cent
Ret
aine
d
0
20
40
60
80
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
20% Lo Meth
58% Bup
73% Hi Meth
53% LAAM
Study WeekJohnson et al, 2000
Buprenorphine, Methadone, LAAM:Opioid Urine Results
Mea
n %
Neg
ativ
e
Study Week
All Subjects
Lo Meth
BupHi Meth
LAAM
1 3 5 7 9 11 13 15 170
20
40
60
80
100
19%
40%
39%
49%
Effect of counseling in buprenorphine treatment
(Fiellin, 2002)
0
0.2
0.4
0.6
0.8
1
Induction week 2-4 week 5-7 week 8-10
Op
ioid
po
sit
ive
uri
ne
s
MM
MM+DC
Retention in treatment
Treatment duration (days)
Remaining in treatment (nr)
0
5
10
15
20
0 50 100 150 200 250 300 350
Control, 6-day detox
Buprenorphine maintenance
Kakko et al, 2003,
Pharmacotherapy in context: correct glossaryAbstinence includes pharmacotherapy
Maintenance, not substituion or replacement (new term also: MAT)
Tapering from maintenance, not detoxification, (also ‘medically supervised withdrawal’, or MSW)
Discontinuation, not discharge
Toxicology screens: pos/neg, not clean/dirty)
Opioid pharmacotherapy, summary:
Methadone, buprenorphine and LAAM all approved by the FDA for treatment of opiate dependence. (LAAM not currently available from any drug company)
Best evidence so far supports maintenance.
Detoxification attempts should have maintenance as a back up in case of relapse.