Tuesday, September 23, 2014
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Methadone, Buprenorphine, and Heroin Maintenance Treatment Update
News And Information About Opiate Agonist Therapy
According to an August 20, 2009 report by Canada's All Headline News, Canadian scientists who conducted a study "of 251 drug addicts in Montreal and Vancouver" found "that giving recovering addicts diacetylmorphine" - the active ingredient in heroin - "is more effective and leads to higher rates of recovery than administering oral methadone" ("NAOMI Study: Heroin Better Than Methadone for Recovering Drug Addicts"). The North American Opiate Medication Initiative (NAOMI) conducted the study, providing "115 addicts with diacetylmorphine, 111 methadone and 25 hydromorphone, which is an approved opiate as a pain reliever." In the end, "medical morphine" - or diacetylmorphine - "users had an 88 percent recovery," while those receiving methadone recovered at a rate of only 54 percent. As NAOMI's principal investigator, Dr. Martin Schecter, "said in a statement, 'We now have evidence to show that heroin-assisted therapy is safe and effective treatment for people with chronic heroin addiction who have not benefited from previous treatments. A combination of optimal therapies [...] can attract those most severely addicted to heroin, keep them in treatment and more importantly, help improve their social and medical conditions."
In addition to the important aforementioned findings, the study also showed that "the participants' involvement in illegal activities and money spend on drugs fell by almost 50 percent." The full study appears in the August 20 edition of the New England Journal of Medicine, and was initially released in October of 2008.
Britain Installs Methadone Vending Machines in Prisons
As the Telegraph reported on July 16, 2009 ("Government Spends £4m on Methadone Vending Machines for Prisons"), Britain has established a program "install[ing] 'vending machines' in prisons to supply drug-addicted offenders with methadone." According to the piece, "The machines allow prisoners to receive a personalized dose of methadone automatically by giving a fingerprint or iris scan." The article states that "Phil Hope, a justice minister, told MPs that vending machines have so far been installed in 57 prisons." However, "the plan is to [eventually] have the machines in 70 of the 140 prisons in England and Wales."
Not all British officials are happy with the program (or programme, as it were). Dominic Grieve, "the shadow justice secretary," told the Telegraph that "The public will be shocked that Ministers are spending more on vending machines than the entire budget for abstinence based treatments." He continued, saying that Britain "need[s] to get prisoners off all drug addiction - not substitute one dependency for another" and characterizing the "Government's approach of trying to 'manage' addiction" as "an admission of failure." However, an unnamed "spokesman for the Department of Health" contended that "Methadone dispensers are a safe and secure method for providing a prescribed treatment."
The Drug War Chronicle's July 24, 2009 edition includes an extensive feature on this issue; click here to read it.
According to a report contained within the June 5, 2009 edition of the Drug War Chronicle, "The German parliament has voted to allow the prescription of heroin to addicts who have not responded to other treatments" ("German Parliament Approves Heroin Maintenance"). The new law applies only to those "who have been using [heroin] for at least five years, are at least 23 years old, and who have failed to stop in other treatment programs." Eligible individuals will "receive pharmaceutical heroin in designated treatment centers," following a successful pilot program on which the law is based.
Other countries - including Britain, Canada, the Netherlands, Spain, and Switzerland - have implemented similar measures, which have generally produced positive outcomes. Germany's pilot study, "conducted in seven cities between 2002 and 2006," concluded that the program resulted in "reduce[d] crime, overdose fatalities, and HIV among hard-core [heroin] users."
In its June 5, 2009 edition, the Drug War Chronicle reported that "Canada's conservative federal government is providing funding for a heroin prescription pilot program in Vancouver and Montreal," which "will begin providing heroin to some 200 hard-core users later this year" ("New Heroin Maintenance Pilot Program to Get Underway Later This Year"). The program comes as a welcome surprise to drug policy reform advocates, who earlier expressed disappointment in the Canadian government's court battle to close the region's sole safe injection facility, dubbed Insite.
As the Chronicle reports, the study - called the Study to Assess Longer-term Opioid Medication Effectiveness or SALOME - primarily consists of a "three year trial" that "builds on a similiar multi-year program," the North American Opiate Maintenance Initiative (NAOMI), that took place in Vancouver and ended in the summer of 2008. SALOME "will offer heroin in both pill and injectable forms, and will also offer hydromorphone to see if it could be used as a substitute." In doing so, the government hopes to "assess whether prescription heroin is a safe and effective treatment and whether users will accept the drug in pill form." The program will cost around $1 million, and as of early June, researchers were still recruiting participants in order to begin the study in the Fall of 2009.
For a more indepth analysis, see the Chronicle piece linked above.
A federal court issued a ruling recently allowing restrictions on methadone clinics in Baltimore County to remain in place. The ACLU and a treatment provider had filed suit to have the county-imposed restrictions thrown out because, they claimed, such restrictions are violations of the Americans with Disabilities Act, however the court failed to rule on that issue.
The Baltimore Sun reported on Feb. 24, 2008 ("Drug Clinic Limits Stand") that "With a less-than-definitive opinion from a federal appeals court, Baltimore County officials say they have no intention of scrapping their restrictions on the location of methadone clinics. As a result, at least one proposed methadone clinic in Baltimore County could find it harder to open. A panel of federal judges, sitting one level below the U.S. Supreme Court, issued an opinion this month, finding that a Pikesville methadone clinic should be allowed to stay open. But the appellate court didn't directly answer whether the county law violates the Americans with Disabilities Act - which was the chief complaint made by a Pikesville methadone clinic and the American Civil Liberties Union of Maryland."
According to the Sun, "The opinion handed down by the 4th U.S. Circuit Court of Appeals vacates an injunction issued by a federal District Court judge that had prohibited the county from enforcing its law on the location of clinics. But the appellate court decision also allows the clinic, A Helping Hand, to request a new trial on the ADA questions. The clinic owner and the ACLU of Maryland said they have not decided whether to seek a new trial. 'Part of our decision hinges on what the new injunction says,' said Deborah A. Jeon, legal director for the ACLU of Maryland. 'We have to weigh the costs and the benefits of a new trial.' County officials say they don't plan to revise the regulations on methadone clinics."
The Sun noted that "The Baltimore County Council passed a zoning law in 2002 requiring additional approval for methadone clinics and other state-licensed medical facilities that want to open less than 750 feet from homes in areas zoned for business and office uses. The law allows the clinics to operate in areas designated for manufacturing without special approvals."
It should be noted that according to the Drug Enforcement Administration, "Baltimore is home to higher numbers of heroin addicts and heroin-related crime than almost any other city in the nation and these problems tend to spill over into adjoining counties where many heroin distributors maintain residences. The enormous demand for heroin in the Baltimore metropolitan area led to an increase in the drug's abuse among teens and young adults, who routinely drive into the city to obtain heroin for themselves and other local abusers."
The city of Tel Aviv, Israel, is considering a plan to provide heroin maintenance treatment to hardcore opiate addicts who have not stabilized with other available treatment modalities.
The Jerusalem Post reported on Feb. 17, 2008 ("TA Considers Supplying Heroin to Addicts") that "Tel Aviv has come up with a controversial new plan to give free heroin to addicts who have failed rehabilitation attempts, reports the Hebrew weekly Yediot Tel Aviv. City health and welfare officials are putting together the revolutionary plan, which is aimed at preventing the social damage caused by addicts trying to obtain money to buy the illicit drugs. According to the report, four out of every five heroin addicts who complete rehabilitation programs eventually end up back on the drug, and three out of every four property crimes are committed by drug addicts. The city's welfare service has decided to follow the example of some European countries and has come up with a plan to provide controlled quantities of heroin free to adult addicts who have failed several rehabilitation attempts. The distribution would be done at a specific medical clinic under the supervision of doctors. The plan will need to come before the Health Ministry for approval before it can go ahead."
The Post noted that "The report said the city's welfare service is currently dealing with 1,707 households for drug-related problems, and workers in the field have long recognized that major problems arise from addicts' attempts to get money for drugs. Police statistics show that 75 percent of property crimes and many of the recent attacks on elderly people have been committed by addicts trying to get money. The figures also show that only 20% of addicts succeed in rehabilitation programs in the long term. The report said there are currently some 15,000 drug addicts in Israel, most of them addicted to heroin."
To learn more, check out Drug War Facts, particularly the section on Heroin Maintenance and Heroin Assisted Treatment. Also for more information, check out the North American Opiate Medication Initiative study of heroin assisted therapy, with clinical trials being conducted in Canada in Vancouver, BC and Montreal, Quebec.
The state of Indiana is considering restrictions which would limit access to effective drug treatment.
The Courier Journal reported on Feb. 12, 2008 (Panel OKs Clinic Restrictions") that "Legislation to impose new restrictions on methadone clinics, including a requirement that patients be tested for marijuana and have a designated driver after appointments, cleared a House committee yesterday. The House Health Committee unanimously approved Senate Bill 157, but some members said they did so with reservations, particularly about the driving provision added yesterday. 'I'm concerned we'll lose people in treatment who are riding a bus or walking or don't have a designated driver,' said Rep. Carolene Mays, D-Indianapolis."
According to the Courier Journal, "The bill already has passed the Senate, although without the designated-driver requirement. It would require the Indiana Family and Social Services Administration to adopt new rules to regulate clinics and require state approval for all patients who would receive more than 14 take-home doses of the drug. The House committee approved another amendment yesterday requiring clinics to test patients for marijuana use."
The Courier Journal noted that "But the committee did not act on a proposed amendment by Rep. Terry Goodin, D-Crothersville, that would have banned patients from bringing children to treatment centers. Clark County Commissioner Michael Moore testified for the amendment. He told the committee that too many of the clinic's patients have their children with them when they come in early in the morning to receive treatments. Moore said many of those patients come to a restaurant he owns before or after their appointments and often fall asleep or act erratically. 'This is the kind of behavior that would make most social-service agencies jump in and act,' Moore said. But Rep. John Day, D-Indianapolis, said he was worried about a single mother who might have to miss an appointment if she couldn't bring her children."
A federal court ruled against Reading, PA officials who sought to prevent a methadone clinic from opening in their area. The court ruled that a Pennsylvania law imposed undue restrictions on these treatment programs. The Allentown Morning Call reported on June 19, 2007 ("Methadone Clinic Wins Right To Open In Reading") that "When Glen Cooper sought to open a methadone clinic in Reading, city officials said no, citing a 1999 Pennsylvania statute that barred such clinics from operating near a residential area. Cooper, executive director of New Directions Treatment Services in Bethlehem Township, filed a federal lawsuit, claiming the city's action was unconstitutional. He lost but appealed, and on Friday, a federal appeals court struck down the state statute, saying it violated federal law. 'The court says you cannot impose restrictive zoning requirements solely on methadone treatment facilities,' said Richard Churchill, a Philadelphia attorney who represented Cooper and New Directions. 'It was a complete win.' The decision by the 3rd U.S. Circuit Court of Appeals in Philadelphia -- which described the case in a 52-page opinion as a 'familiar conflict between the legal principle of nondiscrimination and the political principle of not-in-my-backyard' -- ended a six-year battle between Cooper and Reading officials, who denied his application to open a methadone clinic in 2001."
According to the Morning Call, "Cooper said the court's decision will force municipal leaders throughout the state to revisit previous denials of methadone clinic applications. Just last month, officials in Du Bois, Clearfield County, denied a methadone clinic based on the 1999 state law. 'We feel this is a landmark decision,' Cooper said. 'Assuming it is not appealed to the Supreme Court, we feel it will prevail and make the world a better place for those who need services and the general public who needs relief from those who are addicted.' Methadone has long been used to treat heroin addiction. Of the 46 clinics licensed by the state Department of Health, a dozen are in the Philadelphia area and seven in the Pittsburgh area. There are no clinics in Lehigh, Carbon, Monroe or Schuylkill counties. Bucks has three; Montgomery and Berks counties each have one. Because the overturned law was based on fears and the stigma associated with addiction and drug abuse, Cooper said, he would not be surprised if the decision eases siting restrictions for other kinds of drug treatment centers."
The Morning Call also reported that "Sue Miosi, administrator for mental health/mental retardation and drug and alcohol services in Lehigh County, said the county needs and should have its own methadone clinic but has found it difficult to obtain. 'In general,' she said, 'there's not a huge excitement for a methadone clinic opening in my backyard.' Under a contract with the state Department of Public Welfare, Lehigh County must offer methadone treatment to Medicaid patients in need, she said. Patients have instead been referred to the New Directions clinic. And the need is there, she said, noting that 18 percent of all adults seeking drug and alcohol treatment last month were addicted to heroin. That's the third-largest addiction after marijuana and a tie between alcohol and crack cocaine. New Directions has about 40 addicts waiting to enter the program at its main clinic in Bethlehem Township, which draws clients from as far away as Wilkes-Barre. 'People need the right to obtain treatment, and currently that is extremely difficult,' Cooper said. 'Entire counties have no methadone clinics.'"
The Morning Call noted that "Despite the legal victory, Cooper said he is re-evaluating plans to open the center city Reading clinic. In the six years he's fought for the clinic, his nonprofit organization bought and renovated a building it had been leasing in West Reading to treat heroin addicts. That facility has no waiting list. 'To operate a clinic, you need a minimum number of patients' to make ends meet, Cooper said. 'Having run one for 11 years, I don't think you could do it with less than 150 patients.' Though the court decision should make it easier for methadone clinics to open in places where they are needed, it doesn't mean there'll be one on every street corner, he said. 'We are very happy to see justice done,' Cooper said of the decision. 'Stigmatization is extremely widespread. Addicts are one of a few groups of people the general public still feels it's acceptable to openly hate.'"
Former Drug Czar Barry McCaffrey spoke out recently in favor of methadone treatment, stepping squarely into and on the right side of a debate in the state of West Virginia over availability of methadone maintenance -- a debate in which the current drug czar, John Walters, has been conspicuously absent.Gen. McCaffrey wrote in the Sunday Gazette-Mail on Jan. 28, 2007 ("Methadone Saves Lives, Restores Productivity"):
"I am concerned that the recent rash of negative publicity and political commentary on methadone treatment might lead to unwise changes to treatment regulations that are not consistent with science. Changes that are not consistent with evidenced-based clinical protocols will adversely affect treatment outcomes and therefore negatively impact West Virginia communities and families. I have fought for greater public awareness of the benefits of science-based drug treatment from the time that I served as Director of the Office of National Drug Control Policy ( 1996-2001 ) to the present. This issue is so crucial that I wanted to express my concern directly. Science-based methadone maintenance treatment helps those addicted to opiates sustain their recovery. The result is less crime, fewer emergency room admissions, more citizens working, and less suffering for families and the community. More individuals contribute in taxes instead of costing in health or imprisonment."
Gen. McCaffrey did note that he now has an economic involvement in methadone treatment. According to Gen. McCaffrey, "I am a member of the Board of Directors of CRC Health Group, Inc. -- as well as someone who is proud to have spent a significant amount of my professional life supporting effective drug and alcohol treatment." He noted that "CRC Health Group provides nationwide treatment services for science-based substance abuse and behavioral health disorders. We also own and operate a number of opiate treatment clinics in West Virginia. We are very proud to be the largest drug and alcohol treatment provider in the nation. CRC is dedicated to providing the absolute highest quality care to our patients. We focus on achieving the lowest possible relapse rates. We focus on outcome-based evidence of treatment effectiveness for opiate addiction."
Gen. McCaffrey wrote that "According to the National Institute on Drug Abuse Treatment Outcomes Study, 'Methadone treatment reduced patients' heroin abuse by 70 percent, their criminal activity by 57 percent and increased their full-time employment by 24 percent.' Treatment has major economical benefits as well. The National Institute of Drug Abuse has concluded, 'Every $1 invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs and theft alone. When savings related to health care are included, total savings can exceed costs by a ratio of 12 to 1.' CRC's and my goal is to assist state health departments and state methadone authorities to improve the quality and effectiveness of substance abuse services. Of CRC patients, 93.7 percent report that their problems are 'somewhat' or 'a great deal' better because of treatment."
Prisons in three Pennsylvania counties are beginning to provide methadone treatment to opiate-addicted inmates. The Allentown Morning Call reported on Jan. 23, 2007 ("Area Prisons Open Up To Methadone") that "Lehigh County Prison has agreed to join Northampton and Berks county prisons in taking the next controversial step: continuing methadone treatment for short-term inmates who had been taking the medicine before incarceration. 'It's effective immediately,' Lehigh County Director of Corrections Edward G. Sweeney said about providing methadone maintenance in the prison. Spurred by proponents who say treatment helps addicts resist heroin and avoid returning to jail, Sweeney said, 'It's a growing trend.'"
According to the Morning Call, "Administered daily at government-regulated clinics, methadone helps long-time, heavy-use heroin addicts abide by the law, hold jobs, raise families. Yet for years, a Rikers Island jail in New York was the first and only correctional facility in the country providing methadone treatment to more than pregnant inmates. Regulations and costs associated with establishing a methadone clinic and a mindset that prisoners 'deserve to suffer' have kept the treatment a rarity in most county jails and state prisons. 'Jails weren't methadone centers,' explained Todd Haskins, vice president of operations for PrimeCare Medical, the Harrisburg company providing medical services to 27 county prisons in Pennsylvania, including Lehigh, Northampton, Berks, Monroe and Schuylkill. 'It was illegal for them to prescribe it,' he said. And few jails have had enough money or heroin addicts to start their own."
The Morning Call reported that "Maintaining methadone treatment in prisons also has the support of federal health officials, such as former White House drug czar Barry McCaffrey, private foundations and state drug and alcohol agencies. And authorities say it could be argued that the Supreme Court's recent rulings against withholding prior medical care to prisoners could apply to methadone as well. 'People don't understand that heroin is a lasting addiction, a chronic condition like diabetes,' said R. Scott Chavez, administrative vice president for the National Commission on Correctional Health Care, which accredits prison methadone programs. 'You wouldn't think of not giving diabetics insulin,' he said. 'Studies have pretty much shown that the heroin addict must consider some replacement therapy or he will go back into heroin-seeking behavior.' A handful of jails and prisons in Connecticut, Chicago, California and New York have started their own methadone clinics within the correctional facilities, Chavez said. More, though, have gone the route of local jails -- working with community methadone programs to bring the service inside."
The Morning Call noted that " In this area, Berks County Prison led the way 11/2 years ago, when prisons and PrimeCare officials agreed to give continued methadone maintenance a try. Northampton County Prison followed suit six months ago. The concept came largely at the suggestion of Glen J. Cooper, a former Bethlehem health director who 10 years ago became executive director of New Directions Treatment Services, a multi-service organization that provides methadone, drug testing and counseling, mental health and HIV and hepatitis education at clinics in Bethlehem and West Reading. Cooper's clinics provide daily doses of methadone to 665 people who had been addicted to opiates such as heroin, morphine and oxycodone. Some have been free from illegal drugs for 30 years by coming to the clinic, he said, but the average length of treatment is 31/2 years. In prison, however, only those held for six months or less are considered, Cooper said. No 'lifers.' Also, the methadone clinic confirms by phone call that the prisoner had been a client before treatment begins. Appropriate doses for the week are delivered to the jail for the medical staff to administer to prisoners each day. And a clinic staffer goes to the prison to provide counseling. Cooper sent the protocol to all 41 methadone clinics in Pennsylvania, emphasizing that studies show methadone maintenance reduces the demand for heroin inside the prison and reduces the transmission of HIV and hepatitis, which can be spread by sharing drug-injecting needles. 'We are very proud of this,' he said."
A move by the US Congress has expanded the availability of buprenorphine treatment for opiate addiction. The Baltimore Examiner reported on Dec. 19, 2006 ("Congress Improves Heroin Treatment Options") that "Organizations such as Sheppard Pratt Health System can now treat more than three times as many heroin addicts with the highly effective drug buprenorphine, thanks to a move by Congress to amend the Controlled Substances Act. The changes, approved Dec. 8, raise from 30 to 100 the number of patients a clinic or hospital can treat with the drug."
According to the Examiner, "That is a boon to drug abuse counselors and to addicts in the Baltimore region, said addictions educator Michael Gimbel, of Sheppard Pratt. 'This is a very important piece of legislation. It will immediately allow us to treat more heroin and opiate addicts. Buprenorphine seems to be a very effective alternative to methadone in treating addicts.'"
The Examiner noted that "The drug is the only controlled medication doctors may prescribe in private practices with certification. However the law still has flaws, Sheppard Pratt spokeswoman Bonnie Katz said. The entire Sheppard Pratt system can only treat 100 patients with the drug, she said, which is a deterrent to spending the money to train and certify additional doctors."
The mounting toll from Hurricane Katrina includes the addicted, in more ways than one. The Chicago Tribune reported on Sept. 11, 2005 ( "Storm Chaos Cuts Help For Addicts") that "Among the estimated 1 million people left homeless by Katrina are thousands of drug abusers and alcoholics, some who have never been in treatment but many who have been torn from recovery programs. Doctors, counselors and treatment centers across the country are trying to fill the void left by the disaster, bringing in supplies, volunteering their services, even offering free residential care to refugees."
According to the Tribune, "Even before the hurricane, Louisiana suffered a dearth of treatment options for drug and alcohol abusers. As many as 1,800 clogged waiting lists on any given day, said Samantha-Hope Atkins of Hope Networks, a recovery advocacy group in Baton Rouge. 'Very few people realized that Louisiana had 32 medical detox beds for 4 million residents,' she said. 'Twenty are in [New Orleans'] Charity Hospital, which is gone.' Katrina wiped out other recovery options as well. The New Orleans area hosted dozens of 12-step meetings every day, and the city's methadone clinics served about 1,300 patients. Some were able to find help after evacuating. The Baton Rouge Treatment Center picked up an extra 200 methadone patients, but infusions of staffers from other clinics have allowed the center to persevere despite long lines that promise only to get longer. 'We know they're just going to keep coming,' said clinic director Carl Kelley."
The Tribune noted that "Some addicts appear to be treating their addictions in other ways. A Reuters reporter in New Orleans earlier this week found several opiate addicts buying or bartering for looted morphine, prescription painkillers or sleeping pills outside a Bourbon Street bar. Charles Curie, head of the Substance Abuse and Mental Health Services Administration, said the federal government has released $600,000 to help pay for treatment for displaced people. More will be available as Congress provides additional funds, he said. Curie said the hurricane could harm more than those who lost their treatment programs. History shows that trauma causes drug and alcohol problems for others--including police and medics--to increase. 'We can anticipate . . . spikes in abuse after an event like this,' he said. Recovery specialists from across the country have vowed to help. Hope Networks' Atkins said some of the nation's largest treatment centers have offered to provide free transportation and accommodations, while smaller groups have donated Big Books--the bible of AA. Dr. Sarz Maxwell, medical director for the Chicago Recovery Alliance, is hoping to provide relief in person. She said a drug manufacturer has released $50,000 worth of Suboxone, a methadone-like medication for heroin addicts, and she is trying to get federal permission to distribute the drug to those not yet in treatment programs."
The Journal of the American Medical Association published the results of a study which shows that so-called "ultra-rapid" heroin detoxification is less effective and more dangerous than other, traditional methods. The Los Angeles Times reported on Aug. 24, 2005 ( "Heroin Detox Using Anesthesia Limited And Risky, Study Says") that "Using general anesthesia to help detoxify heroin addicts is no more effective than other treatments and potentially much more dangerous, says a study to be published today by Columbia University researchers. The method -- going by names such as "rapid detox" and "detox in a day" -- has been promoted as a quick and easy way to relieve the stress and pain of withdrawal from heroin as well as from more easily accessible opiates, such as Vicodin and OxyContin."
According to the Times, "Dr. Eric D. Collins, an assistant professor of psychiatry at Columbia, studied 106 addicts, who were divided into three groups. One group was put under general anesthesia for about five hours and given a high dose of naltrexone, a drug used to neutralize heroin's effects. Another was given a heroin substitute called buprenorphine and eased onto naltrexone. A third group was given the antihypertensive clonidine, which lessens withdrawal symptoms. All patients were then offered 12 weeks of additional naltrexone therapy and psychotherapy designed to prevent a relapse into heroin use. None of the methods was very successful. The results showed high relapse rates, with 11% of the patients finishing treatment and providing no more than two heroin-positive urine samples. Three patients who underwent general anesthesia nearly died. One suffered a severe buildup of fluid in the lungs and pneumonia, and another developed dangerously high blood sugar levels. A third patient entered a bipolar mental state that required hospitalization. All of the incidents were related to the use of general anesthesia. The benefits of the method "were limited to the few hours when patients were under general anesthesia, and they came with risks that should be intolerable," said Collins, lead author of the study, to be published in the Journal of the American Medical Assn."
A copy of the article, "Anesthesia-Assisted vs Buprenorphine- or Clonidine-Assisted Heroin Detoxification and Naltrexone Induction -- A Randomized Trial," is available from the Journal or from this site as a PDF.
A federal restriction on access to buprenorphine treatment for opiate addicts was eased in August 2005. The Boston Globe reported on Aug. 7, 2005 ( "Greater Access To Treatment Hailed") that "A federal limit on a medication that has been used to treat thousands of OxyContin and heroin addicts was lifted last Tuesday, opening the door for hundreds of addicts across Boston to immediately begin treatment after months or even years on waiting lists."
According to the Globe, "The previous law, passed in 2000, limited individual clinical practices from treating more than 30 patients with buprenorphine at a time, but did not distinguish among single-physician practices, hospitals, and health care organizations. As a result, the 200 doctors belonging to Boston Medical Center's internal medicine practice could treat a combined 30 patients. Harvard Vanguard, which has 14 clinics throughout Greater Boston, was likewise limited to treating just 30 patients. The new law allows a single doctor to treat 30 patients after passing a certification course. 'We actually have four certified physicians, so the practical effect of this is we immediately go from a capacity of 30 patients to a capacity of 120 patients,' said Dr. Steve Adelman, a psychiatrist with Harvard Vanguard. John Auerbach, executive director of the Boston Public Health Commission, said his agency already offers free training programs for doctors and a free hot line with on-call physicians who can field treatment questions. He said he expects the number of city residents receiving buprenorphine -- sold under the brand name Suboxone -- to double within a year."
The City of New York's Health Dept. began a potentially significant promotion of Buprenorphine treatment for the city's opiate addicts. New York Newsday reported on July 10, 2005 ( "New Option To Wean Off Heroin") that "In an unusual move, city Health Department officials are quietly encouraging physicians, hospitals, methadone clinics and prisons to prescribe the drug buprenorphine to heroin addicts, believing it will lure more addicts into treatment. Buprenorphine - a relatively new drug that goes by the nickname 'bupe' and comes in a pill form - offers a new set of treatment options for opiate abusers, said Dr. Lloyd Sederer, executive deputy commissioner of the city Department of Health and Mental Hygiene."
The Health Department's goals are ambitious. According to Newsday, "Despite the potential benefits of buprenorphine, the drug remains virtually unknown and unused by the city's heroin addicts. According to city health officials, only about 1,000 people use it, compared with an estimated 34,000 taking methadone. Sederer and other city health officials want to see a significant change in those numbers. The goal is to have more than 100,000 opiate addicts using buprenorphine for detox maintenance by 2010. 'We are not reaching enough people with the treatments that we have,' Sederer said. 'Not everybody should be on methadone.' Like methadone, buprenorphine is heavily regulated, and may be prescribed only by certified doctors, of which there currently are 345 statewide. In addition, those prescribing the drug are bound by a 30-patient limit, a federal restriction guarding against prescription abuse that Sederer and other health officials hope will be changed so that more patients can be treated. Some private doctors have been reluctant to prescribe the drug, fearing their offices would be inundated with addicts. The drug's pill form would be more attractive to white-collar users trying to avoid methadone clinics, experts said."
The size of New York City's addicted population and the current costs of treatment are staggering. Newsday noted that "The goal, drug treatment experts said, is for more doctors to be able to prescribe buprenorphine and for patients to be able to pick it up at the pharmacy. Potentially, thousands of people could benefit from the drug. The city spends $50 million annually on treatment of an estimated 200,000 heroin addicts and 200,000 others addicted to prescription painkillers like Vicodin, Percocet and OxyContin. The state Office of Alcoholism and Substance Abuse Services will spend $313.7 million in 2005-06 to treat those battling against alcohol and other drug-related addictions, spokeswoman Jennifer Farrell said. 'Buprenorphine expands the availability of treatment for those who are addicted to opiates and allows recovering addicts to more likely follow treatment to completion,' Farrell said. Opiate addicts on buprenorphine for maintenance have a better chance of working because it has fewer side effects than methadone, Sederer said. Also, having more opiate addicts in recovery would reduce crime and the spread of HIV and other diseases related to needle use, he said."
The first clinical trial of prescription heroin in North America began in Feb. 2005. As the Canadian health ministry, Health Canada, wrote in its news release of Feb. 9, 2005 ( "North America's First Trial Of Prescribed Heroin Begins Today"), "The North American Opiate Medication Initiative (NAOMI) is a carefully controlled (clinical trial) that will test whether medically prescribed heroin can successfully attract and retain street-heroin users who have not benefited from previous repeated attempts at methadone maintenance and abstinence programs. The NAOMI study will enrol 470 participants at three sites in Vancouver, Montreal and Toronto. The Toronto and Montreal sites are expected to begin recruitment this spring. Each site will enroll about 157 participants. About half of these volunteers will be assigned to receive pharmaceutical-grade heroin (the experimental group) and half will receive methadone (the control group). The prescribed heroin will be self-administered under careful medical supervision within a specially designed clinic. Those in the heroin group will be treated for 12 months then transitioned, over three months, into either methadone-maintenance therapy or another treatment program. The researchers expect a 6-9 month recruitment period, so that the total time to complete the study will be 21 to 24 months."
"According to Health Canada, "In 1973 the federal Commission of Inquiry into the Non-Medical Use of Drugs recommended that heroin-assisted therapy be tested in clinical trials. More recently, large studies in Switzerland and the Netherlands have indicated that heroin-assisted therapy is useful in helping some chronic users to stabilize their addictions, reduce criminal activity and lead more healthy and productive lives. The Canadian Institutes of Health Research (CIHR) is providing at total of $8.1 million and the study is approved by Health Canada. The principal investigator is Dr. Martin Schechter of the University of British Columbia Faculty of Medicine. Ethical review boards at each of NAOMI's three sponsoring institutions-the University of British Columbia, Toronto's Centre for Addictions and Mental Health and Université de Montréal-have approved the study. 'Results from the European studies suggest that medically prescribed heroin could greatly help our most troubled heroin addicts --those for whom we have no effective treatments,' said Dr. Schechter. 'But we won't know whether the same results hold true in the Canadian setting until we complete this carefully designed scientific study.' 'Heroin addiction afflicts an estimated 60 to 90,000 Canadians and the costs associated with it--in terms of human misery, public health, social problems and crime--are staggering,' said Dr. Alan Bernstein, President of CIHR. 'Canada, and many other countries, therefore, need studies such as NAOMI to investigate new approaches to reducing the harm caused by heroin addiction.'"
Though the plan has some critics, particularly the US Office of National Drug Control Policy (the 'Drug Czar'), many are lining up in support of the NAOMI project. The Globe & Mail reported on Jan. 31, 2005 ( "Is Free Heroin Just A Quick Fix?") that "In Vancouver, the plan has the support of top politicians and law enforcers, including the mayor and the police chief. Mayor Larry Campbell, who was once a coroner and drug cop, said the trials are needed because current treatments aren't working for hard-core addicts. 'The critical thing is to accept this as a medical condition,' Mr. Campbell said. 'The side effects of this medical condition is that it forces you to . . . do things that you would never do, be it work as a sex-trade worker, be a B and E [break-and-enter] artist or a purse snatcher. So if I can mitigate that by putting you on heroin, imagine the changes you could have.'"
A report by researchers in Glasgow, Scotland, has stirred a debate in the United Kingdom over the question of controlled heroin use. BBC News reported on Feb. 3, 2005 ( "Heated Debate Over Heroin Report") that "The Glasgow Caledonian University study of 126 users of the class A drug found many were holding down normal jobs and relationships and passing exams. The report said heroin could be taken in a controlled way for a period."
Critics panned the report as promoting heroin use. Calmer voices explained that this was not the case. According to BBC, "However, Lord Victor Adebowale, the chief executive of specialist alcohol and drug organisation Turning Point, said the report was not saying that heroin was safe. He explained: 'It says that if you have a job, if you have a house, an income, are well educated and have a health system to support you, it's possible to survive an addiction to a pretty serious substance. Most people don't have this and have mental health challenges as well as a heroin problem.'"
Indeed, even the study's author stressed that the report should not be taken as minimizing the danger of heroin. As the BBC noted, "The report's author, Dr David Shewan, agreed that heroin was not a safe drug. He said the concept of controlled drug use was a 'largely unexplored' area of research and warned that the results should be treated with caution. The doctor added: 'However, this study shows that the chemical properties of specific substances, including heroin, should not be assumed to inevitably lead to addictive and destructive patterns of drug use. Drug research should incorporate this previously hidden population to more fully inform theory and practice. Psychological and social factors have to be taken into account when looking at how to deal with any form of addiction, including heroin addiction.'"
According to the BBC:
The study is to be published in the British Journal of Health Psychology.
The politics.co.uk website features an excellent discussion of this report as an "Issue of the Day: Evidence For Controlled Heroin Use?".
The Commonwealth of Virginia is once again attempting to restrict access to methadone treatment in spite of the growing numbers of its citizens in need of such care. The Bristol Herald-Courier reported on Jan. 20, 2005 ( "State Senate Approves Meth Bill") that "The state Senate approved a bill unanimously Wednesday that would halt licensing of methadone clinics until regulations could be developed. The measure was one of the first to get full Senate approval in this General Assembly session. 'It flew through,' said Sen. William Wampler, R-Bristol, the bill's sponsor. Lawmakers understood the bill and recognized the need to develop comprehensive regulations, Wampler said. The measure now goes to the House of Delegates, which will review the bill along with legislation drafted by Delegate Terry Kilgore, R-Gate City, that would keep the clinics from targeting counties without zoning regulations. Bills become law if approved by the House and Senate and signed by the governor. Wampler's bill would put the licensing of the controversial clinics on hold until state mental health and substance abuse officials could establish standards and evaluate the need for new clinics."
According to the Herald-Courier, "Critics call the treatment ineffective and say methadone clinics could increase neighborhood crime rates. Washington Countians kept a clinic away from John Battle High School, and Pound and Wise County residents kept a proposed facility from opening near U.S. Highway 23 at the Kentucky border. Scott Countians remain opposed to a proposed clinic near Gate City. Under the legislation, the director of the Department of Mental Health, Mental Retardation and Substance Abuse Services would develop regulations governing methadone clinics within 280 days of the measure's effective date, Wampler said. The director would take into account security issues, the proximity of other clinics and the number of people in a given area who need drug treatment."
Yet SW Virginia, home to some of the stiffest resistance to methadone treatment facilities, is also home to what officials say is a serious problem with diversion and abuse of prescription narcotics. According to the Bristol Herald-Courier on Jan. 7, 2005 ( "Prescription Abuse Still Deadly Threat"), "While OxyContin abuse no longer dominates the headlines, our region's deadly love affair with prescription painkillers continues. The proof came in a study by Virginia's Department of Health. That study found that drug overdose deaths in Southwest Virginia tripled from 1993 to 2003, jumping from 66 to 217. At the height of the OxyContin epidemic in 2001, 164 people in our region died of overdoses. But even after the OxyContin crackdown, that number continued to climb. We remain in the throes of a prescription drug abuse crisis with no easy solution in sight. In fact, some counties in our region had overdose death rates that beat out Richmond's death rate by 300 to 600 percent. Russell County, which had 14 overdose fatalities in 2003, had the highest death rate in the state -- 48.5 deaths per 100,000 people. Lee, Wise and Tazewell counties all made the top 10. Those statistics are a wake-up call for our region. There's much less OxyContin available on the streets these days, but the twin problems of addiction and abuse didn't go away. Instead, addicts found a new drug of choice -- methadone. The shift from OxyContin to methadone might indirectly be to blame for some of the increase in overdose deaths. Methadone is slow-acting and doesn't give the immediate pain relief of some other narcotics, medical experts said. That might prompt users to combine it with other painkillers, a potentially deadly mistake. 'All these drugs are dangerous. Any of them can kill you if they're used improperly,' Dr. John Dreyzehner, director of the Cumberland Plateau Health District, said. That's the take-home message here. By demonizing a single drug -- OxyContin -- we might have missed the bigger picture. We waged war on Oxy but failed to address the underlying issues that play a role in addiction and drug abuse. We locked up the dealers and the doctors but didn't treat the users. And, the problem is still very much with us. Some suggest part of the problem is cultural acceptance of drug use in our region, particularly in the coalfields. Unemployment and the prevalence of the disability lifestyle also are factors."
The Herald-Courier editorial concludes: "It is an uphill battle, but it is one we must fight. Education about the dangers of prescription drug misuse and treatment for those already addicted are good places to start."
Federal Report: Methadone Diversion, Surge In Overdose Reports Related Pain Prescriptions, Not Treatment Clinics
The US Substance Abuse and Mental Health Services Administration in February 2004 issued a report on methadone-related mortality based on proceedings from a consensus panel. The report, "Methadone-Associated Mortality: Report of a National Assessment," was prepared in response to "media reports, coupled with an increase in requests for consultation and assistance from State authorities and practitioners in the field," arising from "an apparent increase in deaths among persons using the medication."
According to the report:
The report notes that:
Indeed, according to the panel, "Methadone seldom is reported as the sole cause of death. In those relatively rare cases, the drug often was ingested accidentally. The majority of methadone-associated deaths involved at least one other drug, often another opioid or central nervous system depressant such as alcohol or a benzodiazepine (Borron, et al., 2001; Haberman, et al., 1995)."
The state of Virginia has moved closer to putting restrictions
on new methadone clinics in spite of increasing demand for
treatment services. The Bristol Herald Courier on Feb. 4, 2004 reported (
"Meth Clinic Bill Passes Senate") that
"The state House of Delegates could get its turn in two
weeks to consider a measure limiting the establishment of
methadone clinics. Senate Bill 607, co-sponsored by Sens.
William C. Wampler Jr., R-Bristol, and Brandon Bell, R-Roanoke,
passed the Senate on Tuesday by a 39-1 vote. The bill would:
The Senate bill is not the only attempt to restrict clinics that the state legislature has considered recently. As the Herald Courier noted, "Wampler, Bell and other legislators on both sides of the General Assembly had introduced similar bills this year in response to three unrelated attempts to open new methadone clinics in the Roanoke area and in Washington County, near Bristol. Washington County officials in December learned of South Carolina-based Appalachian Treatment Services' plan to open a methadone clinic on Old Dominion Road near the Lowry Hills community and John S. Battle High School. Washington County's county administrator, Mark Reeter, said this week that the county has 90 days instead of the 45 first thought to make a decision on whether to allow the clinic to locate near Lowry Hills. That could put a decision by the end of February. Wampler earlier said his and Bell's legislation would not affect the Roanoke clinic, although it, in effect, could limit the Appalachian Treatment Services effort because the clinic has not yet obtained a state license."
The state of West Virginia's Health Care Authority in January 2004 declared a 6-month moratorium on new methadone clinics in the state. The Charleston Daily Mail reported on Jan. 22, 2004 ( "Methadone Clinics Forced To Wait") that "Now that the state won't approve any new methadone clinics for at least six months, those eight waiting in the wings will just have to wait. 'I'm disappointed,' said Gerald Schmidt, chief operations officer for Valley HealthCare System in Morgantown. 'But this is an excellent opportunity to look at the system.' Schmidt's agency already had filed a request with the state Health Care Authority to team up with a company that develops methadone clinics. Currently, seven clinics operate in the state. They treat people addicted to opium-based drugs such as OxyContin with a synthetic narcotic to wean them off the illegal substances. Authority Chairwoman Sonia Chambers announced the moratorium Wednesday. She said taking some time out would allow state officials to examine the issues and develop standards to which clinics should adhere."
In addition, the Daily Mail noted, "Delegate Marshall Long, D-Mercer and a physician, is working on legislation to regulate methadone."
As the reported use of opiates including OxyContin has increased in some rural parts of the US over the past few years, so has demand for treatment services. Yet in spite of the increased need, some in these communities are fighting access to methadone treatment.
Some residents of Roanoke, VA are fighting a proposal to locate a methadone clinic there. The Roanoke Times reported on Sept. 24, 2003 ( "Roanoke County Gets Ready To Fight Drug Clinic") that "The Roanoke County Board of Supervisors is gearing up to fight a proposed methadone clinic at the corner of Ogden Road and Colonial Avenue. 'We will certainly do everything in our power,' board Chairman Joe McNamara told a citizens' task force Tuesday. Later, the board went behind closed doors to discuss probable litigation related to the clinic."
The fight is also being carried out in the state legislature. The Roanoke Times reported on Jan. 4, 2004 ( "Legislators Plan To Submit Bills Restricting Methadone Clinics") that "First there was community agitation, then the threat of litigation, and now proposed legislation. Such has been the reaction in the past four months to proposed methadone clinics in the Roanoke Valley. When the General Assembly convenes next week , two legislators plan to submit bills that would prohibit methadone clinics from opening within a half-mile of a school. Legislation proposed by Sen.-elect Brandon Bell, R-Roanoke County, and Del.-elect William Fralin, R-Roanoke, would also require the state agency that regulates drug treatment centers to notify the jurisdiction where a clinic is planned within 15 days after an application for a state license is filed. Bell and Fralin suggested the legislation as candidates in September, when a planned methadone clinic in Roanoke County near Green Valley Elementary School stirred up strong neighborhood opposition."
This opposition to increased availability of treatment services for opiate addiction comes at the same time as increased concern in the state and region regarding OxyContin and other prescription drug abuse, particularly opiates. The Roanoke Times reported on Dec. 11, 2003 ( "114,000 Prescriptions Put In Database") that "More than 114,000 prescriptions filled at pharmacies across Western Virginia have been entered into a database designed to identify drug abusers who con doctors into giving them painkillers. The prescription monitoring program, which was approved as a pilot program by the General Assembly last year, began operation in September. Authorities hope that by tracking prescriptions for drugs such as OxyContin and methadone, they will be able to curb the practice of 'doctor shopping,' in which drug abusers go to multiple physicians and feign ailments in order to obtain their drug of choice. Since it began Sept. 11, the database has grown to include more than 114,000 prescriptions filled at about 300 pharmacies in a region that stretches from Appomattox County to the westernmost tip of the state."
There is also certainly demand for such a clinic in rural Roanoke County, VA, a demand attributed by some to prescription drug abuse, particularly Oxycontin. The Roanoke Times reported on Jan. 4, 2004 ( "Methadone A Booming Business In Western VA") that "Four years ago, there were no methadone clinics in Virginia west of Richmond. Now there are three. Soon there may be six. The proliferation of the treatment programs, which dispense methadone daily to help addicts break their dependence on other drugs, is attributed to the region's long-standing problem with prescription drug abuse that peaked around 2000 with the emergence of OxyContin."
This increased demand has led to some support for a methadone clinic locally. The Roanoke Times editorialized on Sept. 12, 2003 ( "End The Commute For Recovering Addicts"), "INSTEAD of traveling 100 miles to Galax or 120 miles to Charlottesville for treatment, recovering drug addicts in the Roanoke Valley need help closer to home. A plan by Life Center of Galax to open a satellite methadone clinic in Southwest Roanoke County is a sensible solution to eliminating the lengthy commute for addicts of opium-based drugs trying to turn their lives around. Because the Roanoke area is the urban center of Southwest Virginia, situating a treatment facility here will provide easier access for more of those needing help in the region. About 70 patients from the Roanoke Valley are now enrolled in Life Center's program in Galax. Officials have received calls from as many as 100 others unable to begin treatment because they cannot make the daily visits, which the program initially requires. Once the clinic is fully operational, Life Center expects 200 to 300 patients to regularly visit the Roanoke County site."
A sidenote: Some areas are reporting an increase in methadone-related deaths, specifically related to use of the pill form of methadone -- the sort prescribed to pain patients, distinctly different from the liquid form used in methadone clinics. The Roanoke Times, in its Dec. 11, 2003 story "114,000 Prescriptions Put In Database," reported that "While OxyContin abuse remains a problem, authorities have since noticed a growing problem with methadone, a synthetic narcotic that is used as a painkiller and a form of treatment for addicts of opium-based drugs. Last year, 62 people died from methadone overdoses in the western half of Virginia, said Dr. William Massello of the medical examiner's office in Roanoke. The methadone that caused the overdoses appeared to have been tablets prescribed by physicians for pain, Massello said, and not the liquid form of the drug that is used by methadone clinics such as the ones that have generated controversy in the Roanoke Valley."
The Roanoke Times reported on July 20, 2002 ( "Methadone Deaths Rise In Western VA") that "'We're theorizing that perhaps because of the bad publicity that OxyContin has received, there are physicians who are switching to methadone' to treat pain, Massello said. The pharmaceutical black market is driven primarily by 'doctor shoppers' who fake ailments to obtain drugs from multiple physicians and then sell them on the street. Another theory is that prescription drug abusers are being forced to turn to other drugs such as methadone because increased law enforcement efforts have made it harder for them to find OxyContin on the street. 'I still think OxyContin is the drug of choice,' said Tazewell County Commonwealth's Attorney Dennis Lee, who serves on a state task force studying prescription drug abuse. 'But in a pinch, people will buy methadone and use it also.'"
Roxane Labs, the pharma which produces LAAM, has informed the US Food and Drug Administration that it is ending production and distribution of the opiate agonist. According to Roxane's letter to FDA, dated Aug. 23, 2003 (Editor's Note: last accessed Feb. 9, 2004), "Roxane Laboratories, Inc. is discontinuing the sale and distribution of ORLAAM® (Levomethadyl hydrochloride acetate) Oral Solution, 10 mg/mL after the current inventory is depleted. We estimate that this will occur early in the first quarter of 2004. Since the introduction of ORLAAM in 1995, Roxane Laboratories has received increasing reports of severe cardiac-related adverse events, including QT interval prolongation (15), Torsades de Pointes (8) and cardiac arrest (6). Other cardiac-related adverse events have also been reported, including arrhythmias, syncope, and angina. These events led to the removal of ORLAAM from the European market in March 2001, and extensive changes (including additional warnings & contraindications) were made to the US package insert in April 2001 (Dear Healthcare Professional letter dated April 11, 2001). Since these changes, the use of ORLAAM has decreased dramatically over the last two years. While there may be a very small number of patients who may benefit from ORLAAM, it is our belief that the risks of continued distribution and use in the face of less toxic treatment alternatives no longer outweigh the overall benefits."
The Food & Drug Administration has approved two formulations of Buprenorphine for use in opiate treatment. The FDA reported on Oct. 8, 2002 ( "Subutex And Suboxone Approved To Treat Opiate Dependence) that "The Food and Drug Administration (FDA) announced the approval of Subutex (buprenorphine hydrochloride) and Suboxone tablets (buprenorphine hydrochloride and naloxone hydrochloride) for the treatment of opiate dependence. Subutex and Suboxone treat opiate addiction by preventing symptoms of withdrawal from heroin and other opiates. These products represent two new formulations of buprenorphine. The first of these formulations, Subutex, contains only buprenorphine and is intended for use at the beginning of treatment for drug abuse. The other, Suboxone, contains both buprenorphine and the opiate antagonist naloxone, and is intended to be the formulation used in maintenance treatment of opiate addiction. Naloxone has been added to Suboxone to guard against intravenous abuse of buprenorphine by individuals physically dependent on opiates. Both drugs are supplied in 2 mg and 8 mg tablets which are placed under the tongue and must be allowed to dissolve."
The drugs will also be the first to be prescribed through doctor's offices rather than through clinics. Research on Office-Based Treatment, as noted in Drug War Facts, shows that this will allow a significant expansion of treatment availability. The FDA notes that "Subutex and Suboxone are the first narcotic drugs available for the treatment of opiate dependence that can be prescribed in an office setting under the Drug Addiction Treatment Act (DATA) of 2000. Until recently, opiate dependence treatments in Schedule II, like methadone, could be dispensed in a very limited number of clinics that specialize in addiction treatment. As a consequence, there have not been enough addiction treatment centers to accommodate all patients desiring therapy. Under this new law, medications for the treatment of opiate dependence that are subject to less restrictive controls than those of Schedule II can be prescribed in a doctor's office by specially trained physicians. This change is expected to provide patients greater access to needed treatment."
The FDA has this information page on Subutex and Suboxone for additional resources on these substances. For more info, see the Drug War Facts sections on Methadone, LAAM & Buprenorphine Treatment and also on Heroin.
A program established in Scotland to help former addicts stay in control when released from prison has come under attack. The Herald reported on July 1, 2002 ( "Prison Policy 'Surrender To Drugs Crisis') that "The Scottish Executive has said that a handful of 'totally chaotic' prisoners are offered a heroin substitute to prevent them from overdosing or reoffending when released. Richard Simpson, deputy health minister, yesterday defended the scheme, which he said was aimed at preventing people from dying. However, Bill Aitken, the Tory justice spokesman, attacked the scheme as being 'total and abject surrender' to the drugs crisis. Three out of every four prisoners enter jail with some kind of drug problem, and 15 drug addicts died within two weeks of being released from jail in 1999."
According to the Herald, "The Scottish Prison Service introduced the controversial scheme, called the Retox Programme, earlier this year to prevent the growing number of released prisoners overdosing on heroin while on parole. Inmates are assessed by psychologists and drug counsellors, and are offered a place on the programme if it is thought there is a strong possibility they will return to drugs when released." The Herald reports that "Vic Walker, of the Open Door Trust, a charity that works with people affected by unemployment, drugs, alcohol and crime, said yesterday: 'I think there is a place ( for re-toxification ) within an overall strategy, but . . . should always be seen as a stepping stone to get people to the ultimate destination of being able to be free to reach their potential.'"
The Herald notes that "Dr Simpson stressed that the re-tox programme applied to 'a group of totally chaotic people who repeatedly, in going out of prison, have risked their lives by taking quantities of hard drugs. If we can stop them from dying, this is a measure we are prepared to take.' He said the alternative was for people to come out of jail and commit crimes for drug money. 'There are 7500 prisoners entering treatment systems and only a handful in re-toxification. This must be kept in total perspective,' he said."
The Swiss government announced a new system for prescription heroin, whereby insurers will now pay 75% of the cost of the heroin for users. Swissinfo, a service of the Swiss Broadcasting Corporation, reported on June 12, 2002 ( "Health Insurers To Foot Bill For Heroin") that "Under the new system announced by the government, health insurers will be required to fork out 75 per cent of the cost of heroin prescriptions. That works out SFr16.5 million ($10 million) a year, or SFr40 per addict per day. Health insurers already foot a quarter of the bill. Currently 1,169 addicts are given daily doses of the drug as part of the government's Heroin Assisted Treatment (HAT) programme at a cost of SFr55 per addict per day. The addicts themselves are expected to foot the balance - SFr15 a day - but for those without the means to do so the local authorities will pick up the rest of the bill."
Insurance companies are not pleased with the government's plan. Swissinfo reports that "Health insurer, Swica, told swissinfo that, in its view, addicts were a public responsibility and that it was not up to health insurers to see to their needs. 'I was surprised to hear of the government's decision because it doesn't make any sense,' said Swica spokeswoman, Nicole Graf. 'All it does is change who has to pay for heroin medication.' She said ultimately it would be the public who footed the bill, through their health premiums, adding that it would take at least six months to see whether premiums would be raised to cover the additional costs." Swissinfo notes that "Under the HAT programme, addicts receive daily doses of Diaphine (soluable heroin) – under strict supervision – at one of 22 injection centres across the country. Addicts either inject heroin, which is legally produced by a Swiss pharmaceutical firm, or take it orally. Those who have been on the programme for several months - and are viewed as 'stable' - are eventually allowed 'take home' doses of the oral form of heroin or methadone to counter withdrawal symptoms."
The Swiss program has met with a great deal of success. As Swissinfo reports, "In the ten years since the heroin prescription programme was introduced, drug experts say it has saved hundreds of lives. Drug-related deaths, mostly from heroin overdoses, have dropped by half since 1992, while Aids-related deaths among drug users have fallen by a third since 1994. Critics of the scheme have long maintained that the heroin prescription programme fails to wean addicts off drugs. But Dr Daniel Meili, a leading member of the association for the reduction in the risks of drug abuse, insists they are missing the point. 'The final goal is abstinence, but there are a lot of people who never reach that goal,' he told swissinfo in a recent interview. 'If you measure success only by the rate of abstinence you are on the wrong track because that's not the primary goal – first people have to survive.' Meili points out that statistics show that those outside the treatment programme die at a rate of two to three per cent a year. After ten years that means a death rate of 20-30 per cent – 'maybe more', he said. 'For me the programme has been a success because, from a medical point of view, the main aim is to reduce mortality', he added."
The article notes other indicators showing that the program has been a success, for example a drop in crime. "Dr Jürgen Rehm, director of the Addiction Research Institute in Zurich, told swissinfo that other important factors also need to be taken on board when assessing the merits of the programme. He said that by reducing the prevalence of illicit drug consumption some indicators of social integration – most notably criminality – have also improved. This is supported by statistics from the Federal Office of Public Health which show that at the start of their treatment, 70 per cent of addicts are involved in some kind of criminal activity. This figure drops to just ten per cent after 18 months on the programme. Other studies reveal that the economy also benefits since the cost of treating a patient amounts to SFr55 daily, whereas those not on the programme cost the government SFr96 a day in terms of policing, imprisonment and poor health."
The Baltimore County Council passed a resolution in mid-April 2002 that attempts to ban new methadone clinics in the county. The Baltimore Sun reported on April 22, 2002 ( "Clinics Foresee Legal Battles") that "By passing a zoning law, the Baltimore County Council has tried again to restrict where private methadone clinics can operate and sidestep the community uproar that often accompanies such facilities. But as the owners of two clinics prepare to challenge the law in court, it appears that the longstanding fight is far from over."
The Sun reports that "treatment advocates contend that the law violates the federal court order. Mid-Atlantic Realty Trust, which rents 100,000 square feet of space in the county to medical facilities, some of which would be subject to the restrictions, also has objected to the law. 'We'll go to court with it,' said Chip Silverman, a consultant for START Inc. ( Success Through Acceptable Rehabilitation Treatment ), which wants to open a clinic in Pikesville. 'We think it is definitely in violation of the Americans with Disabilities Act. We don't really see much difference between what the county has done here and what they did in the case several years ago.'"
According to the Sun, the sponsor of the clinic ban legislation, Councilman Kevin Kamenetz (D-Pikesville-Randallstown) "said he isn't opposed to methadone clinics but thinks their locations should be regulated. He says he took the same approach with legislation on pawnshops and kennels. 'There has to be some sensitivity,' he said. 'The operators of these businesses have to put themselves in the shoes of the people who live next to these businesses. Would they want to live there?'"
The Sun story noted that "According to the Maryland Department of Health and Mental Hygiene, 14 methadone clinics operate in Baltimore City, four in Anne Arundel County and one each in Howard, Carroll, Harford and Baltimore counties. The Baltimore County clinic, a public-private hybrid, is in an industrial zone off York Road in Timonium, south of the Maryland State Fairgrounds. It can serve 647 people and at last count had 534 clients, Gimbel said." In addition, "The 11 city-run clinics are augmented by three privately operated programs. But Gimbel said he's wary of private, for-profit centers because they are not required to treat people who can't pay. Private methadone treatment costs $70 a week or more. Publicly funded programs charge on a sliding scale based on income and cannot refuse treatment."
Additionally, "Dr. Peter L. Beilenson, the city's health commissioner, said he cannot believe only 534 people in Baltimore County could benefit from methadone treatment. The 11 city-run clinics have 4,451 slots, and not a day goes by that they aren't all full, he said. Official statistics show that 13 percent of the clients are from outside the city, but Beilenson said he suspects that many people give the address of a relative who lives in the city instead of their own. When Mayor Martin O'Malley told police Commissioner Edward T. Norris to clean up a handful of the worst drug corners in the city, 50 percent to 75 percent of the people caught trying to buy drugs came from the suburbs, the bulk of them from Baltimore County, Beilenson said."
As reported by Canada's National Post on September 1, 2001 ( "HIV Spreads While Ottawa Ponders Drug Policy") that "A federally funded research organization has criticized Health Canada for its 'vague' response to a report that recommends radical changes to Canada's drug policies in order to reduce HIV and AIDS. In 1999, the Canadian HIV/AIDS Legal Network released a report commissioned by Health Canada that said HIV and AIDS is a crisis among injection drug users. It said Canada's drug policies make the problem worse by criminalizing drug use and forcing users to hide their addiction, share needles and avoid medical help. The report recommended sweeping changes to Canadian drug policies, such as the establishment of safe injection sites, medical prescriptions for heroin and cocaine, and the decriminalization of small amounts of illegal drugs for personal use. Yesterday, after almost two years, Health Canada released a response to the report."
Regarding the report, the
Toronto Globe and Mail on September 1, 2001 (
"Ease Up On Heroin Addicts, Federal Study Says")
said of Health Minister Allan Rock that
"By publishing the report, Mr. Rock, sometimes mentioned as a
possible future prime minister, stepped deeper into a war zone
between those who favour strict drug enforcement and those who call
the current law outdated. It calls for sentences of up to seven
years for possession of heroin and life for possession for
purposes of trafficking." The Globe and Mail continued:
In its response to Health Canada's response, the Canadian HIV/AIDS Legal Network called the Health Canada report and another report, the Federal/Provincial/Territorial Committee on Injection Drug Use's "Reducing The Harm Associated With Injection Drug Use In Canada," "an important and significant step in the right direction. The federal and provincial/territorial governments have made important acknowledgements and commitments. It remains to be hoped that action will follow the words."
The US Centers for Disease Control published a study May 18, 2001 ( "Trends In Injection Drug Use Among Persons Entering Addiction Treatment -- New Jersey, 1992-1999), which "summarizes an analysis of trends in injection drug use among persons admitted to New Jersey addiction treatment programs during 1992--1999; the findings suggest substantial increases in injection use among young adult heroin users throughout the state and an increase in heroin use among young adults who reside in suburban and rural New Jersey."
Some of this change reflects a decrease in use in urban areas as well as an increase in use in suburban and rural areas. The CDC report notes that "Decreases in heroin use in urban areas may reflect risk reduction resulting from intensive efforts to reduce the transmission of HIV and acquired immunodeficiency syndrome in these communities(2). Another possible explanation for these changes is a substantial decrease in heroin purity. Decreased injecting among heroin users in the northeastern United States during the 1980s and early 1990s has been attributed, in part, to increases in heroin purity, from <10% to >50%(3). Purer heroin allows users to maintain their addiction by inhaling (snorting), which has a lower risk for transmission of HIV and other bloodborne infections than injecting. However, during the period of increases in the proportion of young heroin users in New Jersey who reported injecting, the purity of heroin continued to be >60%*. Another explanation may be population shifts from the cities to suburban and rural areas that may have contributed to the regional changes in heroin use and injection. However, U.S. census data for 1990 through 1998 indicate that suburban growth in New Jersey resulted from increases in the number of residents aged >35 years while the number of young adults in these regions declined."
"* Among 23 US cities surveyed in 1999, Newark and Philadelphia (the two largest heroin distribution centers for the area) had the highest mean purity levels (72% in Philadelphia and 67.5% in Newark) (Drug Enforcement Administration, Department of Justice, unpublished data, 1999)."
The US Centers for Disease Control published a study titled "Update: Syringe Exchange Programs -- United States, 1998" in the May 18, 2001 edition of its Morbidity and Mortality Weekly Report. The study, performed by staff from New York's Beth Israel Medical Center and the North American Syringe Exchange Network (NASEN) is based on survey responses and telephone interviews from 110 syringe exchange programs (SEPs) around the country. According to the report, "SEPs operated in 81 cities and 31 states, the District of Columbia, and Puerto Rico. The largest number of SEPs were in four states: 21 in California, 14 in New York, 12 in Washington, and nine in New Mexico. SEPs were classified by the number of syringes exchanged during 1998 (Table 1); 107 reported exchanging 19,397,527 syringes. The 12 largest programs exchanged 62% of all syringes. In addition to the basic syringe exchange service, SEPs also frequently provide other health and harm reduction services:
Victims of Hepatitis C who are receiving methadone maintenance treatment may have to forego treatment for HCV if they wish to remain in MMT. The Journal of the American Medical Association recently reported that "Some former addicts who develop HCV-related liver disease -- notably those receiving methadone maintenance therapy (MMT) -- are confronted with barriers to getting much-needed treatment for their illness, barriers that sometimes force them to choose between dying of liver disease and risking relapse and a return to abusing drugs."
The United Nations recently issued the Report of the International Narcotics Control Board for 2000. The INCB report was critical of Australian policies allowing prescription heroin and allowing states to set up legal heroin injection rooms, as the Australian Associated Press reported ( "UN Slams States' Drug Stance").
Meanwhile, Reuters reported on March 16, 2001 "Sydney Heroin Injecting Room Ready For Business") that in Sydney, "Australia's first official heroin injecting room is ready for business, but its doors remain closed as a legal battle over its fate rages, leaving drug addicts to shoot up in a street around the corner." Previously, it was reported that "Victoria is likely to have a heroin trial if there is a change of leadership in Canberra this year, according to an expert who is about to take a senior role in the Bracks Government's battle against drug abuse."
The Swiss program of legal heroin-assisted treatment for hardcore users was also criticized in the report. The Swiss policy was approved by Swiss voters in 1999 and is viewed as highly effective in helping reduce the harms from injection drug use.
According to "The Swiss Drug Policy," a publication of the Swiss Federal Office of Public Health (SFOPH), the prescription of narcotics is strictly limited to "a clearly limited group of severely addicted drug users in specialized treatment centers (criteria for admission: heroin addiction for a minimum of two years, more than 18 years old, at leaset two relapses to drug use after failures in out- or in-patient treatment and obvious adverse effects of drug use on health and/or social relations)."
(The SFOPH also has on its website the abstracts from the International Symposium on Heroin-Assisted Treatment for Dependent Drug Users: State of the Art and New Research Perspectives, held March 10-12, 1999, in Bern, Switzerland.)
The Department of Health and Human Services issued its final rules on opioid drugs in maintenance and detox treatment of opiate addiction on Jan. 17, 2001. The text of the rule is available on the website for the Substance Abuse & Mental Health Services Administration. SAMHSA is part of the US Department of Health and Human Services.
According to an AP story by Lauren Neergaard on the rule, "Methadone clinics for the first time must be accredited in a manner similar to other health facilities, say new government rules intended to improve quality of treatment for heroin addiction."
The move to accreditation follows recommendations made by a Consensus Statement on Effective Medical Treatment of Opate Addiction which strongly support methadone maintenance treatment (MMT). The rule became effective March 19, 2001.
This report in the Medical Journal of Australia is on providing injectable methadone or heroin to addicts.
NIDA recently conducted a survey of practitioners showing support for office-based provision of methadone.
This study from the British Medical Journal supports heroin maintenance programs.
This report from the British Medical Journal on the Swiss heroin maintenance experiment contains valuable information.
(For more information about use of naloxone in cases of heroin overdose, see "Heroin-related deaths in New South Wales, 1992: toxicological findings and circumstances" from the Medical Journal of Australia.
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Some organizations working on AIDS, needle exchange and methadone