ADDICTION TREATMENT

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Vol. 14, #1 • WINTER 2005 Clinical Concepts Research Update Drug screening Substance-Abuse Pregnancy & MMT Monitoring in MMT Substance abuse in preg- Drug screening and testing – sub- nant women is of great con- & testing have stance-abuse monitoring – is an aspect of cern due to the risks to maintenance treatment (MMT) unborn children. Methadone that has great potential for doing either maintenance treatment (MMT) great potential good or harm. Yet, this is an area in which is the standard of care, yet treatment clinics are provided very little there have been controver- for doing either specific, evidence-based guidance and sies through the years few best-practices recommendations. regarding effective and safe methadone dosing good or harm Consequently, most clinics have tra- in these women, and the ditionally established policies and proce- advisability of breast- dures in this area based on convenience feeding after delivery. during MMT. or habit, while adhering to the few regu- There also has been increasing interest in lations that do exist. Monetary con- using buprenorphine. straints also are taken into account, but These issues have been extensively there often is a simple acceptance of studied and some current findings are whatever screening and testing services briefly summarized here. are most readily available, rather than choosing the best approach from a thera- Methadone vs Buprenorphine? IN THIS ISSUE peutic perspective. There have been reports that This article discusses a few areas of buprenorphine may be equally effective Substance-Abuse Monitoring in MMT 1 confusion that have surfaced during and safe as methadone during pregnan- research for a more comprehensive and cy. However, whereas methadone is clas- Pregnancy & MMT 1 evidence-based White Paper report cur- sified by the FDA as a Pregnancy Catego- rently in development by AT Forum. ry B medication, relatively limited data EVENTS TO NOTE 2 are available on buprenorphine during A Therapeutic Tool pregnancy and it carries a C classifica- EDITOR: Therapy or Tyranny? 2 In general medicine, “monitoring” is tion, recommending greater caution in its a therapeutic tool allowing oversight of a use. A recent Treatment Improvement Wide Reach of AT Forum 3 patient’s progress and response to treat- Protocol from CSAT specifically notes ment. It is not intended as a form of that buprenorphine has not as yet been www.ATForum.com Updated 3 meddling surveillance merely to detect fully approved for use in pregnant noncompliance or misbehavior by the patients.[1] Survey Results: Sleep Disorders 5 patient. A neonatal abstinence syndrome (NAS) requiring medical intervention is MMT Pioneers: Marie Nyswander, MD 6 For example, blood glucose levels are used to gauge response to insulin in con- sometimes experienced by methadone- exposed newborns, and some prelimi- Does Age Matter in MMT? 8 trolling diabetes. Blood pressure read- ings assess the effectiveness of antihyper- nary evidence suggests that buprenor- tensive medication. phine may help reduce the incidence and/or severity of NAS.[2] However, AT Forum is made possible by an Similarly, monitoring for substances most investigations have found that the educational grant from Mallinckrodt Inc., of abuse in MMT settings is one important two opioid medications are generally a manufacturer of methadone & naltrexone. Continued on Page 3 Continued on Page 7 Events to Note Straight Talk... from the Editor For additional postings & information, see: www.atforum.com Drug Monitoring: Therapy or Tyranny? April 2005 Drug screening and testing – “sub- should do, it ends up creating a hostile American Counseling Association stance-abuse monitoring” – is a challeng- environment of antagonism, distrust, Annual Convention ing and difficult aspect of methadone and dishonesty. April 6-10, 2005 maintenance treatment (MMT). However, it seems unfair to hold Atlanta, Georgia Studies have found persistent sub- MMT programs solely accountable when Contact: 800-347-6647; stance abuse in 20% of patients during they are provided little in the way of spe- www.counseling.org MMT, with half of those persons also cific guidance from federal and state Western Psychological Association continuing to use illicit opioids. A prior authorities or accreditation organiza- 85th Annual Convention AT Forum survey (Spring 2004) found tions. And, the few explicit regulations April 14-17, 2005 that up to a third of patients may experi- that do exist are of minimal help for Portland, Oregon ence full-blown relapses, with most cases improving substance-abuse monitoring Contact: 253-851-7546; occurring within 6 months of entering practices. www.westernpsych.org/ treatment. However, there is an ever- Thus, clinics are left on their own to ASAM (American Society of Addiction present danger of drug lapses or relapses educate themselves and satisfy the Medicine) - 36th Annual Conference even in the most abstinent and stable requirements of agencies to which they April 15-17, 2005 patients. are accountable. At the same time, ques- Dallas, Texas If any level of substance abuse can be tions about where funding will come Contact: 301-656-3920; www.asam.org detected sooner rather than later, more from for better approaches remain effective and timely interventions might largely unanswered. May 2005 be implemented to stem relapses and Substance-abuse monitoring is im- American Psychiatric Association prevent treatment dropouts. Substance- portant and we will be exploring this Annual Meeting abuse monitoring can play an important subject further from various perspec- May 21-26, 2005 role, as part of an overall therapeutic tives. Please help by responding to the Atlanta, Georgia strategy, for achieving those objectives. Contact: 703-907-7300; www.psych.org survey in this edition of AT Forum. Do It Right, Or Pay A Price? Stewart B. Leavitt, PhD, Editor June 2005 As our interview with Greg Carlson [email protected] NMHA (Natl. Mental Health Assn.) in this edition makes clear, the federally- Annual Conference Addiction Treatment Forum mandated 8 substance-abuse assess- June 9-11, 2005 P.O. Box 685; Mundelein, IL 60060 Washington, DC ments per year can make an MMT pro- Phone/Fax: 847-392-3937 Contact: 703-684-7722; www.nmha.org gram look good, because a great deal of Internet: http://www.atforum.com drug use will go unrecorded. But this is E-mail: [email protected] CPDD (College on Problems of Drug ineffective for providing better patient Dependence) – 67th Annual Meeting care. June 18-23, 2005 NEW SURVEY: Realistically, a greater frequency of Orlando, Florida Drug Monitoring in MMT? Contact: 215-707-3242; www.cpdd.org monitoring can create a burden in terms of added staff time and expense. Howev- Please respond to the following survey questions: UPCOMING 2005… er, as Carlson suggests, unless drug American Psychological Association screening is done often enough it has lit- 1. At your clinic, how many drug screens 113th Annual Convention tle value; so either do it right or the or tests at a minimum must each patient have during a 12-month period? _____ August 18-21, 2005 money might be wasted. Washington, DC 2. What substances are always assessed? There are additional cost issues: ❏ Contact: 202-336-5500; www.apa.org What is the cost of formerly stable (check all that apply): alcohol; ❏ amphetamines; ❏ barbiturates; patients relapsing without it being recog- American Psychiatric Association ❏ benzodiazepines; ❏ cocaine; 57th Institute nized and contracting HIV or hepatitis? ❏ marijuana; ❏ methadone; ❏ opioids; October 5-9, 2005 What is the cost to an MMT program ❏ PCP; ❏ other: ______. when patients leave treatment prema- San Diego, California 3. Are on-site drug screens (not requiring Contact: 703-907-7300; www.psych.org turely due to continuing substance abuse shipping to a laboratory) used? that wasn’t detected? ❏ ❏ ❏ American Public Health Association Often; Sometimes; Never. 133rd Annual Meeting Who Is Accountable? 4. If on-site screening devices are used, November 5-9, 2005 what specimens are collected? Unfortunately, urinalyses are used ❏ Urine; ❏ Oral fluid; ❏ Both. New Orleans, Louisiana too often to identify and punish offend- Contact: 202-777-APHA; 5. Are you responding as a ❏ patient, or ing MMT patients. Such practices might www.apha.org/meetings/ ❏ clinic staff member? be characterized as “therapeutic tyran- ny” (recently noted by Robert Newman, There are several ways to respond to AT [To post your announcement in AT Forum Forum surveys: A. provide your answers on MD, in European Addiction Research and/or our web site, fax the information to: the postage-free feedback card in this issue; B. [2005;11, p.12]). C. 847-392-3937 or submit it via e-mail from write, fax, or e-mail [info above]; or, visit Rather than contributing to the thera- our web site to respond online. As always, www.atforum.com] your written comments are important. A.T.F. peutic process, as effective monitoring 2 Wide Reach of AT Forum Clinical Concepts Continued from Page 1 Where Are Substance-Abuse Did you know… Monitoring Assays Performed? AT Forum reaches way to assess patient progress in treat- On-Site Laboratory more readers than ment, as well as effectiveness of the pro- most other pub- gram itself. There also are vital safety Screening lications in the concerns in identifying patients who are Detects a Yes Possibly addiction treat- experiencing a drug relapse or using range of substances. ment field. substances that may lead to drug over- dose or interact with methadone in a Testing According to data Not harmful manner. Confirms Yes recently compiled by the International presence of Practical Society of Addiction Journal Editors, In addiction treatment settings, moni- substances. there are 75 journal and newsletter toring also has a surveillance role. For allowing immediate feedback to MMT publications worldwide specifically example, there have been long-standing addressing addiction treatment topics. patients and an appropriate therapeutic regulatory interests in monitoring, espe- response, if necessary. Laboratories also The average print circulation of each is a cially screening for methadone, to curtail mere 1,250 copies (median 1,000; range can perform screening procedures as a methadone diversion. Yet, its effective- first step in the specimen analysis but, 155 to 4,000). In contrast, AT Forum is ness for this purpose is debatable. mailed free of charge to 12,000 sub- considering the availability of on-site screening devices, this may not always be scribers in the U.S. every quarter. Misbehaving patients with diabetes the best approach. See Table. Plus, all of our publications are or hypertension who binge on sweets or salty snacks, respectively, receive repri- freely accessible at our website: Confirmatory Testing www.ATForum.com. Each month mands and education from their physi- Testing, on the other hand, uses more there are more than 20,000 visitors to cians. However, MMT patients who technically sophisticated and precise the site from around the world. abuse drugs may face worse fates. Pun- ishments for drug-positive urinalyses methods to “definitively confirm” if a sub- So, as you think about submitting have included methadone dose decreas- stance detected in a drug screen specimen articles or responding to AT Forum sur- es, loss of take-home methadone privi- is truly present. It requires delicate equip- veys, keep in mind that you will be leges, or withdrawal from methadone ment and trained operators, beyond the reaching the widest audience of any entirely; although, the advantages of such capabilities of almost all MMT clinics, so publication in the field. “negative reinforcers” have never been it entails shipping the specimen to a qual- convincingly demonstrated. ified laboratory and waiting for results. www.ATForum.com Updated Substance-abuse monitoring in MMT When is Lab Testing Necessary? ADDICTION TREATMENT Site Search: Go is typically a 2-stage process, involving MMT Clinic Locator Patient Brochures Privacy / Terms of Use Since it is more rigorous and less Back to Home FAQs Events Calendar Contact Us Related Web Sites drug screening and drug testing. Distinc- Newsletters News & Updates Addiction Resources Rx Methadone affected by specimen adulteration, and tions between the two types of analyses, medications or other substances patients Visit our website for the most com- or assays, are important from perspec- may be taking – called “cross-reactivity” plete offering of FAQs in the field. Six- tives of patient benefit, clinic operations, – laboratory testing is required for legal teen new frequently asked questions, regulatory compliance, and cost. Still, this proceedings. It also is used when drug along with evidence-based answers, is a source of some confusion. monitoring results might decide issues of have been added and the remainder employment, professional licensing, have been updated – a total of 36 FAQs. Presumptive Screening sports eligibility, and the like. Other improvements to the site are Screening uses relatively straightfor- In most MMT clinics, only a minor ongoing. Navigation tabs have been ward techniques for detecting the pres- proportion of patient specimens typically reordered and sections added. See the ence or absence of an illicit drug or drug would be positive for substances of abuse new Terms of Use and Privacy Policy class (e.g., opioids) in a specimen provid- during screening, and not all of those regarding the site. Also, links to Related ed by the patient. Urinalysis is the “gold would require confirmatory lab testing. Websites have been checked and standard” in this regard. updated. When informed of the results, many This has been described as a prelimi- patients will attest to their drug use – News & Updates, primarily focusing nary or “presumptive” approach, meaning along with the quantity and quality of on methadone maintenance treatment, that it may serve to quickly eliminate or drug, mode of administration, and fre- are now added bimonthly to keep read- rule-out the most common substances of quency of use. Considerable research evi- ers informed of the latest research and abuse; except for methadone, which dence suggests that patient self-reports developments in the field. should be present in the screen. Positive can provide valuable information, screening results for illicit drugs should As always, the Addiction Resources beyond that gained from screening or be accepted with less certainty. section contains a variety of important testing alone, if the therapeutic environ- documents for readers. And, be sure to Easy-to-use drug-screening devices ment is supportive and nonthreatening. respond to the latest reader survey on a have been developed – using urine or, topic of interest to the field, or provide Therefore, except for specific cases, less commonly, oral fluid specimens – your comments and feedback – click such as court-mandated monitoring, the that can provide results in the clinic, at on the new Contact Us tab. necessity of the added time and expense A.T.F. the point-of-collection (POC). These POC on-site screens offer important benefits by Continued on Page 4 3 greater the chances of helping the patient Unless substance-abuse monitoring is done before he/she drops out of treatment frequently enough it offers little of value. entirely. Money saved by infrequent mon- itoring is offset by high costs of clinical ineffectiveness. Clinical Concepts Monitoring Frequency Continued from Page 3 Unless monitoring is done frequently On-Site Screen Advantages enough it has little value, Carlson believes. for routine laboratory testing of all MMT- On-site drug-screening devices are rel- Federal Regulations revised in 2001 patients’ specimens is highly questionable. ative newcomers to substance-abuse mon- require only a minimum of 8 random sub- Yet, it appears that many MMT programs itoring, although they have been available stance-abuse assessments each year dur- – as well as regulatory and accreditation for more than a ing MMT (without actually distinguishing agencies – often do not make necessary decade. They between screening or testing, or the type of distinctions between screening and come in differ- specimen to be assessed). testing, or between the relative appropri- ent formats: dip ateness of on-site versus laboratory sticks, cups, cas- Why 8 was chosen is unknown. Carl- approaches. settes, and card son and colleagues used a computer-gen- devices – all of This is despite recommendations from erated model to simulate how long a which visually CSAT’s own National Advisory Council patient’s drug use might go undetected display results (NAC) that, “Drug testing is a medical ser- with different scenarios (reported in AT in only minutes vice and therefore decisions about how it should Forum, Fall 2004). Theoretically, with 8 while patients be done, or when/whether it can be changed, are yearly screens, a patient relapsing to week- are present. completely within the purview of the program’s ly cocaine abuse could go nearly 11 Medical Director.” In other words, there months before it is detected. During recent years, costs for these should be no official barriers to MMT pro- have decreased while their quality has grams modifying and improving their This makes sense, since on a truly ran- increased dramatically. It is important to substance-abuse monitoring practices. dom basis all 8 urinalyses could come in understand that looking only at past the first month. Even if only one urinalysis research studies conducted using older on- is done each month, on a random day, Federal Mandates site devices, rather than more current ver- patients will soon figure out that the sions, can be misleading. According to Greg Carlson – Director, remainder of each month and 4 months Addiction Medicine, Hennepin County every year will be unmonitored “holi- The effectiveness of these modern Medical Center, Minneapolis – when he days” to freely abuse drugs if they are so on-site devices for preliminary screening started work in the MMT field more than inclined. Increasing the monitoring fre- purposes in MMT programs has been 35 years ago substance-abuse monitoring quency to every month – 12 times yearly – underestimated. Their ability to produce was not required at all. offers little improvement. results that are accurately either drug- positive or drug-negative approaches that FDA regulations in 1972 were the first In Carlson’s opinion, “drug screening to mandate drug testing in MMT, requir- of more sophisticated laboratory assays, in less frequently than twice-monthly is clin- most cases. ing a minimum of 8 random screens dur- ically ineffective and a waste of money. At ing the first year of treatment. However, the current minimum urinalyses per year And, as Carlson notes, “the quicker this was interpreted by most MMT pro- only daily or near-daily drug users would you have access to information the grams, not as a “minimum” but as the be easily detected and you may not even more helpful it can be. On-the-spot drug clinical “standard.” need drug screening for that if proper screening results provide a more powerful counseling is ongoing.” “So we went from no monitoring clinical tool.” requirement at all to a relatively rigorous Therefore, clinics need to be flexible in schedule,” he says. “However, it took a their approach. Some clinicians have sug- Official Recognition week or two to get test results back from gested that specimen collection should New government guidelines from the lab, costs were high, and the results become a very frequent and routine part SAMHSA for Federal Workplace Testing were often unreliable.” of the therapeutic regimen. To control programs have accepted on-site screening Through the years, laboratory urinaly- expenses only a random portion of all procedures and recognized their potential sis techniques and turnaround times great- specimens collected need to be assessed. utility. And, CSAT’s NAC has stated, ly improved. “Still, this represents a signif- There have been studies demonstrating “Properly conducted POC urine testing [that icant financial investment during each that the mere act of collecting samples is, point-of-collection on-site screening] … is year,” Carlson observes. as part of ongoing monitoring, whether adequate and probably offers clinical benefits, or not all samples are assayed, has bene- in terms of rapidity of clinical feedback, over He believes that properly-applied ficial effects on treatment outcomes, and above those of laboratory testing of either monitoring can provide therapeutic bene- Carlson notes. OF [oral fluid] or urine.” fits in helping to bring about and measure positive changes in patients’ lives; howev- A critical therapeutic question is: How Furthermore, they recommend that er, he adds, “If you’re not going to do long should a drug relapse continue before it additional monitoring should be per- anything constructive with the results, is detected? Serious relapse is always a pos- formed whenever there is an appearance why invest the time and money in the sibility during any stage of recovery, and first place?” the sooner problems are detected the Continued on Page 5 4 AT Forum Survey Results: Sleep Disorders Patient safety and therapeutic merit should Sleep Disturbances Are Common problems. If these patients do not get During MMT relief from trazodone or short-term be driving forces behind zolpidem, we try to refer them for sleep Approximately 130 readers (60% of evaluations.” monitoring in MMT. them clinic staff) responded to the survey on “Sleep Disorders in MMT” relating to “I’ve been on methadone for 32 years Clinical Concepts a feature article on the subject in the and have always had sleeping problems – Continued from Page 4 Summer 2004 edition of AT Forum (Vol. I wake up every 2 hours.” of patient intoxication, and “POC testing 13, #3). “At our clinic we’ve had success [i.e., screening] of urine may be especial- On average, respondents noted that with acupuncture in helping patients ly helpful for this purpose.” half (50%) of the patients at their respec- achieve greater quality of sleep. It also tive clinics had complained of persistent helps with pain management, anxiety, Therefore, there is nothing in any sleep disorders. However, nearly a third and depression.” guidelines or regulations prohibiting on- of those responding said that 80% or more site drug screening and, in fact, this “I’ve been an MMT patient for 10 of patients had serious problems with years and the only thing that helps me modality appears to have been recom- sleep, which is consistent with other sur- mended by official sources. sleep is splitting my take-home dose; oth- veys of MMT populations. erwise, I frequently wake up due to with- drawal during the night. Yet, the clinic Few Patients Get Rx Meds Safety & Therapeutic Challenges doesn’t approve of this.” Most readers (89%, see graph) agreed The driving force behind substance- to some extent that sleep disturbances can New Sleep Meds Soon Available abuse monitoring in MMT, as with other trigger drug or alcohol abuse during practices, should be patient safety and Most of the current sleep-aid medica- MMT. Yet, responses indicated that only 1 the therapeutic merit in fostering addic- tions are recommended for short-term in 4 clinics (25%) prescribe medications to tion recovery. As Carlson stresses, “this is use only; whereas, sleep problems are help patients sleep. but one clinical tool that must be inte- often chronic afflictions. A newer genera- grated with other information about the tion of drugs is coming along that may provide involuntary night individual patient.” 60 Sleep Problems Trigger Substance Abuse? owls with the sweet dreams they He notes that, if clinic staff are using 50 are longing for. At the same time, urinalyses to “catch” patients in a game 40 these agents are not expected to promote abuse or dependency. of “cops ‘n robbers,” or if results from 30 infrequent assessments are being misin- Last December (2004), the FDA terpreted, it could do more harm than 20 approved eszopiclone, the first good. “For example, we’ve had transfers % Responding 10 prescription non-benzodiazepine from programs where patients were sleep medication considered safe 0 administered only the minimum 8 No Possibly Yes and effective for long-term use. It screens per year and were supposedly is indicated for patients who have doing very well,” he says. “When we do The most frequently prescribed sleep difficulty falling asleep as well as for weekly drug screens during the first medications included (in order of fre- those unable to sleep soundly through the month after transfer they ‘suddenly’ quency): zolpidem, trazodone, diphenhy- night. Studies are continuing on its effec- become patients with serious substance dramine, doxepin, quetiapine, and some tiveness for patients also suffering from abuse problems.” benzodiazepines (e.g., diazepam, alpra- depression or pain. zolam). However, a few physicians noted As noted at the outset, this is an Another drug, indiplon, is a unique concerns about addictive potential with non-benzodiazepine agent that works on aspect of MMT for which clinics have no quetiapine. officially sanctioned manual or protocol specific brain receptors responsible for promoting sleep. Studies demonstrated to follow. Therefore, the challenge ahead Readers Share Experiences will be for clinic staff to become more its safety and effectiveness for long-term “I’ve always had sleep problems, educated and develop better substance- use. An application for approval of which have gotten worse since starting abuse monitoring practices based on indiplon to treat multiple forms of insom- MMT. I have a very hectic lifestyle and available evidence. AT Forum plans to nia has been submitted to the FDA. can’t seem to make myself lay down at assist in that endeavor. Finally, ramelteon is a unique med- A.T.F. night. I get on average about 2 to 3 hours of sleep each night. The clinic doctor has ication that may promote sleep by helping to regulate the body’s 24-hour NOTE: Due to space limitations, given me sleep aids but all they do is make me groggy in the evening and don’t sleep-wake cycle. It is a non-benzodi- references for information contain- azepine agent affecting special brain ed in this article have not been allow me to stay asleep. I’ve tried mela- tonin and valerian root, and [diphenhy- centers comprising a “master clock” that listed. Watch for a comprehensive helps the body shift easily between evidenced-based report from AT dramine] but nothing helps.” phases of day and night to encourage Forum titled, “SAM* in MMT “Many patients at our clinic suffer sleep onset. A new drug application for (*Substance-Abuse Monitoring).” from PTSD (post-traumatic stress ramelteon has been submitted. disorder) and that adds to their sleep A.T.F. 5 MMT Pioneers: Marie Nyswander, MD - Listening to Patients

Despite a life marked by many changes, work, A Doctor Among the Addicts (1968), she Marie Nyswander, MD, seems destined to tells of once attempting to quit: “The craving have become a leader in the addiction treat- for cigarettes exists as an entity, separate from ment field. pleasure. Nor did the craving diminish with time. …if it’s this hard to stop smoking, think Her straightforward manner, her unsenti- what it must be like to stop taking a drug such mental compassion, and her easy rapport with as .” patients were legendary. Most important, at a time when her fellow psychiatrists viewed Birth of MMT drug-addicted persons with disdain as being mentally-deficient moral outcasts, she promot- Another turning point came for Nyswander ed the idea of addiction as a disease. in the early 1960s when she was invited to join Vincent Dole, MD, at in It is commonly recognized that no other . He was embarking on a project American psychiatrist of her generation bene- exploring new pharmacotherapies for opioid fitted the lives of so many opioid-addicted addiction and had read Nyswander’s book. patients. He believed she had the necessary skills and experience in working with drug-addicted patients. In 1964, a Addiction as a Medical Problem third member joined the team – Mary Jeanne Kreek, MD – who Marie was born Mary Elizabeth Nyswander (which she later was a young clinical investigator and first year resident in inter- changed to Marie) in Reno, Nevada, in 1919. Her father, James, nal medicine. was a mathematics professor and her mother, Dorothy, earned a After testing a number of agents, the team soon discovered doctorate in psychology after the couple’s divorce when Marie that methadone stemmed withdrawal and relieved narcotic was still a toddler. hunger, yet at stabilized doses it did not produce the euphoria of Marie was raised by her mother and the two eventually other opioids. By spring 1965, the team had data on 22 patients moved to New York City in 1936. Marie attended Sarah Lawrence successfully treated with methadone and published their remark- College and later went to Medical College, able findings. Expansion of their program and further publica- graduating in 1944. tions soon followed, giving birth to the methadone maintenance treatment field. After completing a surgical internship, she joined the Navy as a surgeon. However, the Navy had no place for female surgeons Essential Lessons; Seeing the Inner Person in those days and Nyswander was posted to the Lexington Narcotic Hospital in Kentucky run by the U.S. Public Health According to Mary Jeanne Kreek – who is now Professor and Service. Head of the Laboratory of the Biology of Addicted Diseases at Rockefeller University – Nyswander was intense and rather firm The Lexington experience was a turning point. Nyswander at times. However, she was always open-minded when it came to saw drug addicts from all walks of life branded as psychopaths, discussing individual patients and their treatment. mistreated, and subjected to racial insults. She became convinced that these patients could and should be treated more humanely, “Many therapists and clinicians would dismiss what patients as individuals. were saying as the ramblings of disturbed, addicted minds,” Kreek notes. “Yet, Marie reminded us again and again, ‘listen to When she left the service, Nyswander decided that surgery the patient.’” was not for her and pursued a career in psychiatry. She trained at New York Medical College in the late 1940s and established a pri- “Marie felt that much could be learned by careful listening,” vate psychiatric practice in the early 1950s. Kreek says. “Then, if the whole story was not forthcoming, patients could be questioned.” She volunteered much of her time treating impoverished drug-addicts and, in 1955, Nyswander helped establish the Nar- A major new concept of the team was viewing addiction as a cotic Addiction Research Project — a first of its kind outpatient brain disease. Patients should not be defined by their past behav- program providing actively addicted patients with intensive indi- iors and merely viewed as criminals or weak-willed. “Marie vidual psychotherapy. She also set up a clinic to treat jazz musi- knew that behavior management alone was insufficient to deal cians addicted to heroin and by the early 1960s was treating with addiction,” Kreek continues. “However, the notion of using addicts in an East Harlem storefront clinic. pharmacotherapy, such as with methadone, to treat the drug- addicted brain was a new idea and slow to catch on.” Nyswander described her clinical experiences in a book, The Drug Addict as a Patient (1956). Her patients’ repeated cycles of In 1965, Nyswander married Vincent Dole, and she passed brief recovery inevitably followed by drug relapse were frustrat- away in 1986 at the age of 67. Each year since 1983 the ing, yet she believed they could be helped by clinicians willing to Nyswander-Dole Award created in their honor – and now simply learn more about addiction. She presented a radical viewpoint, at known as “The Marie Award” – has been bestowed on individu- the time, that addiction should be approached from the perspec- als who have made outstanding contributions to the methadone tive of patients with a medical problem. treatment field. Nyswander’s empathy with patients may have been influ- Looking back, Dole once remarked that her secret was an abil- enced by her self-acknowledged addiction to nicotine; she was a ity to see the inner person. No doubt, such vision was aided by 3-pack-a-day smoker. In ’s excellent book on her better listening to patients. A.T.F. 6 Pregnancy & MMT Continued from Page 1 Pregnant women should receive whatever methadone dose is most therapeutically adequate comparable in terms of health outcomes for mothers and their newborns, including on an individual basis. NAS.[3,4] found equivalent rates of retention in fits versus risks should be considered; tak- Usually, small groups of pregnant treatment and ongoing substance abuse. ing into account any potential contraindi- patients were studied,[4] and doses may [11] A newly-reported Swiss study found cations to breastfeeding, such as HIV have been inadequate for some; ranging that 64% of pregnant women continued infection, and the mother’s continued sub- from 30 to 100 mg/day of methadone, and abuse of heroin and cocaine, and this stance abuse, if any. 8 to 24 mg/day of buprenorphine.[2,4] reversed the normally positive effects of Patient selection criteria defining which 1. CSAT. Substance Abuse Treatment for Persons With methadone on birthweight in their Co-Occurring Disorders. TIP 42. Rockville, MD: pregnant women might do better on newborns.[12] Substance Abuse and Mental Health Services methadone versus buprenorphine when Administration; 2005. DHHS Publication (SMA) entering treatment are still unresolved. Some researchers have reported even 05-3992. higher rates of substance abuse.[11] And, 2. Jones H. Role of buprenorphine in the treatment of Adequate Methadone Dosing? such problems also are found in pregnant opioid dependent pregnant women. In: Program and abstracts of the 6th European Europad MMT continues to be plagued by mis- women treated with buprenorphine.[4] Conference; November 1-3, 2004; Paris, France. understandings of its use during pregnan- Research in this area often neglects to 3. Gourarier L, et al. A prospective study of 259 preg- cy. In a recent newspaper advice column, consider how low, subtherapeutic mater- nant women treated with either buprenorphine or methadone through delivery, and neonatal an obstetrician described methadone as nal methadone doses may affect continued parameters of their 260 children. Paper presented having harmful effects, especially at high- illicit-drug use. Women in the Swiss trial at: CPDD (College on Problems of Drug er doses. It was alleged that all fetuses Dependence) 65th Annual Meeting; June 2004; with high rates of substance abuse, noted San Juan, Puerto Rico. develop dependence and, after birth, go above,[12] were receiving only 50 mg/d of 4. Primorac A, et al. Double-dummy, double-blind through a painful withdrawal that is wors- methadone on average, with most admin- comparison of buprenorphine and methadone in ened by the amount of methadone the istered less than 70 mg/d. In contrast, a pregnant opioid-dependent women. Paper pre- mother is taking.[5] sented at: CPDD (College on Problems of Drug recent study found that three-quarters of Dependence) 65th Annual Meeting; June 2004; It was once thought that methadone women receiving methadone doses aver- San Juan, Puerto Rico. during pregnancy should not exceed 20 aging 94 mg/d (and ranging up to 240 5. Cressman B. Methadone. Daily Mountain Eagle (Jasper, AL). August 26, 2004. mg/day. Current guidelines acknowledge mg/d) achieved illicit-drug abstinence during their pregnancies.[13] 6. Jarvis MA, Wu-Pong S, Knisley JS, Schnoll SH. that pregnant women require at least 50 to Alterations in methadone metabolism during late 150 mg/d for therapeutic efficacy, often pregnancy. J Addict Dis. 1999;18[4]:51-61. Breastfeeding Concerns? more.[1] Additionally, significant dose 7. Kuschel CA, Austerberry L, Cornwell M, Couch R, increases are often required during later Participation in MMT does not prohib- Rowley RS. Can methadone concentrations pre- it breastfeeding, although methadone is dict the severity of withdrawal in infants at risk stages of pregnancy.[6] of neonatal abstinence syndrome? Arch Dis Child excreted in human milk. Long ago, Fetal Neonatal Ed. 2004;89(5):F390-F393. Researchers have determined that researchers observed that the typical 0.012 NAS is unaffected by maternal methadone 8. Berghella V, Lim PJ, Hill MK, Cherpes J, Chennat J, to 0.057 mg/day of methadone in breast Kaltenbach K. Maternal methadone dose and dose,[7] even in women receiving up to milk would not have any adverse clinical neonatal withdrawal. Am J Obstet Gynecol. 2003;189:312-317. 200 mg/d.[8] In fact, NAS tended to be effect on a newborn;[14] also, due to vari- more severe in newborns of women 9. DePetrillo PB, Rice JM. Methadone dosing and able metabolism, this amount does not pregnancy. Int J Addict. 1995;30[2]:207-217. receiving low doses. Consequently, preg- correlate with any particular daily nant women should receive whatever dose 10. Wittmann BK, Segal S. A comparison of the effects methadone dose in the mother. of single- and split-dosing methadone adminis- is most therapeutically adequate on an tration on the fetus: ultrasound evaluations. Int J individual basis.[6-8] The American Academy of Pediatrics Addict. 1991;26[2]:213-218. [15] and the American Osteopathic Associ- 11. Crandall C, Crosby RD, Carlson GA. Does preg- Furthermore, it seems the best way to ation [16] have both come out in favor of nancy affect outcome of methadone maintenance deliver adequate methadone during preg- treatment? J Subst Abuse Treat. 2004; 26(4):295- mothers in MMT breastfeeding their 303. nancy is to split the daily dose into two or infants. They emphasize the health bene- more amounts, particularly during the 3rd 12. Kashiwagi M, Arlettaz R, Lauper U, Zimmermann fits of breastfeeding for those infants R, Hebisch G. Methadone maintenance program trimester.[9] This has been found benefi- whose mothers are in successful recovery in a Swiss perinatal center. Management and out- come of 89 pregnancies. Acta Obstet Gynecol cial for the developing fetus [10] as well as from addiction. in helping to reduce ongoing substance Scand. 2005;84(2):140-144. abuse by the mother.[9] To minimize possible infant exposure, 13. Welle-Strand GK. Medication assisted rehabilita- tion and pregnancy: the Norwegian experience. it might be recommended that breastfeed- In: Program and abstracts of the 6th European Continued Substance Abuse? ing not be done during the time of expect- Europad Conference; November 1-3, 2004; Paris, Pregnancy and concerns about the ed peak serum methadone level (SML) in France. health of their unborn children appear to the mother, which is typically from 1 up to 14. Kreek MJ, Schecter A, Gutjahr CL, et al. Analyses of methadone and other drugs in maternal and motivate many women to enter MMT and 6 hours after dosing. For example, the neonatal body fluids: use in evaluation of symp- achieve illicit-drug abstinence. However, mother might take her daily methadone toms in a neonate of mother maintained on ongoing stresses often seem to overcome dose just after breastfeeding and prior to methadone Am J Drug Alcohol Abuse. 1974;1(3):409-419. this motivation and pregnant patients do the infant’s longest sleep time, or use a 15. American Academy of Pediatrics Committee on not appear to become more abstinent in milk supplement for feeding during peak Drugs. The transfer of drugs and other chemicals treatment than any other women.[11] SML periods.[14] into human milk. Pediatrics. 2001;108(3):776-789. 16. AOA stands strong on breastfeeding [press In comparing pregnant and non-preg- Some flexibility in the scheduling of release]. US Newswire, July 21, 2003. nant groups of women, investigators have dosing would be required. And, the bene- A.T.F. 7 Forum RETURN SERVICE REQUESTED Mundelein, IL 60060 P.O. Box 685 DITO TREATMENT ADDICTION Does Age Matter in MMT?

At a recent national The authors note that forum on drug addiction they did not expect that the in the elderly sponsored by older patients would do so the National Institute on well in MMT. They specu- Drug Abuse (NIDA), federal late that this group might be officials said the number more compliant with treat- of seniors with alcohol ment and have more stabili- and other drug problems ty in their lives. is expected to leap 150% Another possibility is by 2020 to 4.4 million. that, as patients age, they Most, two-thirds, of sub- tend to engage in fewer stance abuse in these older drug-related activities and, adults – in their 50s and 60s – consequently, less drug is long-standing, rather than abuse while in treatment. late-onset. However, other recently-reported research NIDA noted that elderly addicts have found that if older patients are exposed to many of the same problems as young per- illicit-drug use in their neighborhoods and sons with addictions, plus other issues social relationships they are significantly unique to their age group. Furthermore, at more likely to abuse drugs.[2] least half have problems with drugs other than alcohol, with opioids becoming a Time for Action prominent problem requiring attention. The evidence suggests that older Unfortunately, methadone maintenance patients can do just as well in MMT as treatment (MMT) was not a part of younger ones and, in many cases, much NIDA’s agenda. better. Yet, there is still very little research on the special needs of those older More Than Just Getting Old patients. AT Forum has previously focused on Prior articles in AT Forum have called this topic – broadly called the “Graying of for broader surveys regarding the aging Methadone” (see, Fall 1995; Winter 2003; population in MMT, as well as special pro- and Fall 2003). Generally, the MMT popu- grams, seminars, or other efforts focusing lation is aging, with a quarter to a third of on “graying of methadone” issues. Yet, to patients in some clinics age 50 or older. date, there have not even been presenta- It was suggested that aging is more tions or panel discussions on this topic at than simply “getting old,” but is a process association conferences in the field. involving biological, social, emotional, 1. Firoz S, Carlson G. Characteristics and treatment and often financial changes affecting a outcome of older methadone-maintenance patient’s health and well-being. MMT fed- patients. Am J Geriatr Psychiatry. 2004;12(5): eral regulations, state guidelines, and 539-541. many clinics have largely ignored the spe- 2. Rosen D. Factors associated with illegal drug use among older methadone clients. Gerontologist. cial needs of elderly patients. 2004;44(4):543-547. A.T.F. Elders Do Well in MMT A recently reported study[1] examined ADDICTION TREATMENT a large cross section of older patients in MMT. Among 10 programs surveyed, estimates of patients age 55 or older Forum ranged from 2% to 60%. The researchers is published quarterly by: found that significantly more older Clinco Communications, Inc. patients were married and were “highly P.O. Box 685 successful” in treatment, although fewer Mundelein, IL 60060 were employed. Phone/Fax: 847-392-3937 Overall, older patients had more chronic medical problems than younger Editor: Stewart B. Leavitt, PhD ones, but the differences were not statisti- Publisher: Sue Emerson PERMIT # 7117 U.S. POSTAGE

cally significant. Of particular concern © 2005 Stewart B. Leavitt, PhD PALATINE, IL PRSRT STD were hypertension, diabetes, liver disease, Addiction Treatment Forum is made possible by an educational grant from Mallinckrodt Inc., a manufacturer of methadone and PAID and stroke – which are illnesses expected naltrexone. All facts and opinions are those of the sources cited. in an aging population. Older and The publishers are not responsible for reporting errors, omissions younger patients were identical in terms or comments of those interviewed. of psychiatric problems. 8 ATF Winter 2005 BRC.qxd 2/23/05 2:03 PM Page 1

Please respond to the following survey questions: 1. At your clinic, how many drug screens or tests at a minimummust each patient have during a 12-month period? ______2. What substances are always assessed? (check all that apply): ❏ alcohol; ❏ amphetamines; ❏ barbiturates; ❏ benzodiazepines; ❏ cocaine; ❏ marijuana; ❏ methadone; ❏ opioids; ❏ PCP; ❏ other: ______. 3. Are on-site drug screens (not requiring shipping to a laboratory) used? Addiction Treatment Forum ❏ Often; ❏ Sometimes; ❏ Never. is supported by 4. If on-site screening devices are used, what specimens are collected? ❏ Urine; ❏ Oral fluid; ❏ Both. an educational grant from 5. Are you responding as a ❏ patient, or ❏ clinic staff member?

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